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Co nt act Le ns Pract ice
To Suzanne, Zoe and Bruce
 Co nt act Le ns
Pract ice

T h i r d Ed i t i o n

EDITED BY
Nat han Efro n
AC, DSc (Manche ste r), PhD, BScO p tom (Me lb ourne ),
FACO , FAAO , FIACLE, FCCLSA
Profe ssor Eme ritus, School of O p tome try,
Q ue e nsland Unive rsity of Te chnolog y,
Brisb ane , Australia

EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO

iii
© 2018 Elsevier Ltd. All rights reserved.

First published 2002

Reprinted 2005
Second edition 2010
Reprinted 2013
T ird edition 2018

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Notices

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have a pro essional responsibility.
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 CO NTENTS

Contrib uting Authors vii 13 Rig id Le ns O p tics 130

W NEIL CHARMAN
Pre ace to the Third Ed ition ix
14 Rig id Le ns Me asure me nt 136
Trib ute s x KLAUS EHRMANN

Acknowle d g e me nts xi 15 Rig id Le ns De sig n and Fitting 143

GRAEME YO UNG

PART 1 Int ro d uct io n 16 Rig id Toric Le ns De sig n and Fitting 156

RICHARD G LINDSAY

1 History 3 17 Rig id Le ns Care Syste ms 163

NATHAN EFRO N
PHILIP B MO RGAN

2 Ante rior Eye 10

JO HN G LAWRENSO N
PART 4 Le ns Re p lace me nt
3 Visual O p tics 28 Mo d alit ie s
W NEIL CHARMAN
18 Daily Disp osab le So t Le nse s 167
NATHAN EFRO N

PART 2 So ft Co nt act Le nse s

19 Re usab le So t Le nse s 175
4 So t Le ns Mate rials 45 JO E TANNER | NATHAN EFRO N

CARO LE MALDO NADO -CO DINA

20 Planne d Re p lace me nt Rig id Le nse s 187
5 So t Le ns Manu acture 61 CRAIG A WO O DS

NATHAN EFRO N

6 So t Le ns O p tics 68 PART 5 Sp e cial Le nse s and Fit t ing

W NEIL CHARMAN
Co nsid e rat io ns
7 So t Le ns Me asure me nt 73 21 Scle ral Le nse s 195
KLAUS EHRMANN
NATHAN EFRO N

8 So t Le ns De sig n and Fitting 86 22 Tinte d Le nse s 204

GRAEME YO UNG
NATHAN EFRO N | SUZANNE E EFRO N

9 So t Toric Le ns De sig n and Fitting 95 23 Pre sb yop ia 214

RICHARD G LINDSAY
JO HN MEYLER | DAVID RUSTO N

10 So t Le ns Care Syste ms 103 24 Exte nd e d We ar 231

PHILIP B MO RGAN
NO EL A BRENNAN | M-L CHANTAL CO LES

25 Sp ort 246
PART 3 Rig id Co nt act Le nse s NATHAN EFRO N

11 Rig id Le ns Mate rials 115 26 Ke ratoconus 251

NATHAN EFRO N LAURA E DO WNIE | RICHARD G LINDSAY

12 Rig id Le ns Manu acture 123 27 Hig h Ame trop ia 263

NATHAN EFRO N JO SEPH T BARR

v
vi CO NTENTS

28 Bab ie s and Child re n 268 41 Dig ital Imag ing 410

CINDY TRO MANS | HELEN WILSO N ADRIAN S BRUCE | MILTO N M HO M

29 The rap e utic Ap p lications 275 42 Comp liance 420

NATHAN EFRO N | SUZANNE E EFRO N NATHAN EFRO N

30 Post-re ractive Surg e ry 282 43 Practice Manag e me nt 427

SUZANNE E EFRO N NIZAR K HIRJI

31 Post-ke ratop lasty 287

BARRY A WEISSMAN
Ap p e nd ice s
32 O rthoke ratolog y 296 A Contact Le ns De sig n and Sp e cif cations 438
PAUL GIFFO RD

B Contact Le ns Tole rance s 440

33 Myop ia Control 306
PADMAJA SANKARIDURG | BRIEN A HO LDEN
C Ve rte x Distance Corre ction 441
34 Diab e te s 314
CLARE O ’DO NNELL
D Corne al Curvature – Corne al Powe r
Conve rsion 443

E Exte nd e d Ke ratome te r Rang e Conve rsion 445

PART 6 Pat ie nt Examinat io n and
Manag e me nt F So t Le ns Ave rag e Thickne ss 446
35 History Taking 323 G So t Le ns O xyg e n Pe r ormance 447
JAMES S W WO LFFSO HN

H Constant Ed g e Cle arance Rig id Le ns

36 Diag nostic Instrume nts 327 De sig ns 449
LYNDO N W JO NES | SRUTHI SRINIVASAN | ALISO N NG |
MARC SCHULZE
I So t Toric Le ns Misalig nme nt
37 Pre liminary Examination 346 De monstrator 450
ADRIAN S BRUCE
J Dry-e ye Q ue stionnaire 451
38 Patie nt Ed ucation 356
SARAH L MO RGAN K E ron Grad ing Scale s or Contact Le ns
Comp lications 453
39 A te rcare 364
LO RETTA B SZCZO TKA-FLYNN | NATHAN EFRO N L Scle ral Le ns Fit Scale s 456

40 Comp lications 385

NATHAN EFRO N Ind e x 459
 CO NTRIBUTING AUTHO RS

J o se p h T Barr, O D, MS, FAAO Suzanne E Efro n, BSc(Ho ns), MPhil,

Emeritus Pro essor, College o Optometry, T e Ohio State PGCe rt O cThe r
University, Columbus, Ohio, USA Locum Optometrist, Broadbeach, Queensland, Australia
27 High Ametropia 22 inted Lenses
29 T erapeutic Applications
No e l A Bre nnan, MScO p t o m, PhD, FAAO , 30 Post-re ractive Surgery
FCLSA
Clinical Research Fellow and Global Plat orm Lead, Myopia Klaus Ehrmann
Control, Johnson & Johnson Vision Care Inc., Jacksonville, Director – echnology, Brien Holden Vision Institute,
Florida, USA University o New South Wales, Sydney, Australia
24 Extended Wear 7 Sof Lens Measurement
14 Rigid Lens Measurement
Ad rian S Bruce , BScO p t o m, PhD, FAAO , FVCO
Lead Optometrist, Australian College o Optometry, Paul Giffo rd , PhD, MSc, BSc(Ho ns), MCO p t o m,
Melbourne, Victoria, Australia; Senior Fellow, Department FBCLA, FIACLE, FAAO
o Optometry and Vision Sciences, University o Melbourne, Private Practice, Brisbane, Queensland, and Adjunct Senior
Parkville, Victoria, Australia Lecturer, University o New South Wales, Sydney, Australia
37 Preliminary Examination 32 Orthokeratology
41 Digital Imaging
Nizar K Hirji, BSc, PhD, MBA, FCO p t o m,
M-L Chant al Co le s, BS, O D FAAO , FIMg t
Optometrist, Johnson & Johnson Vision Care Inc., Optometrist and Principal Consultant, Hirji Associates,
Jacksonville, Florida, USA Birmingham, UK; Visiting Pro essor o Optometry,
24 Extended Wear University o Manchester, Manchester, UK; Visiting
Pro essor o Optometry, City University, London, UK
W Ne il Charman, BSc, PhD, DSc, FO p t So cAm, 43 Practice Management
FCO p t o m(Ho n)
Emeritus Pro essor, T e University o Manchester, Manchester, UK Brie n A Ho ld e n, O AM, PhD, DSc(Ho n),
3 Visual Optics BAp p Sc, LO Sc (d e ce ase d )
6 Sof Lens Optics Founding Chie Executive O cer, Brien Holden Vision
13 Rigid Lens Optics Institute, University o New South Wales, Sydney, Australia
33 Myopia Control
Laura E Do w nie , PhD, BO p t o m, PGCe rt O cThe r,
FACO , FAAO , Dip Mus(Prac), AMusA Milt o n M Ho m, O D, FAAO FACAAI(Sc)
Lecturer and NHMRC ranslating Research Into Practice Private Practice, Azusa, Cali ornia, USA
( RIP) Fellow, Department o Optometry and Vision 41 Digital Imaging
Sciences, T e University o Melbourne, Parkville,
Victoria, Australia Lynd o n W J o ne s, PhD, FCO p t o m, Dip CLP,
26 Keratoconus Dip O rt h, FAAO , FIACLE, FBCLA
University Research Chair, Pro essor, School o Optometry
Nat han Efro n, AC, DSc, PhD, BScO p t o m, FACO , and Vision Science, and Director, Centre or Contact
FAAO , FIACLE, FCCLSA Lens Research, University o Waterloo, Waterloo, Ontario,
Pro essor Emeritus, School o Optometry, Queensland Canada
University o echnology, Brisbane, Queensland, Australia 36 Diagnostic Instruments
1 History
5 Sof Lens Manu acture J o hn G Law re nso n, BSc, PhD, MCO p t o m
11 Rigid Lens Materials Pro essor o Clinical Visual Science, City, University o
12 Rigid Lens Manu acture London, London, UK
18 Daily Disposable Sof Lenses 2 Anterior Eye
19 Reusable Sof Lenses
21 Scleral Lenses Richard G Lind say, BScO p t o m, MBA, FAAO ,
22 inted Lenses FCLSA, FVCO
25 Sport Private Practice, East Melbourne, Victoria, Australia
29 T erapeutic Applications 9 Sof oric Lens Design and Fitting
39 Af ercare 16 Rigid oric Lens Design and Fitting
40 Complications 26 Keratoconus
42 Compliance
vii
viii CO NTRIBUTING AUTHO RS
Caro le Mald o nad o -Co d ina, BSc(Ho ns), MSc,
PhD, MCO p t o m, FAAO , FBCLA
Senior Lecturer in Optometry, T e University o Manchester,
Manchester, UK
4 Sof Lens Materials
J o hn Me yle r, BSc(Ho ns), FCO p t o m, Dip CLP
Senior Director, Global Pro essional Af airs, Johnson &
Johnson Vision Care Companies, Wokingham,
Berkshire, UK
23 Presbyopia
Philip B Mo rg an, BSc(Ho ns), PhD, MCO p t o m,
FAAO , FBCLA
Pro essor o Optometry and Director, Eurolens Research,
T e University o Manchester, Manchester, UK
10 Sof Lens Care Systems
17 Rigid Lens Care Systems
Sarah L Mo rg an, BSc(Ho ns), MPhil, MCO p t o m,
FAAO , FBCLA
Staf Development Consultant, Manchester, UK;
Vision Sciences Fellow in Optometry, T e University
o Manchester, Manchester, UK
38 Patient Education
Aliso n Ng , PhD, MCO p t o m
Post Doctoral Fellow, Centre or Contact Lens Research,
University o Waterloo, Waterloo, Ontario, Canada
36 Diagnostic Instruments
Clare O ’Do nne ll, BSc(Ho ns), MBA, PhD,
MCO p t o m, FAAO , FBCLA
Head o Eye Sciences, Optegra Manchester Eye Hospital,
Didsbury; Reader, Aston University, Birmingham, UK
34 Diabetes
David Rust o n, BSc, FCO p t o m, Dip CLP, FAAO ,
FIACLE
Director, Global Pro essional Af airs, Johnson & Johnson
Vision Care Companies, Wokingham, Berkshire, UK
23 Presbyopia
Pad maja Sankarid urg , BO p t o m, MIP, PhD
Associate Pro essor, Program Leader – Myopia, Manager,
Intellectual Property, Brien Holden Vision Institute,
University o New South Wales, Sydney, Australia
33 Myopia Control
Marc Schulze , PhD, Dip lIng (AO ), FAAO
Clinical Scientist, Centre or Contact Lens Research,
University o Waterloo, Waterloo, Ontario, Canada
36 Diagnostic Instruments
Srut hi Srinivasan, PhD, BS O p t o m, FAAO
Clinical Research Manager and Senior Clinical Scientist,
Centre or Contact Lens Research, University o Waterloo,
Waterloo, Ontario, Canada
36 Diagnostic Instruments
Lo re t t a B Szczo t ka-Flynn, O D, PhD, FAAO
Pro essor, Department o Ophthalmology and Visual Science,
Case Western Reserve University; Director, Contact Lens
Service, University Hospitals Case Medical Center,
Cleveland, Ohio, USA
39 Af ercare
J o e Tanne r, BO p t o m
Pro essional Services Manager, CooperVision Australia and
New Zealand
19 Reusable Sof Lenses
Cind y Tro mans, BSc(Ho ns), PhD, MCO p t o m,
Dip (Tp )IP, FEAO O
Consultant Optometrist, Manchester Royal Eye Hospital;
Honorary Clinical Lecturer, Department o Ophthalmology,
T e University o Manchester, Manchester, UK
28 Babies and Children
Barry A We issman, O D, PhD, FAAO
Pro essor o Optometry, Southern Cali ornia College o
Optometry at Marshall B Ketchum University, Fullerton,
Cali ornia, USA; Emeritus Pro essor o Ophthalmology,
Stein Eye Institute, David Gef en School o Medicine at
UCLA, Los Angeles Cali ornia, USA
31 Post-keratoplasty
He le n Wilso n, BSc(Ho ns), MCO p t o m, Dip Tp (IP),
Dip O C, Dip Glauc
Principal Optometrist, Manchester Royal Eye Hospital,
Manchester, UK.
28 Babies and Children
J ame s S W Wo lffso hn, BSc(Ho ns), PGCe rt HE,
PGDip Ad vClinO p t o m, MBA, PhD, FCO p t o m,
FHEA, FSB, FAAO , FIACLE, FBCLA
Pro essor and Deputy Executive Dean, School o Li e and
Health Sciences, Aston University, Birmingham, UK
35 History aking
Craig A Wo o d s, BSc(Ho ns), PhD, MCO p t o m,
Dip CLP, PGCe rt O cThe r, FAAO , FACO , FBCLA
Pro essor, Head o Clinical Partnerships, Deakin Optometry,
School o Medicine, Deakin University, Geelong, Australia
20 Planned Replacement Rigid Lenses
Grae me Yo ung , BSc, MPhil, PhD, FCO p t o m,
Dip CLP, FAAO
Director, Visioncare Research, Farnham, Surrey; Honorary
Pro essor, School o Li e and Health Sciences, Aston
University, Birmingham, UK
8 Sof Lens Design and Fitting
15 Rigid Lens Design and Fitting
 PREFACE TO THE THIRD EDITIO N
T is book strives to achieve the ‘middle ground’ among contact
lens textbooks. It is not intended to be a brie clinical manual o
contact lens tting; nor is it intended to be a weighty tome with
extensive research coverage. Like its predecessors, this third
edition o Contact Lens Practice seeks to be a comprehensive,
easily accessible book that provides in ormation o immediate
relevance to contact lens practitioners, underpinned by well-
ounded evidence and expert clinical insight by the authors
o the various chapters, each o whom is an expert in the area
covered.
T is new edition is not just a cosmetic make-over. T ere
have been extensive revisions to most chapters, many o which
have been written by authors who are new or this edition.
T ere is also a new chapter on myopia control – an area o
considerable interest at present in view o the current myo-
pia epidemic (especially in Asia), and the potential or tting
contact lenses that can arrest myopia progression to a cer-
tain degree. T e chapter on daily disposable lenses has been
updated and expanded, which is particularly important given
that this modality now represents nearly one-third o contact
lenses prescribed worldwide.
I hope that students using this book nd it to be a valuable
guide to their studies and acquisition o knowledge in the sci-
ence and art o contact lens tting, and I trust that this work
will be a valuable companion to practitioners in their ef orts to
satis y the needs o those patients tted with contact lenses.
Professor Nathan Efron AC
ix
TRIBUTES
Here we pay tribute to two contributors to Contact Lens Practice
who have passed away since the second edition o this book was
published.
Keith Edwards, who wrote the chapter on History Taking
in the rst two editions o this book, lost a long- ought battle
with cancer in 2014. Keith was an inspirational educator, cli-
nician and researcher who had an impact internationally in
the eld o contact lenses and intraocular lenses. Following
his Optometry degree at City University, he worked in private
practice and served as secretary o the London Re raction Hos-
pital and examinations advisor at the College o Optometrists.
He was an inaugural director o Optometric Educators Ltd and
later worked or Madden and Layman, which was acquired by
Bausch & Lomb in the late 1980s. He expanded his role rom
UK Pro essional Services to Director o Global Clinical Devel-
opment or Surgical at Bausch & Lomb, which took him to the
US, where his nal job was as Vice-President o Clinical and
Regulatory A airs at LENSAR.
x
Brien Holden, who co-authored the chapter in this book on
Myopia Control, passed away suddenly in 2015. He was Chie
Executive O cer o the Brien Holden Vision Institute and Pro-
essor at the School o Optometry and Vision Science at the
University o New South Wales, Australia. Pro essor Holden
was a global leader in eye care and vision research, and an inter-
nationally renowned and awarded scientist and humanitarian.
He was widely acknowledged as the most inf uential optome-
trist o our generation. His career was spent inspiring scientists
and health-care pro essionals around the world with his dream
o ‘vision or everyone, everywhere’. Pro essor Holden was the
recipient o seven honorary doctorates rom universities around
the world, and was awarded an Order o Australia Medal or his
work in eye health and vision science.

I am grate ul to the contributing authors o this third edition o
Contact Lens Practice. All have worked diligently to update their
chapters, or write new chapters, to bring the latest clinically rel-
evant in ormation to the ore.
I continue to enjoy the strong support o the long-standing
publisher o all o my books – Elsevier. In particular, I am grate-
ul to Russell Gabbedy (Commissioning Editor) and Alexan-
dra Mortimer (Development Editor) or their encouragement
and support during the planning and production o this book.
T anks also to Samuel Crowe, or assisting e ciently with vari-
ous aspects o production.
Editing a book o this size and scope is a substantial undertak-
ing, and in this regard I wish to o er special thanks to my lovely
wi e, Suzanne, who has served as a ‘virtual co-editor’ by way o
ACKNO WLEDGEMENTS
spending many long hours assisting me in assembling, editing,
organizing and proo reading the contributed material. She has
done a wonder ul job. I really could not have completed this task
without her assistance. I also thank Suzanne or co-authoring
Chapters 22 and 29 with me, and or revising and authoring
Chapter 30.
Let me also pay tribute to the photographers and illustra-
tors, many o whom were not contributing authors o this
book, or their extraordinary skills and insights in creating
such antastic imagery. I also thank them or giving me per-
mission to use this material in the book. I apologize i I have
made any errors in attribution; please let me know i I have
erred in this regard, and I shall correct this at the f rst reprint-
ing opportunity.
xi
This pa ge inte ntiona lly le ft bla nk
 PART

1
Int ro d uct io n

PART O UTLINE
1 History 3
Nathan E ron
2 Ante rior Eye 10
John G Lawre nson
3 Visual O p tics 28
W Ne il Charman
This pa ge inte ntiona lly le ft bla nk
 1
Hist o ry
NATHAN EFRO N

Int ro d uct io n snugly into the orbital rim (Young, 1801) (Figs. 1.3 and 1.4).
A microscope eyepiece was tted into the base o the eyecup,
thus orming a similar system to that used by Descartes. Young’s
We canno t co nt inue t he se b rilliant succe sse s in t he invention was somewhat more practical in that it could be held
fut ure , unle ss we co nt inue t o le arn fro m t he p ast . in place with a headband and blinking was possible; however,
Calvin Coolid g e , inaug ural US p re sid e ntial ad d re ss, 1923 he did not intend this device to be used or the correction o
re ractive errors.
Coolidge was re erring to the successes o a nation, but his In a ootnote in his treatise on light in the 1845 edition o
sentiment could apply to any eld o endeavour, including con- the Encyclopedia Metropolitana, Sir John Herschel suggested
tact lens practice. As we continue to ride on the crest o a huge two possible methods o correcting ‘very bad cases o irregular
wave o exciting developments in the 21st century, we would not cornea’: (1) ‘applying to the cornea a spherical capsule o glass
wish to lose sight o the past. Hence the inclusion in this book o
this brie historical overview.
Outlined below in chronological order (allowing or some
historical overlaps) is the development o contact lenses, rom
the earliest theories to present-day technology. Each heading,
which represents a major achievement, is annotated with a year
that is considered to be especially signi cant to that develop-
ment. T ese dates are based on various sources o in ormation,
such as dates o patents, published papers and anecdotal reports.
It is recognized, there ore, that some o the dates cited are open
to debate, but they are nevertheless presented to provide a rea-
sonable chronological perspective.

Early The o rie s (1508–1887)

Although contact lenses were not tted until the late 19th cen- Fig . 1.1 Id e a o Le onard o d a Vinci to alte r corne al p owe r.
tury, a number o scholars had earlier given thought to the
possibility o applying an optical device directly to the eye-
ball to correct vision. Virtually all o these suggestions were
impractical.
Many contact lens historians point to Leonardo da Vinci’s
Codex o the Eye, Manual D, written in 1508, as having intro-
duced the optical principle underlying the contact lens. Indeed,
da Vinci described a method o directly altering corneal power
– by immersing the eye in a bowl o water (Fig. 1.1). O course,
a contact lens corrects vision by altering corneal power. How-
ever, da Vinci was primarily interested in learning the mecha-
nisms o accommodation o the eye (Heitz and Enoch, 1987) Fig . 1.2 Fluid -f lle d tub e d e scrib e d b y Re né De scarte s.
and did not re er to a mechanism or device or correcting
vision.
In 1636, René Descartes described a glass uid- lled tube
that was to be placed in direct contact with the cornea (Fig. 1.2).
T e end o the tube was made o clear glass, the shape o which
would determine the optical correction. O course, such a device
is impractical as blinking is not possible; nevertheless, the prin-
ciple o directly neutralizing corneal power used by Descartes is
consistent with the principles underlying modern contact lens
design (Enoch, 1956).
As part o a series o experiments concerning the mecha-
nisms o accommodation, T omas Young, in 1801, constructed
a device that was essentially a uid- lled eyecup that tted Fig . 1.3 Eye cup d e sig n o Thomas Young .
3
4 PART 1 Int ro d uct io n

Fig . 1.4 Thomas Young .

Fig . 1.6 Ad ol Gaston Eug e ne Fick.

Fig . 1.5 ‘Animal je lly’ sand wiche d b e twe e n a ‘sp he rical cap sule o
g lass’ (contact le ns) and corne a, as p rop ose d b y Sir Jo hn He rsche l.

lled with animal jelly’ (Fig. 1.5), or (2) ‘taking a mould o the
cornea and impressing it on some transparent medium’ (Her-
schel, 1845). Although it seems that Herschel did not attempt to
conduct such trials, his latter suggestion was ultimately adopted
some 40 years later by a number o inventors, working indepen-
dently and unbeknown to each other, who were all apparently
unaware o the writings o Herschel.

Glass Scle ral Le nse s (1888)

T ere was a great deal o activity in contact lens research in the late
1880s, which has led to debate as to who should be given credit
or being the rst to t a contact lens. Adol Gaston Eugene Fick
(Fig. 1.6), a German ophthalmologist working in Zurich, appears
to have been the rst to describe the process o abricating and
tting contact lenses in 1888; speci cally, he described the tting
o a ocal scleral contact shells rst on rabbits, then on himsel and
nally on a small group o volunteer patients (E ron and Pearson,
1988). In their textbook dated 1910, Müller and Müller, who were
manu acturers o ocular prostheses, described the tting in 1887
o a partially transparent protective glass shell to a patient re erred
to them by Dr Edwin T eodor Sämisch (Müller and Müller,
1910). Pearson (2009) asserts that the tting was done by Albert
C Müller-Uri. Fick’s work was published in the journal Archiv ür
Augenheilkunde in March 1888, and must be accorded historical
precedence over later anecdotal textbook accounts.
French ophthalmologist Eugène Kalt (Fig. 1.7) tted two
keratoconic patients with a ocal glass scleral shells and obtained
Fig . 1.7 Eug è ne Kalt.
a signi cant improvement in vision. A report o this work, pre-
sented to the Paris Academy o Medicine on 20 March, 1888
by Kalt’s senior medical colleague, Pro essor Photinos Panas,
acknowledges and there ore e ectively con rms that the work
o Fick occurred earlier (Pearson, 1989).
Credit or tting the rst powered contact lens must be given
to August Müller (Fig. 1.8) (no relation to Müller and Müller,
mentioned above), who conducted his work while he was a med-
ical student at Kiel University in Germany (Pearson and E ron,
1989). In his inaugural dissertation presented to the Faculty o
Medicine in 1889, Müller described the correction o his own
high myopia with a powered scleral contact lens. Paradoxically,
Müller subsequently lost interest in ophthalmology and went on
to practise as an orthopaedic specialist.

Fig . 1.8 Aug ust Mülle r. (Courte sy of Richard Pe arson.)
T e lenses worn by Müller were made by an optical engineer,
Karl Otto Himmler (1841–1903), whose rm enjoyed, until the
outbreak o World War II, an international reputation or the
manu acture o microscopes and their accessories. Himmler
must there ore be acknowledged as the rst manu acturer o
optically ground contact lenses (Pearson, 2007).
Little development occurred in the 50 years subsequent to
these early clinical trials. Improvements in methods o scleral
lens tting were described by clinicians such as Dallos, who
emphasized the importance o designing the lens to acilitate
tear ow beneath the lens (Dallos, 1936). Dallos also went on
to develop techniques or taking impressions o the human eye
and grinding the lenses rom these impressions.
Plast ic Scle ral Le nse s (1936)
Carl Zeiss o Jena, Germany applied or a patent that proposed
the manu acture o contact lenses rom ‘cellon, celluloid or an
organic substance with similar mechanical and optical prop-
erties’, which was eventually issued in 1923 (Pearson, 2015).
Cellon is cellulose acetate and celluloid is cellulose nitrate plas-
ticized with camphor; there ore, this is a re erence to a lens
made o a plastic material. T is was also the rst mention o
the manu acture o contact lenses by moulding. T e Zeiss pat-
ents envisaged that contact lenses made rom plastic materi-
als would be less expensive, have some exibility that would
improve the t, be ‘unbreakable’ and o er ocular protection
(Pearson, 2015).
It appears that in Germany there may have been some largely
unsuccess ul attempts to t plastic lenses rom around 1930.
It was reported in that year that Zeiss contact lenses moulded
rom cellon and celluloid lacked the degree o polish achieved
with glass lenses and were unstable owing to the in uences o
humidity and temperature. More serious ndings were that they
put a ‘tourniquet’ on the conjunctiva in the region o the lim-
bus and caused extensive corneal erosion. T ese un avourable
results were possibly due to the act that they were made with a
single back scleral radius o 12 mm (Pearson, 2015).
1 Hist o ry 5
T e Rohm and Haas company introduced transparent plas-
tic (polymethyl methacrylate: PMMA) into the USA in 1936,
and in the same year Feinbloom (1936) described a scleral lens
consisting o an opaque plastic haptic portion and a clear glass
centre. Soon a er, scleral lenses were abricated entirely rom
PMMA using lathing techniques. T e earliest report o the t-
ting o PMMA lenses appears to have been made by T ier in
1939. T ese lenses were said to be ‘about hal the weight o ordi-
nary glass, unbreakable and quicker to manu acture’. T ey did
not provoke any irritation, but the optical zone needed to be
repolished every 6 months (Pearson, 2015).
A key rationale or using PMMA or the manu acture o
contact lenses was that this material was considered to be bio-
logically inert in the eye. T is view was ormed by military
medical o cers who examined the eyes o pilots who su ered
eye injuries during World War II as a result o ragments rom
shattered cockpit windscreens (as would occur during aerial
dog ghts) becoming permanently embedded in the eye. T ese
eyes remained unreactive or years a er such accidents. Other
advantages o PMMA included its light weight, break resistance
and being easy to lathe and polish.
Plast ic Co rne al Le nse s (1948)
T e development o corneal lenses – or rigid lenses, as they are
re erred to today – began as the result o an error in the labora-
tory o optical technician Kevin uohy. During the lathing o a
PMMA scleral lens, its haptic and corneal portions separated.
uohy became curious as to whether the corneal portion could
be worn, so he polished the edge, placed it in his own eye and
ound that the lens could be tolerated (Bra , 1983). Further tri-
als were conducted, leading to the development o the rigid con-
tact lens (rigid lenses were previously re erred to as ‘hard’ lenses
i they were manu actured rom PMMA). uohy led a patent
or his invention in February 1948.
So began an era o popularization o the contact lens. T e
spherical uohy lens design su ered rom two main drawbacks:
considerable apical bearing, which caused central corneal abra-
sion and oedema, and excessive edge li , which made the lens
easy to dislodge. It was soon realized that these problems could be
overcome by altering the peripheral curvature o the posterior lens
sur ace, heralding the development o multicurve and aspheric
designs, which remain in widespread use today, albeit with supe-
rior gas-permeable materials (PMMA is now virtually obsolete).
Silico ne Elast o me r Le nse s (1965)
Silicone rubber orms a unique category amongst contact lens
materials. It is a ‘so lens’ in terms o its physical behaviour and
lenses are abricated rom this material in the orm o a so lens.
Unlike all other so lens materials, silicone elastomer does not
contain water and in this respect is analogous to a hard lens
material. Silicone elastomer is highly permeable to oxygen and
carbon dioxide and there ore provides minimal inter erence to
corneal respiration; however, it is di cult to manu acture and
its sur ace is hydrophobic and must be treated to allow com ort-
able wear. T e considerable di culties involved in enhancing
sur ace wettability have limited the clinical application o this
lens, and ew advances have been made since it was originally
tted. T e precise date o silicone elastomer lenses becoming
commercially available is unclear. T ere was some patent activ-
ity in the mid 1960s to early 1970s, and Mandell (1988) claims
6 PART 1 Int ro d uct io n
to have personally observed ten patients who were wearing such
lenses in 1965, noting very poor clinical results.
So ft Le nse s (1972)
Possibly the greatest understatement that can be ound in the
literature pertaining to contact lens development is the nal
sentence o a paper entitled ‘Hydrophilic gels or biological use’,
published in Nature on 9 January, 1960, by Wichterle and Lim
(1960): ‘Promising results have also been obtained in experi-
ments in other cases, or example, in manu acturing contact
lenses, arteries, etc.’
Initial attempts by Otto Wichterle (Fig. 1.9) to produce so
lenses abricated rom hydroxyethyl methacrylate (HEMA), and
manu actured using cast moulding, met with limited success.
Unable to attract support rom the Institute o Macromolecular
Research in Czechoslovakia (now the Czech Republic) where
he worked, and indeed discouraged by his superiors, Wichterle
was orced to conduct urther secret experiments in his own
home. Working with a children’s mechanical construction kit,
Wichterle developed the spin-casting technique (Fig. 1.10) and
Fig . 1.9 O tto Wichte rle . (Courte sy of De b b ie Swe e ne y.)
Fig . 1.10 The p rototyp e sp in-casting machine b uilt at home b y Wich-
te rle using his son’s toy Me ccano construction se t.
eventually managed to persuade his peers to conduct urther
trials at the Institute. He claims to have produced ‘the rst suit-
able contact lenses’ in late 1961 (Wichterle, 1978), which pre-
sumably approximates to the rst occasion when a so lens was
actually worn on a human eye. T e patent to develop so con-
tact lenses commercially was subsequently acquired by Bausch
& Lomb in the USA, who introduced so lenses into the world
market in 1972.
Lenses manu actured rom HEMA were an immediate
market success, primarily by virtue o their superior com ort
and enhanced biocompatibility. However, clinical experi-
ence and laboratory studies indicated that the poor physi-
ological response o the anterior eye during wear o the early
thick HEMA lenses could be enhanced by making so lenses
more permeable to oxygen – speci cally by making them
thinner and o a higher water content. Much o the research
and development in contact lenses up to the present time
has been concerned with the development o materials and
lens designs that optimize biocompatibility, primarily by
enhancing corneal oxygenation and minimizing absorption
o proteins, lipids and other tear constituents (McMahon and
Zadnik, 2000).
Rig id Gas-p e rme ab le Le nse s (1974)
In most respects, PMMA is considered to be an ideal contact
lens material; however, its single drawback is its impermeability
to gases that are exchanged at the corneal sur ace as part o aer-
obic metabolism. Speci cally, oxygen is prevented rom moving
rom the atmosphere into the cornea, and carbon dioxide ef ux
into the atmosphere is impeded. T is drawback has been the
major driving orce in the development o rigid lens materials
that are permeable to gases.
One o the rst rigid gas-permeable materials to be tried was
cellulose acetate butyrate, which a orded some oxygen perme-
ability but was subject to warpage. In 1974, Norman Gaylord
managed to incorporate silicone into the basic PMMA struc-
ture, heralding the introduction o a new amily o contact lens
polymers known as silicone acrylates (Gaylord, 1974). Subse-
quently, other ingredients such as styrene and uorine have
been incorporated into rigid materials in attempts to enhance
material biocompatibility urther.
Disp o sab le Le nse s (1988)
In the early days o so lens development, patients would typi-
cally use the same pair o lenses until the lenses became too
uncom ortable to wear, caused severe eye reactions, or were
damaged or lost. It became apparent that lens deposition and
spoilation over time were major impediments to success ul
long-term lens wear. Although regular lens replacement was
an obvious solution to some o these problems, the high unit
cost o lenses proved to be a signi cant disincentive. In the early
1980s, orward-thinking practitioners – notably Klas Nilsson
o Gothenburg, Sweden – convinced patients o the bene ts o
replacing lenses on a regular basis (6-monthly in Nilsson’s case)
and began prescribing lenses in this way. A subsequent land-
mark scienti c publication co-authored by Nilsson – known as
the ‘Gothenburg study’ (Holden et al., 1985) – unequivocally
proved the bene ts o regular lens replacement. So was born the
concept o regular lens replacement, albeit relatively expensive
or the patient at the time.

I regular lens replacement were to become the norm, some-
thing had to be done about lens cost. A group o Danish cli-
nicians and engineers, led by ophthalmologist Michael Bay,
developed a moulding process so that low-cost, multiple indi-
vidual lens packs could be produced (Mertz, 1997). T is prod-
uct – known as ‘Danalens’ – was released into the Scandinavian
market in 1984 and must be recognized as the rst truly dispos-
able lens. However, the initial manu acturing process was crude
and numerous problems with the lenses and packaging were
reported (Benjamin et al., 1985; Bergmanson et al., 1987).
T e pharmaceutical giant Johnson & Johnson, which had
not previously been involved in the contact lens business,
purchased the Danalens technology in 1984 and completely
overhauled the lens polymer ormulation, packaging system
and moulding technology (Mertz, 1997). T e result was the
Acuvue lens, an inexpensive weekly-replacement extended-
wear lens, which was released in the USA in June 1988, and
worldwide shortly therea er. T e success o this lens elevated
Johnson & Johnson to a leadership position in the contact lens
market. All other major contact lens companies ollowed suit,
and today the majority o so lenses prescribed worldwide
(85%) are designed to be replaced monthly or more requently
(Morgan et al., 2015).
Daily Disp o sab le Le nse s (1994)
T e ultimate requency with which lenses can be replaced
is daily. A Scottish company, Award (which was acquired by
Bausch & Lomb in 1996), developed a manu acturing technique
whereby the male hal o the mould that ormed the lens became
the lens packaging. T is technique urther reduced the unit cost
o a lens, making daily disposability a viable proposition. T e
‘Premier’ daily disposable lens was launched in the UK in 1994.
Johnson & Johnson released the ‘1-Day Acuvue’ daily dispos-
able lens into western regions o the USA around the same time,
leading to an ongoing dispute as to which company (Award or
Johnson & Johnson) was the rst to release a daily disposable
contact lens into the market (Meyler and Ruston, 2006). CIBA
Vision entered the daily disposable lens market in 1997 with a
product called ‘Dailies’.
Silico ne Hyd ro g e l Le nse s (1998)
T e allure o a so contact lens made rom a material with a
phenomenally high oxygen per ormance never escaped the
contact lens industry. T e development o such a lens would be
critical to solving hypoxic lens-related problems, which severely
limit the clinical utility o contact lenses, especially or extended
wear. Silicone elastomers were the obvious answer, but, or rea-
sons outlined above, success ul lenses could never be produced
rom this material. Polymer scientists in the contact lens indus-
try had long recognized that many o the problems associated
with silicone elastomers or contact lens abrication could theo-
retically be overcome by creating a silicone–hydrogel hybrid.
A er more than a decade o intensive research and devel-
opment, two spherical-design silicone hydrogel lenses were
introduced into the market in 1998: Focus Night & Day (CIBA
Vision) and Purevision (Bausch & Lomb). T e introduction o
these lenses is considered by many to be the most signi cant
advance in contact lens material technology since the devel-
opment o HEMA by Wichterle in the 1960s. Within a decade
o these products entering the market, all major contact lens
1 Hist o ry 7
manu acturers had introduced silicone hydrogel lenses; this
lens type is now available in toric and multi ocal designs and
a range o replacement modalities, including daily disposable
lenses.
Myo p ia Co nt ro l Le nse s (2010)
In 2010, CooperVision released into some Asian markets a daily
disposable so lens that is designed to arrest the rate o progres-
sion o myopia. A variety o optical designs can be employed
to achieve this so-called ‘anti-myopia’ e ect. T e CooperVision
MiSight lens has a ‘dual- ocus’ design that contains a large cen-
tral correction area surrounded by concentric zones o alternat-
ing distant and near powers. T e near power is intended as a
‘treatment’ zone to prevent myopic progression (see Chapter 33
or a detailed account o myopia control lenses).
Co nt act Le ns ‘Flat Pack’ (2011)
Japanese manu acturer Menicon introduced an ultra-thin orm
o packaging – known as the ‘ at pack’ – or their ‘Magic’ brand
o daily disposable contact lenses. As well as being highly e -
cient or storage and convenient or the user, this orm o pack-
aging reduces lens contamination because the lens back sur ace
is always presented to the patient upon opening the pack, which
means that the person can pick up and insert the lens into the
eye without touching and contaminating the posterior lens sur-
ace, which comes into contact with the eye (Nomachi et al.,
2013). T e contact lens is essentially sandwiched within a 1 mm
thick aluminium oil sleeve that is resistant to evaporation, thus
preserving the small amount o uid trapped within the pack
that moisturizes the lens.
Fig. 1.11 presents a historical timeline o key developments
in the contact lens eld rom the time contact (scleral) lenses
were rst tted to human eyes in the late 1880s up to the
present.
The Fut ure
So lenses are likely to dominate the uture contact lens mar-
ket. Although rigid lenses are seldom tted today or purely
cosmetic reasons, there are many clinical indications or rigid
lenses, such as keratoconus, distorted corneas, irregular and / or
high astigmatism, certain anterior eye pathologies and par-
ticipation in extreme sports. Accordingly, specialized rigid
lens ttings will continue to be an important aspect o contact
lens practice, albeit at relatively low levels. T e recent renewed
interest in scleral or mini-scleral lenses is unlikely to have a sig-
ni cant impact on the overall proportion o lenses prescribed
owing to the specialist nature o tting such lenses.
T e convenience and ocular health bene ts o daily dispos-
able lenses are likely to see this modality o lens wear continue
to increase in popularity. T is trend will be accelerated with
improvements in methods and e ciency o lens mass produc-
tion, which in turn will drive prices down and make these lenses
more a ordable. O course, any increase in daily disposable
lens usage will be matched by a commensurate decrease in the
demand or, and use o , contact lens care solutions.
Silicone hydrogels are set to continue as the main material
type rom which lenses are abricated in view o their abil-
ity to obviate hypoxic complications o lens wear; however,
the possibility o the arrival in the uture o an entirely new
8 PART 1 Int ro d uct io n

Fig . 1.11 Historical time line o contact le ns d e ve lop me nt. PMMA = p o lyme thyl me thacrylate ; HEMA = hyd roxye thyl me thacrylate .

category o lens material with even greater bene ts should not
be discounted.
Contact lenses are likely to be used increasingly or the cor-
rection o presbyopia; this trend may be uelled by the devel-
opment o superior multi ocal lens designs and the increasing
availability o such products as daily disposable lenses. Look-
ing urther into the uture, contact lenses that switch power
electronically or through some other means may acilitate
enhanced presbyopic correction.
Extended wear is the ultimate modality in terms o patient
convenience, but it is unlikely that this modality o lens wear
will break through the ‘glass ceiling’ o a prescribing rate o
around 10% o lenses tted in the oreseeable uture, in view o
the ve times greater risk o microbial keratitis when sleeping in

all orms o contact lenses (Schein et al., 1989). Again, develop-
ment or invention o an entirely new category o lens material
with superior ocular biocompatibility or an ability to minimize
microbial colonization would need to be developed be ore
extended wear can capture an appreciably greater slice o the
contact lens market.
As better toric lens designs become available, especially in
daily disposable modality, toric lenses tting is likely to increase
steadily to represent approximately 45% o all so lenses pre-
scribed, which is the level at which all astigmatism ≥ 0.75 D is
being corrected. We may see a resurgence in tinted lens tting
as the newly developed coloured silicone hydrogel lenses gain in
popularity and similar products enter the market.
Finally, current developments in innovative contact lens appli-
cations – such as lens sur ace modi cations to include channels
and patterns or improving post-lens tear exchange (Weidemann
1 Hist o ry 9
and Lakkis, 2005; Lin et al., 2006), alternative anti-myopia designs
(Sankaridurg et al., 2011), anti-in ective and anti-in ammatory
lenses (Weisbarth et al., 2007; Zhu et al., 2008), drug delivery
(Mohammadi et al., 2014), glucose monitoring and other orms
o metabolic sensing (Farandos et al., 2015), intraocular pressure
measurement (Chen et al., 2014), digital in ormation acquisition
and display (e.g. a contact lens version o Google Glass [Google
Inc., Mountain View, CA]) and liquid crystal diode optical
switching (Milton et al., 2014) – may open up whole new markets
or contact lenses and move at least part o the industry in new
and interesting directions. Contact lens practitioners may need to
acquire new knowledge and tting skills so that they can embrace
any such innovative developments.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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9.e 1
 2
Ant e rio r Eye
JO HN G LAWRENSO N

Int ro d uct io n
A critical aspect o contact lens practice is monitoring the
ocular response to lens wear, which ranges rom acceptable
physiological changes to adverse pathology. In order to do this,
practitioners must possess a thorough understanding o the
normal structure and unction o the anterior eye, which is the
subject o this chapter. In the course o reading other chapters
in this book, the reader may need to re er back to this chapter
on the unctional anatomy and physiology o the anterior eye
in order to develop a uller understanding o the phenomena
being described.
The Co rne a
cornea is conventionally divided into our zones (central, para-
central, peripheral and limbal). T e central zone, which covers
the entrance pupil o the eye, is spherical, approximately 4 mm
wide, and principally determines high-resolution image or-
mation on the ovea. T e paracentral zone, which lies outside
the central zone, is atter and becomes optically important in
dim illumination when the pupil dilates. T e peripheral zone
is where the cornea is attest and most aspheric (Klyce et al.,
1998). Due to a di erence in curvature between its posterior
and anterior sur aces, the cornea shows a regional variation
in thickness. Centrally the thickness is approximately 0.54
mm (Doughty and Zaman, 2000), with a peripheral thickness
between 11% and 19% higher than in the centre (Khoramnia
et al., 2007).

T e cornea ul ls two important unctions: together with the Microscop ic Anatomy

sclera it orms a tough brous outer coat that encloses the When the cornea is viewed in transverse section, ve distinct
ocular tissues and protects the internal components o the layers can be resolved: epithelium, Bowman’s layer, stroma, Des-
eye rom injury. Signi cantly, the cornea also provides two- cemet’s membrane and endothelium (Fig. 2.1).
thirds o the re ractive power o the eye. It is particularly well
suited to its role: the cornea is curved and transparent, and the Epithelium. T e epithelium represents approximately 10% o the
air–tear inter ace provides a re ractive sur ace o good optical thickness o the cornea (55 µm) (Feng and Simpson, 2008). It is a
quality. strati ed squamous non-keratinized epithelium, consisting o 5–6
layers o cells (Fig. 2.2), which undergo a constant process o cyclic
CO RNEAL ANATO MY
Gross Anatomy
T e cornea is elliptical when viewed rom in ront, with its long
axis in the horizontal meridian ( able 2.1). T is asymmetry is
produced by a greater degree o overlap o the peripheral cornea
by opaque limbal tissue in the vertical meridian. T e sur ace
area o the cornea is 1.1 cm 2, which represents about 7% o the
sur ace area o the globe (Maurice, 1984). opographically, the

TABLE Co rne al Dime nsio ns and Re lat e d

2.1 Me asure me nt s
Parame t e r Value
Are a 1.1 cm 2
Diame te r
Horizontal 11.8 mm
Ve rtical 10.6 mm
Rad ius of curvature
Ante rior ce ntral 7.8 mm
Poste rior ce ntral 6.5 mm
Thickne ss
Ce ntral 0.54 mm
Pe rip he ral 0.67 mm
Re fractive ind e x 1.376
Powe r 42 D Fig . 2.1 Transve rse se ction throug h the corne a. The stroma, which
re p re se nts 90% o the thickne ss o the corne a, is b ound e d b y the e p i-
(Data ad ap te d rom Bron e t al., 1997.) the lium (aste risk) and e nd othe lium (arrow).
10

shedding and replacement to maintain corneal integrity. T ree
distinct epithelial cell types are recognized: a single row o basal
cells, 2–3 rows o wing cells and 2–3 layers o super cial (squamous)
cells. In addition, several non-epithelial cells are present (e.g.
lymphocytes, macrophages and Langerhans cells). T e epithelium
orms a permeability barrier to water, ions and hydrophilic
molecules above a certain size, as well as orming an e ective
barrier to the entry o pathogens. Further epithelial specialization
enhances adhesion between cells, to withstand shearing and
abrasive orces. Furthermore, throughout the thickness o the
epithelium, adjacent cells are connected to one another by water
channels (aquaporins) that are engaged in transcellular water
transport and gap junctions to allow the trans er o ions and small
molecules between cells (Bron et al., 2015).
Super cial cells are structurally modi ed or their barrier
unction and interaction with the tear lm. Scanning elec-
tron microscopy o sur ace cells shows extensive nger-like
and ridge-like projections (microvilli and microplicae), which
increase the epithelial sur ace area. Light, medium and dark
cells can be distinguished depending on the number and pat-
tern o sur ace projections (P ster, 1973). It has been sug-
gested that dark cells, which are relatively ree o these sur ace
eatures, are close to being desquamated into the tear lm. By
contrast, the newly arrived light cells possess a more extensive
array o sur ace projections. In high-power transmission elec-
tron micrographs, microvilli and microplicae show an extensive
lamentous covering known as the glycocalyx. T e glycocalyx
is ormed rom membrane-bound mucin glycoproteins and is
important or spreading and attachment o the precorneal tear
lm. In accordance with their barrier unction, a complex net-
work o tight junctions links super cial cells that exclude water-
soluble dyes such as uorescein (Bron et al., 2015).
Wing cells are so named because o their characteristic
shape, with lateral extensions and a concave in erior sur ace to
accommodate the apices o the basal cells. T eir nuclei tend to
be spherical or elongated in the plane o the cornea. T e cell
borders o the polygonal wing cells show prominent in oldings
that interdigitate with adjacent cells, and numerous desmo-
somes. T is arrangement results in a strong intercellular adhe-
sion. T e cytoplasm contains prominent cytoskeletal elements
(predominantly actin and cytokeratin intermediate laments),
and although the usual complement o organelles is present they
are ew in number.
Fig . 2.2 Corne al e p ithe lium (d e tail). Thre e ce ll typ e s are p re se nt:
b asal ce lls (aste risk), wing ce lls (arrowhe ad ) and sq uamous ce lls (arrow).
BL= Bowman’s laye r.
2 Ant e rio r Eye 11
Basal cells consist o single-layer columnar cells with a verti-
cally oriented oval nucleus. Ultrastructurally, they are similar in
appearance to wing cells. T e plasma membrane similarly shows
pronounced in olding and the cytoplasm contains prominent
intermediate laments. A variety o cell junctions are present
including: desmosomes, which mediate adhesion between cells;
hemidesmosomes, which are involved in the attachment o basal
cells to the underlying stroma; and gap junctions, which allow or
intercellular metabolic coupling. Basal cells orm the germative
layer o the cornea, and mitotic cells are o en seen at this level.
Basal Lamina and Bowman’s Layer. T e basal lamina
(basement membrane) is synthesized by basal cells. It varies
in thickness between 0.5 and 1 µm, and under the electron
microscope can be di erentiated into an anterior clear zone
(lamina lucida) and a posterior darker zone (lamina densa).
T e basal lamina is part o a complex adhesion system, which
mediates the attachment o the epithelium to the underlying
stroma (Fig. 2.3). Hemidesmosomes link the cytoskeleton via a
series o anchoring brils to anchoring plaques in the anterior
stroma. T e molecular components o this adhesion complex
have been identi ed and include type VII collagen, integrins,
laminin and bullous pemphigoid antigen (Gipson et al., 1987).
Bowman’s layer (anterior limiting membrane) varies in thick-
ness between 8 and 14 µm. With the light microscope it appears as
an acellular homogeneous zone. Ultrastructurally, it is composed
o a randomly oriented array o ne collagen brils, which merge
with the brils o the anterior stroma (Hogan et al., 1971). Fibrils
are composed primarily o collagen types I, III and V. Collagen VII,
associated with anchoring brils, is also present. T ere is evidence
that Bowman’s layer is ormed and maintained primarily by the epi-
thelium, although its unction is unclear. T e absence o Bowman’s
layer rom the cornea o most mammals, and the act that corneas
devoid o this layer over the central cornea ollowing photore rac-
tive keratectomy (PRK) apparently unction normally, suggest that
it is not critical to corneal integrity (Wilson and Hong, 2000).
Stroma. T e stroma is approximately 500 µm thick, and
accounts or 90% o the thickness o the cornea. It is composed
predominantly o collagen brils (70% dry weight) embedded in
a highly hydrated matrix o proteoglycans. A variety o collagen
Fig . 2.3 Sche matic re p re se ntation o the ad he sion syste m o the cor-
ne al e p ithe lium. Inte rme d iate lame nts in the cytoske le ton (CS) are
linke d throug h he mid e smosome s (HD) via anchoring b rils (AF) to an-
choring p laq ue s (AP) in the ante rior stroma. BL= b asal lamina; D = d e s-
mosome .
12 PART 1 Int ro d uct io n
Fig . 2.4 Se ction throug h the stroma. Ke ratocyte s (arrowe d ) are locat-
e d b e twe e n lame llae .
Fig . 2.5 Ele ctron microg rap h o stromal lame llae that cross e ach othe r
ap p roximate ly at rig ht ang le s. Note the re g ular arrang e me nt o colla-
g e n b rils within lame llae .
types have been identi ed. ype I is the major bril- orming
collagen, with lesser amounts o types III and V. Non- bril-
orming collagens, including types VI and XII, are ound in the
inter brillar matrix (Meek and Boote, 2009). A section taken
perpendicular to the corneal sur ace reveals that the collagen
brils are arranged in 200–250 layers (lamellae) running parallel
to the sur ace (Fig. 2.4). Lamellae are approximately 2 µm thick
and 9–260 µm wide, and extend rom limbus to limbus. Fibrils
o adjacent lamellae make large angles with each other. In the
super cial stroma the angles are less than 90°, but brils become
orthogonal in the deeper stroma (Hogan et al., 1971; Meek and
Boote, 2009). T is pre erred orthogonal orientation gradually
changes in avour o circum erentially aligned collagen at the
limbus. T is particular arrangement o collagen imparts a high
tensile strength or corneal protection, which is important given
its exposed position. Within lamellae, all collagen brils are
parallel with uni orm size and separation (Fig. 2.5). Accurate
Fig . 2.6 Flat se ction throug h the stroma staine d with g old chlorid e .
Ke ratocyte s (arrowe d ) d isp lay a ste llate ap p e arance .
physiological measurements o collagen bre diameter and
spacing can be obtained or the hydrated cornea with the aid o
X-ray di raction. Using this technique, the mean bril diameter
in the human cornea is 31 nm, with an inter brillar spacing o
55 nm (Meek and Leonard, 1993). T is narrow bril diameter
and constant separation, which is a characteristic o corneal
collagen, are necessary prerequisites or transparency.
T e inter brillar space contains a matrix o proteoglycans
(approximately 10% o dry weight). T ese molecules are highly
sulphated, and along with bound chloride ions create a polyan-
ionic stromal inter brillar matrix that induces osmotic swelling.
As well as playing a major role in corneal hydration, collagen–
proteoglycan interactions are also thought to be important in
determining the size and spatial arrangement o stromal colla-
gen brils (Scott, 1991; Quantock and Young, 2008).
Collagen and proteoglycans are maintained by keratocytes.
T ese cells occupy 3–5% o stromal volume and lie between col-
lagen lamellae, attened in the plane o the cornea (Fig. 2.6).
Keratocyte density examined by con ocal microscopy and bio-
chemical methods (Møller-Pederson and Ehlers, 1995; Prydal
et al., 1998) is non-uni orm. Density decreases rom super cial
to deep stroma (Hollingsworth et al., 2001) and increases rom
centre to periphery. Keratocytes display a large central nucleus
and long slender processes extend rom the cell body. Processes
rom adjacent cells sometimes make tight junctions with each
other. Cell organelles are not numerous but the usual comple-
ment o organelles, including endoplasmic reticulum, Golgi
apparatus and mitochondria, can be observed (Hogan et al.,
1971).
Newer lamellar corneal transplantation techniques have
been developed that allow selective replacement o the diseased
corneal layers. Deep anterior lamellar keratoplasty (DALK),
which is increasingly being used to treat keratoconus and cor-
neal scarring, involves replacement o the a ected stroma while
retaining the host’s healthy Descemet’s membrane and endo-
thelium. Separation between the posterior stroma and Des-
cemet’s / endothelium can be achieved by intrastromal injection
o air, viscoelastic or saline. Dua and co-workers per ormed a
histological examination o donor corneas using air bubble sep-
aration and claimed to have identi ed a novel ‘pre-Descemet’s
posterior stromal layer’, which was widely publicized (Dua et al.,

Fig . 2.7 Hig h-p owe re d microg rap h o the p oste rior stroma. De s-
ce me t’s me mb rane (DM) is locate d b e twe e n the stroma (S) and the e n-
d othe lium (arro w).
Fig . 2.8 Thre e -d ime nsional re p re se ntation o the p oste rior corne a
showing the e nd othe lium (e ), De sce me t’s me mb rane (d ) and stroma (s).
A stromal lame lla has b e e n re f e cte d to re ve al an intralame llar ke rato-
cyte (k).
2013). However, the current consensus amongst corneal experts
is that this layer is not suf ciently unique to constitute a new
corneal layer (Jester et al., 2013).
Descemet’s Membrane. Descemet’s membrane is the basement
membrane o the corneal endothelium. It lies between the
endothelium and the overlying stroma (Fig. 2.7). At birth it is
3–4 µm thick, and increases to a thickness o 10–12 µm in the
adult. In the periphery o aged corneas, Descemet’s membrane
displays periodic sections o thickening, which are known as
Hassall–Henle warts. T e anterior one-third o Descemet’s
membrane represents that part produced in etal li e and, under
the electron microscope, is characterized by a periodic banded
pattern (Fig. 2.8). T e posterior two-thirds, which is ormed
postnatally, has a more homogeneous granular appearance.
Descemet’s membrane has a unique biochemical composition
in contrast with other basement membranes (Lawrenson
et al., 1998). T e major basement membrane collagen type is
type IV, whereas in Descemet’s membrane type VIII collagen
predominates.
Endothelium. T e endothelium is a monolayer o squamous
cells that lines the posterior sur ace o the cornea (Fig. 2.9)
and plays a critical role in maintaining corneal transparency
(Bonanno, 2012). As it has a limited capacity or mitosis to
2 Ant e rio r Eye 13
Fig . 2.9 Tang e ntial (f at) se ction throug h the corne al e nd othe lium: a
sing le laye r o p olyg onal ce lls with irre g ular b ord e rs can b e ob se rve d .
replace damaged or e ete cells, there is a progressive reduction
in endothelial cell number with age. At birth the cornea
contains a total o approximately 500 000 cells, which represents
a mean density o 4500 cells / mm 2. During in ancy, cell loss
is particularly marked and a 26% reduction occurs in the rst
year o li e (Sherrard et al., 1987). T erea er the rate o loss
progressively declines into old age. Since gra ed corneas appear
to maintain transparency and unctional normality with an
endothelial cell density o less than 1000 cells / mm 2, it seems
that normal cell density represents a considerable ‘physiological
reserve’ (Klyce and Beuerman, 1998). When viewed en ace, or
example using a specular microscope, the endothelium appears
as a mosaic o polygonal (typically hexagonal) cells (E ron et al.,
2001). In response to pathology, trauma, age and prolonged
contact lens wear, the endothelial mosaic becomes less regular,
and shows a greater variation in cell size (polymegethism) and
shape (pleomorphism) as cells spread to ll gaps caused by
cell loss. Under the electron microscope, the lateral borders o
the cells are markedly convoluted and adjacent cells are linked
by tight junctions (with less- requent gap junctions) (Hogan
et al., 1971). T e complement o organelles seen in endothelial
cells re ects their high metabolic activity, with numerous
mitochondria and a prominent rough endoplasmic reticulum.
CO RNEAL INNERVATIO N
Source and Distrib ution of Corne al Ne rve s
T e cornea is the most richly innervated sur ace tissue in
the body. Corneal nerves are responsible or the detection o
somatosensory stimuli and play an important role in initiating
the blink re ex, wound healing and tear secretion (see Sha-
heen et al., 2014, or a recent review). T e majority o corneal
nerves are sensory and derive rom the nasociliary branch o
the trigeminal nerve (Ruskell and Lawrenson, 1994). T ere is
also evidence or the existence o a modest sympathetic inner-
vation rom the superior cervical ganglion (Mar urt and Ellis,
1993). Branches rom the nasociliary nerve either pass directly
to the eye as long ciliary nerves or traverse the ciliary ganglion,
leaving it as short ciliary nerves that enter the eye close to the
14 PART 1 Int ro d uct io n
Fig . 2.10 Whole -mount g old chlorid e -staine d p re p aration o corne al
ne rve s (arrows) locate d at b asal le ve l.
optic nerve. Nerves destined or the cornea travel initially in
the suprachoroidal space, be ore crossing the sclera to advance
radially towards the cornea.
Most o the 50–80 precorneal nerve trunks, which contain
a mixture o myelinated and unmyelinated bre bundles, enter
the cornea at mid-stromal level. Myelin is soon lost and the
unmyelinated nerve bre bundles divide repeatedly and move
anteriorly to orm a rich plexi orm network in the anterior one-
third o the stroma. Axons are particularly dense immediately
beneath Bowman’s layer, orming an extensive subepithelial
plexus (Oliveira-Soto and E ron, 2001). From this plexus, axons
pass vertically through Bowman’s layer, losing their Schwann
cell sheath in the process. Upon entering the epithelium, axons
turn through 90° and divide into a series o ne branches that
course between basal cells (Fig. 2.10). Some branches pass into
the more super cial layers be ore terminating. T e density o
nerve terminals is greatest centrally, corresponding to approxi-
mately 600 terminals / mm 2, which results in large overlapping
receptive elds (Shaheen et al., 2014).
Corneal nerves display a complex neurochemistry. A variety
o neurotransmitters and neuromodulators have been identi-
ed, including acetylcholine, substance P, and calcitonin gene-
related peptide. However, it is unclear how these particular
neurochemicals correlate with unction (Belmonte et al., 1997).
Functional Consid e rations
Corneal nerves serve important sensory, re ex and trophic
unctions. Interest in the sensitivity o the cornea dates back to
the 19th century (Lawrenson, 1997), when the pioneering Ger-
man physiologist von Frey concluded that pain was the only
sensation perceived by the cornea. T is was consistent with his
theory o the speci city o sensory receptors, which maintained
that each sensory modality was subserved by a separate anatom-
ically distinct nerve terminal. In his experiments on the cornea,
von Frey could elicit only a sensation o pain and, as the cornea
contained exclusively ree (unspecialized) nerve endings, he
concluded that ree nerve endings were the exclusive receptors
or pain. Although the speci city theory has subsequently been
challenged, particularly with respect to its exclusivity, the ques-
tion as to whether pain is the only sensory modality perceived
by the cornea remains.
Modern experiments using care ully controlled corneal
stimulation, with a variety o mechanical, chemical and ther-
mal stimuli, have evoked only sensations o irritation or pain.
By contrast, electrophysiological studies o corneal a erent
neurones have identi ed neurones that respond to mechanical,
thermal and chemical stimulation. However, since the conscious
perception o these sensations has not been demonstrated, it
is likely that such speci city o modality is lost during central
nervous system processing. Electrophysiological recording also
allows or the mapping o receptive elds. T ese are o en large
and overlapping, which explains the inability o the cornea to
localize a stimulus accurately (Belmonte et al., 1997). T e sen-
sitivity o the cornea to mechanical stimulation is particularly
acute, and acts as a trigger or the protective blink and lacrimal
re exes. Cold receptors may be important in signalling evapo-
rative cooling, which is a major determinant o spontaneous eye
blink requency ( subota, 1998).
Corneal a erent bres also exert important trophic in u-
ences. Damage to corneal sensory nerves by surgery, trauma or
in ection produces neuroparalytic keratitis – a condition that is
characterized by progressive epithelial cell loss and oedema. T e
mechanism o this trophic role is not ully understood, although
the release o neuropeptides (e.g. substance P and calcitonin
gene-related peptide) may be a actor. Sympathetic nerves also
play a role in epithelial maintenance by regulating ion transport
processes, and cell proli eration and migration during wound
healing.
CO RNEAL METABO LISM
Source of O xyg e n and Nutrie nts
In order to per orm its vital unctions, the cornea requires a
constant supply o oxygen and other essential metabolites (e.g.
glucose, vitamins and amino acids). However, its avascularity
dictates that alternative routes must exist or the provision o its
metabolic needs. T ere are three possibilities: rom the perilim-
bal vasculature, rom the tear lm or rom the aqueous humour.
In open-eye conditions the bulk o the oxygen required or the
cornea is obtained rom the atmosphere via di usion across
the precorneal tear lm. Under steady-state conditions it can
be assumed that the tears are saturated with oxygen, and there-
ore at an oxygen tension corresponding to the atmosphere (155
mmHg at sea level). It has been estimated that the oxygen ten-
sion o the aqueous humour in the human eye lies between 30
and 40 mmHg (Klyce and Beuerman, 1998).
Experiments using nitrogen- lled goggles or sealed scleral
lenses have shown the corneal dependence on tear-side oxygen
to avoid oedema and maintain normal unction. T e reason
why the cornea swells during contact lens wear is explained in
Fig. 2.11. During eye closure the oxygen level in the tears is in
equilibrium with the palpebral vasculature (55 mmHg) (E ron
and Carney, 1979).
Signi cantly, corneal thickness increases by approximately
5% during sleep, and returns to baseline levels within 1 hour
o eye opening. It has been suggested that overnight swell-
ing is related to tear lm tonicity rather than reduced oxygen

Fig . 2.11 (A) Cross-se ction o an e ye we aring a contact le ns, which
imp e d e s ing re ss o oxyg e n into, and the e g re ss o carb on d ioxid e rom,
the corne a. (B) The contact le ns b locks oxyg e n sup p ly to the corne a (1),
causing lactic acid to accumulate in the stroma (2). This d raws in wate r
(3), le ad ing to stromal oe d e ma (4). (Ad ap te d rom E ron, N. (1997). Con-
tact le nse s and corne al p hysiolog y. Biol. Sci. Re v., 9, 29–31.)
availability (Klyce and Beuerman, 1998). T e oxygen ux into
the cornea can be measured using polarographic oxygen sen-
sors. It is in the region o 6 µl / cm 2 / h or the cornea as a whole,
although the consumption rate or its composite layers is not
equal. Consumption rates have been estimated as 40 : 39 : 21 or
the epithelium, stroma and endothelium, respectively (Free-
man, 1972).
Several lines o evidence indicate that the aqueous humour is
the primary source o glucose and essential amino acids or the
cornea (Maurice, 1984). T e glucose concentration o tears is
low compared with that in the aqueous humour, and the inser-
tion o nutrient-impermeable implants into the stroma results
in degeneration o the tissue lying anterior to the implant.
Although exogenous glucose is primarily utilized, glycogen
stores are present in all corneal cells to provide glucose in con-
ditions o metabolic stress.
T e role o the perilimbal vasculature in the provision o
oxygen and nutrients appears limited and it is likely that it is
signi cant only or the corneal periphery (Maurice, 1984).
O xid ative Me tab olism
T e cornea derives its energy principally rom the oxidative
breakdown o carbohydrates (Riley, 1969). Glucose, which
is the primary substrate or the generation o adenosine tri-
phosphate (A P), is catabolized by three metabolic pathways:
glycolysis, the tricarboxylic acid (Krebs) cycle and the hex-
ose monophosphate shunt (Fig. 2.12). Anaerobic glycolysis
accounts or the majority (85%) o glucose metabolism. In
this pathway, glucose is rst oxidized to pyruvate and then
subsequently reduced to lactate, with a net yield o two mol-
ecules o A P per mole o glucose. T e CA cycle results in
a greater energy yield (36 A P). T is pathway is most active
in the corneal endothelium, which has the greatest energy
requirement.
Metabolic waste products can be potentially damaging i
allowed to accumulate. Although carbon dioxide can readily
di use out o the cornea across its limiting layers, lactate is less
easily eliminated. Under normoxic conditions, lactate is able to
2 Ant e rio r Eye 15
Fig . 2.12 Me tab olic p athways p re se nt in the co rne a. HMP = he xose
monop hosp hate shunt; TCA cycle = tricarb oxylic acid (Kre b s) cycle ;
ATP = ad e nosine trip hosp hate ; NADPH = nicotinamid e ad e nine d inucle -
otid e p hosp hate (re d uce d orm).
di use slowly across the endothelium into the anterior cham-
ber. However, during periods o hypoxia the proportion o glu-
cose that is metabolized anaerobically increases. T e resulting
accumulation o lactate causes stromal oedema via an increased
osmotic load (Klyce, 1981) and localized tissue acidosis (Klyce
and Beuerman, 1998).
T e hexose monophosphate shunt (also known as the pen-
tose phosphate shunt) plays an important role in the corneal
epithelium (Berman, 1981), where it ul ls several important
unctions, including the generation o intermediates or biosyn-
thetic reactions and the prevention o oxidative damage by ree
radicals.
CO RNEAL TRANSPARENCY
Under normal conditions the cornea is highly transparent,
transmitting more than 90% o incident light. Structurally, the
cornea is a typical connective tissue consisting principally o a
matrix o collagen and proteoglycans. Under normal circum-
stances such an arrangement would avour light scatter with
consequent loss o transparency. T is raises two undamental
questions: how is transparency achieved, and how is it main-
tained? o begin to answer these questions it is necessary to
understand the spatial organization o the stromal matrix and
the importance o corneal hydration control.
Stromal O rg anization
Maurice (1957) explained the transparency o the cornea on the
basis o the small diameter and regular separation o the stro-
mal collagen. He suggested that the collagen brils o the stroma
were disposed in a regular crystalline lattice, and that light scat-
tered by the brils is eliminated by destructive inter erence in
all directions other than the orward direction. T is situation
will hold as long as the axes o the collagen brils are arranged
in a regular lattice with a separation less than the wavelength o
light. It has been suggested, however, that the brillar arrange-
ment need not be in a per ect crystal lattice to maintain trans-
parency (Maurice, 1984), although disruption o short-range
order between brils will lead to increased scatter and a loss o
transparency.
16 PART 1 Int ro d uct io n
T e actors involved in the maintenance o collagen bril size
and spatial order are not ully understood. It has been proposed
that collagen bril diameters may be controlled by the incorpo-
ration o minor collagens (e.g. type V) into the predominantly
type I brils (Meek and Leonard, 1993) and that their spatial
separation is a unction o proteoglycan–collagen interactions
(Scott, 1991). Proteoglycans are a amily o glycoproteins that
consist o a protein core to which are attached sugar chains
o repeating disaccharide units termed glycosaminoglycans
(GAGs). T ese molecules are increasingly being recognized
as important prerequisites or transparency (Quantock and
Young, 2008; Hassell and Birk, 2010). Proteoglycans were origi-
nally classi ed according to their glycosaminoglycan composi-
tion; however, current nomenclature groups them into amilies
based on homologous sequences o amino acids in their protein
core. Corneal stromal proteoglycans are members o the small
leucine-rich amily, which are small enough to t in the space
between collagen brils. T e most prevalent glycosaminoglycan
in the cornea is keratan sulphate, which is ound in three types
o proteoglycan: lumican, keratocan and mimecan (Funder-
burgh et al., 1991; Funderburgh 2000). T e other type o corneal
proteoglycan is decorin, which contains a hybrid chondroitin
sulphate / dermatan sulphate side chain. Evidence rom several
sources has shown that lumican and decoran play important
roles in regulating collagen bril diameter and maintaining the
spacing between brils once ormed, which are essential or
transparency.
Hyd ration Control
T e state o corneal hydration is another important determi-
nant o corneal transparency (Bonanno 2012). T e hydrophilic
properties o the stroma are to a large part determined by pro-
teoglycans, which contribute to the xed negative charge o the
stroma and produce a passive gel swelling pressure through
electrostatic repulsion (Hodson, 1997). Physiologically, corneal
hydration is maintained at approximately 78%. I the cornea is
allowed to swell ±5% o this value, it begins to scatter signi cant
quantities o light (Hodson, 1997).
Maintenance o physiological corneal hydration is to a large
part dependent on the corneal endothelium, which possesses
both a barrier property and a metabolically driven pump. T e
endothelial barrier to the ree passage o molecules rom the
aqueous humour is ormed principally by ocal tight junctions
between adjacent endothelial cells. However, in contrast to
other barrier epithelia, these junctions are o low electrical resis-
tance and allow the passage o ions and small molecules. T is
leak is o set by the metabolically driven pumping o ions out o
the stroma by the endothelium, which maintains a transcellular
potential di erence (aqueous side negative) to balance stromal
swelling pressure (Maurice, 1984). Disruption o this osmotic
gradient will result in stromal uid imbibition.
T e speci c endothelial ion transport mechanisms respon-
sible or the maintenance o physiological hydration are not
ully understood. A simpli ed model representing our cur-
rent level o knowledge is represented in Fig. 2.13. T ere is
compelling evidence that a ux o bicarbonate ions is the pre-
dominant component o the endothelial ion transport system
(Hodson and Miller, 1976). Subsequent studies have identi ed
that Cl− transporters may also be important in maintaining the
pump (Bonanno 2012). T e bicarbonate is generated either
by a Na+ / HCO3− co-transporter located on the basolateral
plasma membrane or via the intercellular conversion o carbon
Fig . 2.13 Sche matic re p re se ntation o the corne al e nd othe lial p ump .
CA = carb onic anhyd rase ; TJ = tig ht junctio n.
dioxide by the enzyme carbonic anhydrase. Bicarbonate leaves
the cell via an apical bicarbonate ion channel. T e driving orce
or the bicarbonate ux is generated by a sodium–potassium
A Pase that resides on the basolateral endothelial membrane.
T e energy associated with subsequent sodium re-entry (via
Na+ / H + and Na+ / HCO3− transporters) is coupled to active
HCO3− ux (Hodson et al., 1991).
T e epithelium also contributes to corneal hydration con-
trol (Klyce and Beuerman, 1998). T e tight junctions between
super cial epithelial cells orm an e ective permeability barrier
to ions and polar solutes. For example, the anionic molecule
sodium uorescein does not penetrate an intact epithelium.
However, damage to the super cial cells allows uorescein to
enter the epithelium, with resulting corneal staining. In addition
to its barrier properties, the epithelium also possesses active ion
transport systems or Na+ and Cl−. As these pumps contribute
to the tonicity o the tear lm, it is likely that they are involved
in the maintenance o stromal hydration.
Re sp onse to O e d e ma
When corneas swell, light scattering increases, with an ensued
transparency loss due to the disruption o the regular collagen
matrix. T e collagen brils themselves swell very little and most
o the additional water goes into the inter brillar spaces. rans-
mission electron micrographs o oedematous corneas show
bril aggregation, with the result that large areas are devoid o
collagen brils (Stiemke et al., 1995). T ere is evidence that col-
lagen aggregation occurs as a result o loss o GAGs, which pre-
viously had maintained bre separation (Stiemke et al., 1995).
CO RNEAL EPITHELIAL WO UND HEALING
A smooth and intact corneal epithelium is necessary in order
or the cornea to maintain clear vision. However, due to its
exposed position the cornea is potentially vulnerable to a vari-
ety o external insults. It possesses several protective mecha-
nisms to avoid injury, but i tissue damage occurs it is capable
o an e ective wound-healing response (Gipson and Inatomi,
1995; Nishida and anaka, 1996). Corneal epithelial repair is a
complex process involving an orchestrated interaction between
cells and extracellular matrix, which is coordinated by a variety

o growth actors. T e process can be divided into three phases:
(1) initial covering o the denuded area by cell migration, (2)
cell proli eration to replace lost cells and (3) epithelial di eren-
tiation to re- orm the normal strati ed epithelial architecture.
Following a ull-thickness epithelial de ect, bronectin, an
adhesive glycoprotein, is synthesized and covers the sur ace o
the bared stroma where it serves as a temporary matrix or cell
migration. T e adhesion between bronectin and the epithe-
lium is mediated by integrin–matrix interactions (integrins are a
amily o cell sur ace receptors that bind to certain extracellular
matrix proteins). Several growth actors have been implicated in
the control o the wound-healing response, including epidermal
growth actor, trans orming growth actor beta, platelet-derived
growth actor and broblast growth actor (Gipson and Ina-
tomi, 1995). Growth actors, which are produced by a variety o
sources (e.g. ocular sur ace epithelia and the lacrimal gland), are
able to regulate the process o epithelial migration, proli eration
and di erentiation. T ere is evidence that epithelial–stromal
interactions play an important role in corneal wound healing
(Wilson, 2000). Epithelial injury triggers keratocyte apoptosis
(programmed cell death) in the anterior stroma, via the release
o apoptosis-inducing cytokines rom epithelial cells. Kerato-
cyte apoptosis subsequently triggers a wound-healing cascade,
which in uences epithelial repair.
Regeneration o the corneal epithelium is highly dependent
on the integrity o the limbus (Lavker et al., 2004). Cumulative
evidence indicates that a proportion o limbal basal epithelial
cells possess the properties o stem cells, which are ultimately
responsible or corneal epithelial replacement. Stem cells have
several unique characteristics: they are poorly di erentiated,
long lived and have a high capacity or sel -renewal. When these
cells divide, one o the daughter cells replenishes the stem cell
pool, whilst the other is destined to undergo urther cell divi-
sions be ore di erentiating. Such a cell is re erred to as a tran-
sient ampli ying cell. ransient ampli ying cells undergo several
rounds o cell division be ore ully di erentiating. T ese cells
play an important role in epithelial wound healing, where their
proli erative capacity is increased by shortening cycle times and
increasing the number o times that the transient ampli ying
cells can divide be ore maturation.
The O cular Ad ne xa
T e ocular adnexa are those structures that support and pro-
tect the eye, and include the eyelids, conjunctiva and lacrimal
system. T ey play an important role in the ormation o the pre-
ocular tear lm and collectively de end the eye against antigenic
challenge.
EYELIDS
T e eyelids are two mobile olds o skin that per orm several
important unctions: they act as occluders that shield the eyes
rom excessive light, and through their re ex closure they a ord
protection against injury. T e lids also orm a precorneal tear
lm o uni orm thickness during the upturn phase o each
blink. T e action o blinking is also important or tear drainage.
Gross Anatomy
T e eyelids are joined at their extremities, termed ‘the canthi’,
and when the eye is open, an elliptical space, the palpebral s-
sure, is ormed between the lid margins. In the adult, the length
2 Ant e rio r Eye 17
Fig . 2.14 Sur ace anatomy o the e ye lid s. (Ad ap te d rom Bron, A. J.,
Trip athi, R. C. & Trip athi, B. (1997). Wol ’s Anatomy o the Eye and O rb it
(8th e d .). Lond on: Chap man and Hall.)
o the ssure is approximately 30–31 mm, with a vertical height
o 10–11 mm. In the primary position, the upper lid, which is
the larger and more mobile o the two, typically covers approxi-
mately the upper third o the cornea, whilst the lower lid is level
with the in erior corneal limbus (Fig. 2.14). Important di er-
ences in eyelid anatomy exist between Asian and Caucasian eyes
(Saonanon, 2014). T e most obvious eature o the Asian eye is
the absent or very low lid old and uller upper eyelid.
T e eyelid margins are about 2 mm thick rom ront to back.
T e posterior quarter consists o conjunctival mucosa and the
anterior three-quarters is skin. T e junction between the two is
re erred to as the mucocutaneous junction. T ere has recently
been a renewed interest in the marginal zone o the human eyelid,
with the identi cation o the role o the inner lid border, termed
the ‘lid-wiper’ owing to the analogy to a windscreen wiper, in
the distribution o the tear lm (Knop et al., 2011a, 2012). wo
or three rows o eyelashes (cilia) arise rom the anterior border
o the lid margins. T ese are longer and more numerous in the
upper lid. T e lashes receive a rich sensory nerve supply, and
their sensitivity provides an e ective alerting mechanism.
T e meibomian (tarsal) gland ori ces emerge just anterior
to the mucocutaneous junction (Fig. 2.15). About 30–40 glands
open onto the upper margin, and slightly ewer (20–40) onto
the lower. On eversion o the lids the yellowish meibomian
acini are visible as yellow clusters through the tarsal conjunc-
tiva (Bron et al., 1991; Knop et al., 2011b). Meibomian glands
can be more clearly visualized using in rared meibography, and
instruments that use this method are now commercially avail-
able (Srinivasan et al., 2012) (Fig. 2.16). At the medial angle,
the eyelid margins enclose a triangular space – the lacus lacri-
malis – which contains the plica semilunaris and the caruncle.
Lacrimal papillae are small elevations located 5–6 mm rom the
medial canthal angle, which contains a small aperture (punc-
tum) that is the opening to the lacrimal drainage system.
Muscle s of the Eye lid s
Movements o the eyelids are governed by the coordinated
action o several muscles.
Orbicularis Oculi. T e orbicularis oculi is the sphincter muscle
o the eyelids, and can anatomically be divided into two main
divisions: the palpebral and the orbital (Fig. 2.17). Fibres o the
palpebral division arise rom the medial palpebral ligament
and arc across the eyelids in a series o hal -ellipses, meeting at
the lateral canthus to orm a lateral raphe. T e lateral palpebral
18 PART 1 Int ro d uct io n
Fig . 2.15 (A) Sche matic re p re se ntation o the e ye lid marg in. mcj = mu-
cocutane ous junction. (B) Gross ap p e arance o the e ye lid marg in.
O p e ning s o the me ib omian g land s are cle arly visib le (arrow). (Ad ap te d
rom Bron, A. J., Trip athi, R. C. & Trip athi, B. (1997). Wol ’s Anatomy o
the Eye and O rb it (8th e d .). Lond on: Chap man and Hall.)
Fig . 2.16 Normal me ib omian g land s o the up p e r tarsus (top ) and low-
e r tarsus (b ottom) o a 38-ye ar-old woman, imag e d using no n-invasive
in rare d me ib og rap hy. (Imag e courte sy o Re iko Arita.)
Fig . 2.17 Sche matic re p re se ntation o the d ivisions o the orb icularis
oculi and the rontalis. a = p re tarsal; b = p re se p tal; c = orb ital; d = ronta-
lis. (Ad ap te d rom Bron, A. J., Trip athi, R. C. & Trip athi, B. (1997). Wol ’s
Anatomy o the Eye and O rb it (8th e d .). Lond on: Chap man and Hall.)
ligament also acts as an anchor point. T e palpebral division
can be urther subdivided into marginal, pretarsal and preseptal
parts. T e marginal part (pars ciliaris), which is also known as
Riolans muscle, is responsible or maintaining the apposition
o the lid to the cornea during lid closure. A third part o the
muscle (pars lacrimalis) is closely associated with the lacrimal
out ow pathway. T e pars lacrimalis (also known as Horner’s
muscle) encloses the canaliculi and provides attachments to the
lacrimal sac and its associated ascia.
T e orbital part o the orbicularis oculi lies outside the palpe-
bral division and extends or some distance beyond the orbital
margins. Muscle bres arise predominantly rom bone at the
medial orbital rim and appear to sweep around the lids without
interruption as a series o complete ellipses. However, studies
have shown that the muscle bres o the orbital and palpebral
division o the orbicularis are relatively short (0.4–2.1 mm) and
overlapping (Lander et al., 1996). T e regional divisions o the
orbicularis also show a unctional distinction. T e action o the
palpebral part o the muscle is to produce the re ex or voluntary
closure o the lids during blinking. Contraction o the orbital
division produces the orcible closure o the lids that occurs in
sneezing or in response to a pain ul stimulus.
Levator Palpebrae Superioris. T e levator palpebrae superioris
is primarily responsible or elevating the upper lid during
blinking and or maintaining an open palpebral aperture. T e
levator palpebrae arises rom the lesser wing o the sphenoid,
above and anterior to the optic canal, and runs orward along
the roo o the orbit above the superior rectus be ore terminating
anteriorly in a an-shaped tendon (aponeurosis). Some bres
are attached to the anterior sur ace o the tarsal plate, whilst the
remainder pass between ascicles o the orbicularis (Fig. 2.18).
T e superior palpebral sulcus orms at the upper border o the
attachment to the orbicularis.
Superior and Inferior Tarsal Muscles (of Müller). T ese
smooth muscles arise rom the lower border o the levator in the
upper lid and the in erior rectus in the lower lid, and insert into
the orbital margins o the tarsal plates. T e role o the superior
tarsal muscle is to assist the levator in maintaining the width
o the palpebral aperture. A mild degree o ptosis results rom
damage to its sympathetic nerve supply (Horner’s syndrome).

Fig . 2.18 Diag ram showing the re lations o the le vator p alp e b rae
sup e rioris. a = le vator ap one urosis; tm = sup e rior tarsal muscle (o Mül-
le r); t = tarsal p late ; s = orb ital se p tum. (Ad ap te d rom Gray, H., Bannis-
te r, L. H., Be rry, M. M. & Williams, P. L. (1995) Gray’s Anatomy: The Ana-
tomical Basis o Me d icine and Surg e ry (38th e d .). Ed inb urg h: Churchill
Living stone .)
Control of Eye lid Move me nts
Movements o the eyelids occur through the coordinated action
o several muscles – the levator palpebrae, tarsal muscles, the
orbicularis oculi and the rontalis. T e elevation o the upper lid
and the control o its vertical position are mediated principally
by the levator. In vertical gaze, lid position and eye movements
are closely linked. During elevation the state o contraction o
the levator is varied to maximize visibility. In extreme upgaze,
lid retraction is augmented by the action o the rontalis, which
elevates the eyebrows. In downgaze, coordinated lid move-
ments similarly occur through levator relaxation. In periodic
and re ex blinks, the levator is spontaneously inhibited prior to
orbicularis contraction in lid closure. Similarly, in lid opening
the orbicularis relaxes, ollowed by contraction o the levator.
Spontaneous eye-blink activity is in uenced by both central and
peripheral actors ( subota, 1998).
Compared with the upper lid, the lower lid is relatively
immobile and has no counterpart to the levator palpebrae. T e
depression o the lower lid that occurs in downgaze is due to the
attachment o the sheaths o the in erior oblique and in erior
rectus muscles to the tarsal plate via a brous extension.
Microscop ic Anatomy
T e histological appearance o the upper and lower lids is similar,
and in sagittal section the ollowing six tissue layers can be resolved:
skin, subcutaneous connective tissue, muscle layer, submuscular
connective tissue, tarsal plate and palpebral conjunctiva (Fig. 2.19).
T e eyelid skin is thin and very elastic. It is continuous with
the palpebral conjunctiva at the lid margin, and keratinization
is maintained up to this mucocutaneous junction. T e subcu-
taneous connective tissue is composed o a loose areolar tissue
and contains hair ollicles and associated glands. T e muscle
layer consists o striated muscle bres o the orbicularis oculi,
which are arranged in bundles ( ascicles) separated by con-
nective tissue. T e orbicularis extends throughout the lid. T e
marginal part o the muscle (Riolan’s muscle) is separated rom
the pretarsal portion by connective tissue that contains the eye-
lash ollicles. T e loose submuscular connective tissue layer lies
between the orbicularis and the tarsal plate and contains the
major nerves and vessels o the lid.
T e tarsal plates (tarsi) are composed o dense brous con-
nective tissue and provide support and determine lid shape.
2 Ant e rio r Eye 19
Fig . 2.19 Sag ittal se ction throug h the up p e r lid . TP = tarsal p late ;
O O c = orb icularis oculi; R = Riolan’s muscle ; EF = e ye lash ollicle s;
PC = p alp e b ral conjunctiva; ES = e ye lid sur ace .
T ey are anchored to the orbital margins by the medial and lat-
eral palpebral ligaments. Each tarsus is approximately 25 mm
long and 1–2 mm thick. T e upper tarsus is semioval with a
height o 11 mm at its midpoint, whereas the in erior tarsus is
narrower (4 mm in height). T e posterior sur ace o the eyelid
is lined by the palpebral conjunctiva, which is rmly adherent
to the underlying tarsal plate.
Gland s of the Eye lid s
Meibomian Glands. T e tarsal plates contain the acini and ducts
o the meibomian (tarsal) glands. Ducts are vertically oriented with
respect to the lid margins, with multiple secretory acini that open
laterally onto each duct. T e glands occupy nearly the ull length
and width o each tarsus, and are ewer and shorter in the lower
lid. Histologically, the acini are lined by a layer o undi erentiated
basal cells that divide, and cells are displaced rom the basement
membrane. As they progress towards the duct they gradually
enlarge and develop lipid droplets in their cytoplasm (Fig. 2.20).
Ultimately, cell membranes rupture and cellular debris, together
with the lipid product, is discharged into the duct.
T e stimulus or meibomian gland secretion is unclear.
Although a modest autonomic innervation o the meibomian
glands has been demonstrated, there is still some doubt regard-
ing a neuromodulation o glandular secretion; it is likely that the
principal control o the glands is hormonal, and both androgens
and oestrogens have been shown to regulate meibomian secre-
tion (Sullivan et al., 2000; Knop et al., 2011b). A long ductal
system carries the secretion to the lid margin, and the compres-
sive action o the palpebral division o the orbicularis oculi on
the meibomian ducts acilitates the ow o lipid and its eventual
delivery onto the lid margins.
20 PART 1 Int ro d uct io n
Fig . 2.20 Histolog ical se ction showing me ib omian g land acini. Se cre -
tory ce lls d e g e ne rate (aste risk) as the y ap p roach the d uct (D).
Fig . 2.21 Histolog ical se ction throug h the ciliary zone o the e ye lid .
Gland s o Ze is (Z) d ischarg e the ir conte nts into an e ye lash ollicle (EF),
which contains the re mnants o an e ye lash. M = g land o Moll.
Glands of Zeis and Moll. Ciliary glands o Zeis and Moll are
ound in association with eyelash ollicles ( akahashi et al.,
2013) (Fig. 2.21). Zeis glands are unilobular sebaceous glands
that open directly into the ollicle. T e unction o their oily
secretion is to lubricate the lashes to prevent them rom drying
out and becoming brittle. Glands o Moll are modi ed sweat
glands (apocrine) consisting o an unbranched spiral tubule.
T e exact unction o these glands is unclear, although their
secretion is rich in IgA, which suggest a role in the immune
de ence o the ocular sur ace (Stoeckelhuber et al., 2003).
Blood and Ne rve Sup p ly
Nerves of the Eyelids. T e levator palpebrae and orbicularis
oculi muscles are innervated by the oculomotor and acial
nerves, respectively. T e sensory supply o the upper lid
derives rom branches o the ophthalmic nerve (supraorbital,
supratrochlear and lacrimal). T e supply to the lower lid comes
rom branches o the maxillary nerve (zygomatic, in raorbital).
Blood and Lymphatic Supply to the Eyelids. T e arterial
supply derives rom branches o the ophthalmic, lacrimal
and in raorbital arteries, which contribute to two palpebral
arcades in the upper lid and one in the lower. Branches rom
these arcades supply the skin, orbicularis, tarsal glands and
Fig . 2.22 Sche matic re p re se ntation o a mid -sag ittal se ction throug h
the e ye lid and conjunctival sac showing the d i e re nt conjunctival re -
g ions. M = marg inal; T = tarsal; O = orb ital; B = b ulb ar; L= limb al; F = or-
nical.
Fig . 2.23 Static d ime nsions o the conjunctival sac in millime tre s.
M = me d ial canthus. (Ad ap te d ro m Ehle rs, N. (1965). O n the size o the
co njunctival sac. Acta O p hthalmol., 43, 205–210.)
palpebral conjunctiva. Veins o the eyelids empty into veins o
the orehead and temple, and some empty into the ophthalmic
vein. Lymphatics drain to the preauricular and submandibular
lymph nodes.
THE CO NJ UNCTIVA
Gross Anatomy
T e conjunctiva is a thin transparent mucous membrane that
extends rom the eyelid margins anteriorly, providing a lining to
the lids, be ore turning sharply upon itsel to orm the ornices,
rom where it is re ected onto the globe, covering the sclera up
to its junction with the cornea. It thus orms a sac that opens
anteriorly through the palpebral ssure. T e conjunctiva is con-
ventionally divided into the ollowing regions: marginal, tarsal,
orbital (these three collectively orm the palpebral conjunctiva),
bulbar and limbal (Fig. 2.22).
T e static dimensions o the conjunctival sac in the primary
position are illustrated in Fig. 2.23 (Ehlers, 1965). T e marginal
zone extends rom a line immediately posterior to the openings
o the tarsal glands and passes around the eyelid margin, rom
where it continues on the inner sur ace o the lid as ar as the
subtarsal old (a shallow groove that marks the marginal edge
o the tarsal plate). T e tarsal conjunctiva is highly vascular
and is rmly attached to the underlying brous connective tis-
sue. From the convex border o the tarsal plate, the orbital zone
 2 Ant e rio r Eye 21

Fig . 2.24 Hig h-p owe r slit-lamp vie w o the conjunctival p alisad e s o
Vog t (aste risks) at the lowe r limb us.

extends as ar as the ornices. Over this region the conjunctiva is

more loosely attached to underlying tissues, and so readily olds.
Elevations o the conjunctival sur ace in the orm o papillae
and lymphoid ollicles are commonly observed in this region.
T e transparency o the bulbar conjunctiva readily permits
the visualization o conjunctival and episcleral blood vessels.
Here, the conjunctiva is reely movable owing to its loose attach-
ment to enon’s capsule (the ascial sheath o the globe). As the
bulbar conjunctiva approaches the cornea, its sur ace becomes
smoother and its attachment to the sclera increases. T e limbal
conjunctiva extends approximately 1–1.5 mm around the cornea.
Its junction with the cornea is ill de ned, particularly in the ver-
tical meridian, owing to a variable degree o conjunctival / scleral
overlap. T e limbus has a rich blood supply, and in the majority
o individuals a radial array o connective tissue elevations – the
palisades o Vogt – can be seen adjacent to the corneal margin
(Fig. 2.24). T e palisades are most prominent in the vertical
meridian, and their visibility is enhanced in pigmented eyes.
Microscop ic Anatomy
In histological section, two distinct layers can be resolved: an
epithelium containing a variable number o goblet cells, and a
vascular stroma that consists o a super cial lymphoid layer and
a deep brous layer (Fig. 2.25). T e appearance o the conjunc-
tiva shows a marked regional variability.
Epithelium. In the marginal zone, the epithelium is strati ed
and squamous with relatively ew goblet cells, although this has
recently been disputed ollowing the description o intracellular
crypts lined with goblet cells lying deep within the epithelium in
the region o the so-called ‘lid wiper’ region (Knop et al., 2012).
It has been suggested that a subpopulation o epithelial cells that
lie close to the mucocutaneous junction may be acting as stem
cells or the palpebral conjunctiva (Wirtscha er et al., 1999).
Approaching the tarsus, the epithelium thins to 2–3 layers o
cuboidal cells with scattered goblet cells. T e epithelium o the
orbital zone is slightly thicker (2–4 cells) with more numerous
goblet cells. T e number o goblet cells declines over the bulbar
conjunctiva and at the limbus the epithelium is again strati ed
squamous, and goblet cells are absent. T e limbus contains a
Fig . 2.25 Histolog ical se ction throug h the b ulb ar conjunctiva. E = e p i-
the lium; S = stro ma. Gob le t ce lls can b e se e n in the e p ithe lium (arrows).
The stroma can b e re solve d into an ad e noid laye r (arrowhe ad ) and a
d e e p b rous laye r (aste risk).
Fig . 2.26 Histolog ical se ction throug h the p alisad e re g ion. Conne c-
tive tissue rid g e s can b e se e n p roje cting into the ove rlying e p ithe lium
(arrows).
unique array o connective tissue ridges (the palisades o Vogt),
which project into the overlying epithelium (Fig. 2.26). Clinical
and experimental evidence suggests that the palisades are the
repositories o stem cells and there ore act as the regenerative
organ o the corneal epithelium (Dua and Azuara-Blanco,
2000). T e conjunctival epithelium additionally contains several
non-native cell types, including dendritic cells, melanocytes and
lymphocytes.
Goblet and Other Secretory Cells. Goblet cells provide the
mucous component o the tear lm. T ey arise in the basal
cell layers and migrate to the sur ace, there becoming ully
di erentiated. Mature goblet cells are larger than the surrounding
epithelial cells and contain a peripherally placed nucleus. T e
cytoplasm is packed with membrane-bound secretory granules
that discharge rom the apical sur ace in an apocrine manner.
T e number o goblet cells shows a marked regional variation
in density (Kessing, 1968) (Fig. 2.27), and these cells are
occasionally seen lining intraepithelial crypts (o Henle).
22 PART 1 Int ro d uct io n

Fig . 2.27 Diag ram showing the re g ional variation in g ob le t ce ll d e nsi-

ty. Gob le t ce ll d e nsity is g re ate st ove r the caruncle , p lica se milunaris and
in e rior nasal p alp e b ral conjunctiva. (Ad ap te d rom Bron, A. J., Trip athi,
R. C. & Trip athi, B. (1997). Wol ’s Anatomy o the Eye and O rb it (8th e d .).
Lond on: Chap man and Hall. Re p rod uce d ro m Bron, 1997.)
Fig . 2.28 Histolog ical se ction throug h a lymp hoid ollicle (F). Note the
mod i cation o the ove rlying e p ithe lium (aste risk).
T e apices o many sur ace epithelial cells o the conjunc-
tiva contain numerous carbohydrate-containing secretory
vesicles, which are seen to migrate to the cell sur ace where
they use with the plasma membrane (Dilly, 1985). It is likely
that this represents a mechanism or recycling the cell sur-
ace glycocalyx rather than a secondary source o secretory
mucin.

Conjunctival Stroma. T e conjunctival stroma (substantia

propria) is variable in thickness. It can be resolved into
two distinct layers: a super cial adenoid layer and a deeper
brous layer (see Fig. 2.25). T e adenoid layer contains
numerous lymphocytes with local accumulations in the orm
o lymphoid ollicles (Fig. 2.28). Follicles represent aggregates
o predominantly B cells, which orm part o the so-called
conjunctiva-associated lymphoid tissue (Knop and Knop,
2005). T e adenoid layer also contains a large number o mast
cells, which play a major role in ocular allergy (McGill et al.,
1998). T e deep brous layer is generally thicker than the
adenoid layer and contains the majority o conjunctival blood
vessels and nerves.
Inne rvation and Blood Sup p ly
Nerves. he conjunctiva receives nerves rom sensory,
sympathetic and parasympathetic sources. Sensory nerves,
which are trigeminal in origin, reach the conjunctiva via
branches o the ophthalmic nerve. he principal unction
o these ibres is to equip the conjunctiva with the ability
to detect a variety o sensations – or example, touch, pain,
warmth and cold. Sensory nerve terminals include both
ree (unspecialized) nerve endings and the more complex
corpuscular endings (classically re erred to as Krause end
bulbs) (Lawrenson and Ruskell, 1991). Conjunctival blood
vessels receive a dual autonomic innervation. Parasympathetic
ibres issuing rom the pterygopalatine ganglion and
sympathetic ibres rom the superior cervical ganglion
are responsible or vasodilation and vasoconstriction,
respectively.
Fig . 2.29 Hig h-p owe r slit-lamp p hotog rap h showing the limb al vascu-
lar arcad e s. (Courte sy o Eric Pap as.)
Blood Vessels and Lymphatics. T e arterial supply derives
rom two sources: palpebral branches o the nasal and lacrimal
arteries, and anterior ciliary arteries.
Palpebral vessels serve two vascular arcades within the eye-
lid. T e in erior (marginal) arcade sends branches through the
tarsal plate to the eyelid margin and tarsal conjunctiva. T e
superior (palpebral) arcade supplies the tarsal, orbital, ornix
and bulbar conjunctiva. T e limbal zone, in contrast, is served
by anterior ciliary arteries. T e anterior ciliary arteries travel
along the tendons o the rectus muscles and give o branches
at episcleral level prior to dipping down into the sclera to link
with the major iridic circle. Episcleral branches pass orward
and loop back a ew millimetres short o the cornea to become
conjunctival vessels. Forward extensions o these vessels orm
the limbal arcades (limbal loops), which are a complex net-
work o ne capillaries (Fig. 2.29). Conjunctival veins are more
numerous than arteries. T ey can be readily di erentiated rom
arteries owing to their larger calibre, darker colour and more
tortuous path.

Fig . 2.30 Late ral vie w o the orb it showing the position o the lacrimal
g land. The levator ap oneurosis (LA) p artially divid e s the g land into an
orb ital (OD) and palpe bral (PD) d ivision. (Adapted rom Kron eld, P. C.,
McHug h, S. L. & Polyak, S. L. (1943). The Human Eye in Anatomical
Transp are ncie s. Roche ste r, NY: Bausch & Lomb .)
Functional Consid e rations
T e conjunctiva contributes the mucin component o the pre-
ocular tear lm and plays an important role in the de ence o
the ocular sur ace against microbial in ection. Mucins are a
amily o high-molecular-weight glycoproteins that include
membrane-bound and secretory varieties (Cor eld et al., 1997;
Gipson and Inatomi, 1997; Hodges and Dartt, 2013). Goblet
cells are the primary source o secretory mucin, whilst sur-
ace epithelial cells o both the conjunctiva and cornea possess
mucin-like molecules within their glycocalyx. T e conjunctiva
also orms part o a common mucosal de ence system, which
is an important component o the de ence o the human body
against microorganisms (McClellan, 1997; Knop and Knop,
2005). T e conjunctiva possesses the immunological capacity
or antigen processing, and cell-mediated and humoral immu-
nity. Humoral immunity is provided by speci c antibodies (par-
ticularly immunoglobulin A [IgA]) produced by trans ormed B
cells (plasma cells) in the stroma. lymphocytes orm the basis
o cell-mediated immunity.
LACRIMAL SYSTEM
T e lacrimal apparatus provides or the production and main-
tenance o the preocular tear lm. T e normal unction o this
system is essential or the integrity o the ocular sur ace and the
provision o a smooth re ractive sur ace. T e lacrimal apparatus
comprises a secretory system that includes the main and acces-
sory lacrimal glands, and a drainage system that consists o the
paired puncta and canaliculi, the lacrimal sac and the nasolac-
rimal duct.
Lacrimal Gland
Gross Anatomy. T e main lacrimal gland is the key provider
o the aqueous component o the tears. T e gland is located in a
shallow depression o the rontal bone behind the superolateral
orbital rim (Fig. 2.30). It is partially split by the aponeurosis
o the levator palpebrae into an upper larger orbital lobe and
2 Ant e rio r Eye 23
Fig . 2.31 Low-p owe r lig ht microg rap h o the lacrimal g land . Acini are
arrowe d . Ad ip ose conne ctive tissue (aste risks) e xte nd s across the g land .
Fig . 2.32 Ele ctron microg rap h o p art o a lacrimal acinus showing
lig ht and d ark se cre tory ce lls.
a lower palpebral lobe, which can o en be visualized through
the conjunctiva upon lid eversion (Bron, 1986). T e gland is
pinkish in colour, with a lobulated sur ace. Between 6 and 12
ducts leave the gland through the palpebral lobe and discharge
into the conjunctival sac at the upper lateral ornix.
Microscopic Anatomy. T e lacrimal gland is tubuloacinar in
orm (Fig. 2.31). Its secretory units (acini) contain secretory
cells surrounded by myoepithelial cells (Ruskell, 1975). Acinar
secretory cells show extensive olding o their plasma membrane
and apical microvilli. Adjacent cells are linked by tight junctions
that restrict di usion between cells. T e most prominent eature
o these cells is the presence o abundant secretory granules.
wo principal secretory cell subtypes have been identi ed on
the basis o their granule content (Fig. 2.32). T e majority o
cells contain dark granules (dark cells), with a smaller number
o cells containing light granules (light cells). T e unctional
signi cance o this heterogeneity is uncertain at present. Ducts
consist o a single layer o cuboidal cells that lack secretory
granules. Myoepithelial cells are dendritic cells that are closely
associated with the perimeter o acini and ducts. It is likely that
these contractile cells play a role in the expulsion o tears rom the
gland. T e interstices o the gland contain numerous blood vessels
and nerves. A large population o immune cells (particularly IgA-
secreting plasma cells) are also ound between acini.
24 PART 1 Int ro d uct io n
Fig . 2.33 Diag ram showing the role o the g astrointe stinal tract g e n-
e rating sp e ci c immunog lo b ulin A (Ig A) in the lacrimal g land . Antig e ns
which challe ng e the ocular sur ace ultimate ly d rain to the g astrointe s-
tinal (GI) tract whe re the y stimulate B ce lls in Pe ye r’s p atche s (g ut-as-
sociate d lymp hoid tissue ). Se nsitize d B ce lls the n p ass to the lacrimal
g land via the circulation. SC = se cre tory comp one nt. (Ad ap te d rom Al-
lansmith, M. R. (1992). The Eye and Immunolog y. Maryland He ig hts, MO :
Mosb y. Cop yrig ht Else vie r 2002.)
Blood and Nerve Supply. T e arterial supply to the lacrimal
gland is provided by the lacrimal artery, which enters the posterior
border o the gland. Venous drainage occurs via the lacrimal
vein. A rich autonomic innervation includes secretomotor
(parasympathetic) bres that issue rom the pterygopalatine
ganglion and sympathetic (vasomotor) bres rom the carotid
plexus. T e lacrimal nerve traverses the gland to provide a sensory
innervation to the conjunctiva and lateral aspect o the eyelid.
Accessory Lacrimal Glands. Numerous small accessory
lacrimal glands, which include the eponymous glands o
Wol ring and Krause, are ound within the conjunctival stroma.
T ey have a particular predilection or the upper ornix and
above the tarsal plate, and, on the basis o proportion o total
lacrimal tissue, it has been estimated that they contribute
5–10% o aqueous tear volume. Structurally, they have a similar
appearance to the lacrimal gland proper. However, true acini are
absent and glands consist o elongated tubules that connect with
ducts opening onto the conjunctival sur ace (Sei ert et al., 1993).
Functional Considerations. In addition to its role as the principal
provider o the aqueous phase o the tear lm, the lacrimal gland
is also a major component o the ocular sensory immune system,
which acts as the rst line o de ence against microbial in ection
(Sullivan and Sato, 1994). T e secretory immune system is
mediated through secretory IgA. T e lacrimal gland is the main
source o tear IgA and the gland contains a large number o IgA-
producing plasma cells. T e mechanism by which an antigenic
challenge o the ocular sur ace induces a lacrimal antibody
response is not ully understood. However, as the administration
o an antigen by a gastrointestinal route raises speci c IgA levels
in tears, one suggested mechanism is that ocular antigens – a er
drainage through the nasolacrimal duct – stimulate B cells in
gut Peyer’s patches. T ese sensitized B cells then populate the
lacrimal gland where they trans orm into plasma cells (Fig. 2.33).
Fig . 2.34 Illustration o the lacrimal d rainag e syste m. C = canaliculi;
LS = lacrimal sac; P = p unctum; NLD = nasolacrimal d uct. (Ad ap te d rom
Kron e ld , P. C., McHug h, S. L. & Polyak, S. L. (1943). The Human Eye in
Anatomical Transp are ncie s. Roche ste r, NY: Bausch & Lomb .)
It has been demonstrated that the lacrimal gland also
secretes into the tears growth actors that are important or the
maintenance o the ocular sur ace and epithelial wound healing
(P ug elder, 1998). Prominent amongst these growth actors are
epidermal growth actor and trans orming growth actor beta.
Lacrimal Drainag e Syste m
ears collect at the medial canthal angle, where they drain into
the puncta o the upper and lower lids. Each punctum is a small
oval opening approximately 0.3 mm in diameter that is located
at the summit o an elevated papilla. From each punctum the
canaliculus passes rst vertically or about 2 mm and then turns
sharply to run medially or about 8 mm (Fig. 2.34). At the angle,
a slight dilation, the ampulla, can be seen. T e canaliculi con-
verge towards the lacrimal sac, usually orming a common can-
aliculus be ore entry. T e lacrimal sac occupies a ossa ormed
by the maxillary and lacrimal bones. It measures 1.5–2.5 mm in
diameter and approximately 12–15 mm in vertical length. From
the lacrimal sac tears drain into the nasolacrimal duct, which
extends or about 15 mm, passing through a bony canal in the
maxillary bone, to an opening in the nose beneath the in erior
nasal turbinate. A old o mucosa is o en observed at the ter-
mination o the duct: this has been termed ‘the valve o Hasner’,
although there is no strong evidence that it unctions as a valve.
T e process o tear drainage is an active process mediated
by the contraction o the orbicularis during blinking (Doane,
1981). ears enter the canaliculi principally by capillary action.
During the early part o the blink the puncta are occluded as
the orbicularis urther contracts. T e canaliculi and lacrimal
sac are also compressed, orcing uid into the nose. An alterna-
tive hypothesis has been proposed whereby orbicularis contrac-
tion dilates the sac, creating a negative pressure, which draws
in the tears rom the canaliculi (Jones, 1961). An investigation
by Paulsen et al. (2000) described a vascular plexus embedded
in the wall o the lacrimal sac and duct that may in uence tear
out ow. It is postulated that opening and closing o the lumen o
 2 Ant e rio r Eye 25

TABLE Physical Pro p e rt ie s o f t he Pre o cular Te ar

2.2 Film
Parame t e r Value
O smolarity 302 (± 6.3) mO sm/l
pH 7.45
Thickne ss 3 µl
Volume 7.0 (± 0.2) µl
Rate of p rod uction
Unstimulate d 1–2 µl / min
Stimulate d >100 µl / min
Re fractive ind e x 1.336

the lacrimal passages can be achieved by regulating blood ow

within this plexus.

The Pre o cular Te ar Film

FUNCTIO N AND PRO PERTIES O F THE
PREO CULAR TEAR FILM
T e tear lm is a complex uid that covers the exposed parts o the
ocular sur ace ramed by the eyelid margins. T e physical charac-
teristics o this uid are summarized in able 2.2. Classically, the
tear lm has been regarded as a trilaminar structure with a super-
cial lipid layer secreted by the meibomian glands, which overlies
an aqueous phase derived rom the main and accessory lacrimal
glands, and an inner mucinous layer consisting o membrane-
spanning mucins o the ocular sur ace epithelium and secretory
mucins produced mainly by conjunctival goblet cells. T e tear
lm per orms several important unctions, which can be broadly
classi ed as optical, metabolic support, protective and lubrication.
By smoothing out irregularities o the corneal epithelium, the
tear lm creates an even sur ace o good optical quality that is re-
ormed with each blink. T e air–tear inter ace orms the principal
re ractive sur ace o the optical system o the eye and provides two-
thirds (43 D) o its total re ractive power. As the cornea is avascular Fig . 2.35 Schematic rep rese ntation o the orbital g lands, which contrib -
ute the various components o the preocular tear lm. (Adapted rom Dartt,
it is dependent on the tear lm or its oxygen provision. When the D. A. (1992). Physiology o tear production. In M. A. Lemp & R. Marquardt
eye is open the tear lm is in a state o equilibrium with the oxygen (ed s) The Dry Eye: A Comprehensive Guide. Berlin: Springer-Verlag.)
in the atmosphere, and gaseous exchange takes place across the
tear inter ace. T e constant turnover o the tear lm also provides
a mechanism or the removal o metabolic waste products. (i.e. in response to strong physical or emotional stimulation) is
ears play a major role in the de ence o the eye against mediated by the main lacrimal gland. However, Jordan and Baum
microbial colonization. T e washing action o the tear uid (1980) questioned the concept o basic and re ex secretion, and
reduces the likelihood o microbial adhesion to the ocular sur- suggested that it is more accurate to think o tear output as a con-
ace. Moreover, the tears contain a host o protective antimicro- tinuum, whereby the rate o production is proportional to the
bial proteins. T e tear lm acts as a lubricant, smoothing the degree o sensory or emotive stimulation (Dartt, 2009). T is con-
passage o the lids over the corneal sur ace and preventing the cept would also mean that a unctional distinction between main
transmission o damaging shearing orces. o acilitate this, tear and accessory lacrimal glands, in terms o basal and re ex tear
uid displays non-Newtonian behaviour with respect to shear production, is unnecessary. Rather, it is more likely that tear ow
( i any, 1991). Newtonian uids maintain a constant viscosity is the combination o contributions rom both glands, although
with increasing shear rates. By contrast, tear uid has a rela- the output rom the accessory glands alone is suf cient to main-
tively high viscosity between blinks to aid stability, and with tain a stable tear layer (Maitchouk et al., 2000).
increasing shear rates during the blink process the viscosity alls
dramatically, thereby easing the movement o the lids over the SO URCES AND CO MPO SITIO N
ocular sur ace.
ears are composed o a complex secretion that combines the
Te ar Prod uction products o several glands (Fig. 2.35). Although the precise com-
Jones (1966) rst used the terms ‘basic (basal)’ and ‘re ex’ to position o tear uid varies with collection method, ow rate and
describe tear ow. He proposed that the accessory lacrimal glands time o day, it can be considered as a watery secretion containing
were the basic (minimal ow) secretors, and that re ex secretion electrolytes and proteins, with lesser amounts o lipid and mucin.
26 PART 1 Int ro d uct io n

is a constitutively secreted lacrimal protein whose rate o secre-

TABLE Bio che mical Co mp o sit io n o f t he Pre o cular tion is independent o ow rate. During sleep, the levels o IgA
2.3 Te ar Film increase as secretory IgA production continues and as acinar
Co mp o ne nt Co nce nt rat io n secretion declines (Sack et al., 1992). IgA plays an important
role in the de ence o the ocular sur ace against microbial in ec-
ELECTRO LYTES* tion by preventing bacterial and viral adhesion, and inactivating
Na + 135 mEq / l
Cl− 131 mEq / l
bacterial toxins. Other immunoglobulins (e.g. IgG and IgM) are
K+ 36 mEq / l present in tears at much lower levels.
HCO 3 − 26 mEq / l Lysozyme, lacto errin and lipocalin, in contrast, originate
Ca 2+ 0.46 mEq / l rom acinar cells and their rate o secretion roughly matches
Mg 2+ 0.36 mEq / l ow rate. Lysozyme is a well-known bacteriolytic protein that
MAJ O R PRO TEINS* has the ability to lyse the cell wall o several Gram-positive bac-
Lysozyme 2.07 g / l teria. Lacto errin serves an important bacteriostatic unction by
Se cre tory Ig A 3.69 g / l binding iron and making it unavailable or bacterial metabo-
Lactofe rrin 1.65 g / l lism. It also acts as a ree radical scavenger, thereby reducing
Lip ocalin 1.55 g / l
Alb umin 0.04 g / l ree-radical-mediated cell damage ( i any, 1997). Lipocalins
Ig G 0.004 g / l are a amily o lipid-binding proteins with an af nity or a broad
LIPIDS† array o lipids, including atty acids, phospholipids and choles-
Wax e ste rs 41% terol. It has been suggested that tear lipocalins act as scavengers
Chole ste ryl e ste rs 27.3% or a wide range o meibomian lipids, which could spill onto
Polar lip id s 14.8% the corneal sur ace and perturb its wettability (Glasgow et al.,
Hyd rocarb ons 7.5% 2000). Furthermore, lipocalin may promote lipid solubility at
Die ste rs 7.7% the aqueous–lipid inter ace to acilitate the ormation o a thin
Triacylg lyce rid e s 3.7%
Fatty acid s 2.0% layer o lipid on the sur ace o the tear lm.
Fre e ste rols 1.6%
Mucins
MUCIN ‡
MUC1 nd
Mucins are a amily o high-molecular-weight glycoproteins, o
MUC5AC nd which sugars contribute up to 85% o their dry weight. Structur-
MUC4 nd ally, they consist o a polypeptide backbone to which chains o
MUC16 nd sugar molecules attach via O-linkages to the amino acids serine
(Data ad ap te d rom Ti any, 1997.) and threonine. Mucins are a heterogeneous group o molecules
Source s: that can be subdivided into secretory and integrated-membrane
*Main and acce ssory lacrimal g land s. varieties (Cor eld et al., 1997; Hodges and Dartt, 2013). So ar,
†Me ib omian g land s.
‡Ep ithe lial ce lls / g ob le t ce lls.
modern molecular biology techniques have identi ed up to
nd = not d e te rmine d .
20 mucin (MUC) genes, although only our o these (MUC1,
MUC5AC, MUC4 and MUC16) are expressed on the human
ocular sur ace (Gipson and Inatomi, 1997; McKenzie et al., 2000;
Ele ctrolyte s P ug elder et al., 2000; Mantelli and Argüesco, 2008). T e epithelia
Human tears contain approximately the same range o electro- o the cornea and conjunctiva express the transmembrane mucins
lytes as ound in plasma ( i any, 1997). able 2.3 gives typi- MUC1, and to a lesser extent MUC4 and MUC16, which attach
cal values or the ionic composition o human tears. However, to apical microvilli where they orm a hydrophilic base to acilitate
as the electrolyte content o tears varies with ow rate, there is the spreading o the goblet-cell-derived mucin MUC5AC. Mucins
signi cant variation in measured values. During the process play a major role in stabilizing and spreading the tear lm and
o secretion by the lacrimal gland, there is a process o active provide protection against desiccation and microbial invasion
electrolyte transport that is coupled to the passive movement o (Gipson and Inatomi, 1997; Hodges and Dartt, 2013).
water by an osmotic process. Acinar-derived uid is essentially
an isotonic ultra ltrate o plasma. Its composition is altered as Lip id s
it passes along the ductal system, where urther chloride and T e source o lipids in the tear lm is the meibomian glands
potassium ions are secreted. A variety o ion transport proteins embedded within the tarsal plates o each lid. T e blinking pro-
have been identi ed in acinar cells, including sodium–potas- cess is an important mechanism in the expulsion o the secre-
sium A Pase and potassium and chloride channels. tion rom the glands ( i any, 1995). Meibomian lipid (also
known as meibum) is delivered directly as a clear oil onto the lid
Prote ins margins and is spread over the tear lm rom the inner edge o
ear proteins are thought to originate rom three main sources: the lid margins with each blink. T e thickness o the lipid layer
the lacrimal gland, ocular sur ace epithelia and conjuncti- is variable (mean thickness 42 nm, range 15–157 nm; King-
val blood vessels. T e major lacrimal proteins include secre- Smith et al., 2000, 2010), and depending on thickness gives rise
tory IgA, lysozyme, lacto errin and lipocalin ( ormerly known to characteristic inter erence patterns when viewed in specular
as tear-speci c prealbumin) (see able 2.3). IgA, which is re ection (Fig. 2.36) (Guillon, 1998). Meibomian secretion con-
the major immunoglobulin in tears, is secreted as a dimer by sists o a complex mixture o lipids ( able 2.3), including wax
plasma cells in the interstices between lacrimal acini. It then and cholesteryl esters (which together constitute approximately
binds to a receptor on the basolateral aspect o acinar cells, and 70% o meibum), atty acids and atty alcohols ( i any, 1995;
is transcytosed across the cell and secreted into tear uid. IgA Butovich, 2013). T e primary unctions o this secretion are to

Fig . 2.36 Lip id laye r o the p re ocular te ar lm vie we d in sp e cular re -
f e ction. A ‘wave ’ ap p e arance can b e se e n, which re p re se nts the most
commonly ob se rve d lip id p atte rn in the p op ulation.
provide a hydrophobic barrier at the lid margin to prevent over-
spill o tears, and to cover the sur ace o the tear lm to retard
evaporation (Craig and omlinson, 1997).
MO DELS O F TEAR FILM STRUCTURE
T e classical trilaminar model o tear lm structure in terms o
a super cial lipid layer, a middle aqueous layer and deep mucin
layer, rst proposed by Wol and subsequently modi ed by
Holly and Lemp (1977), has received broad acceptance. How-
ever, the results o recent studies have led to a re-evaluation o
the nature o the aqueous and mucinous layers. Several pieces o
evidence have suggested that the mucin contribution to the tear
lm is much greater than was previously thought (Prydal et al.,
1992), and an alternative tear lm model, which possesses a
substantial mucinous phase, has been proposed (Fig. 2.37). T e
nature o the mucinous phase has not been ully established, but
2 Ant e rio r Eye 27
Fig . 2.37 Diag ram showing the comp osition o the p re ocular te ar
lm. Inse ts sho w d e tails o the g lycocalyx and lip id –aq ue ous inte r ace .
(Ad ap te d rom Corf e ld , A. P., Carring ton, S. D., Hicks, S. J. e t al. (1997).
O cular mucins: p urif cation, me tab olism and unctions. Prog . Re tin. Eye
Re s., 16, 627–656.)
is thought to consist o a mixture o soluble and gel- orming
mucins (Hodges and Dartt, 2013).
Co nclusio n
It is clear rom the above account that our understanding o the
structure and unction o the anterior eye is ar rom complete,
which places certain limits on our understanding o clinical,
contact-lens-related phenomena. It is essential, there ore, that
uture research continues to ocus on undamental aspects o
ocular anatomy and physiology, as well as on the more applied
clinical applications that are described in the remainder o this
book.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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 3
Visual O p t ics
W NEIL CHARMAN
Int ro d uct io n
T e human eye is a remarkable optical instrument (Navarro,
2009; Artal, 2014). Its per ormance has been honed by mil-
lennia o evolution to meet admirably the needs o the neural
system that it serves. At its best, ew human-engineered photo-
graphic lens systems can match its semi eld o more than 90°,
its range o -numbers rom about / 11 to better than / 3, and
its near di raction-limited axial per ormance when stopped
down under photopic light levels. Moreover, the ocus o the
eye o the young adult can be adjusted with reasonable accuracy
or distances between about 0.1 m and in nity. Nevertheless, all
eyes su er rom a variety o regular and irregular aberrations,
while a substantial subset displays clinically signi cant spheri-
cal and astigmatic re ractive errors. In addition, the ability to
change the power o the crystalline lens to view near objects is
an asset that declines with age, to disappear entirely by the mid
50s, when presbyopia is reached.
T e invention o spectacles in the 13th century, and their sub-
sequent relatively slow re nement, ollowed by the more rapid
development o contact lenses in the 20th century, has done
much to provide solutions to the problems o both re ractive
error and presbyopia: improvements in the design o both types
o lens continue to be made. Re ractive surgical techniques,
including both laser-based methods that modi y the corneal
contour and intraocular lenses, are beginning to compete with
spectacle and contact lens corrections, although unanswered
questions still remain concerning the long-term e cacy and
sa ety o some o the procedures used. In this chapter the basic
optics o the eye and its components will rst be reviewed. T is
will be ollowed by a discussion o the modi cations that the
correction o re ractive error – particularly by contact lenses –
produces in actors such as spectacle magni cation, accommo-
dation and convergence (Douthwaite, 2005).
The Basic O p t ics o f t he Eye and
Ame t ro p ia
GENERAL O PTICAL CHARACTERISTICS
T e amiliar, and deceptively simple, optical layout o the eye is
shown in Fig. 3.1.
About three-quarters o the optical power comes rom the
anterior cornea, with the crystalline lens providing supple-
mentary power that, in the pre-presbyope, can be varied to
ocus sharply on objects at di erent distances. T e actual opti-
cal design is, however, subtle, in that all the optical sur aces
are aspheric, while the lens, and probably also the cornea,
displays a complex gradient o re ractive index. T ere is little
doubt that such re nements play an important role in control-
ling aberration.
28
T e distribution across the population o parameters such
as sur ace radii, component spacing and re ractive indices has
been studied by a variety o authors (McBrien and Barnes, 1984;
Charman, 2010). Re ractive indices o the media vary little
between eyes, apart rom the non-uni orm re ractive index dis-
tribution within the lens, which changes with age as the lens
grows throughout li e (Pierscionek et al., 1988; Pierscionek,
1995; Jones et al., 2005; Kasthurirangan et al., 2008). Each
dimensional parameter appears to be approximately normally
distributed amongst di erent individuals (Stenstrom, 1946;
Sorsby et al., 1957). T e values o the di erent parameters in
the individual eye are, however, correlated so that the resultant
distribution o re ractive error is strongly peaked near emme-
tropia, rather than being normal (Fig. 3.2).
T is correlation is thought to be due to a combination o
genetic and environmental actors; visual experience helping to
‘emmetropize’ the eyes actively ( roilo, 1992; Saunders, 1995;
Wildsoet, 1997; Weale, 2003; Mutti, 2010; Flitcro 2014). T e
apparently greater incidence o myopia in recent times has been
attributed to the greater prevalence o near tasks and other
changes in environment and li estyle (Rosen eld and Gilmar-
tin, 1998; Pan et al., 2011).
MO DEL EYES AND AMETRO PIA
Many authors have produced paraxial models o the emmetropic
eye, based on typical measured values o the ocular parameters
(T ibos and Bradley, 1999; Atchison and Smith, 2000; Rabbetts,
2007; Atchison, 2009). T ese simpli y the optical complexities
o the real eye while having approximately the same basic imag-
ing characteristics. Some examples are given in able 3.1; uller
details o these and other more elaborate eye models (e.g. Gon-
charov and Dainty, 2007) are given in the cited re erences.
Using the parameters o the model eyes it is straight orward to
calculate the positions o the cardinal points, which, in thick-lens
theory, can be used to summarize paraxial imagery (Fig. 3.3).
Fig . 3.1 Sche matic horizontal se ction o the human e ye .
 3 Visual O p t ics 29

It is, however, important to stress that these eye models are only
representative. In practice, an eye o shorter or longer axial length
may still be emmetropic. T is behaviour and the various possible
origins o re ractive error are easy to understand in terms o these
basic models. Consider, or simplicity, the generic reduced eye
shown in Fig. 3.4, with a single re ractive sur ace o radius r, re rac-
tive index n′ and axial length k′. T e power o the eye, Fe, is given by:
Fe = (n' − 1) /r
For a distant object (zero object vergence) the image vergence
n′ / l′ equals Fe. For emmetropia we require that the image o the dis-
tant object lies on the retina, i.e. l′ = k′, implying that Fe = n′ / k′ = K′,
where K′ = n′ / k′ is the dioptric length o the eye. T ere are, then, in
principle an in nite number o matching pairs o values o Fe and
K′ that lead to emmetropia, so that eyes that are relatively larger or
smaller than the ‘standard’ models may still be emmetropic.
In the case o ametropia Fe and K′ are no longer equal. I the
power o the eye is too high (Fe > K′) we get myopia; i too low
(Fe < K′) we get hypermetropia. T e ocular re raction K is given by:
K= K' − Fe
T us, or example, myopia (K negative) can occur i K′ is too
low, corresponding to an axial length k′ that is relatively too
great (axial ametropia), or i Fe is relatively too large (re ractive
ametropia). A high Fe may arise as a result o either too small a
corneal radius r or because n′ is too large (note, however, that
changes in n′ a ect both Fe and K′). Although more sophisti-
cated eye models are characterized by more parameters, the
possible origins o ametropia are essentially the same.
Astigmatism can arise either because one or more o the
optical sur aces is toroidal or because o tilts o sur aces with
respect to the axis, particularly o the lens.
How accurate do our models and associated calculations
have to be? Although in the laboratory it may theoretically be
possible to measure all the parameters o an individual eye, in
general all that will be known in the consulting room is that the
eye is ametropic. T us, in clinical contact lens practice, precise
calculation o the optical e ects in the uncorrected or corrected
eye is rarely possible; it is more important that the general mag-
nitude o the e ects be borne in mind and that the approximate
changes brought about by correction be ully understood.

ACCO MMO DATIO N AND THE PRECISIO N O F

O CULAR FO CUS

Fig . 3.2 Distrib ution o some ocular p arame te rs and o re ractive e r-
ror. (A) Rad ius o curvature o the ante rior corne a. (B) Ante rior chamb e r
(A.C.) d e p th. (C) Le ns p o we r. (D) Axial le ng th. (E) Sp he rical e q uivale nt re -
ractive e rror. In (A)–(D) the d ashe d curve re p re se nts the corre sp ond ing
normal d istrib ution. Note that, whe re as ind ivid ual p arame te rs are d is-
trib ute d ap p roximate ly normally, re ractive e rrors are strong ly p e ake d
ne ar e mme trop ia. (Afte r Ste nstrom, S. (1946). Unte rsuchung e n ub e r d e r
Variation und Kovaration d e r op tische Ele me nte d e s me nschliche n Au-
g e s. Acta O p hthalmol., 15(Sup p l. 26). [Translate d b y Woo lf, D.])
T e decline with age in the subjective amplitude o accommo-
dation (i.e. the reciprocal o the distance, measured in metres,
o the nearest point at which vision remains subjectively clear to
the distance-corrected patient) is illustrated in Fig. 3.5A.
Few everyday tasks require accommodation in excess o about
4 D, so that it is normally only as individuals approach 40 years
o age that marked problems with near vision start to appear. It
is, however, important to recognize that, even or objects lying

TABLE
3.1 Parame t e rs o f So me Paraxial Mo d e ls o f t he Human Eye
Sche mat ic Eye (mm) Simp lifie d Sche mat ic Eye (mm) Re d uce d Eye (mm)
Surface rad ii (mm) Ante rior corne a 7.80 7.80 5.55
Poste rior corne a 6.50 — —
Ante rior le ns 10.20 10.00 —
Poste rior le ns −6.00 −6.00 —
Distance s from Ante rior Corne a Poste rior corne a 0.55 — —
(mm) Ante rior le ns 3.60 3.60 —
Poste rior le ns 7.60 7.20 —
Re tina 24.20 23.90 22.22
Re fract ive Ind ice s Corne a 1.3771 — —
Aq ue ous humour 1.3374 1.333 1.333
Le ns 1.4200 1.416 —
Vitre ous humour 1.3360 1.333 —

(Data from Charman, W. N. (1991) O p tics of the human e ye . In W. N. Charman (e d .) Vision and Visual Dys unction. Vol. 1: Visual O p tics and Instru-
me ntation (p p . 1–26). Lond on: Macmillan.)
30 PART 1 Int ro d uct io n
Fig . 3.3 Examp le s o p araxial mod e ls o the human e ye . In e ach case F
and F ′ re p re se nt the f rst and se cond ocal p oints, re sp e ctive ly, P and P ′
the f rst and se cond p rincip al p oints, and N and N ′ the f rst and se cond
nod al p oints. (A) Unaccommod ate d sche matic e ye with our re racting
sur ace s. (B) Simp lif e d , unaccommod ate d e ye with thre e re racting sur-
ace s. (C) Re d uce d e ye with a sing le re racting sur ace . (Ad ap te d from
Charman, W. N. (1991). O p tics of the human e ye . In W. N. Charman (e d .)
Vision and Visual Dys unctio n. Vol. 1: Visual O p tics and Instrume ntation
(p p . 1–26). Lond on: Macmillan.)
Fig . 3.4 A g e ne ric re d uce d e ye mod e l, with p arame te rs as ind icate d . r
is the rad ius o curvature o the re racting sur ace , k′ the axial le ng th and
n ′ the re ractive ind e x. The e ye shown is hyp e rme trop ic.
within the available range o accommodation, accommoda-
tion is rarely precise. ‘Lags’ o accommodation usually occur
in near vision and ‘leads’ or distance vision (Fig. 3.5B). As the
accommodation system is driven via the retinal cones, these lags
increase i the environmental illumination is reduced to meso-
pic levels and the accommodation system is e ectively inopera-
tive at scotopic light levels, when the system reverts to its slightly
myopic (around −1 D) tonic level (Ciu reda, 1991, 1998).
Co rne al To p o g rap hy
It has already been stated that the optical sur aces o the eye are
not necessarily spherical. T e topography o the anterior cornea
is o particular interest since, as the dominant re ractive sur-
ace, its orm has a major inf uence on overall re ractive error
and ocular aberration. In contact lens work, it is o enormous
importance to the tting geometry.
Fig . 3.5 (A) The d e cline in monocular sub je ctive amp litud e o ac-
co mmod ation, re e re nce d to the sp e ctacle p lane , with ag e . (B) Typ ical
ste ad y-state accommod ation re sp onse / stimulus curve , showing lag s
o accommod ation or ne ar stimuli. (Data in (A) from Duane , A. (1922).
Stud ie s in monocular and b inocular accommod ation with the ir clinical
imp licatio ns. Am. J. O p hthalmol., 5, 865–877.)
We have already seen (see Fig. 3.2A) that the radius o curvature
over the central region, as measured by conventional keratometers,
shows considerable individual variation, and it has been recog-
nized or more than a century that many corneas display marked
astigmatism. Corneal astigmatism is not, o course, necessarily
equal to the total ocular astigmatism, as additional astigmatism
(residual astigmatism) may be contributed by the crystalline lens.
Earlier work on corneal topography using modi cations o
traditional keratometers concentrated on approximating the
orm o the corneal sur ace by a conicoid, in which each meridian
is a conic section. In this approach the anterior corneal sur ace
can be described by the ollowing equation (Bennett, 1966, 1988):
x2 + y2 + pz2 = 2r 0 z
where the coordinate system has its origin at the corneal apex, z
is the axial coordinate, r0 is the radius o curvature at the cornea
apex and the shape actor p is a constant parameter character-
izing the orm o the conic section or the individual eye. Values
o p < 0 represent hyperboloids, p = 0 paraboloids, 0 < p < 1 f atten-
ing (prolate) ellipsoids, p = 1 spheres and p > 1 steepening (oblate)
 3 Visual O p t ics 31

Fig . 3.6 (A) Histog ram showing the d istrib ution o the shap e actor, p , in 176 e ye s. (B) Typ ical re sult rom a top og rap hic instrume nt, showing the local
variation in nominal sp he rical p owe r across our astig matic corne as. (Ad ap te d from Kie ly, P. M., Smith, G. & Carne y, L. G. (1982). The me an shap e of
the human corne a. O p tica Acta, 29, 1027–1040.)

ellipsoids. T e same equation is sometimes written in terms o the

Q- actor or the eccentricity e o the conic section, where:
p = 1 + Q = 1 − e2
Kiely et al. (1982) ound mean r0 and p values o 7.72 ± 0.27
mm and 0.74 ± 0.18, respectively, these values being supported
by the results o Guillon et al. (1986), that is, 7.85 ± 0.25 mm
and 0.85 ± 0.15; broadly similar p values are ound in di erent
racial groups: 0.70 ± 0.12 in Chinese eyes (Zhang et al., 2011) and
0.74 ± 0.19 in A ro-Americans (Fuller and Alperin, 2013). T us
the typical general orm o the cornea is that o a f attening ellip-
soid, with the curvature reducing in the periphery (Fig. 3.6A).
Recent years have seen the introduction o a range o topo-
graphic instruments, marrying optical with electronic and com-
puter technology, that can routinely give a much uller picture
o the corneal contour (see Chapters 36, 41). T ese videokerato-
graphic and scanning-slit results show that the conicoidal model is
only a rst approximation to corneal shape and that individual eyes
show a wide range o individual asymmetries. In particular, the rate
o corneal f attening is o en di erent in di erent meridians (Fig.
3.6B), while the corneal cap o steepest curvature may be displaced
with respect to the visual axis, on average lying about 0.8 mm below
(Mandell et al., 1995). More elaborate models have been devised to
describe these asymmetries in corneal shape (Navarro et al., 2006)
Currently the most popular orm o output or the topo-
graphic data is probably a colour-coded map o the cornea,
showing regions o di erent axial (sagittal) power (see Chapter
36). T is may be slightly misleading, since each local area o the
cornea is toroidal rather than spherical. For this reason both sag-
ittal and tangential power maps are o en used (Mount ord et al.,
2004). It is possible that other orms o representation, such
as those that plot local departures in height rom a best- tting
sphere, will ultimately prove more use ul, particularly in relation
to the tting o rigid contact lenses (Salmon and Horner, 1995;
Horner et al., 1998). T e contribution o the cornea to the over-
all ocular wave aberration can be deduced rom the videokerato-
gram (Hemenger et al., 1995; Guirao and Artal, 2000). Scanning
slit instruments, such as the Orbscan and Pentacam, allow the
orm o the posterior sur ace o the cornea to be deduced, as well
as that o the anterior sur ace (see Chapters 36, 41).
Fig . 3.7 Formation o the re tinal b lur circle or a myop ic e ye . D is the
p up il d iame te r and d is the b lur circle d iame te r.
Pup il Diame t e r and Re t inal Blur
Circle s
As will be discussed below, although the retinal image is always
blurred by both aberration and di raction, in ametropia and
presbyopia it is o en de ocus blur that is the major source o
degradation. De ocus will occur whenever the object point lies
outside the range o object distances embraced by the ar and
near points o the individual. As noted earlier, even within this
range, small errors o ocus will normally occur owing to the
steady-state errors that are characteristic o the accommoda-
tion system. Using a reduced eye model and simple geometric
optical approximations (Smith, 1982, 1996; Atchison and Smith,
2000; Rabbetts, 2007) – which are normally valid or all errors
o ocus over about 1 D – such blur depends on the dioptric
error o ocus and the pupil diameter. From Fig. 3.7 it can be
seen that, or any object point and assuming that the eye pupil is
circular, spherical de ocus produces a ‘blur circle’ on the retina.
Using similar triangles, it is easy to show that the diameter
(d, in mm) o this blur circle is:
d = ΔFD/K'
where ΔF is the dioptric error o ocus with respect to the object
point, D is the pupil diameter in millimetres and K′ is the diop-
tric length o the eye. I astigmatism is present, the blur patch
32 PART 1 Int ro d uct io n

is an ellipse, with major and minor axes corresponding to the
ocus errors in the two principal meridians.
We can express the blur circle diameter in angular terms as:
α = ΔFD 10 − 3 rads = 3.44ΔFD min arc
T us, or a 3 mm diameter pupil, the blur circle diameter
increases by roughly 10 min arc per dioptre o de ocus. Chan
et al. (1985) measured blur circle diameters experimentally and
ound that results or pupil diameters between 2 and 6 mm and
de ocus between 1 and 12 D were quite accurately predicted by
Eq. 3.1.
T e impact o blur on visual acuity depends somewhat on
the acuity target chosen and the criteria and observation condi-
tions used. We would expect the minimum angle o resolution
(MAR) to be somewhat smaller than the blur circle diameter.
Smith (1996) suggests that, or errors o ocus above about 1 D,
letter targets, a 50% recognition rate, and normal chart lumi-
nances o about 150 cd / m 2 (giving pupil diameters o about 4
mm):
MAR = 0.65ΔFD min arc
With errors o ocus smaller than about 1 D, di raction,
aberration and the neural capabilities o the visual system are
more important than de ocus blur and the MAR exceeds that
Eq. 3.1 predicted by Eq. 3.2.
T e natural pupil diameter is chief y dependent on the ambi-
ent light level. Fig. 3.8 shows typical results or this relationship
in young adults.
Pupil diameters at any light level tend to decrease with age
(senile miosis: Winn et al., 1994) and with accommodation, as
well as varying with a variety o emotional and other actors
(Loewen eld, 1998). Some typical values or older eyes under
di erent lighting conditions are given in able 3.2.
Clearly, reducing the pupil size results in smaller amounts
o blur in the retinal image or any given level o de ocus,
and thus the depth o ocus is increased. For example, an
uncorrected low myope may experience minimal levels o
distance blur under good photopic levels o illumination
but may notice considerable blur when driving at night,
when the pupil is large. Pupil diameter strongly in luences
Eq. 3.2 the design and per ormance o bi ocal and other types
o contact lens or the presbyope (Koch et al., 1991; see
Chapter 23).

Effe ct s o f Diffract io n and Ab e rrat io n

As noted above, these are chie ly important when the eye is
close to its optimal ocus. he point image or a spherical
error o ocus then no longer approximates to a blur circle
(or a point in the absence o de ocus) but has more complex
orm.

Fig . 3.8 De p e nd e nce o p up il d iame te r on f e ld luminance in young
ad ults. (Ad ap te d from Farre ll, R. J. & Booth, J. M. (1984). De sig n Hand -
b ook or Imag e ry Inte rp re tation Eq uip me nt (Se c. 3.2, p . 8). Se attle , WA:
Boe ing Ae rosp ace Co.)
DIFFRACTIO N
I the optical per ormance o the eye were limited only by di -
raction, the in- ocus retinal image o a point object would be an
Airy di raction pattern. T e angular radius o the rst dark ring
in this pattern would be:
θmin = 1.22λ/D radians = 4194λ/D min arc
where the wavelength λ and the pupil diameter D are
expressed in the same units. It is usually assumed that it
will be possible to resolve the images o two identical point
objects i their angular separation equals this value (the Ray-
leigh limit).

TABLE Me ans, St and ard De viat io ns and (Bracke t e d ) Rang e s o f Pup il Diame t e r in Vario us Visual Tasks and
3.2 Illuminance s fo r Pre sb yo p ic Pat ie nt s o f Diffe re nt Ag e s
Pup il Diame t e r Pup il Diame t e r
Co nd it io n Ag e s 40–49 (mm) Ag e s 50–59 (mm)
Nig ht d riving 5.2 ± 0.8 4.6 ± 0.8
(3.8–6.2) (3.1–5.8)
Re ad ing (low illumination, 215 lux) 3.5 ± 0.6 3.0 ± 0.5
(2.l6–4.6) (2.3–4.4)
Re ad ing (hig h illumination, 860 lux) 2.9 ± 0.5 2.6 ± 0.3
(2.2–3.9) (2.1–3.6)
O utd oors (ind ire ct sunlig ht, 3400 lux) 2.7 ± 0.5 2.5 ± 0.4
(1.9–3.4) (1.9–3.4)
O utd oors (d ire ct sunlig ht, 11 000 lux) 2.3 ± 3.4 2.2 ± 0.3
(1.8–3.1) (1.8–2.9)

(Data from Koch D. D., Samue lson S. W., Haft E. A. & Me rin L. M. (1991). Pup illary size and re sp onsive ne ss. Imp lications for sele ction of a b ifocal
intrao cular le ns. O p hthalmolog y, 98, 1030–1035.)
 3 Visual O p t ics 33

Examples o some typical axial results or normal eyes cor-

MO NO CHRO MATIC ABERRATIO NS
rected or any spherocylindrical re ractive error are shown in
Aberration obviously acts to introduce additional blur into both Fig. 3.11. T e wave ront error is usually expressed in microns
in- ocus and out-o - ocus images. Monochromatic aberration (micrometres).
can arise rom a variety o causes. T e eye would be expected Departures rom the re erence sphere (in this case o in nite
to display the classical Seidel aberrations (spherical aberra- radius) o more than a quarter o a wavelength (i.e. around 0.14
tion, coma, oblique astigmatism, eld curvature and distortion) µm or the green region o the spectrum) would be expected
inherent in any system o spherical centred sur aces but, due to to degrade image quality. What is striking is the wide variation
the various asphericities, tilts, decentrations and irregularities between the aberrations shown by di erent eyes. T e aberration
that may occur in its optical sur aces (see Fig. 3.6B), its aberra- in the central 2–3 mm o the pupil is usually modest, but much
tional behaviour is much more complex than that which would larger amounts may be ound in the periphery o dilated pupils.
be expected on the basis o simple schematic eye models o the On the basis o wave ront aberration results, it is possible to
type illustrated in Fig. 3.3 and able 3.1. calculate monochromatic point and line spread unctions and
Early authors attempted to analyse ocular aberration in terms also the ocular modulation and phase trans er unctions or any
o the individual Seidel aberrations. However, these attempts pupil diameter (Hopkins, 1962).
were o limited value because o the lack o rotational symme- Note that the wave ront maps shown in Fig. 3.11 were
try in the system. Monochromatic aberration is now most com- obtained on axis with the eyes under cycloplegia. In each case,
monly expressed in terms o the wave ront aberration (Atchison, ocular aberrations get worse nearer to the peripheral pupil, as
2004; Charman, 2005). T e behaviour o a ‘per ect’ optical sys- with most optical systems. In practice, the aberrations on the
tem, according to geometrical optics, can be visualized either as visual axis o each individual eye vary slightly with time owing
involving rays radiating rom an object point to be converged to
a unique image point, or as spherical wave ronts diverging rom
the object point to converge at the image point, so that the object
point is the centre o curvature o the object wave ronts and the
image point is that o the image wave ronts (Fig. 3.9A).
T e rays and wave ronts are everywhere perpendicular to
one another. I we have aberration, the image rays ail to inter-
sect at a single image point. Similarly, the wave ronts, which are
still everywhere perpendicular to the rays, are no longer spheri-
cal (Fig. 3.9B). It is usual to express the wave ront aberration at
any point in the pupil as the distance between the ideal spherical
wave ront, centred on the gaussian image point, and the actual
wave ront, where both are selected to coincide at the centre o
the exit pupil (Fig. 3.9C).
Recent years have seen an explosion o interest in ocular
aberrations, largely uelled by the realization that the earlier
excimer-laser re ractive surgical techniques o en resulted in
poor vision because these procedures introduced unacceptably
high levels o aberration. As a result, a variety o commercial
aberrometers have become available or measuring the wave-
ront aberration o the eye (Krueger et al., 2004; Atchison,
2005). One o the more elegant designs involves the use o a
Hartmann–Shack wave ront sensor (Liang et al., 1994, 1997;
Liang and Williams, 1997). A regular array o identical micro-
lenses allows the slope o the wave ront across a lattice o points
in the pupil to be determined. T e principle can be understood
with re erence to Fig. 3.10.
Suppose we have a point source on the retina o a per ect
emmetropic eye. T e light leaving the eye can be envisaged
either as a bundle o parallel rays or as a series o plane wave-
ronts (Fig. 3.10A). We now place our array o microlenses in
the path o the emerging light. Evidently each lens will converge
the parallel rays to its second ocal point, so that in the common
ocal plane we shall see an absolutely regular array o image
points. I now the eye su ers rom aberration, the emergent rays Fig . 3.9 (A) With a p e r e ct le ns, rays rom the ob je ct (O ) conve rg e to
a sing le imag e p oint. Alte rnative ly we can visualize d ive rg e nt sp he rical
are no longer parallel and the associated wave ronts are no lon- wave ronts (shown as d ashe d line s) rom the ob je ct p oint co nve rg ing
ger f at (Fig. 3.10B). T us the rays no longer come to a ocus on as sp he rical wave ronts to the imag e p oint. (B) I the le ns su e rs rom
the axes o the lenses; the lateral displacement rom the ocal ab e rration, the imag ing rays ail to conve rg e to a sing le p oint and the
point o each lens is directly proportional to the local inclina- corre sp ond ing wave ronts are not sp he rical. (C) The wave ront ab e rra-
tion, W ′, is sp e cif e d as the d istance b e twe e n the id e al wave ront, or re -
tion o the ray or the slope o the wave ront. It is, then, easy to e re nce sp he re , ce ntre d on the g aussian imag e p oint, O ′, and the actual
calculate the orm o the emergent wave ronts and the wave- wave ront in the e xit p up il. It is usually ad juste d to b e ze ro at the ce ntre
ront aberration rom the distorted pattern o image points. o this p up il.
34 PART 1 Int ro d uct io n
Fig . 3.10 Principle o the Hartmann–Shack techniq ue . (A) E ects with a
pe r ect e mmetropic eye, where the imag es are ormed on the axis o each
microle ns and hence are regularly sp aced . (B) E ects with an ab errated
eye, where the image array is irre g ular as the imag es are no long er ormed
on the axe s o the le nse s (se e te xt). f′ is the ocal le ngth o the microle nse s.
Fig . 3.11 (A–C) Wave ront se nsor imag e s on the visual axis or thre e
e ye s with a p up il d iame te r o 7.3 mm. An ab e rration- re e e ye wo uld
g ive a re g ular he xag onal lattice o p oints. (D–F) Corre sp ond ing d e rive d
wave ront ab e rration. Contours are at 0.15 µm inte rvals or sub je ct O P
and at 0.3 µm inte rvals or sub je cts JL and ML. The p e ak-to-valle y wave -
ront e rror or a 7.3 mm p up il is ab out 7, 4 and 5 µm or JL, O P and ML,
re sp e ctive ly. Note that or an ab e rration- re e e ye the re would b e a com-
p le te ab se nce o contours. (Re p rod uce d with p e rmission from Liang ,
J. & Williams, D. R. (1997). Ab e rrations and re tinal imag e q uality of the
human e ye . J. O p t. So c. Am. A, 14, 2873–2883.)
to actors such as accommodation f uctuations and tear-layer
changes a er a blink (Ho er et al., 2001; Cheng et al., 2004;
Montés-Micó et al., 2004). T ere will also be variation in the
measured wave ront errors owing to the limited reliability o
any aberrometer. It can be seen, or example, that in Fig. 3.11
(A–C) the signal-to-noise o the Hartmann–Shack point images
is poor in some cases; this may lead to errors in the estimates o
the corresponding local slope and orm o the wave ront.
Although the basic wave ront map gives a use ul impression
o the orm and extent o the wave ront errors, it is help ul to be
able to quanti y this in some way. Various methods are available,
but those that are the most popular at the present time are the
total root mean square (RMS) wave ront error and the values o
the Zernike coe cients or the wave ront error.
T e basic method or obtaining RMS wave ront error or any
diameter o pupil is easily understood. We divide the pupil into
equal small areas, and sum the squared values o the wave ront
error or each small area. T is sum is then divided by the num-
ber o areas and the square root o this result gives the RMS
wave ront error. It can be shown that, i the RMS aberration is
less than a 14th o a wavelength (i.e. about 0.04 µm), there is
negligible loss in retinal image quality in comparison with an
eye whose per ormance is limited only by di raction. Obviously
or any eye the RMS error will vary with pupil diameter: in gen-
eral, as the wave ront aberration tends to increase in the outer
zones o the dilated pupil, the RMS aberration increases with
pupil diameter.
Applegate et al. (2007) investigated axial RMS wave ront
errors as a unction o pupil diameter and age in a large sample
o normal eyes that were corrected or spherical and cylindrical
re ractive error. able 3.3 gives the means and standard devia-
tions o their data or subjects aged 30–39 years.
It is interesting to note that the typical axial RMS wave ront
error or a 3 mm pupil (see able 3.3) is close to the limit at
which the image di ers negligibly rom that rom an aberration-
ree system (about 0.04 µm). T e luminance at which this pupil
diameter is ound, a ew hundred cd / m 2, corresponds to that
ound on cloudy days in the UK. T us, in most eyes, wave ront
aberration can play only a minor role in vision under daylight
conditions.
o give some clinical insight into the image degradation
caused by these levels o RMS wave ront aberration, we can
roughly evaluate the blurring e ect o the RMS aberration by
equating it with those o an ‘equivalent de ocus’ – that is, the
spherical error in ocus that produces the same magnitude o
RMS aberration or the same pupil size. T e equivalent de ocus
is given by:
Equivalent defocus (D) = 4.31/2 [RMS error] /R2
where the RMS aberration is measured in microns and the pupil
diameter, R, in millimetres. able 3.3 includes values or the
equivalent de ocus at each pupil diameter; except at the largest
pupil diameter, the equivalent de ocus is always less than 0.25
D. Although the assumption that equal RMS error produces
equal degradation o vision is not completely justi ed (Apple-
gate et al., 2003), it is evident that, in normal eyes, the impact o
optical blur due to monochromatic aberration is modest under
most photopic conditions. For comparison, the reliability o
clinical re ractive techniques is only around ±0.3 D (O’Leary,
1988; Bullimore et al., 1998).
T e second common way o speci ying aberrations is in
terms o Zernike coe cients (Atchison, 2004; Charman, 2005).
T e idea here is that, as very di erent orms o wave ront can
have the same total RMS error yet still produce somewhat di -
erent e ects on vision, it is better to break the complex wave-
ront patterns o the type shown in Fig. 3.11 into a set o simpler
‘building blocks’. Each ‘block’, mathematically described by a

TABLE Variat io n in t he Me an Axial Hig he r-o rd e r Mo no chro mat ic RMS Wave fro nt Erro r and it s St and ard De viat io n in
3.3 t he Eye s o f Sub je ct s Ag e d 30–39 Ye ars*
Pup il Diame t e r (mm) Typ ical Luminance Le ve l (cd / m 2 )
3 400
4 70
5 7
6 0.1
7 0.0005
*Also g ive n is the typ ical amb ie nt luminance le ve l at which the natural p up il d iame te rs occur (take n rom Fig . 3.8) and the e q uivale nt d e ocus (se e
te xt).
(Data from Ap p le g ate , R. A., Donne lly, W. J., Marsack, J. D. e t al. (2007). Thre e -d ime nsional re lationship b e twe e n hig he r-ord e r root-me an-sq uare
wave front e rro r, p up il d iame te r, and ag ing . J. O p t. Soc. Am. A, 24, 578–587.)
Zernike polynomial, corresponds to a speci c type o wave ront
de ormation: some o these are closely related to the traditional
Seidel aberrations. T e set o polynomials, named a er their
originator Fritz Zernike (1888–1966), has the advantage that
the individual polynomials are mathematically independent o
one another. T e overall complex wave ront can then be speci-
ed in terms o the size o the contributions made by each o
these constituent wave ront de ormations: the size o the contri-
bution that each makes is given by the value o the coe cient o
the corresponding polynomial. In the recommended ormula-
tion in current use, each coe cient gives the RMS wave ront
error (in microns) contributed by the particular Zernike mode
(Atchison, 2004; Charman, 2005): the overall RMS wave ront
error is given by the square root o the sum o the squares o
the individual coe cients. T e relative sizes o the di erent
Zernike coe cients thus give detailed in ormation on the rela-
tive importance o the di erent aberrational de ects o any par-
ticular eye.
T e Zernike polynomials can be expressed in terms o polar
coordinates (ρ, θ) in the pupil, where ρ = R / Rmax is the relative
radial coordinate, Rmax being the maximum pupil radius, and θ
is the azimuthal angle, de ned in the same way as in the opto-
metric notation, except that it can rise to 360°. Each polynomial,
or wave ront building block, is de ned by the highest power (n)
to which ρ is raised (the radial order) and the multiple (m) or
the angle θ (the angular requency): m = −2, or example, means
that θ appears as sin2θ, while m = +3 means that it appears as
cos3θ. T e polynomials and coe cients are, then, conveniently
described as Zm m
n and Cn respectively. Fig. 3.12 shows the rst
ew levels o the ‘Zernike tree’ ormed by the di erent polyno-
mials, the levels corresponding to successively greater powers
o n.
T e top two rows o the tree (n = 0 and n = 1) are o no sig-
ni cance or image quality: piston (n = 0) just corresponds to a
longitudinal shi o the wave ront and tilts (n = 1) to small pris-
matic shi s in the image point. T e second-order terms (n = 2)
all depend upon the square o the radius in the pupil. T is is,
o course, a amiliar eature o the sag ormula and in act Z02
represents spherical de ocus and the other terms astigmatism
in crossed-cylinder orm, with the principal meridians either at
45 / 135 ( Z−− 22 ) or 90 / 180 ( Z− 22 ). T us, collectively, the second-
order terms correspond to our amiliar spherocylindrical de o-
cus and can be compensated or by an appropriate contact lens
or other type o correction. T e higher-order (third and greater)
polynomials represent the residual aberrations, which, in the
past, it has not normally been possible to correct. Clinically
these higher-order aberrations have o en been described rather
loosely by terms such as ‘irregular astigmatism’ and ‘spherical
3 Visual O p t ics 35
RMS Wave fro nt Erro r (µm) Eq uivale nt De fo cus (D)
0.052 ± 0.022 0.16
0.102 ± 0.041 0.18
0.174 ± 0.062 0.19
0.289 ± 0.091 0.22
0.513 ± 0.138 0.29
aberration’. T e third order includes vertical and horizontal pri-
mary coma and the ourth order primary spherical aberration.
What levels o Zernike aberrations are ound on the visual
axis in normal eyes? It must be remembered that, like the total
RMS aberration, the values will tend to increase with pupil
diameter, but a variety o studies involving large numbers o
subjects give very similar results (Salmon and van de Pol, 2006).
T e study by Applegate et al. (2007) generated mean values or
the magnitudes o di erent types o third- and ourth-order
Zernike aberration or di erent pupil sizes and age (coe cients
or still higher-order Zernike modes are usually much smaller).
able 3.4 gives their values or 30–39-year-old eyes. Note that,
where appropriate, the coe cients or similar, but di erently
oriented, Zernike polynomials have been combined.
It is evident that, at the smaller 3 mm pupil size, third-order
coma and tre oil aberrations tend to dominate over ourth-order
aberrations, including spherical aberration, although spherical
aberration becomes comparable to coma or the larger 6 mm
pupil.
A somewhat di erent picture emerges i we average the
signed coe cients, rather than considering the RMS values.
Fig. 3.13 gives some typical data, in this case or a large sample
(109) o normal eyes with a pupil diameter o 5.7 mm (Porter
et al., 2001). What is striking is that almost all the modes have a
mean close to zero, although individual eyes may have substan-
tial aberration, as shown by the relatively large standard devia-
tions. A notable exception is the j = 12, Z04 spherical aberration
mode, where the mean is positive and di ers signi cantly rom
zero. T us, the picture that emerges is that most eyes have a cen-
tral tendency to be ree o all higher-order aberration, except
or spherical aberration, which shows a signi cant bias towards
slight positive (undercorrected) values. T e Zernike coe cients
o normal individual eyes vary randomly about these mean val-
ues in a way that presumably depends upon the idiosyncratic
sur ace tilts, decentrations and other asymmetries o the indi-
vidual eye. T e aberrations o eyes where pathology, such as
keratoconus, is present may, however, be much larger.
Away rom the visual axis, the major contribution to retinal
image blur in the axially corrected eye is usually oblique astig-
matism (Atchison, 2012a). T e magnitude o the dioptric di er-
ence between the sagittal and tangential oci is similar in most
eyes. Atchison and Smith (2000) suggest that this di erence
between the two power errors can be described by:
A (θ) = 2.66 × 10 − 3 θ2 − 2.09 × 10 − 7 θ4
where θ degrees is the eld angle with respect to the visual axis
and the oblique astigmatism, A(θ), is in dioptres. Although the
amount o astigmatism shows little variation, the relationship
36 PART 1 Int ro d uct io n

Fig . 3.12 The f rst f ve le ve ls o the Ze rnike ‘p yramid ’ or ‘tre e ’ showing the contour map s corre sp ond ing to the f rst 15 Ze rnike p olynomia ls (up to
the ourth ord e r). The contour scale is arb itrary and , in the ind ivid ual e ye , will vary with the coe f cie nt o e ach p olynomial. Rows re p re se nt succe ssive
ord e rs, n (i.e . the maximal p owe r to which the normalize d p up il rad ius is raise d ) and columns d i e re nt azimuthal re q ue ncie s, m. Also shown (in b rack-
e ts) are the ind e x numb e rs, j, o the p olynomials and some o the name s use d to d e scrib e the m: p olynomials (11) and (13) are o te n calle d se cond ary
astig matism. H / V astig matism = horizontal / ve rtical astig matism.

TABLE Me an Ab so lut e Le ve ls RMS Wave fro nt Erro rs (WFE) o f Diffe re nt Typ e s o f Hig he r-o rd e r Ze rnike Ab e rrat io n,
3.4 and t he ir St and ard De viat io ns, fo r 30–39-ye ar-o ld Sub je ct s and Tw o Pup il Diame t e rs
RMS WFE (µm) fo r 3 mm RMS WFE (µm) fo r 6 mm
Ab e rrat io n Co mb inat io n o f Co e fficie nt s Pup il Diame t e r Pup il Diame t e r
Tre foil (j = 6 and 9) 0.027 ± 0.017 0.139 ± 0.089
Coma (j = 7 and 8) 0.031 ± 0.022 0.136 ± 0.087
Te trafoil (j = 10 and 14) 0.010 ± 0.004 0.056 ± 0.030
Se cond ary astig matism (j = 11 0.015 ± 0.008 0.055 ± 0.027
and 13)
Sp he rical ab e rration 0.014 ± 0.010 0.130 ± 0.090
Total hig he r-ord e r RMS (j = 12) 0.052 ± 0.022 0.289 ± 0.091

(Data from Ap p le g ate , R. A., Donne lly, W. J., Marsack, J. D., e t al. (2007) Thre e -d ime nsional re lationship b e twe e n hig he r-ord e r root-me an-sq uare
wave front e rror, p up il d iame te r, and ag ing . J. O p t. Soc. Am. A, 24, 578–587.)
 3 Visual O p t ics 37

Fig . 3.13 Typ ical d ata or the me ans o the sig ne d value s o the Ze rnike
coe f cie nts o e ye s at a p up il d iame te r o 5.7 mm: among the hig he r-
o rd e r coe f cie nts only j = 12 ( ), sp he rical ab e rration, has a value that
d i e rs sig nif cantly rom ze ro. ANSI = Ame rican National Stand ard s In-
stitute . (Ad ap te d from Porte r J., Guirao, A., Cox, I. G. & Williams, D. R. Fig . 3.14 The long itud inal chromatic ab e rration o the e ye as ound
(2001). The human e ye ’s monochromatic ab e rrations in a larg e p op ula- b y d i e re nt inve stig ators. (Ad ap te d from Charman, W. N. (1991). O p tics
tion. J. O p t. Soc. Am. A, 18, 1793–1803.) o f the human e ye . In W. N. Charman (e d .) Vision and Visual Dys unction.
Vol. 1: Visual O p tics and Instrume ntation (p p . 1–26). Lond on: Macmillan.)

between the two image sur aces and the retina varies across
eyes and re ractive groups. It has been speculated that those
eyes where the mean sphere shows relative hyperopia in the
periphery may be more susceptible to the development o myo-
pia (Charman and Radhakrishnan, 2010; Smith, 2011; Flitcro ,
2012). For this reason there is ongoing interest in exploring the
extent to which modi ying the pattern o peripheral re raction,
in particular by reducing relative peripheral hyperopia, by the
wearing o suitably designed spectacles or contact lenses (Shen
et al., 2010; Sankaridurg et al., 2011; Aller and Wildsoet, 2013),
or by orthokeratology (Cho et al., 2005; Walline et al., 2009; Si
et al., 2015), may reduce myopia progression in children. Results
to date appear to be promising.

CHRO MATIC ABERRATIO N

As the re ractive indices o all the ocular media vary with wave-
length, the eye su ers rom both longitudinal and transverse
chromatic aberration. At the ovea, the ormer is more impor-
tant – the amount o aberration approximating to that which
would occur i the eye media were all water. Unlike the mono-
chromatic aberrations, longitudinal chromatic aberration varies
very little between individuals and equals about 2.5 D across the
visible spectrum (Fig. 3.14).
As the visual axis is usually displaced rom the nominal Fig . 3.15 White -lig ht op tical line sp re ad unctions or e ye s with d i -
optical axis o the eye by about 5°, some individually varying, e re nt p up il d iame te rs (mm) at op timal ocus. The solid line curve s g ive
transverse chromatic aberration is ound at the ovea, typically the e xp e rime ntal me asure me nts, and the d ashe d curve s the the ore tical
amounting to about 0.8 min arc (Rynders et al., 1995); this ur- re sult or a d i raction-limite d syste m. (Ad ap te d from Camp b e ll, F. W. &
Gub isch, R. W. (1966). O p tical q uality of the e ye . J. Physiol. (Lond on),
ther degrades oveal image quality. 186, 558–578.)

O VERALL O PTICAL PERFO RMANCE O F THE EYE

IN WHITE LIGHT
Both monochromatic and chromatic aberration will degrade
the in- ocus retinal image in comparison with that which would
be expected or an aberration- ree eye with the same pupil size.
Fig. 3.15 illustrates this or the case o the image o a ne line –
that is, the line spread unction.
T e experimental results are compared with the calculated
pro les or the aberration- ree case (Campbell and Gubisch,
1966). With small pupils, aberration has only minor e ects, but
the per ormance de cit due to aberration steadily increases as
the pupil diameter increases. It should, however, be borne in
mind that under natural conditions large pupils are ound only
when eld luminances are low and neural per ormance is poor.
T us di raction-limited optical per ormance with large pupils
would be o little value as the neural retina could not utilize the
available in ormation. Although monochromatic aberrations at
constant pupil diameter tend to increase in later li e, under nat-
ural conditions the pupil diameter is smaller, so that the quality
o the retinal image changes very little (Applegate et al., 2007).
38 PART 1 Int ro d uct io n
O CULAR DEPTH O F FO CUS
I the retinal image is gradually de ocused, its quality will deteri-
orate owing to de ocus blur. Nevertheless, there is a nite range
o ocus over which this blur causes no appreciable deteriora-
tion in visual per ormance. T e precise value o the total depth
o ocus depends on how it is assessed (e.g. Atchison, 2012b),
but Fig. 3.16 gives some representative photopic values rom
di erent studies. It can be seen that, or typical photopic pupils
o about 4 mm diameter, visual per ormance will remain rela-
tively una ected provided that the spherical error o ocus does
not exceed about ±0.25 D.
CO RRECTIO N O F HIGHER-O RDER O CULAR
ABERRATIO N
Conventional corrections are designed to compensate or the
spherocylindrical errors o the eye. As noted earlier, in wave-
ront terms these correspond to second-order wave ront aber-
rations. Would it be possible to improve visual per ormance
urther by also correcting the higher-order aberrations o the
eye, as we can now easily measure these under clinical condi-
tions? Until recently, the irregular and individual nature o
the monochromatic wave ront aberrations o the eye made it
impossible to correct them ully, although some reduction in
the average spherical aberration could be achieved with appro-
priately aspheric contact lenses (see Chapters 6 and 13).
Longitudinal chromatic aberration can be corrected by a
suitable achromatizing doublet lens, but the improvement in
retinal image quality in white light is small and occurs mainly at
intermediate spatial requencies (Campbell and Gubisch, 1967);
no improvement in conventional high-contrast, white-light
visual acuity is normally detectable (Hartridge, 1947).
More recently, however, real progress has been made in cor-
recting monochromatic aberration using either adaptive optics
Fig . 3.16 Examp le s o e xp e rime ntal me asure me nts o p hotop ic, total
monocular d e p th o ocus / f e ld as a unction o p up il d iame te r (op ti-
mal ocus lie s mid way throug h the total d e p th o ocus). (Ad ap te d from
Charman, W. N. (1991). O p tics of the human e ye . In W. N. Charman (e d .)
Vision and Visual Dys unction. Vol. 1: Visual O p tics and Instrume ntation
(p p . 1–26). Lond on: Macmillan.)
or liquid crystal phase plates (Liang et al., 1997; Vargas-Martin
et al., 1998). Although all these corrections are, at present, ea-
sible only in the laboratory, they do show that marked improve-
ments in spatial vision can be achieved over the uncorrected
eye, particularly i both monochromatic and chromatic aber-
rations are corrected; i only monochromatic aberrations are
corrected, per ormance in white light improves only modestly
(Yoon and Williams, 2001).
Will it prove possible to correct axial ocular aberrations in
everyday li e? In theory, having measured the wave aberrations
o the individual eye, the orm o the cornea could be appro-
priately shaped, or example by a computer-controlled scan-
ning spot excimer laser, to compensate or the aberrations.
T is has been the inspiration behind the development o many
commercial aberrometers that, when coupled to suitably con-
trolled excimer lasers, are used in wave ront-guided re ractive
surgery (Krueger et al., 2004). In practice, rather than eliminat-
ing monochromatic aberrations, this approach has so ar only
been able to ensure that postsurgery aberrations are comparable
with normal levels, partly because o our limited knowledge o
regression e ects associated with corneal healing.
Alternatively a tight- tting, customized, contact lens with
minimal transverse and rotational movement might be engi-
neered to play the same role (Klein and Barsky, 1995; Klein,
1998; Schweigerling and Snyder, 1998). T e lenses would lack
rotational symmetry and would be customized so that their
local optical thickness varied in such a way as to compensate
or the wave ront aberration o the individual eye. o improve
optical per ormance in eyes with normal levels o aberration,
any lens decentration should be less than about 0.5 mm and
any rotation less than 10° (Bara et al., 2000; Guirao et al., 2001).
However, such approaches would reduce only the monochro-
matic aberrations, which, in any case, change with the level
o accommodation (Ivano , 1956; Lopez-Gil et al., 1998) and
other actors (Charman and Chateau, 2003). T e blur e ects
due to chromatic aberrations would remain uncorrected. More-
over, the worst monochromatic aberration occurs in the periph-
ery o the dilated pupil, and pupil dilation occurs only when
light levels are low and visual per ormance is largely limited by
neural, rather than optical, actors. For these reasons, custom-
ized correction o aberration seems likely to be pro table only
in the case o individuals whose monochromatic aberration is
particularly high, as in keratoconus (Jinabhai et al., 2012). T is
problem is discussed urther in Chapters 6 and 13.
Effe ct ivit y, Sp e ct acle Mag nificat io n,
Acco mmo d at io n and Co nve rg e nce
Effe ct s w it h Co nt act Le ns and
Sp e ct acle Co rre ct io ns
Many patients may wish to change rom a spectacle to a con-
tact lens correction, and vice versa. Although the corrections
may be equally e ective in producing in- ocus retinal images in
both eyes, they do have a number o slightly di erent secondary
e ects, most o which are associated with the act that, whereas
contact lenses are placed directly on the cornea, spectacle lenses
are placed at a signi cant distance, typically 10–20 mm, in ront
o this sur ace. Corrections achieved by corneal ablation using
excimer lasers, such as photore ractive keratectomy (PRK), laser
in situ keratomileusis (LASIK) or other corneal surgical proce-
dures, such as radial keratotomy or intrastromal rings, produce

broadly similar e ects to contact lenses, although their e ective
optical zones are usually smaller.
EFFECTIVITY
T e role o the distance correction is to produce an intermediate
image at the ar point o the particular eye. Due to the non-zero
vertex distance o any spectacle correction, this ar point will lie
at slightly di erent distances rom the two types o correcting
lens. T us the spectacle and contact lens powers required to cor-
rect a particular eye will di er.
From Fig. 3.17A we can see that, using a reduced eye model,
i the vertex distance is a (taken as positive) and the ocular
re raction is K, giving a ar point distance rom the cornea
k = 1 / K, the second ocal point o the correcting lens lies at a
distance a + k.
T us the power o the correcting lens (Fc) is:
Fc = 1/ (a + k) = 1 (a + 1/K) = K/ (1 + aK)
For a contact lens, a will be zero so that the required value o
Fc equals the ocular re raction in this simple model. T is does not
apply with a spectacle lens. T e result is that a hypermetrope will
require a higher-powered contact lens than a spectacle lens, the
reverse occurring or a myope. T e di erence between the two
correcting powers is plotted as a unction o the spectacle cor-
rection or a vertex distance o 14 mm in Fig. 3.17B, rom which
it can be seen that the di erence between the required powers
o correction becomes signi cant (i.e. greater than 0.25 D) only
Fig . 3.17 (A) Ge ome try re lating the ar p oint o an ame trop ic e ye (hy-
p e rme trop ic in the case shown) and the corre cting le ns. (B) Di e re nce
b e twe e n the re q uire d p owe rs o contact le ns and sp e ctacle corre ctions,
as a unction o the sp e ctacle corre ction, assuming that the ve rte x d is-
tance o the sp e ctacle le ns is 14 mm.
3 Visual O p t ics 39
when the magnitude o the ocular re raction exceeds about ±4
D. Appendix C provides a tabulation o ocular re raction values
based on spectacle lens re ractions or various vertex distances.
SPECTACLE MAGNIFICATIO N
Spectacle magni cation, as its name implies, describes the ratio
o the image size in the corrected ametropic eye to that in the
uncorrected eye. It is particularly signi cant in cases o aniso-
metropia, where a er correction the di erential magni cation
o the two retinal images may give rise to symptoms o aniseiko-
nia, and with cylindrical errors, where the di erent magni ca-
tions in the two principal meridians caused by the correction
may lead the patient to complain o distorted images.
T e retinal images o any object in the eyes o an uncorrected
ametrope have a scale that is governed by the chie rays passing
rom the extremities o the object through the centres o the
entrance and exit pupils o the eye. Each image point will, o
course, be blurred (Fig. 3.18A). Although placing a contact lens
on the cornea does not a ect the course o the chie ray, and
hence does not alter the size o the retinal image, this is not the
case with a spectacle lens. A positive correction increases the
angle that the chie ray makes with respect to the axis, whereas
a negative correction reduces it.
Fig. 3.18B illustrates this e ect or a positive, thin lens cor-
rection and a reduced eye with both entrance and exit pupils at
the cornea. We de ne the spectacle magni cation, SM, as the
retinal image height in the corrected eye, h′, divided by that in
the uncorrected eye, h0′. From the diagram it can be seen that, i
all angles are assumed to be small:
SM = h'/h0 ' = w'k'/w0 'k' = w'/w0 ' = (w/n') / (w0 /n') = w/w0
Fig . 3.18 (A) Ray g e ome try in the case o an uncorre cte d hyp e rme t-
rop e . (B) E e ct o a corre cting sp e ctacle le ns. Note that the ang le that
the incid e nt chie ray make s with the axis is incre ase d rom w0 with-
out corre ction to w with corre ction. Corre sp ond ing ly, the ang le o the
chie ray with the axis a te r re raction is incre ase d rom w0′ to w′ a te r
co rre ction.
40 PART 1 Int ro d uct io n
Fig . 3.19 Typ ical value s or sp e ctacle mag nif cation ob taine d with
sp e ctacle le ns and contact le ns corre ctions. The ratio o the two sp e c-
tacle mag nif cations is also shown. E e ctivity has b e e n allowe d or, so
that p oints on any ve rtical line re e r to the same ame trop ia. (Ad ap te d
from We sthe ime r, G. (1962). The visual world of the ne w contact le ns
we are r. J. Am. O p tom. Assoc., 34, 135–138.)
As the role o the correcting lens is to orm an image o height
h1′ at the ar point, we thus have (Fig. 3.18B):
SM = [h1 '/ (fc' − a)] / [h1 '/fc'] = 1/ [1 − aFc]
In this simple model, the spectacle magni cation will be
unity or contact lenses (vertex distance a = 0), less than unity
or negative, myopic spectacle corrections and greater than 1
or positive corrections. Somewhat perversely, spectacle cor-
rection is o en expressed as the percentage by which it di ers
rom unity, so that a spectacle magni cation o 1.05× would be
described as ‘5% magni cation’.
In practice we cannot strictly treat corrections as thin
lenses and the entrance and exit pupils do not lie at the cor-
nea. For practical purposes the pupils may be taken as being
situated about 3 mm behind the cornea. Using a thick-lens
extension o the arguments already used, it can then be
shown that:
SM = [(1 − bF ′v) (1 − (t/n) F1 )]
−1
≈ (1 + bF ′v) (1 + (t/n) F1 )
where b is the vertex distance measured rom the back sur ace
lens to the entrance pupil, and t, n, F1 and F′ v are the lens thick-
ness, re ractive index, anterior sur ace power and back vertex
power, respectively. It can be seen that the magni cation is a
unction o both lens design and vertex distance. Fig. 3.19 shows
typical values o spectacle magni cation or both contact lens
and spectacle corrections.
Note particularly that spectacle magni cation is always close
to unity or contact lenses, so that there are likely to be ew
magni cation-related complaints rom patients when moving
directly rom no correction to a contact lens correction or rom
one contact lens correction to another. Casual contact lens wear-
ers who normally wear spectacle corrections may theoretically
notice spatial distortion, although or myopes this is counter-
balanced by the bene t o relatively larger retinal images, which
may improve acuity. Spectacle magni cation e ects a er cor-
neal re ractive surgery are similar to those with contact lenses
(Applegate and Howland, 1993).
In addition to spectacle magni cation as de ned above, rela-
tive spectacle magni cation (RSM) is sometimes discussed. T is
is the ratio o the retinal image size in the corrected ametropic
eye to that in a speci ed emmetropic schematic eye. T eoreti-
cally it has the advantage o putting retinal image size on an
absolute basis. However, in most clinical work it is the changes
described by spectacle magni cation that are o interest and
RSM is o limited practical use.
As noted earlier, when anisometropes are corrected by
spectacle lenses, marked di erences in spectacle magni ca-
tion may occur between the two eyes, which may result in
symptoms o aniseikonia. It is obvious that these are much
reduced in the case o contact lenses, which there ore mini-
mize the possibility o aniseikonic symptoms (Winn et al.,
1986). A closely related e ect occurs when the anisometrope
looks in di erent directions with the head in a xed position.
When ordinary spectacles are worn and the visual axes do not
pass through the optical centres, prismatic e ects are intro-
duced, o magnitude given by Prentice’s rule P = cFc, where P
is the induced prism power in prism dioptres, c the decentra-
tion in centimetres and Fc the lens power in dioptres. I the
corrections are the same or both eyes, these prismatic e ects
cause no problems or the spectacle wearer. In anisometropia,
however, the prismatic e ects will be di erent or each eye. For
example, in reading, the visual axes o a young anisometrope
would normally intercept the lenses o the distance correc-
tion at some distance below the optical centres. Assuming this
distance to be 8 mm and the corrections to be right eye (RE)
−3.00 D, le eye (LE) −6.00 D, the prismatic e ects would
be RE 2.4Δ and LE 4.8Δ, respectively, both base-down. T e
di erence in vertical prism power exceeds normal usional
abilities, so that, to avoid the problem, the spectacle-corrected
anisometrope would have to execute head turns during read-
ing rather than simply depress the visual axes. T is problem is
absent with well-centred contact lenses.
ACCO MMO DATIO N DEMAND
Just as the position o the correcting lens a ects the correct-
ing power required and the spectacle magni cation, so too
does it inf uence the accommodation required to view a near
object. T e accommodation necessary with any particular cor-
rection can easily be calculated or any given object distance,
lens position and correcting power by determining the di er-
ence between the vergence o the light striking the cornea when
viewing a near object and that or a distant object. However, an
adequate approximation or most purposes is that the accom-
modation demand (A, in dioptres) is given by:
A ≈ −L(1 + 2aK)
where L is the object vergence (negative or real objects), a
is the vertex distance and K is the ocular re raction. In this
approximation, a is zero or a contact lens, so that we can see
that or a myope (negative K) the accommodation demand is
higher with contact lenses than with spectacle lenses, whereas
the reverse is true or hypermetropes. I we consider an object
at 33 cm (L = −3 D) and a spectacle vertex distance a = 14 mm,
we nd that the di erence in demand with the two types o
correction becomes signi cant (>0.25 D) when the magni-
tude o the re ractive error, K, is larger than about 3 D. T us,
higher myopes approaching presbyopia might slightly delay
the need or a reading addition by wearing spectacles, whereas

Fig . 3.20 Ocular accommodation required when a patient with the spec-
tacle ametropia given on the abscissa views targets at either 0.50 or 0.33
m (vergence, L= −2 or −3 D) when corrected with either spectacles (a = 14
mm) or contact lenses. (Adapted from Westheimer, G. (1962). The visual
world of the new contact lens wearer. J. Am. Optom. Assoc., 34, 135–138.)
Fig . 3.21 Prismatic e e cts o d istance sp e ctacle corre ctions d uring
ne ar vision.
hypermetropes would nd near vision easier with a contact
lens correction.
Fig. 3.20 shows results rom a slightly more re ned model or
the accommodation demand at two object distances.
3 Visual O p t ics 41
CO NVERGENCE DEMAND
Contact lenses move with the eyes, hence convergence demands
when viewing near objects are identical to those applying in the
uncorrected state. In contrast, myopes with a negative spectacle
correction or distance observe near objects through base-in
prisms, as they are no longer looking through the optical centres
o their lenses (Fig. 3.21).
T e base-in prismatic e ects reduce the convergence
requirement, compared with the naked eye or contact lens
situation. Spectacle-corrected hypermetropes, however, experi-
ence a base-out e ect at near, which increases the convergence
demand. Allowing or a typical interpupillary distance o 65
mm and the centre o rotation o each eye being about 12 mm
behind the cornea, application o Prentice’s rule shows that, or
an object distance o 33 cm, the convergence demand or each
eye is reduced by about 0.25Fc prism dioptres or a negative
spectacle correction and similarly increased or a positive cor-
rection. In most cases, then, the change in convergence demand
is small compared with the usion reserves. Since both accom-
modation and convergence demands are higher or myopes
with contact lenses, and lower or hypermetropes, the accom-
modation–convergence links are minimally disturbed.
O t he r O p t ical Effe ct s
T ere are certain additional phenomena related to prismatic
e ects o ophthalmic lenses that are not encountered by contact
lens wearers. T ese phenomena, which are experienced by spec-
tacle lens wearers, relate to the e ective eld o view in static
gaze, the extent o eye movements required to maintain xation
and the appearance o the eyes as viewed by another person (or
when looking in a mirror).
FIELDS O F VIEW AND FIXATIO N
With spectacle lenses, the prismatic e ects associated with the
lens peripheries result, when the eyes are stationary, in an annu-
lar zone o the visual eld being invisible (a ring scotoma) with a
positive correction, and being seen diplopically with a negative
correction. Analogously, when the eye is rotated to view objects
away rom the axis o the correction, a larger eye movement, in
comparison with the uncorrected eye, is required with a nega-
tive spectacle lens and a smaller one with a positive correction.
T is can be seen in Fig. 3.22.
I C is the centre o rotation o the eye, the e ective eld o
view as seen through the spectacle lens is governed by the posi-
tion o its image, C′, as ormed by the correcting lens.
T ese xation e ects are absent with contact lens corrections,
as the lenses ollow the movements o the eyes rom xation to
xation. T e periphery o the static eld o view may, however,
be slightly a ected i the contact lens or its optical zone is small,
and in the case o rigid lenses f are or glare may occur owing
to discontinuities at the edge o the lens or optic zone a ecting
ray pencils rom the periphery o the eld. A er laser re ractive
surgery, the optic zone diameter may be smaller than the dilated
pupil, leading to complaints o haloes at night.
APPARENT SIZE O F THE EYES
A cosmetic disadvantage o spectacle lenses is that they alter the
apparent size o the eyes o the wearer as seen by other people:
42 PART 1 Int ro d uct io n
Fig . 3.22 Fie ld s o vie w as se e n throug h sp e ctacle le ns corre ctions.
The ce ntre o rotation o the e ye is at C, and its imag e as se e n throug h
the sp e ctacle le ns is at C′. B is the ap p are nt macular f e ld o vie w and A
the actual f e ld .
the eyes appear larger with positive spectacle corrections and
smaller with negative ones. Using a thin lens approximation,
where the power o the correcting lens is Fc and the eye is at a
distance l rom the lens, it is easy to show that the paraxial mag-
ni cation, M, o the anterior eye is given by:
M = 1/ (1 + Fcl)
Because l is small (<0.02 m) this can be approximated by:
M = 1 − Fcl
T us i l is −20 mm and Fc is −10 D, the eyes nominally appear
to be only 80% o their true size. In act, or the viewer the
apparent size will vary depending upon the viewing direction,
as conditions will not necessarily be paraxial. T ese magni ca-
tion e ects can be reduced by minimizing the vertex distance
with high-powered spectacle corrections.
Clearly, with contact lenses this cosmetic disadvantage is
absent.
Co nclusio n
It has been shown that, although various types o correction
all produce sharp retinal images in the ametropic eye, the
sizes o the associated retinal images will di er, as will the
demands on accommodation and convergence. A particular
advantage o contact lenses is that they produce little change
in the retinal image size in comparison with the uncorrected
eye.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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 PART

2
So ft Co nt act Le nse s

PART O UTLINE
4 Soft Le ns Mate rials 45
Carole Mald onad o-Cod ina
5 Soft Le ns Manufacture 61
Nathan E ron
6 Soft Le ns O p tics 68
W Ne il Charman
7 Soft Le ns Me asure me nt 73
Klaus Ehrmann
8 Soft Le ns De sig n and Fitting 86
Grae me Young
9 Soft Toric Le ns De sig n and Fitting 95
Richard G Lind say
10 Soft Le ns Care Syste ms 103
Philip B Morg an
This pa ge inte ntiona lly le ft bla nk
 4
So ft Le ns Mat e rials
CARO LE MALDO NADO -CO DINA
Int ro d uct io n
So contact lenses have had a massive impact on the global
contact lens market since they became widely available in the
early 1970s. Since their introduction, the number o so contact
lenses being prescribed around the world has steadily increased
and it is mainly the sale o so contact lenses that is responsible
or an industry that is estimated to be worth around US$ 8 bil-
lion annually (Nichols, 2015). A recent survey has indicated that
so lenses currently make up about 87% o all contact lens re ts
worldwide (Morgan et al., 2016).
T e saturation o the contact lens market with so lenses has
occurred primarily or two reasons. First, so lenses provide
wearers with what they see as the two most important require-
ments or success ul contact lens wear – good vision and good
com ort. T e major obstacle as ar as rigid lenses are concerned
is generally accepted as being their lack o com ort and, in
particular, their initial discom ort (Polse et al., 1999). Second,
advances in manu acturing technology have directed the indus-
try towards so lenses and, still urther, towards the concept o
disposability.
Contact lens materials (both so and rigid) are good exam-
ples o biomaterials. A biomaterial may be de ned as a natural
or synthetic material that is suitable or introduction into living
tissue, especially as part o a medical device. T e term encom-
passes a vast array o technologies, including tissue engineering,
arti cial organs, bioceramics, medical devices and implantable
drug delivery systems. Contact lenses are classed as a medical
device in most countries.
Very ew o us are likely to get through li e without having
some kind o biomaterial introduced into our bodies. T e most
common examples in use today include dental llings, contact
lenses, intraocular lenses, heart valves and stents. T is list in
itsel highlights just how diverse biomaterials must be in order
to satis y their very speci c end application – or example, a
contact lens material has very di erent properties to a material
used or dental llings.
I a biomaterial is to be success ul in its application, it ol-
lows that it must also be biocompatible. Biocompatibility re ers
to the ability o a material to per orm with an appropriate host
response in a speci c application. An ‘appropriate host response’
would include not having toxic or injurious e ects on biologi-
cal systems. Biomaterials manu actured or use as contact lenses
must not only satis y all these requirements or sa e use within
the eye, but additionally they must also have very speci c char-
acteristics such as being transparent (and remain so on-eye), be
com ortable and be relatively cheap to manu acture.
T is chapter reviews the building blocks, properties and
characteristics o the materials that are used to manu acture
so contact lenses and provides some o the history o develop-
ment o these materials. Most clinicians are amiliar with the
United States Adopted Name (USAN) o a particular lens mate-
rial (e.g. eta lcon A or lotra lcon A), but any urther under-
standing o the material is o en lacking. T is chapter aims to
give meaning and background to these USAN names in order
to help the reader understand and di erentiate between di er-
ent so lens materials.
Po lyme rs
All contact lens materials may be classi ed as polymers. T e
word ‘polymer’ is derived rom ancient Greek, meaning ‘many
parts’. Polymers are solid materials (as opposed to gases or liq-
uids) that are made up o high-molecular-weight chains (i.e.
long chains), which in turn are made up rom small repeating
units. T ese repeating units are called monomers. Polymers
are macromolecules (giant molecules) made rom thousands
o atoms. T e term ‘polymer’ is there ore an umbrella term or
materials that include plastics (e.g. polymethyl methacrylate
[PMMA], used in the manu acture o ‘hard’ rigid lenses), bres
(e.g. nylon), elastomers (i.e. rubbers such as silicone rubber)
and the materials being discussed in this chapter – hydrogels.
T e term ‘hydrogel’ is o en used interchangeably with the
term ‘so ’ when re erring to contact lenses. So lenses are so
named because they are made rom water-swollen, cross-linked,
hydrophilic polymers that are exible and compliant. T e term
‘hydrophilic’ is used to describe the act that the networks rom
which these materials are made are ‘water-loving’.
T e widespread use o polymers in many areas o our every-
day lives has become a common and accepted phenomenon –
so much so that they have been re erred to as the ‘steel o the
21st century’. Polymers possess many properties that make
them suitable or a wide range o applications, some o which
are unique. T ese properties are in part due to the length o the
molecules rom which they are made. Additionally, polymers
also derive their unique characteristics rom the ability o cer-
tain atoms to join together to orm stable covalent bonds.
Many polymers are composed o hydrocarbons (i.e. carbon
[C] and hydrogen [H] alone) such as polyethylene and poly-
styrene. However, even though the basic make-up o many
polymers is carbon and hydrogen, other elements can also be
involved. Oxygen (O), nitrogen (N), chlorine (Cl), uorine
(F) and silicon (Si) are other elements commonly ound in the
molecular make-up o polymers. Many polymers have carbon
backbones (these are considered organic polymers), but some
can also have silicon or phosphorous backbones (these are con-
sidered inorganic polymers).
T e kinds o atoms making up a polymer as well as their
geometric arrangement give each polymer its chemical distinc-
tiveness, and thus, its particular use and unction. Polymers
themselves may be completely natural (e.g. cellulose), partly
natural (e.g. cellulose acetate) or completely synthetic (e.g.
45
46 PART 2 So ft Co nt act Le nse s
PMMA). Most o the polymers used in the manu acture o so
contact lenses all into this last category, i.e. they are man-made.
THE STRUCTURE O F PO LYMERS
A polymer chain can be described by speci ying the kind o
repeating units present and their spatial arrangement. In this
way, several broad categories o polymer can be described.
A homopolymer is one in which only one type o monomer
is used, i.e. the units are chemically and stereochemically iden-
tical, with the exception o the end units. I the chain units are
arranged in a linear sequence the polymer is re erred to as a
linear homopolymer. T is is shown schematically in Fig. 4.1.
Departures rom this simple array lead to structures o increas-
ing geometric complexity. A non-linear or branched structure is
shown in Fig. 4.2.
T e chemical di erences between linear and branched
polymers may be quite small, yet, because o the structural
di erences, the two molecules can have quite markedly di er-
ent properties. A good example o these di erences is ound
between low-density polyethylene (branched) and high-density
polyethylene (linear). Low-density polyethylene is commonly
used as a packaging lm (e.g. cling lm and or carrier bags),
whereas high-density polyethylene is used or making pipes and
durable plastic bottles because o its higher impact strength.
Non-linear and network structures can also be prepared
rom a collection o linear chains by covalently linking together
chain units selected rom di erent molecules. Such a system is
said to be cross-linked. T is is shown schematically in Fig. 4.3.
Here, X represents the chemical species (the cross-linker) that
covalently links together the A units rom di erent molecular
chains. When a suf cient number o units are intermolecularly
cross-linked, an in nite network is ormed. A cross-linker is
an important ingredient in a so contact lens monomer mix,
which will be discussed later.
A copolymer is one in which more than one type o mono-
mer is used. T e properties o a copolymer depend not only on
the chemical nature and amounts o the co-units, but also very
markedly on how the units are distributed along the chain. For
linear copolymers, three ‘ideal’ arrangements can be described.
Fig . 4.1 Line ar homop olyme r.
Fig . 4.2 Branche d homop olyme r.
T e rst is an alternating copolymer, which is shown in Fig. 4.4.
In this scenario, each monomer pre ers to interact with the el-
low monomer rather than itsel .
At the opposite extreme is the ordered or block copolymer,
where there is an overwhelming tendency or a unit to be suc-
ceeded by another o the same kind. Here, long sequences o
one type o unit alternate with long sequences o the other kind
(Fig. 4.5).
T e third major classi cation is the random copolymer.
Here, di erent units are randomly distributed along the chain
(Fig. 4.6).
Departing rom the restrictions o a linear array, branched
copolymers, known as ‘gra polymers’, can also be prepared.
T e backbone o the molecule is composed o one type o unit,
and the long side chains, or gra s, are made up o another. More
sophisticated types o gra polymers have backbones made up
o di erent repeating units and several distinctly chemically
di erent side groups. T is type o polymer is represented sche-
matically in Fig. 4.7.
One nal important classi cation is that o polymers into
either amorphous or crystalline polymers (i.e. their macro-
molecular order) (Fig. 4.8). Crystalline polymers have a geo-
metrically regular structure and are generally sti , resistant to
chemicals and tough. T ey have limited use as materials or
contact lenses owing mainly to their poor optical qualities (i.e.
they tend to be translucent or opaque). A good example o a
semicrystalline polymer is polypropylene, which is o en used
to make the casts in the cast-moulded manu acturing process
o contact lenses.
Amorphous polymers, on the other hand, do not have a
regular structure. T e polymer chains intermingle and are in
Fig . 4.3 Cross-linke d syste m.
Fig . 4.4 Alte rnating cop olyme r.
Fig . 4.5 Block cop olyme r.

random positions (imagine a pile o spaghetti on a plate), which
o en allows these polymers to be transparent. Depending on
their chain mobility, amorphous polymers can be classi ed as
either ‘plastic’ or ‘glassy’ ( ighe, 1997).
PO LYMERIZATIO N
T e chemical reaction that monomers undergo in order to orm
long-chained polymers is known as polymerization. Broadly
speaking, monomers can be chemically joined together in two
ways: by step growth (condensation) or chain growth (addition)
processes. Condensation polymers are produced by the reaction
o monomeric units with each other, resulting in the elimination
o a small molecule (e.g. water). However, hydrogels are gener-
ally ormed through chain growth (addition) polymerization.
Be ore entering into the intricacies o polymerization it is
important to establish that, in order to make a contact lens mate-
rial, the ollowing three basic ‘ingredients’ are required in the
monomer ‘mix’: (1) the monomer(s), (2) a cross-linking agent
and (3) an initiator. In some cases a solvent is also added to the
Fig . 4.6 Rand om cop olyme r.
Fig . 4.7 Gra t cop olyme r.
Fig . 4.8 Sche matic re p re se ntation o macromole cular ord e r showing
an amorp hous p olyme r (le t) and a crystalline p olyme r (rig ht). (Re -
d rawn rom Kastl, P. R., Re ojo, M. F. & Dab e zie s, O . H. (1984) Re vie w
o p olyme rization or the contact le ns f tte r. In O . H. Dab e zie s (Ed .) The
CLAO Guid e to Basic Scie nce and Clinical Scie nce . O rland o: Grune &
Stratton Inc.)
4 So ft Le ns Mat e rials 47
monomer mix. A solvent is used when lenses are manu actured by
‘wet casting’, where the solvent is gradually replaced with saline. I
a solvent is not used, the manu acturing process is o en re erred
to as a ‘dry casting’ (i.e. the contact lens is cast as a xerogel).
Chain Polyme rization
T e monomers used in chain polymerization are unsaturated
and are sometimes re erred to as vinyl monomers. Essentially
this means that the monomer has one or more carbon-to-
carbon double bonds. During the polymerization process the
monomer concentration decreases steadily with time, resulting
in a reaction mixture that contains monomer, high-molar-mass
polymer and a low concentration o growing chains. Chain
polymerization is characterized by three distinct stages: initia-
tion, propagation and termination.
Initiation. A hydrogel monomer mixture usually contains
an initiator. T is is a chemical whose role is to start o the
polymerization process. Initiators readily ragment into ree
radicals (a highly chemically reactive atom, molecule or molecular
ragment with a ree or unpaired electron) when activated by heat
or some other orm o radiation (e.g. ultraviolet light).
T e type o initiator used will depend on the manu actur-
ing method. For example, a thermal initiator would usually be
required in the manu acture o buttons or rods that will eventu-
ally orm lathed lenses and a photo initiator would usually be
required or spun-cast and cast-moulded lenses.
T e ragmentation o the initiator is schematically repre-
sented by the ollowing equation, where I represents the initia-
tor molecule and I• represents a ree radical.
I− I 2I
T e ree radicals ormed are then able to combine with the
monomer (M), resulting in a ree radical o the monomer (this
is why the polymerization o hydrogels is sometimes re erred to
as ree radical polymerization):
I• + M →IM•
Propagation. T e monomer radical, which is a transient
compound, is now able to combine with another monomer unit,
resulting in another new compound:
IM• + M →IMM•
By the continuation o this process, the polymer chain is propa-
gated. T e resultant chain may consist o thousands o mono-
mer units:
IMn • + M →IM• (n + 1)
Termination. Polymerization does not usually continue until
all o the monomer has been used up because the ree radicals
involved are so reactive that they inevitably nd a variety o ways
o losing their reactivity. Polymerization can be terminated in
two main ways. T e rst method is recombination. T is occurs
when two growing molecules containing ree radicals meet,
share their unpaired electrons and so orm a stable covalent
bond, thereby extinguishing their reactivity. T e second
method o termination is known as disproportionation. T is
occurs when two radicals interact via hydrogen abstraction,
leading to the ormation o two reaction products, one o which
is saturated and one o which is unsaturated.
48 PART 2 So ft Co nt act Le nse s
T e conditions under which polymerization take place
become important when one considers that so contact lenses
are currently made using three main methods o manu acture:
lathing, spin casting and cast moulding; however, cast mould-
ing is by ar the most commonly used method. Lenses made
by these di erent methods o manu acture will undergo very
di erent polymerization conditions that are likely to have an
e ect on the resultant material. How a material is processed is
likely to a ect almost every aspect o a lens, rom its clinical per-
ormance to its physical and chemical properties (Maldonado-
Codina and E ron, 2004).
Pro p e rt ie s o Hyd ro g e l Mat e rials
T e ocular environment places signi cant demands on the per-
ormance o hydrogels as biomaterials. T ese materials must:
• maintain a stable, continuous tear lm
• be permeable to oxygen in order to maintain normal cor-
neal metabolism
• be permeable to ions in order to maintain on-eye move-
ment
• be com ortable
• provide clear, stable vision
• be durable or the li etime o the lens.
T ese essential properties are expanded upon below.
O PTICAL TRANSPARENCY
A hydrogel to be used as a contact lens material needs to be
transparent in order to achieve maximal visual per ormance.
T e light transmittance o polymers includes the descrip-
tion o materials as being transparent, translucent or opaque.
ransparent polymers are those that you can see through,
translucent polymers are those that you cannot see through
but allow light to pass through, and opaque polymers are
those that you can neither see through nor allow light to pass
through. Usually the optical clarity o contact lens materials
is expressed as the percentage o transmission o the visible
electromagnetic spectrum. Hydrogels that are use ul as con-
tact lens materials transmit over 90% o light in the visible
part o the spectrum.
When a hydrogel loses its transparency it is likely to be due to
microphase separation o water. T is is due to regions o di er-
ing re ractive index being ormed within the gel. Hydrogels that
show this type o behaviour (typically synthesized by making
copolymers with large blocks or segments o hydrophobic and
hydrophilic monomers rather than randomly dispersing them)
do have advantages in terms o enhanced strength and perme-
ability per ormance.
I the phase separation is limited (e.g. the phase size is
shorter than the wavelength o light), transparent materi-
als can still be obtained. Some hydrogels are known to lose
their transparency when heated and this is an important con-
sideration as there is an increase in temperature rom lens
packaging to eye and, additionally, some patients still ther-
mally disin ect their lenses, although this practice is seldom
employed today.
rying to combine hydrophilic hydrogel monomers and
hydrophobic silicone-based monomers into transparent hydro-
gels has been a major technical dif culty in the development o
success ul silicone hydrogel materials. ighe (2004) likens this
technical challenge to trying to mix oil with water.
MECHANICAL PRO PERTIES
T e mechanical properties o hydrogel contact lenses are unda-
mentally important because they are directly related to actors
such as the com ort, visual per ormance, tting characteristics,
physiological impact, durability and handleability o the lenses.
In the hydrated state most hydrogels are so and exible.
When they are allowed to dehydrate they become hard and
brittle. Lower-water-content polymers tend to become more
hard and brittle than higher-water-content materials. Hydrogels
take up water because they are hydrophilic; that is, hydrogels
swell in water (as well as many other liquids), which causes
them to become so with elastic properties (the water acts as
a plasticizer).
Unlike per ectly elastic materials, which de orm under stress
but return to their original size and shape when the stress is
released, hydrogels are viscoelastic. T is means that they de orm
time-dependently when a stress is applied to them and recover
time-dependently when the stress is removed. T eoretically,
this can result in permanent de ormation o the material.
One o the main dif culties in characterizing the mechanical
properties o a contact lens is that there is no single property
measurement that will accurately re ect its ‘in-use’ situation.
raditional material mechanical testing involves applying a
de orming orce (the ‘stress’) to a sample and observing the way
that the sample responds (the ‘strain’).
Stress can be compression, tensile or shear. Compression is a
stress that acts to shorten an object. ension is a stress that acts
to lengthen an object. Shear is a stress that acts parallel to a sur-
ace. Strain is de ned as the amount o de ormation an object
undergoes compared with its original size and shape. When a
tensile stress is applied to a material, the stress gradually builds
up until the specimen breaks ( ractures).
A generalized stress–strain curve is shown in Fig. 4.9 and
provides several mechanical characteristics o the material
under test. T e strength o a material is de ned as the orce
per cross-sectional unit area required to cause ailure when the
Fig . 4.9 Typ ical te nsile stre ss–strain curve or a the ore tical mate rial.
Point A on the g rap h re p re se nts the e long ation at b re ak, p oint B re p -
re se nts the ultimate stre ng th and p oint C re p re se nts the yie ld p oint o
the mate rial. A typ ical so t le ns hyd rog e l d oe s not d e monstrate a yie ld ;
inste ad , it would b re ak at p oint C on the g rap h.

sample is subjected to a particular type o stress. Some materi-
als will go through a yield point, which is de ned as the stress
at which a material begins to de orm plastically. Contact lens
hydrogels typically do not demonstrate a yield point. Young’s
modulus (E), or the elastic modulus, is determined by the initial
slope o the stress–strain curve and is, there ore, a constant (i.e.
it is the stress divided by the strain). Young’s modulus and the
thickness o the material (t) are related together in determining
the sti ness o a lens. Just as Dk / t indicates the relative trans-
missibility o di erent lenses, so the sti ness actor multiplied
by the thickness (E × t) indicates the relative resistance to de or-
mation o the lens.
It is important to note that several di erent moduli can be
measured, but Young’s modulus is the one that is most com-
monly re erred to in association with contact lenses. T e elon-
gation at break o the material, also re erred to as the strain, is
the raction o its original length that a material stretches when
placed under a load. It is a measure o how much the material
can de orm be ore breakage. Strain is dimensionless (i.e. it has
no units attached to it).
A point o potential con usion in the literature is the lack o
standardization o the units used or measuring stress. Stress is
de ned as orce per unit area. T e Système Internationale (SI)
unit o stress is N / m 2 (newtons per square metre). One newton
is the orce required to give a mass o 1 kg an acceleration o
1 m s−2. A newton spread out over a square metre is a pretty
eeble orce, so MN / m 2 (mega newtons per square metre or 106
N / m 2) is a more use ul unit.
T e pascal is also seen in the literature with re erence to
stress. T e pascal is actually the SI unit o pressure. T e units
o pressure are de ned in the same way as those or stress:
orce / unit area. One pascal is the pressure generated by a
orce o 1 N acting on an area o 1 m 2 (1 Pa = 1 N / m 2). Mega
newtons / m 2 and mega pascals, there ore, have numerically
equal values.
In US customary units, stress is expressed in pounds- orce
per square inch (psi). T e conversion actor is as ollows:
1 MPa = 145.0377 psi
T e strength o a hydrogel gives some indication o the
behaviour o the material during handling, whilst the modulus
indicates the extent to which the eyelid will de orm it and has
an impact on the tting characteristics o the lens in addition to
its com ort. Rigid lens materials have a relatively high modulus
(in the region o 103 MPa), whereas so lens materials have a
much lower value when in the hydrated state (in the region o
0.2–1.5 MPa).
Since the introduction o silicone hydrogels in the late 1990s
there has been renewed interest in the concept o ‘modulus’ as
an important so lens physical property. T ese lenses (particu-
larly the early ‘sti er’ rst-generation silicone hydrogel lenses)
generally have a higher tensile modulus than do hydrogels. T e
higher moduli o these materials have certain clinical implica-
tions, which are discussed in more detail in the silicone hydro-
gel materials section o this chapter.
T e generally poor mechanical strength (including tear
strength) o so lenses is arguably the main reason why they
have relatively short li etimes. T is problem has been somewhat
overcome by the introduction o disposable lenses, which essen-
tially means that the majority o so lenses no longer need to
last more than a day, 2 weeks or a month, depending on their
intended replacement schedule.
4 So ft Le ns Mat e rials 49
Several actors can a ect the mechanical properties o a
hydrogel material and these can be broadly divided into: (1)
material composition actors and (2) polymer-processing ac-
tors. Examples o material composition actors include changing
the comonomers used in the hydrogel preparation. I the hydro-
gel is not a homopolymer, then increasing the relative amount
o physically stronger component(s) will lead to an increase in
the nal mechanical strength o the material. T is may have the
e ect o altering the mechanical strength by increasing the sti -
ness o the backbone polymer, or example by replacing acry-
lates with methacrylates, or it may alter the hydrophilicity o the
polymer by replacing hydroxyethyl methacrylate (HEMA) with
methacrylic acid (MAA). In general, as the equilibrium water
content (EWC) o a hydrogel increases, its modulus decreases.
Another important material composition actor is that the
mechanical properties o a hydrogel are dependent on the cross-
link density in the system. Cross-links act as anchors or physi-
cal links and prevent the polymer chains rom slipping past
each other. In general, the strength o a hydrogel increases with
increasing cross-link density, particularly when in the swollen
state, where physical entanglements are low.
Cross-link density can be increased by the addition o larger
amounts o cross-linking agent. Although increasing the cross-
link density within a hydrogel network is bene cial in relation
to its mechanical properties, it must also be considered that
changes to other properties o the polymer will occur. T e swell-
ing capacity o the hydrogel is likely to be reduced with increas-
ing cross-link density, and hence, its oxygen permeability will
also be reduced, which is undesirable in a contact lens material.
A balance o all the properties o a polymer is critical to its end
application.
Polymer-processing actors that can a ect the mechanical
properties o a hydrogel essentially re er to the act that hydrogel
materials are highly sensitive to the processing and abrication
conditions to which they are subjected. Lenses made by di er-
ent methods o manu acture will undergo very di erent mate-
rial processing, particularly polymerization. T ese di erent
material-processing steps may have an e ect on the mechani-
cal properties o the resultant lens. For example, lathed lenses
are ormed rom solid buttons o dehydrated material and these
buttons are usually bulk-polymerized over relatively long peri-
ods compared with a cast-moulded lens. T ermal initiators are
o en used in button production, which have low activation
energies, allowing water baths or ovens to be set to relatively low
temperatures. T is type o polymerization is likely to lead to a
polymer structure consisting o longer chains (higher molecular
weights) and there ore more chains.
In the cast-moulding process a small amount o monomer is
placed between two casts to orm the lens directly. T e polym-
erization process is typically very ast, which is one o the rea-
sons why this is the method o choice or bulk (disposable) lens
manu acture. Rapid polymerization times are likely to produce
shorter chains, more chain ends and less ef cient cross-links.
SURFACE PRO PERTIES
T e sur ace characteristics o a hydrogel lens will directly a ect
its interactions with the tear lm and consequently its biocom-
patibility in the ocular environment. ‘Wettability’ is used to
describe the tendency or a liquid to spread on to a solid sur-
ace, and in vivo wettability in a contact lens context implies
the ability o the tear lm to spread and maintain itsel over a
50 PART 2 So ft Co nt act Le nse s

contact lens sur ace. In vivo wettability is a key measure o clini- Fig. 4.11 shows the contact angles o two contact lenses.
cal per ormance because the success o any contact lens is con- Note that the contact angle o lens B is considerably larger than
sidered to be related to its ability to support a stable tear layer that o lens A. However, it is important to bear in mind that the
in the eye. General clinical consensus is that ailure to meet this wettability o a given sur ace depends on a number o actors,
requirement is likely to result in a lens that is uncom ortable, including the sur ace tension o the test liquid and, as such, it is
has reduced visual per ormance and orms deposits rapidly. T e a property o a liquid–solid combination rather than o the solid
quality o the pre-lens tear lm will also have an e ect on the sur ace alone.
riction between the eyelid and the lens sur ace. T is in turn T e most commonly used techniques applied to contact
is thought to be important in the aetiology o physiological lenses include sessile drop and captive bubble methods. In the
responses such as contact-lens-related papillary conjunctivitis sessile drop technique a drop o liquid (usually water) is applied
(CLPC) and lid wiper epitheliopathy (LWE). T e issue o wetta- to a dry or drying hydrogel lens sur ace in air (see Fig. 4.11). In
bility has received considerable attention since the introduction the captive bubble technique, the hydrogel lens is submerged in
o silicone hydrogel materials at the turn o the century, in view liquid (usually water, saline or arti cial tears) and a bubble o
o the potentially poor wettability o lenses manu actured rom air is applied to the lens sur ace. T e contact angles obtained or
this material. a lens–liquid combination are highly methodologically depen-
In vivo wettability is generally assessed with a range o rela- dent (Maldonado-Codina and Morgan, 2007) and any report-
tively crude clinical tests that have been used or several decades. ing o contact angles should include the experimental details
T ese include tear lm break-up time (with or without the pres- such as the method itsel , the probe liquid and prior treatment
ence o uorescein), inter erometry and various techniques o the material under test.
based around specular re ection. Un ortunately, these methods T e sessile drop and the captive bubble techniques give dis-
requently ail to di erentiate adequately between lens sur ace crepant results or a given sample because a di erent type o
types, even when relatively di erent lens sur aces are evaluated. contact angle is measured in each technique: an advancing-type
On the other hand, laboratory measures o wettability are contact angle is measured in the sessile drop technique and a
well established and are o en better at di erentiating lens sur-
aces. Wettability in relation to contact lenses has traditionally
been assessed in vitro using contact angle analysis. When a drop
o liquid is placed on a solid sur ace, an angle is ormed at the
solid–liquid–air inter ace (Fig. 4.10). T is angle is re erred to as
the contact angle.
Contact angles can be equilibrium, advancing or receding.
T e advancing contact angle is the angle ormed when a liq-
uid is advanced over an unwetted sur ace. T e receding contact
angle is the angle ormed when a liquid is withdrawn over a
previously wetted sur ace. T ere is usually a di erence between
the advancing and receding contact angles (the advancing angle
is usually the larger one) or hydrogel materials and this di -
erence is re erred to as the ‘hysteresis’. Essentially, the smaller
the contact angle, the better the liquid spreads over the solid
sur ace and the more wettable is the solid sur ace. It is, however,
important to bear in mind that the relationship between these
laboratory measurements and the clinical per ormance o the
lenses is not ully understood.

Fig . 4.10 Sche matic re p re se ntation o the se ssile d rop te chniq ue Fig . 4.11 Se ssile d rop contact ang le imag e s o a contact le ns with
showing the contact ang le (θ) me asure d whe n a d rop is p lace d on a a g ood we tting sur ace (A) and a p oor we tting sur ace (B). Note the
solid sur ace . larg e r contact ang le or le ns with the p oor we tting sur ace .

receding-type contact angle is measured in the captive bubble
technique. Additionally, both o these techniques can be used
to assess the hysteresis o a given material; that is, advancing
and receding angles respectively can be obtained using the ses-
sile drop technique alone or the captive bubble technique alone
(Read et al., 2011).
T e receding contact angle obtained in vitro is especially
relevant when considering the per ormance o a contact lens
in vivo. T e advancing angle corresponds more to the establish-
ment o the tear lm, which is assisted mechanically by the eye-
lid. Conversely, the receding angle is thought to be important in
the stability o the tear lm between blinks.
Another aspect o the lens sur ace that has important clini-
cal implications is its rictional characteristics. Friction is de ned
as the resistance that a solid sur ace encounters when it moves
over another. In doing so, these solid sur aces can undergo ‘wear
and tear’ which can be reduced i there is suf cient lubrication
between the sur aces. In the eye, the tear lm acts as such a lubri-
cant between the eyelid margin conjunctiva and the ocular sur-
ace. T e area o the eyelid margin conjunctiva that ‘rubs’ over the
ocular sur ace has been termed the ‘lid wiper’ (Korb et al., 2002).
When a contact lens is in situ, the ‘lid wiper’ ‘rubs’ over the
lens sur ace many thousands o times during a wearing day and
it is thought that this interaction is highly important in govern-
ing the com ort o a lens – particularly its end-o -day com ort
(Coles and Brennan, 2012). T e rictional characteristics o a
lens sur ace are a unction o not only the lens material chem-
istry but also o how that sur ace interacts with the ocular envi-
ronment. Dehydration, spoilation, poor tear lm characteristics
and irregularities o the ocular sur ace can all lead to increased
riction between the lens and the eyelid margin during wear.
T ese rictional properties are an important consideration in
the overall design o a contact lens.
Coef cient o riction (CoF) laboratory measurements have
now become commonplace or contact lens materials. T e CoF
is the ratio o the orce needed to initiate or sustain sliding to the
normal orce holding the two sur aces together and in the labo-
ratory some kind o lubricant would be required. As with many
other laboratory set-ups, it is very dif cult to simulate on-eye
conditions and this is primarily why di erent CoF results have
been obtained by di erent research groups carrying out these
experiments (Ross et al., 2005; Roba et al., 2011).
WATER CO NTENT
T e EWC o a hydrogel lens is de ned as:
weight of water in polymer
EWC = × 100
total weight of hydrated polymer
T e EWC o a hydrogel may vary depending on the environ-
mental conditions. For example, pH, tonicity and temperature
may alter the EWC o a hydrogel. Increased temperature is an
important consideration because there is a signi cant increase
in temperature when a contact lens is taken rom its packag-
ing solution (normally at room temperature) and placed on the
eye. Most contact lens hydrogels will undergo a small change in
EWC when placed in solutions o di erent pH and osmolality,
but these changes will be most pronounced in ionic materials.
T e oxygen and ion permeability o a contact lens material
are intimately associated with its EWC. T is is discussed in
more detail in the ollowing sections.
4 So ft Le ns Mat e rials 51
T e sur ace EWC o a contact lens can be measured using a
so contact lens re ractometer (E ron and Brennan, 1987). T is
is a hand-held instrument that can be readily used in the clinical
setting. It utilizes the inverse relationship between the re ractive
index and EWC o hydrogel materials. T e measured re rac-
tive index o a contact lens is converted to percentage water in
sucrose using the Brix scale. T is approach does, however, have
limitations in that it assumes that dehydrated hydrogels all have
the same re ractive index (i.e. that o dry sucrose). However, this
assumption is not strictly true and the di erence in re ractive
index o a particular hydrogel material and sucrose will lead
to the di erence between Brix measures and manu acturer-
reported water contents.
Dif culties are also encountered with this instrument when
attempting to measure the EWC o silicone hydrogel lenses.
T ese lenses have a lower re ractive index compared with hydro-
gels and their EWC is overestimated with the so contact lens
re ractometer. Additionally, since it is sur ace EWC that is being
measured with this instrument, it is unknown what e ect the
sur ace coatings on some o these lenses have on the nal result.
British and International Organization or Standardization
(ISO) standards speci y both thermogravimetric and re ractive
index methods as valid techniques or measuring the EWC o
a hydrogel lens (BSI, 2006a). T e thermogravimetric method
involves measuring the weight o a lens in the hydrated state and
then remeasuring the lens in the completely dehydrated state.
T e disadvantages o this method are that it is time consuming
and destroys the lens.
O XYGEN PERMEABILITY
Since the cornea receives most o its oxygen rom the atmo-
sphere, the oxygen transmissibility pro le o a contact lens is
one o its most important properties. Oxygen permeability is a
property o the material itsel and is described as the Dk, where
D is the di usivity o the material and k is the solubility o the
material. T e di usivity is a measure o how quickly oxygen can
move through a material, whilst the solubility is a measure o
how much oxygen the material can hold. Oxygen permeability
o a hydrogel will vary with temperature.
Oxygen permeability is governed by the EWC in hydro-
gels. T is relationship is based on the ability o oxygen to pass
through the water rather than through the material itsel . T e
relationship between the EWC and oxygen permeability has
been ound to be (Morgan and E ron, 1998):
Dk = 1.67e0.0397EWC
where e is the natural logarithm (Fig. 4.12).
In order to calculate the amount o oxygen that will move
rom the anterior to the posterior sur ace o a lens, the oxygen
permeability (Dk) is divided by the thickness o the lens (t). T e
units o Dk have been traditionally known as Fatt units (a er
Pro essor Irving Fatt, who carried out much o the early work
on oxygen permeability o contact lens materials) or Barrer,
whereby:
− 11
( 2 )
Dk (Barrer) = 10 cm × mlO2 / (s × ml × mmHg)
Dk/t (Barrer/cm) = 10− 9 (cm × mlO2 ) / (s × ml × mmHg)
However, the SI unit or pressure is the pascal (Pa). Because
the unit mmHg is now becoming obsolete internationally,
it is being advocated that the closest accepted metric unit o
52 PART 2 So ft Co nt act Le nse s
Fig . 4.12 Re lationship b e twe e n Dk and e q uilib rium wate r conte nt or conve ntional hyd rog e l and silicone hyd rog e l le nse s.
pressure – 100 Pa, or hectopascal (hPa) – should replace mmHg
(BSI, 2006b). T e new units are re erred to as ‘Dk units’ in this
latest British and international standard. When hPa is used, Dk
and Dk / t values are quoted as below:
− 11
( 2 ) known (and vice versa), which is the basis or the use o the so
Dk in 'Dk units' = 10 cm × mlO2 / (s × ml × hPa)
(Dk/t) in 'Dk/t units' = 10− 9 (cm × mlO2 ) / (s × ml × hPa)
T e dif culty here is that converting rom the traditional Barrer
or Fatt units to ISO units involves multiplying Dk or Dk / t by the
constant 0.75006. T us, or example, a lens quoted with a tradi-
tional Dk / t o 40 units will have a revised ISO Dk / t o 30 units.
It is understandable that such a ‘downsizing’ will be resisted by
contact lens manu acturers, because higher numeric Dk / t are
perceived clinically as being ‘superior’.
FLUID AND IO N PERMEABILITY
T e development o silicone hydrogel materials has highlighted
the importance o the so-called hydraulic permeability or water
transport o a contact lens material. Essentially, a minimum
level o hydraulic (as well as ionic) permeability is necessary in
order to maintain adequate lens movement. T is is important in
allowing the post-lens tear lm to re- orm between blinks, thus
reducing the likelihood o these quite elastic lenses rom bind-
ing to the cornea. Water is able to move through a hydrogel in
quite a di erent way to sodium ions; that is, it is more dif cult
or sodium ions to travel through the gel as in order to do so
they must be accompanied by a shell o water ( ighe, 2004). In
the eye, the sodium ion permeability o contact lens materials
is particularly important as it is a major constituent o the tear
lm. Sodium ion transport is impeded in gels with water con-
tent below 20%.
REFRACTIVE INDEX
Ideally hydrogels abricated or contact lens materials should
have a re ractive index similar to that o the cornea (i.e. near
to 1.37). T e variation o re ractive index with EWC in hydro-
gels is almost linear, with most hydrogel re ractive indices
alling within 1.46–1.48 at 20% water content and 1.37–1.38 at
75% water content – that is, the re ractive index decreases with
increasing water content. Because o this relationship, it is pos-
sible to calculate the re ractive index o a hydrogel i its EWC is
contact lens re ractometer, as discussed above. T is relationship
is well established or hydrogel lenses but not or silicone hydro-
gel lenses.
It is unlikely that a relationship between the re ractive index
and the water content will hold or all silicone hydrogel lenses
on the market as many are based on completely di erent mate-
rial chemistries. British and ISO standards recommend the use
o an Abbé re ractometer to measure the re ractive index o a
hydrogel contact lens (BSI, 2006a). However, other more auto-
mated instruments have been used or the assessment o hydro-
gel lens re ractive index (Nichols and Berntsen, 2003; Lira et al.,
2008).
SWELL FACTO R AND DIMENSIO NAL STABILITY
T e dimensional stability o a hydrogel lens re ers to its ability
to maintain its original dimensions under various conditions.
It is dependent on any actor that will change the water content
or swelling behaviour o the hydrogel. Factors that in uence the
swell actor include temperature, pH and tonicity. T e swelling
behaviour is particularly important during the manu acture o
contact lenses in the dry state (e.g. when a so contact lens is
lathed). During the lathing process a smaller, steeper lens o
greater power is made so that, when it is hydrated, it swells to
the required dimensions and power required. It is vital, there-
ore, that the swell actors o the material are accurately known.
T e swell actor is described by the ollowing relationship:
Swell factor (SF) = wet dimension/dry dimension
Initially it was thought that a hydrogel material swelled isotropi-
cally – that is, the same in all directions. With time it was ound,
however, that the consistently anomalous swelling behaviour
o hydrogels could be explained only by speci ying two swell
actors. T ese swell actors are those in the diameter and axial
(thickness) directions. From these, the value o the radial swell
 4 So ft Le ns Mat e rials 53

actor o a contact lens can be calculated using the ollowing

equation:
2
SFrad = (SFdia ) /SFax
where SFrad is the radial swell actor, SFdia is the diametral swell
actor and SFax is the axial swell actor.

So t Le ns Mat e rials
So lens materials can be conveniently divided into two main
groups: (1) hydrogel materials (now sometimes re erred to as
low-Dk materials) and (2) silicone hydrogel materials (high-Dk
materials).

HYDRO GEL MATERIALS

Hydrogel lenses were developed as a result o the extraordinary
pioneering e orts o Pro essor Otto Wichterle and Dr Draho-
slav Lim o the Institute o Macromolecular Chemistry o the
Czechoslovak Academy o Sciences in Prague in the mid 1950s.
Wichterle and Lim were working on the synthesis o a new
material that they hoped could be used or implantation into the
human body. T at material was poly(hydroxyethyl methacry-
late) or pHEMA (Wichterle and Lim, 1960). T ey soon realized
that the material had potential applications in the manu acture
o contact lenses, but were prevented rom researching such a
project by the directors o the institute, who perceived this work
as being a petty distraction rom undamental studies in chem-
istry. Wichterle was eventually orced to carry out his contact
lens experiments at home and, despite such dif cult circum-
stances, he success ully managed to produce the rst spun-cast
lens (made rom his son’s toy construction set) in 1961 (Wich-
terle and Lim, 1961). T e enormity o his breakthrough or the
contact lens industry cannot be understated.
pHEMA is made by polymerizing 2-hydroxyethyl meth-
acrylate monomer with a cross-linker such as ethylene glycol
dimethacrylate (EGDMA) (Fig. 4.13). Most o the hydrophilic
behaviour o HEMA is due to the presence o the hydroxyl group Fig . 4.13 Some o the monome rs use d in hyd rog e l le ns mate ri-
(OH) at the end o the monomer. At this location in the resul- als. HEMA = hyd roxye thyl me thacrylate ; NVP = N-vinyl p yrrolid one ;
tant polymer hydrogen bonding with water molecules occurs, MMA = me thyl me thacrylate ; MAA = me thacrylic acid ; EGDMA = e thyl-
causing them to be drawn into the polymer matrix. T e result is e ne g lycol d ime thacrylate ; GMA = g lyce ryl me thacrylate ; DMA = N,N-
d ime thyl acrylamid e .
that contact lenses made rom pHEMA contain approximately
40% water in the ully hydrated state.
Lenses abricated rom pHEMA were rst distributed in In hydrogel materials, oxygen is transported through the
western Europe in 1962, but sales were disappointing. In 1965, water channels in the lens, and not the polymer itsel . Con-
the National Patent Development Corporation bought the tact lens manu acturers, there ore, had two possible avenues
licence or the American rights to the technology rom the to ollow to increase the oxygen transmissibility o lenses:
Czechs. T is was subsequently sold on to Bausch & Lomb, develop ‘hyperthin’ lenses, or develop materials with higher
which at that time manu actured ophthalmic equipment and water content. Producing lenses that were thinner was a rela-
spectacle lenses. Bausch & Lomb signi cantly re ned Wich- tively straight orward matter or lens designers and several
terle’s spin-casting process and nally obtained approval rom such lenses were launched, such as the Hydrocurve thin lens
the US Food and Drug Administration (FDA) or its pHEMA (So Lenses) in 1977 and subsequently the O3 series (Bausch &
lenses in 1971. T is time, the lenses became very popular very Lomb). T ese lenses were in the region o 0.035–0.06 mm thick,
quickly – both practitioners and patients enjoyed the bene ts o which was less than hal the thickness o the original Bausch &
increased com ort, reduced adaptation time and easier tting Lomb pHEMA lenses.
procedures compared with rigid corneal lenses, which were the Developing materials with a higher EWC led to the success-
main alternative. With time, more companies developed their ul development o HEMA copolymers. One o the rst suc-
own pHEMA lenses; however, it soon became clear that these cess ul copolymerizations was with N-vinyl pyrrolidone (NVP)
lenses were not problem ree. Most o these problems stemmed (see Fig. 4.13). T e amide (N—C=O) moiety is very polar and
rom the act that the lenses caused hypoxia, but other compli- two molecules o water can become hydrogen-bonded to it.
cations relating to solution toxicity and lens spoliation were also NVP-based copolymers lose the slippery eel o pHEMA and
common. consequently can eel quite rubbery. T ese copolymers also
54 PART 2 So ft Co nt act Le nse s
tend to have relatively high evaporation rates o water, which
may be seen as a problem or lens stability and com ort. T is
occurs because the amide group does not bind water as strongly
as a hydroxyl group. In addition, these polymers are also signi -
cantly more temperature sensitive than pHEMA-based materi-
als; that is, their parameters tend to change with increasing or
decreasing temperature. T is is important when tting a lens as
its parameters may change on-eye.
NVP-based lenses have also been associated with increased
corneal staining (solution-induced corneal staining or ‘SICS’)
and decreased com ort when used in conjunction with solutions
containing higher levels o polyhexanide (Jones et al., 1997,
2002). T is does not mean that polyhexanide-based solutions
cannot be used with NVP-containing lenses, but rather that the
interaction should be borne in mind and, i any signi cant cor-
neal-staining or discom ort symptoms arise these can usually
be treated simply by changing the solution to one containing a
lower level o polyhexanide or one ree rom polyhexanide.
Most contact lens practitioners are amiliar with methyl meth-
acrylate (MMA) as the material rom which ‘hard lenses’ are made
(i.e. PMMA) (see Fig. 4.13). When MMA and NVP are copoly-
merized, a completely new material is obtained with very di erent
characteristics to the HEMA / NVP (also known as HEMA / VP)
copolymers. Depending on their composition, contact lenses
made rom MMA / VP copolymers can contain 60–85% water.
MMA is very hydrophobic, but is use ul in so lens hydrogels
as it gives the resultant polymers increased mechanical strength.
Another hydrophilic monomer that has been very success-
ully used in contact lens hydrogels is MAA (see Fig. 4.13).
When added to a so lens polymer ormulation, it results in a
so lens with ionized groups (negatively charged) within the
polymer matrix, allowing the lens to absorb more water. T e
higher the amount o MAA, the higher is the EWC o the result-
ing polymer. Amounts o MAA in the region o 1.5–2.5% will
increase the water content o a HEMA material into the mid-
water-content range o 50–60%, thereby allowing oxygen per-
meability to increase signi cantly. Another advantage o these
ionic lenses is that, although they attract large quantities o pro-
tein (particularly positively charged lysozyme) (Suwala et al.,
2007), a large proportion o these proteins are in their natural,
non-denatured orm (Subbaraman et al., 2006; Suwala et al.,
2007; Subbaraman and Jones, 2010), which is thought to be
bene cial in terms o contact-lens-related complications such
as contact lens papillary conjunctivitis and, very importantly, in
terms o their antimicrobial action (Brennan and Coles, 2008).
Un ortunately, using MAA to increase the water content o a
polymer also has its disadvantages. T ese include:
• A lens that is extremely sensitive to changes in tonic-
ity (McCarey and Wilson, 1982): the Na+ ions present in
saline solution have the e ect o ‘shielding’ the carboxyl-
ate anions. In hypotonic solutions (e.g. pure water), since
these shielding ions are present to a ar lesser degree, more
chain repulsion will occur, which increases the swelling o
the network and consequently the EWC o the material. In
hypertonic solutions, the reverse situation occurs and the
material network shrinks, causing its EWC to decrease.
• A pH-sensitive lens (McKenney, 1990): i the pH o the so-
lution in which the lens is immersed is decreased (i.e. the
hydrogen ion concentration is increased), the carboxylate
anions are more shielded and the network becomes less
expanded. T is will cause a decrease in the lens EWC.
• Dimensional instability when the lens is heat disin ected.
Glyceryl methacrylate (GMA) is more hydrophilic than
HEMA owing to the act that the monomer contains two
hydroxyl groups (see Fig. 4.13). T is monomer has been used
in contact lens materials in two main ways. T e rst method
has used GMA in combination with MMA to produce mate-
rials that have water contents in the range o 30–42%. T ese
materials are thought to be sti er and stronger than pHEMA
hydrogels, but their oxygen permeabilities are not ideal or in-
eye use.
T e second method has been to use GMA in combination
with HEMA to produce a high-water non-ionic contact lens
materials (up to approximately 70% has been possible). T ese
contact lenses are said to be ‘biomimetic’ – that is, they are
claimed to improve biocompatibility by imitating the hydro-
philic properties o mucin. Manu acturers also suggest that
these lenses show a low rate o dehydration and a rapid rate o
rehydration (i.e. they have good ‘water balance ratios’). In addi-
tion, the materials are thought to be relatively deposit-resistant
and seem to be insensitive to pH changes in the range o pH
6–10. An example o such a lens is the hioxi lcon A mate-
rial used in the Clear 1 Day lenses manu actured by Clearlab.
Another example o a so-called biomimetic lens is the Proclear
lens (Coopervision), which contains phosphoryl choline (PC)
and HEMA. PC is said to mimic the natural chemistry o cell
membranes.
In the early 1970s an English optometrist, John de Carle,
proposed that i the EWC o hydrogel lenses could be suf -
ciently increased then these lenses could be worn success ully
on an overnight or extended-wear basis. He developed the rst
extended wear lens to be distributed in the UK, known as Per-
malens (de Carle, 1975). T e lens material had an EWC o 71%
and was made rom a HEMA / VP / MAA copolymer. In 1981
the lens was given FDA approval or ‘extended wear’ o up to
30 days along with another lens, the Hydrocurve II (Wesley
Jessen).
Slowly, other lenses were given approval or extended wear
during the 1980s, but along with the increase in demand or
these lenses came an increase in complications. In 1989 stud-
ies were published showing that the risk o microbial keratitis
was 5–15 times greater or extended wear than or daily wear
(Poggio et al., 1989; Schein et al., 1989). As a result, the FDA
recommended that extended wear be limited to six consecutive
nights and, with that, the enthusiasm or extended wear died
down to some extent until the emergence o silicone hydrogel
lenses in the late 1990s.
able 4.1 lists some o the most common hydrogel lenses on
the market and groups them into their appropriate FDA classi -
cation (see Appendix 4.1, below, or details on the classi cation
o hydrogels).
Most o the work that has been carried out on ‘improving’
hydrogel lenses has been channeled towards developing them
into disposable lenses and especially into daily disposable
lenses. In order to achieve this, manu acturers have invested in
more sophisticated automated manu acturing technologies to
meet demand and make their production economically viable.
T is has been no easy task and it should be emphasized just how
important these hydrogel materials still are to the contact lens
industry today.
Additionally, ‘enhanced’ daily disposable lenses have been
introduced onto the market, such as 1-Day Acuvue Moist (John-
son & Johnson), Dailies AquaCom ort Plus (Alcon) and So Lens
daily disposable (Bausch & Lomb). T ese lenses utilize techniques
 4 So ft Le ns Mat e rials 55

TABLE
4.1 Se le ct e d Hyd ro g e l Le nse s
Name Manufact ure r / Sup p lie r Princip al Co mp o ne nt s EWC (%) USAN No me nclat ure
FDA GRO UP 1 (< 50% EWC < 0.2% IO NIC CO NTENT)
Biome d ics 38 Coop e rvision HEMA 38 Polymacon
Durawave UltraVision CLPL HEMA, GMA 49 Hioxi lcon B
Me nicon So t Me nicon HEMA, VA, PMA 30 Ma lcon A
O p tima Toric Bausch & Lomb HEMA / VP 45 He lcon B
Sauf on 38 Sauf on HEMA 38 Polymacon
So Le ns 38 Bausch & Lomb HEMA 38 Polymacon
FDA GRO UP II ( >50% EWC < 0.2% IO NIC CO NTENT)
Biotrue O ne d ay Bausch & Lomb HEMA, VP 78 Ne so lcon A
Dailie s Aq uaCom ort Plus Alcon PVA 69 Ne lcon A
Focus Dailie s All Day Com ort Alcon PVA 69 Ne lcon A
O mnif e x Coop e rvision MMA, VP 70 Lid o lcon-A
Procle ar Coop e rvision HEMA, PC 62 O ma lcon B
Sauf on-55 Sauf on HEMA, VP 55 N/A
So Le ns d aily d isp osab le Bausch & Lomb HEMA, VP 59 Hila lcon B
UltraWave UltraVision CLPL HEMA, GMA 57 Hioxi lcon A
FDA GRO UP III ( < 50% EWC <0.2% IO NIC CO NTENT)
Accuso t* O p hthalmos HEMA, PVP, MAA 47 Droxi lcon-A
Com ort Fle x* Cap ital Contact Le ns HEMA, BMA, MAA 43 De lta lcon-A
So t Mate II* CIBA Vision HEMA, DAA, MAA 45 Bu lcon-A
FDA GRO UP IV (>50% EWC >0.2% IO NIC CO NTENT)
Acuvue 2 Johnson & Johnson HEMA, MAA 58 Eta lcon A
1-Day Acuvue Moist Johnson & Johnson HEMA, MAA 58 Eta lcon A
Biome d ics 55UV Coop e rVision HEMA, MAA 55 O cu lcon D
Fre shlook ColorBle nd s Alcon HEMA, MAA 55 Phe m lcon A
Fre q ue ncy 55 Coop e rVision HEMA, MAA 55 Me tha lcon A
Pe rmale ns* CIBA Vision HEMA, VP, MAA 71 Pe r lcon-A

*No long e r availab le .

FDA = Food and Drug Ad ministration; EWC = e q uilib rium wate r conte nt; HEMA = 2-hyd roxye thyl me thacrylate ; VP = N-vinyl p yrrolid one ;
MMA = me thyl me thacrylate ; PC = p hosp horylcholine ; GMA = g lyce ryl me thacrylate ; MAA = me thacrylic acid ; VA = vinyl ace tate ; PMA = p olyme thyl
acrylate ; PVA = p olyvinyl alcohol; PVP = p olyvinyl p yrrolid one (i.e . g ra t cop olyme r); BMA = b utyl (p rob ab ly isob utyl) me thacrylate ; DAA = d iac-
e tone , acrylamid e ; USAN = Unite d State s ad op te d name .

o macromolecular entrapment and / or release o hydrophilic
sur ace-active polymers at the lens sur ace in order to improve
end-o -day com ort by stabilizing the pre-lens tear lm.
T e Dailies AquaCom ort Plus lens is manu actured rom
nel lcon A, which consists o a cross-linked unctionalized poly-
vinyl alcohol (PVA) macromer with the addition o non- unc-
tionalized PVA (Winterton et al., 2007). T is un unctionalized
PVA macromer is ree to elute rom the lens into the tear lm
with each blink. T is PVA is thought to emerge rom the lens
matrix as ‘strands’ at the lens sur ace, and it is this e ect together
with the e ect o soluble PVA in the tear lm that is re erred to
as the ‘sur ace modi cation’ o these lenses. T e released PVA
may improve lens com ort by decreasing the sur ace tension o
the tears, or by mimicking mucin, ound naturally in the tear
lm (Mahomed et al., 2004). T e blister packaging also contains
hydroxypropyl methylcellulose (HPMC), which is a lubricat-
ing agent used to improve com ort on lens applications, as well
as polyethylene glycol (PEG), which is a hydrophilic wetting
agent with a high af nity or PVA used or enhancing com ort
throughout the day.
PVA and polyvinyl pyrrolidone (PVP) are common soluble
polymeric components in com ort drops and arti cial tears
and have a viscous consistency at elevated concentrations and
molecular weights, giving them good sur ace spreading char-
acteristics. T e 1-Day Acuvue Moist lens is manu actured rom
the eta lcon A polymer (HEMA / MAA) together with the
incorporation o small concentrations o low-molecular-weight
PVP into the ionic material network. Here the PVP is ‘locked’
into the lens matrix and is not released rom the lens during
wear. T e PVP is adsorbed on to the pre ormed lens sur ace a er
manu acture rom solution. T e lens packaging states that the
lenses are supplied in ‘bu ered saline with povidone’. Povidone
is another name or PVP. PVP is quite polar and it is likely to be
relatively strongly attracted to the eta lcon material, potentially
providing a mechanism or its retention on the lens sur ace. T e
persistence o the PVP at the lens sur ace during wear has been
veri ed by Ross et al. (2007), who have also described the PVP
as being in a predominantly ‘looped structure’ across the lens
sur ace. T e PVP is thought to reduce the coef cient o riction
o the lens sur ace
T e So Lens daily disposable lens is modi ed by the adsorp-
tion o etronic 1107 – a hydrophilic sur ace-active polymer
composed o ethylene oxide / propylene oxide block copolymer
– onto the lens sur ace. T e etronic at the sur ace lowers the
coef cient o riction o the lens, but it has been shown to be pro-
gressively lost rom the sur ace during wear (Ross et al., 2007). It
is likely, there ore, that the etronic is held by weak orces at the
lens sur ace, which would explain the lowest in-eye persistence
o three ‘enhanced’ lenses investigated by Ross et al. in 2007.
SILICO NE HYDRO GEL MATERIALS
When Holden and Mertz (1984) de ned the critical oxygen
levels in order to avoid corneal oedema or daily and extended
wear they concluded that 24.1 Barrer / cm was the oxygen trans-
missibility required or daily wear and 87 Barrer / cm was that
56 PART 2 So ft Co nt act Le nse s
required or overnight wear. T ese values were re-evaluated by
Harvitt and Bonanno (1999), who ound that the minimum
oxygen transmissibility required to avoid anoxia throughout
the entire cornea was 35 Barrer / cm or the open eye and 125
Barrer / cm or the closed eye.
Fig. 4.12 shows the relationship between the EWC and the Dk
o hydrogels and silicone hydrogels. From the graph, it is obvi-
ous that there is an upper limit to how much oxygen permeabil-
ity can be attained simply by increasing the EWC o hydrogel
materials. A hydrogel with a theoretical EWC o 90% and a cen-
tral thickness o 0.1 mm would have an oxygen transmissibility
in the region o 60 Barrer / cm, which still alls ar short o that
required to avoid additional overnight corneal oedema. Such a
lens would need to be in the region o 0.06 mm thick, which is
unrealistic rom both a manu acturing and a clinical point o
view (Holden et al., 1986).
I reducing the thickness o lenses made rom hydrogels was
not an option or achieving success in extended wear, then poly-
mer scientists had to come up with an altogether new kind o
material. T at material was silicone. T e element silicon (Si) is
the most abundant element on earth a er oxygen (e.g. in the
orm o silicates or oxides such as sand and clay). Silicones are
organic compounds o silicon and oxygen.
Incorporating silicone into contact lens materials was not
a new concept when scientists began trying to produce sili-
cone hydrogels. Indeed, the rst material to be used in contact
lenses was silicone dioxide (glass). Additionally, silicone rub-
ber (polydimethyl siloxane, PDMS) (Fig. 4.14) has been used
with limited success as a contact lens material in the orm o
silicone elastomer lenses. T ese lenses have not become popular
mainly because o lens-tightening and sur ace wettability prob-
lems (PDMS is extremely hydrophobic) (Josephson and Ca ery,
1987). PDMS has an oxygen permeability in the region o 600
Barrer but is unwettable by tears, deposits high degrees o lipid
Fig . 4.14 Silicone -b ase d mate rials. PDMS = p olyd ime thyl siloxane ; TRIS = tris(trime thylsiloxy)-me thacryloxy-p rop ylsilane ; TPVC = carb amate -
sub stitute d TRIS.
and needs to be sur ace treated. Sur ace treatments o silicone
elastomer lenses have not been particularly success ul in the
past because Si—O chains have a tendency to rotate very eas-
ily and any hydrophilic parts o a newly treated sur ace tend to
disappear inside the polymer.
Silicon, however, has been very success ully incorporated
into rigid lens materials and it was this development that proved
to be a key milestone in the subsequent development o silicone
hydrogel materials. T e work o Norman Gaylord at Polycon
Laboratories drove the development o the rst siloxane-based
rigid lens material that merged the properties o MMA with
the increased oxygen per ormance o silicone rubber (Gaylord,
1974, 1978). T e resultant siloxymethacrylate monomer was
tris(trimethylsiloxy)-methacryloxy-propylsilane (see Fig. 4.14)
and is more commonly re erred to as RIS.
T e patent literature shows that combining silicone with
hydrogel monomers has been a goal or polymer scientists
since the late 1970s. T e biggest obstacle to this approach, how-
ever, is that silicone is hydrophobic and poorly miscible with
hydrophilic monomers, resulting in opaque, phase-separated
materials. In order to solve this problem, two main approaches
have been utilized ( ighe, 2004). T e rst approach involves
the insertion o polar groups into the section o the RIS mol-
ecule, arrowed in Fig. 4.14, in order to aid its miscibility with
hydrophilic monomers ( anaka et al., 1979; Künzler and Ozark,
1994).
T e second approach is that o utilizing macromers. Mac-
romers are large monomers ormed by preassembly o struc-
tural units that are designed to bestow particular properties
on the nal polymer ( ighe, 2004). T is is illustrated in Fig.
4.15 with an example rom an Alcon patent (Nicolson et al.,
1996) that contains poly( uoroethylene oxide) segments and
oxygen-permeable polysiloxane units. Fig. 4.12 demonstrates
the relationship between Dk and EWC or silicone-containing

hydrogels based on RIS, highlighting the bene ts o increased
oxygen per ormance.
T e rst two silicone hydrogels were launched in the late
1990s – the PureVision lens (Bausch & Lomb) and the Air Optix
Night and Day lens (Alcon) and are now commonly re erred to
as ‘ rst-generation’ silicone hydrogels. Both were licensed or 30
days o continuous wear ( able 4.2). T e exact compositions o
these materials are proprietary, but the USAN-registered com-
ponents o the bala lcon A material show that it is based on
a carbamate-substituted RIS-based material known as PVC
(see Fig. 4.14). T e PVC is then copolymerized with NVP to
orm the bala lcon material.
T e Air Optix Night and Day lens (lotra lcon A) ( able 4.2)
is ‘biphasic’. ighe (2004) describes the lens as being a uoro-
ether macromer copolymerized with RIS and N,N-dimethyl
acrylamide (DMA) in the presence o a diluent. Its biphasic
(two-channel) structure means that oxygen and water perme-
ability channels are not reliant on each other. T e silicone-con-
taining phase allows passage o oxygen whilst the water phase
primarily allows the lens to move.
Without urther treatment both o these rst-generation
silicone hydrogel lenses would be unsuitable or wear owing to
the act that the resultant material sur aces are very hydropho-
bic. In order to overcome this problem, both lenses are sur ace
treated using gas plasma techniques. High-energy gases or
gas mixtures (the plasma) are used to modi y the lens sur ace
properties without changing the bulk properties. T e result
or the bala lcon lens is that sur ace wettability is gained via
plasma oxidation, which produces glassy silicate islands on the
lens sur ace.
T e lotra lcon lens is coated with a dense 25 nm thick coat-
ing. Both resultant sur aces have low molecular mobility, which
minimizes the migration o hydrophobic silicone groups to the
sur ace. However, despite these sur ace modi cations, wetta-
bility problems with these lenses were reported. It is generally
accepted that silicone hydrogel lenses have in erior wettability
compared with hydrogels, which occurs as a result o the hydro-
phobic interaction o silicone with the tear lm.
Another important di erence between these rst-genera-
tion silicone hydrogel materials and hydrogels is that they have
signi cantly greater elastic moduli (i.e. they are ‘sti er’). Such
mechanical characteristics mean that the lenses are easy to han-
dle, but have also been implicated in the aetiology o a num-
ber o clinical complications (Dumbleton, 2003). T ese include
higher incidences o super cial epithelial arcuate lesions, mucin
balls and CLPC (in particular, localized CLPC compared with
generalized CLPC), especially with continuous wear o these
lenses (Skotnitsky et al., 2002). T e sti ness o the material
may contribute to the mechanical irritation o the lens rubbing
against the conjunctiva o the upper eyelid producing a local-
ized response.
Fig . 4.15 Typ ical siloxy-containing macrome r (macromonome r) structure .
4 So ft Le ns Mat e rials 57
T e design o a lens, and in particular the edges, may also
have an impact on ocular compatibility. It has been suggested
that the design o the lens edge in conjunction with the mechan-
ical properties o silicone hydrogel lenses may be responsible
or increased conjunctival staining and conjunctival epithelial
aps observed with these lenses (Lo strom and Kruse, 2005).
A kni e-point edge or chisel-shaped edge may cause more con-
junctival staining and ap ormation than a round edge by
‘carving’ into the conjunctival tissue (Back, 2007). It has been
proposed that certain edge designs incorporating localized
increases in posterior edge li , reduced peripheral thickness or
peripheral channels may reduce the pressure on the conjunctiva
(Back, 2007). However, more recent work has suggested that
lenses that produce more circumlimbal staining are not associ-
ated with reduced levels o com ort (Maissa et al., 2012).
In an attempt to improve on the problems encountered
with these rst-generation lenses, manu acturers have engaged
in a programme o research aimed at manu acturing silicone
hydrogel lenses with improved mechanical and sur ace charac-
teristics. T is has resulted in the gradual emergence o ‘second-
generation’ and ‘third-generation’ silicone hydrogel lenses such
as Acuvue Oasys, 1-Day Acuvue ruEye, Avaira, Clariti, Dailies
otal 1 and MyDay lenses (see able 4.2).
T e main advantage o these newer silicone hydrogels
compared with the early silicone hydrogels is that they have
increased water contents, reduced moduli and do not need to
be sur ace treated. T e mechanical and sur ace properties o the
newest lenses are now similar to that o hydrogels (see able
4.2). Recent clinical work indicates that there may be a lower
incidence o CLPC with these lenses (Maldonado-Codina et al.,
2004).
Some o the lenses in able 4.2 are based on materials con-
taining RIS-like components. Acuvue Advance and Acu-
vue Oasys are based on anaka’s original patent ( ollowing its
expiration a er 25 years) using a modi ed RIS molecule, a
silicone macromer and hydrophilic monomers such as HEMA
and DMA. Alcohol is used as a solvent to aid the miscibility o
these ingredients and is then extracted ollowing polymeriza-
tion. High-molecular-weight PVP is the internal wetting agent
(the Hydraclear) used in these lenses, which is entangled and
there ore ‘entrapped’ within the lens matrix and which allows
them to be manu actured without requiring a sur ace treatment
(Maiden et al., 2002; McCabe et al., 2004). T e PVP essentially
works by shielding the silicone rom the tear lm at the lens
inter ace.
T e Bio nity (com lcon A) and Avaira lenses (en lconA)
are not based on RIS chemistry. T ey are comprised solely
o silicon-containing macromers and require no sur ace treat-
ment or wetting agent. T e patents surrounding the materials
re er to a mono unctional macromer (which contains only one
double bond taking part in the polymerization process) being
 58
PART 2

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Fig . 4.16 Exte nt o silicone hyd rog e l contact le ns f tting as a p e rce ntag e o all so t le nse s p re scrib e d in se ve n nations b e twe e n 2000 and 2015.
combined with another rubber-like siloxy macromer, result-
ing in a material with much longer chains (higher molecular
weight) compared with the other silicone hydrogels (Iwata et al.,
2005, 2006). T e patents also discuss other hydrophilic mono-
mers, which are presumably the key to why these materials do
not need to be sur ace treated.
T e introduction o second- and third-generation lenses has
seen a signi cant rise in the number o silicone hydrogel lenses
being prescribed on a daily-wear basis in addition to the intro-
duction o daily disposable silicone hydrogel lenses (Morgan
et al., 2016) (Fig. 4.16).
Classi icat io n o So t Le ns Mat e rials
T ere are two main classi cation systems or so contact lens
materials. T ese classi cation systems are expanded upon in
Appendix 4.1, below.
Co nclusio n
A basic understanding o the materials rom which contact
lenses are made as well as their behaviour is vitally important to
any contact lens practitioner as it is likely to orm an important
aspect o patient management. So contact lenses have come a
long way since the pioneering e orts o Pro essor Otto Wich-
terle in the late 1950s in terms o material, design and the way
4 So ft Le ns Mat e rials 59
they are manu actured. T ick pHEMA lenses that were replaced
every ew years are now a thing o the past.
Whilst extended-wear hypoxia-related problems with hydro-
gels have been resolved with the introduction o silicone hydrogel
materials, a number o mechanical and sur ace material-related
complications still remain, despite the introduction o second-
and third-generation polymers. For daily wear, there has been
somewhat o a renaissance towards tting hydrogel materials in
recent years. T is has come about because o the lack o evidence
or increased com ort with silicone hydrogels, the lack o evi-
dence to show that signi cant pathology results owing to oxygen
levels reaching the anterior eye during daily wear and the con-
rmation that the incidence o microbial keratitis is no di er-
ent between the two lens material groups. Future development
o so contact lens materials is likely to concentrate on trying
to resolve the issues o in ammation and in ection, improving
lens com ort (particularly towards the end o the day), enhanc-
ing post-lens tear exchange and improving sur ace wettability.
ACKNO WLEDGEMENTS
T e author wishes to thank Andy Broad, revor Glasbey, David Rus-
ton, Guy Whittaker and Inma Perez-Gomez or use ul comments and
discussions.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
60 PART 2 So ft Co nt act Le nse s
APPENDIX
CLASSIFICATIO N O F SO FT LENS MATERIALS
4.1
Fo o d and Drug Ad minist rat io n (FDA)
Classi icat io n Syst e m
T e FDA classi cation system or so lens materials is shown
in able 4A.1. T e classi cation system groups lens materials
based on their water content and physical charge. For many
years the classi cation system consisted o our hydrogel
groups. However, since silicone hydrogels were introduced,
this classi cation system has not been ideal because these
lenses are undamentally di erent in their material chemis-
try. As a result, a h group or silicone hydrogels has been
introduced.
The ISO Classi icat io n Syst e m
BS EN ISO 18369-1 / DAM1: 2009 sets out the new international
standard method or the classi cation o a contact lens material
given as a six-part code as ollows:
(pre x) (stem) (series suf x) (group suf x) (Dk range) (sur-
ace modi cation code)
For so lens materials, the classi cation denotes whether the
material is ionic and the range in which the water content o the
material lies. T e presence or absence o sur ace modi cations
is also indicated.
T e pre x is a term assigned to a material to designate a spe-
ci c chemical ormulation. Use o this pre x, which is adminis-
tered by the United States Adopted Names (USAN) Council, is
optional or all countries other than the USA.
wo types o stem are used. T e lcon stem is af xed to the
pre x and is applied or materials that contain ≥10% water by
mass (hydrogel materials). Focon is applied to materials con-
taining ≤10% water by mass (i.e. non-hydrogel materials).
T e series suf x is also administered by the USAN council,
and is used in cases in which the original ratio o the mono-
mers o an existing contact lens polymeric material is changed
to make a new material. In this case, the capital letter A is added
a er the stem designation. Subsequent changes in monomer
ratio are designated by the next letter o the alphabet. T ese let-
ters are used to di erentiate copolymers o unchanged mono-
mer units, but with di erent ratios. It can be omitted i there is
only one ormulation.
T e group suf x, represented by a Roman numeral, indicates
the range o water content and ionic character o the material
( able 4A.2).
able 4A.3 shows how the oxygen permeability o the materi-
als is classi ed.
T e modi cation code, designated by a letter m, denotes
whether the lens has a sur ace modi cation that renders the
sur ace characteristics di erent to the bulk material. Such
treatments include plasma treatment, acid / base hydrolysis
and incorporation o a material that migrates to the sur ace.
Certain types o tinted lens may also be considered sur ace
modi ed. In the case o an unmodi ed sur ace, this suf x is
omitted.
TABLE FDA Classif cat io n Syst e m o r So t Le ns
4A.1 Mat e rials
Gro up Mat e rial
I Low-wate r-conte nt (<50%), non-ionic p olyme rs
II Hig h-wate r-conte nt (>50%), non-ionic p olyme rs
III Low-wate r-conte nt (<50%), ionic p olyme rs
IV Hig h-wate r-conte nt (>50%), ionic p olyme rs
V Silicone hyd rog e l mate rials
TABLE
4A.2 BS EN ISO Hyd ro g e l Su f x Gro up s
Gro up Suffix Mat e rial
I Low-wate r-conte nt, non-ionic: mate rials that
contain le ss than 50% wate r and contain
1% or le ss (e xp re sse d as mole raction) o
monome rs that are ionic at p H 7.2
II Medium- and high-water-content, non-ionic:
materials that contain 50% water or more, and
contain 1% or less (expressed as mole rac-
tion) o monomers that are ionic at pH 7.2
III Low-wate r-conte nt, ionic: mate rials that con-
tain le ss than 50% wate r and contain g re ate r
than 1% (e xp re sse d as mole raction) o
monome rs that are ionic at p H 7.2
IV Medium- and high-water-content, ionic: ma-
terials that contain 50% water or more, and
contain greater than 1% (expressed as mole
raction) o monomers that are ionic at pH 7.2
V Enhance d oxyg e n p e rme ab le mate rials (e .g .
silicone hyd rog e l)
TABLE
BS EN ISO Hyd ro g e l Dk Gro up s
4A.3
Gro up Dk Rang e (ISO Dk Unit s)
0 <1
1 1–15
2 16–30
3 31–60
4 61–100
5 101–150
6 151–200
7, e tc. Incre asing in incre me nts o 50 Dk
Examp le
In order to demonstrate the BS EN ISO classi cation system,
the 1-Day Acuvue Moist lens would be classi ed as ollows:
Pre x: eta
Stem: lcon
Series suf x: A
Group suf x: IV
Dk range: 2
Modi cation code: none
T e lens can, there ore, be classi ed as (eta lcon A) (IV) (2).
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60.e 1
 5
So ft Le ns Manufact ure
NATHAN EFRO N
Int ro d uct io n
T ree techniques can be employed to manu acture so contact
lenses – lathe cutting, spin casting and cast moulding. As medi-
cal devices that rest against the highly sensitive eyeball, contact
lenses need to be o the highest quality in terms o their physical
construction. As devices that correct optical de ocus, the opti-
cal quality o contact lenses must also be o the highest order.
At the same time, it must be recognized that companies will
manu acture contact lenses only i they are pro table; the domi-
nant orces in the market dictate that these high-quality prod-
ucts must be delivered at minimal cost, and one consequence
o this is a simpli cation o lens parameters to streamline the
high-volume process.
Me t ho d s o f Manufact ure
A key requisite o any technology employed to manu acture a
medical appliance is that the nal product is sa e, predictable
and o high quality, so that it meets the intended need. T e three
technologies discussed below have been developed to meet
these requirements.
LATHE CUTTING
T is process essentially involves the use o a special contact lens
lathe to cut an anhydrous cylindrical button o material (xero-
gel) into the required shape, and then hydrating this to orm
the nished so lens. Lathe manu acture ranges rom labour-
intensive, manual-based cutting systems to sophisticated and
ully automated manu acturing lines, depending on the capital
budget or skill levels available (Fig. 5.1). Even with the use o
automation, however, the number and variability o manu ac-
turing steps that are necessary or lathe cutting means that man-
u acturing so lenses using this technology is necessarily more
expensive than using spin casting or cast moulding.
T ere ore, lathe cutting is generally reserved or the produc-
tion o custom-ordered or extreme range lenses that contain
design eatures not amenable to mass production, such as lenses
o high spherical power and / or high toric power, or aberration-
correcting so lenses or keratoconus (Marsack et al., 2008).
T e raw xerogel is supplied to the lens manu acturer in the
orm o ‘rods’ or ‘buttons’. A rod is a solid cylindrical piece o
xerogel, about 16 mm in diameter and 400 mm long. T e rod
is then sliced, orthogonally to the long axis, into buttons about
10 mm thick. More commonly, the xerogels are abricated and
supplied in button orm. When this occurs buttons have usually
been pre-trimmed to an industry standard size so that they can
be machined in most o the available lathes.
T e button is rst secured to a back sur ace lathe in a clamp or
‘collet’, and this assembly is set spinning at a high rate (typically
8000–12 000 rpm) about its central axis. A diamond-tipped tool
cuts the posterior sur ace lens shape into the button. A second
diamond tool advances rom the side to reduce the diameter to
the required size. T e sur ace is rendered smooth by either ne
machining or polishing. Modern sophisticated lathes are capa-
ble o cutting xerogel sur aces to a tolerance o 8–15 nm. Such
smooth sur ace nishing precludes the need or polishing and
is pre erred when non-spherical sur ace geometries are being
generated. T is approach also serves to preserve the consistency
o one sur ace to the next. T e dimensions o the lathed sur ace
are calculated to allow or eventual expansion when the xerogel
is later hydrated.
T e button is removed rom the collet and the cut posterior
sur ace o the button is mounted onto a support tool o a ront
sur ace lathe, using low-melting-point wax. It is essential during
this process that the button is mounted and xed in an abso-
lutely concentric and level aspect to the support tool in order to
minimize unwanted prism being introduced by the ront sur-
ace cutting. A diamond-tipped tool cuts the anterior sur ace
down to the required thickness, and the sur ace is smoothed.
T e most advanced lathes o er ‘W’ axis cutting options that can
generate rotationally non-symmetric sur aces whilst the pri-
mary ront sur ace is being cut. Polishing tools may be used to
smooth the lens edge, although some advanced lathes obviate
this step.
A er inspecting and measuring all relevant dry lens param-
eters, the lens is hydrated in normal, unpreserved saline until
it is ully equilibrated and impurities have been extracted. T e
hydrated lens is re-inspected or nal wet parameter con or-
mity, sealed in small glass vials and autoclaved at 120°C or at
least 15–20 minutes to e ect sterilization. Advances in lathing
technology and computer-controlled processing have led to the
Fig . 5.1 A lab oratory using the lab our-inte nsive me thod o lathe cut-
ting to manu acture so t contact le nse s.
61
62 PART 2 So ft Co nt act Le nse s

development o semiautomatic systems whereby stacks o but- SPIN CASTING

tons are automatically ed into lathes; however, even this tech-
nology cannot match the mass-production capabilities o cast
moulding.
Fig. 5.2 is a schematic ow diagram illustrating the pro-
cess o manu acturing a so contact lens using lathe-cutting
technology.
T e process o manu acturing rigid contact lenses by lathe
cutting is very similar to the process described above – the key
di erence being that, with so lens manu acture, the xerogel
must eventually be hydrated and sterilized, whereas rigid lenses
need only to be cut to their nal shape and polished. Other
notable manu acturing di erences concerning materials o high
gas permeability are tighter manu acturing tolerances and the
requisite or more critical control o cutting and mounting tem-
peratures in order to preserve their in vivo wetting properties.
A pictorial account o this process o rigid contact lens manu-
acture, and an explanation o how toric lenses are made using
lathe cutting, is given in Chapter 12.
In this process, a convex ‘male-shaped’ stainless steel tool, or
‘insert’, is produced on a high-precision engineering lathe and
lapped to provide an accurate sur ace that matches the dry
dimensions o the proposed anterior sur ace o the contact lens.
Modern non- errous materials are also suitable or producing the
mould tool and these materials can be generated on ‘nano-accu-
rate’ single point turning lathes. T ese lathes can cut mould tools
to a sur ace nish that renders polishing unnecessary. T e nal
sur ace shape o the master mould tool is veri ed using inter er-
ometry or other similar non-contact measuring methods. Any
given tool is used to make hundreds o thousands o moulds.
T e metal tool is impressed against heated liquid polypropyl-
ene or polyvinyl chloride (PVC), which then cools and sets to
orm a solid plastic concave emale mould. A multiple number
o metal tools (typically 8×–12×) is used to produce the same
number o plastic moulds simultaneously. T e moulding meth-
ods and tooling used must be very accurate in order to preserve

Fig . 5.2 The p roce ss o manu acturing a so t contact le ns b y lathe cutting . (1) The d ry p olyme r is sup p lie d as a rod or b utton. (2) A p olyme r b ut-
ton is p lace d on a lathe ; the b utton sp ins and a d iamond tool is ad vance d toward s the b utton to g e ne rate the le ns b ack sur ace . (3) The b utton is
re le ase d rom the b ack sur ace lathe . (4) The b utton is mounte d on a ront sur ace lathe with ad he sive wax; the b utton sp ins and a d iamond tool is
ad vance d toward s the b utton to g e ne rate the le ns ront sur ace . (5) The d ry le ns is re move d rom the lathe and the e d g e s are p o lishe d . (6) The le ns
is insp e cte d at 17× mag nif cation. (7) The d ry le ns is p lace d in saline to hyd rate the le ns, which swe lls to its f nal so t le ns orm. (8) The hyd rate d so t
le ns is insp e cte d at 10× mag nif cation. (9) The so t le ns is inse rte d into a g lass vial containing saline . (10) The g lass vial is se ale d and lab e lle d . (11) The
se ale d g lass vial containing the le ns is ste rilize d in an autoclave . (12) The ind ivid ual g lass vials are d isp atche d .

the concentricity o the resultant plastic part. Any moulding
runout will create unwanted prism in the lens during the spin-
ning process. T is type o injection cast moulding is generally
conducted in a controlled environment (usually to a class 100K
level). It is imperative or a spin-cast manu acturing process to
control the level o potential contaminants to a minimum as it is
an open-moulding system.
T e xerogel lens orm is created by pouring liquid monomers
into the concave moulds, which spin at a controlled rate about
the central mould axis.
T is spinning takes place in a controlled atmosphere o
nitrogen or similar oxygen-deprived atmosphere (Fig. 5.3).
T is is necessary as the spin mould is an open system and thus
exposes one sur ace o the lens (posterior) to air as it is being
cured. Oxygen in air is a natural scavenger o the initiator and
will ultimately inhibit the polymerization process.
T e speed o rotation, combined with both the mould tool
shape and monomer dose, ultimately determines the nal lens
parameters. T e shape o the back sur ace is primarily governed by
centri ugal orce generated by the rate o spin o the mould, sur ace
tension orces between the mould and polymer, and the e ects o
gravity. A greater speed o rotation o the mould will result in more
polymer mass being shi ed towards the lens periphery, and more
negative lens power. Due to this system o manu acture, certain
process controls such as monomer dosing must be more accurate
than those ound in ull cast moulding o contact lenses.
As the mould spin rate stabilizes, ultraviolet radiation
and / or heat is introduced to initiate polymerization. T e lens is
removed rom the mould, and the mould is discarded. Certain
spinning processes hydrate the lens in the original plastic mould
and it is never removed. T is process has been proven advanta-
geous and cost-e ective or the mass production o daily dis-
posable lenses.
Other spinning systems still require that the edges o the
lens are polished and that the lens be inspected, hydrated, re-
inspected, packaged and autoclaved. Spin casting can produce a
much higher output volume than lathe cutting, and in the latest
systems can match the high volume o lenses that can be pro-
duced by cast moulding. T e primary restriction o spin-cast
manu acture lies in its inability to generate a ully ormed edge
rom the posterior to anterior sur ace; however, sophisticated
design modelling, combined with accurate tooling, has largely
Fig . 5.3 A manu acturing line or sp in casting so t contact le nse s.
5 So ft Le ns Manufact ure 63
mitigated this limitation. T e process o spin casting is illus-
trated in Fig. 5.4.
CAST MO ULDING
Cast moulding has become the dominant technology in high-
volume lens manu acture. As with spin casting, a series o highly
polished steel tools is used to abricate polypropylene moulds;
however, matching male and emale moulds are required or
cast moulding. Again, modern non- errous materials are suit-
able or producing the mould tool and can be generated to
extremely ne levels o accuracy and sur ace nish. T ese mas-
ter tools are used to make hundreds o thousands o male and
emale moulds (Fig. 5.5).
T e variations ound in di erent manu acturing acilities
around the world, however, attest to signi cant development in
challenging this norm. Modern moulding machines can create
reproducible results (a critical requirement or the high vol-
ume production o contact lenses, particularly daily disposable
lenses) with higher numbers o tools. Some machines can suc-
cess ully carry as many as 36 cavities (18 males and 18 emales)
in one mould base. Moulding parameters, tool accuracy, cool-
ing and balancing are critical i this is to be success ul. T e man-
u acturer will seek a balance between output and accuracy with
the moulding process.
Cast moulding generally takes place in a continuous, auto-
mated production line (Fig. 5.6). Monomer in liquid orm is
introduced into a concave emale mould, which de nes the
shape o the lens ront sur ace. An ultraviolet-transparent male
mould is mated to the emale mould and the two are clamped
together in a care ully controlled environment.
T e contact lens edge is ormed when the two sides o the
mould come together. T ere is considerable science and art in
the control o the polymerization process and the pressure that
is applied to the mould to orm the lens. A crucial aspect o this
process is to arrange or the excess polymer (so-called ‘ ash’) to
be squeezed out while leaving the edge intact.
Once the polymer is encapsulated in the mould, it is ‘cured’ –
a process in which the assembled moulds are exposed to either
UV light or thermal radiation, or a combination o both, to e ect
polymerization so as to orm the dry contact lens. Most cast-
moulding processes are designed so that when the dry lens is
removed rom the mould there is no need to polish the edge.
T e moulds are disassembled and discarded, and the lens that is
released rom the moulds – still in rigid orm – is hydrated in saline.
Inspection is undertaken either manually (Fig. 5.7) or using
automated video-based computer-controlled image analysis.
Finally, the lens blister packs are sealed, labelled (Fig. 5.8), auto-
claved, and packaged in boxes. Fig. 5.9 is a ow diagram o the
cast moulding process.
It should be recognized that the above descriptions are
highly simpli ed accounts o sophisticated engineering pro-
cesses. Various manu acturers have introduced a number
o unique variations, such as wet-state polymerization, the
employment o reusable glass moulds (Hough, 1998), use o
the male hal o the mould or nal lens packaging, and vertical
production lines to optimize the use o costly oor space. Also,
toric and bi ocal lenses can be manu actured using either spin-
casting or cast-moulding technology by engineering the master
tools to contain the desired lens orms; these design elements
will then be aith ully transposed to the moulds and then to the
nal lens.
64 PART 2 So ft Co nt act Le nse s

Fig . 5 .4 The p ro ce ss o manu acturing a so t co ntact le ns b y sp in casting . (1) A male to o l is machine d ro m stainle ss ste e l; the co nto ur o the
to o l he ad will d e f ne the shap e o the ante rio r le ns sur ace . The same to o l is use d to make hund re d s o tho usand s o mo uld s. (2) A e male mo uld
is mad e b y p re ssing the male to o l into mo lte n p o lyp ro p yle ne , which co o ls and se ts. (3) The e male mo uld is mo unte d , with the concavity ac-
ing up ward s, in a sp ind le that sp ins ab o ut the le ns axis, and liq uid mo no me rs are intro d uce d into the sp inning mo uld . (4) The mo no me rs in the
sp inning mo uld are irrad iate d with ultravio le t lig ht to initiate le ns p o lyme rizatio n. (5) The d ry le ns is re mo ve d ro m the mo uld , the le ns e d g e
may b e p o lishe d and the mo uld is d iscard e d . (6) The e d g e o the d ry le ns is insp e cte d at 10× mag nif catio n. (7) The d ry le ns is p lace d in saline ,
which hyd rate s the le ns, causing it to swe ll to its f nal so t le ns o rm. (8) The hyd rate d so t le ns is insp e cte d at 10× mag nif catio n. (9) The so t le ns
is inse rte d into a b liste r p ack co ntaining saline . (10) The b liste r p ack is se ale d with a sp e cial o il, and a lab e l is stuck o n to this. (11) The se ale d
b liste r p ack co ntaining the le ns is ste rilize d in an auto clave . (12) The ind ivid ual b liste r p acks are inse rte d into p ackag e s, typ ically in multip le s o
e ithe r thre e o r six le nse s.

Fig . 5.5 Ge ne rating a me tal maste r tool. Fig . 5.6 A manu acturing lab oratory or cast mould ing so t contact
le nse s.
 5 So ft Le ns Manufact ure 65

Fig . 5.7 An insp e ction lab oratory or q uality che cking so t cast-mould - Fig . 5.8 A b liste r p acking line or p acking and lab e lling so t cast-
e d contact le nse s. mould e d contact le nse s.

Fig . 5.9 The p roce ss o manu acturing a so t contact le ns b y cast mould ing . (1) Male and e male tools are machine d rom stainle ss ste e l; the contour
o the male tool he ad will d e f ne the shap e o the ante rior le ns sur ace , and the contour o the e male tool he ad will d e f ne the shap e o the p oste rior
le ns sur ace . The same tools are use d to make hund re d s o thousand s o mould s. (2) Male and e male mould s are mad e b y p re ssing the tools into
molte n p olyp rop yle ne , which cools and se ts. (3) The e male mould is mounte d in an accurate alig ning f xture , with the concavity acing up ward s, and
liq uid monome rs are introd uce d into the concavity. (4) The male mould is re g iste re d ove r the e male mould and the two mould s are clip p e d tog e the r.
(5) Exce ss p olyme r is sq ue e ze d out rom the sid e s o the mould . (6) The monome rs insid e the mould asse mb ly are irrad iate d with ultraviole t lig ht
or the rmal e ne rg y to initiate le ns p olyme rization. (7) The d ry le ns is re move d rom the mould and the mould s are d iscard e d . The f nal stag e s o le ns
p rod uction are e sse ntially the same as or sp in casting , which is illustrate d in ste p s 6–12 in Fig . 5.4.
66 PART 2 So ft Co nt act Le nse s
Re p ro d ucib ilit y and Q ualit y o f
Mass-p ro d uce d Le nse s
Practitioners who prescribe lenses, and patients who wear
lenses, need to be assured o the reproducibility o lenses that
have been manu actured using mass-production techniques.
Young et al. (1999) determined the reproducibility o 24 lenses
in three lens powers (−1.00 D, −3.00 D and −6.00 D) o eight
common requent replacement spherical so contact lens types.
T ey ound that the mean power o all the lenses was higher
than their labelled powers, although all were within the toler-
ance ranges. Reproducibility was observed to be worse or all
lenses at higher powers. All but two lens types had mean diam-
eters within tolerance. A slight reduction o optical quality at
high powers was noted. Measures o back optic zone radius,
centre thickness and overall diameter showed reasonably good
repeatability.
In a similar study conducted on three brands o daily
disposable contact lenses, E ron et al. (1999) ound that
450 lenses o −3.00 D in power displayed an overall high
degree o accuracy and reproducibility. hey concluded
that, with a single inconsequential exception, all measured
parameters were ound to all well within clinically accept-
able limits or providing wearers o these lenses with consis-
tent vision and it.
E ron and Veys (1992) examined the quality o three types o
early-generation disposable lenses at 17× magni cation using
an Optimec JFC Contact Lens Analyzer. An overview o the
observed de ects revealed that they could be divided into two
broad categories – edge de ects and non-edge (body) de ects
(Fig. 5.10).
Each o these categories could be urther divided into our
subcategories, as ollows:
EDGE DEFECTS
• Nick – small piece o lens material missing rom lens edge.
• ear – partial or ull separation o lens material continuous
with lens edge (Fig. 5.11).
• Roughness – uneven edge pro le.
• Excess material or ash – lens mass or surplus material
extending beyond lens circum erence.
Fig . 5.10 Syste m or classi ying the typ e s o d e e cts that can b e ob -
se rve d on contact le nse s. Ed g e d e e cts are ind icate d in b old ont, and
b od y d e e cts in p lain ont.
NO N-EDGE (BO DY) DEFECTS
• Split – partial or ull separation o lens material that is not
continuous with lens edge.
• Blemish – hazy, low-transparency region o lens, on lens
sur ace or within lens.
• Eccentric optic zone – optic zone not concentric with lens
perimeter.
• Multiple pieces – lens separated into sections.
Some lenses contained more than one de ect, and a high
prevalence o nicks, tears, roughness and blemishes was
observed. At the time, other authors reported similar ndings
(Wodis et al., 1990; Holden et al., 1991; Lowther, 1991). T ese
studies accorded a valuable service to the contact lens industry
in the early 1990s as they ocused attention on the importance
o the quality o mass-produced lenses, especially edge quality.
Advances in cast-moulding manu acturing technology over the
past quarter o a century, uelled by the attention drawn to the
above issues, has led to a substantial overall improvement in
lens quality.
At a microscopic, subclinical level, it can be observed that
di erent manu acturing techniques can have a signi cant e ect
on the nished lens sur ace. Fine concentric rings can o en be
seen on the sur ace o so lenses that have been manu actured
by lathe cutting; these ‘lathe marks’ are o en visible under high
magni cation using the slit-lamp biomicroscope. Using atomic
orce microscopy, Bhatia et al. (1997) observed that the sur ace
o unused cast-moulded lenses varied rom smooth to rough
with sur ace eatures unique to the polymers and manu actur-
ing process.
Maldonado-Codina and E ron (2005) investigated the
impact o manu acturing method and material composition
on the sur ace characteristics o ve types o hydrogel contact
lenses: three polyhydroxyethyl methacrylate (pHEMA) lenses,
each manu actured by a di erent technique, namely, lathing,
spin casting and cast moulding, a HEMA / methacrylic acid
cast-moulded lens and a HEMA / glycerol methacrylate cast-
moulded lens. Front and back lens sur aces were examined
using scanning electron microscopy (SEM) and atomic orce
microscope (AFM). T e sur aces o the lathed lenses were
covered in lathing / polishing marks. In general, at a micro-
scopic level, the anterior sur ace appeared rougher. All three
cast-moulded lenses had more processing debris than did the
Fig . 5.11 Te ars in the e d g e o a d isp osab le so t le ns ob se rve d at 100×
mag nif cation. Such e d g e d e e cts are uncommon with mod e rn cast-
mould ing te chnolog y.

lathed and spun-cast pHEMA lenses. Overall, the sur aces o
the lathed lens were ‘rougher’ than those o the cast-moulded
lens. Maldonado-Codina and E ron (2005) concluded that sur-
ace topographies o hydrogel contact lenses are dependent on
method o manu acture. T ey also noted that cast-moulded
lenses are associated with apparently ‘stickier’ sur aces, which
may be indicative o sur ace degradation or cure-related issues
during the manu acturing process.
Maldonado-Codina and E ron (2004) measured high- and
low-contrast visual acuity, and the level o protein deposition,
in patients wearing HEMA lenses made by three manu acturing
methods. T ey ound that spun-cast HEMA lenses deposited
less protein than cast-moulded or lathed HEMA lenses; how-
ever, the di erences in the amount o protein deposited did not
a ect visual unction.
T e impact o manu acturing method on pre-lens tear lm o
so HEMA contact lenses was also investigated by Maldonado-
Codina and E ron (2004). Manu acturing method was ound
to have only a minor e ect on the quality and stability o the
pre-lens tear lm in HEMA lenses. T e authors concluded that
pre-lens tear lm structure is likely to be more related to mate-
rial and patient characteristics than to manu acturing method.
O ccup at io nal Safe t y in Le ns
Manufact ure
As with all manu acturing processes, precautions must be put in
place to ensure the personal sa ety o those working in contact
lens manu acturing plants.
Lee et al. (2009) reported the case o a 36-year-old Chinese
man who presented with a 4-month history o a work-related,
recurrent, bilateral dermatitis a ecting the tips o his ngers and
thumbs a er 9 months o work in a actory manu acturing dispos-
able contact lenses. Clinical examination showed scaly, eczematous
plaques limited to the le thumb, index, and middle ngertips as
well as the right index and middle nger tips. Personal protective
equipment included sa ety boots, latex gloves and goggles.
T e manu acturing process o these contact lenses involves
the moulding o polypropylene casts and the injection, spin-
ning, and UV curing o liquid acrylic monomers. T ese pro-
cesses are automated and enclosed. Hence, workers do not
have direct contact with the chemicals. T is worker, however,
5 So ft Le ns Manufact ure 67
a technician involved in the servicing and maintenance o the
manu acturing machines, was apparently exposed to the liquid
monomers in the machines. T e constituent monomers used in
the contact lens manu acture were 2- hydroxyethyl methacry-
late (2-HEMA), glycerol monomethacrylate (GMA) and ethyl-
eneglycol dimethacrylate (EGDMA). Other substances handled
included machine oil, acetone, and isopropyl alcohol.
Although acrylates are common sources o occupational
hand dermatitis, acrylate sensitization rom contact lens manu-
acturing is rarely seen.
T e worker was using latex gloves, which protect poorly
against acrylates, as acrylates penetrate over relatively short
periods. He was moved to another section o the actory, where
the acrylates had been cured and were not in monomer orm;
there was no urther recurrence o his dermatitis.
T is report highlights the sensitizing potential o acrylate
monomers such as 2-HEMA and EGDMA in the manu acture
o contact lenses, and the need or worker education and train-
ing to increase awareness and improve compliance with occu-
pational hygiene precautions. It also highlights the importance
o understanding the work processes so that appropriate recom-
mendations can be made to the management to reduce the risk
o dermatitis.
Co nclusio n
T e three primary methods o manu acturing so contact lenses
are lathe cutting, spin casting and cast moulding. T e technique
o cast moulding has become the dominant orm o so contact
lens manu acture because it is capable o producing suf cient
quantities o high-quality lenses so as to meet the intense clini-
cal demand or a ordable planned replacement and disposable
lens-wearing modalities. Practitioners can be reassured that
modern so lens-manu acturing techniques produce lenses o
high quality and good reproducibility.
ACKNO WLEDGEMENTS
T e author would like to thank Steve Newman or assistance in writing
and illustrating this chapter.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
REFERENCES
Bhatia, S., Goldberg, E. P., & Enns, J. B. (1997). Ex-
amination o contact lens sur aces by atomic orce
microscope (AFM). CLAO J., 23, 264–269.
E ron, N., & Veys, J. (1992). De ects in disposable
contact lenses can compromise ocular integri-
ty. Int. Contact Lens Clin., 19, 8–18.
E ron, N., Morgan, P. B., & Morgan, S. L. (1999).
Accuracy and reproducibility o one day dispos-
able contact lenses. Int. Contact Lens Clin., 26,
168–173.
Holden, B. A., Sulaiman, S., & Cornish, R. (1991).
Acuvue ‘imperfections’ study. Maastricht, Hol-
land: Discussion paper presented at the 25th/30th
Jubilee Con erence o the Netherlands Associa-
tion o Contact Lens Specialists (ANVC) and the
Netherlands Optometric Association (OVN).
16–18 November.
Hough, . (1998). Shedding light on a new high-
volume contact lens manu acturing process. CL
Spectrum, 13, 42–44.
Lee, H. Y., Goon, A., Choy, K., et al. (2009).
Acrylate-induced hand dermatitis in the manu-
acture o contact lenses. Contact Dermatitis, 61,
117–118.
Lowther, G. E. (1991). Evaluation o disposable lens
edges. CL Spectrum, 5, 41–43.
Maldonado-Codina, C., & E ron, N. (2004). Impact
o manu acturing technology and material com-
position on the clinical per ormance o hydrogel
lenses. Optom. Vis. Sci., 81, 442–454.
Maldonado-Codina, C., & E ron, N. (2005). Impact
o manu acturing technology and material com-
position on the sur ace characteristics o hydrogel
contact lenses. Clin. Exp. Optom., 88, 396–404.
Marsack, J. D., Parker, K. E., & Applegate, R. A.
(2008). Per ormance o wave ront-guided so
lenses in three keratoconus subjects. Optom. Vis.
Sci., 85, 1172–1178.
Wodis, M., Hodur, N., & Jurkus, J. (1990). Dispos-
able lens sa ety: the reproducibility actor. Int.
Contact Lens Clin., 17, 96–102.
Young, G., Lewis, Y., Coleman, S., et al. (1999). Pro-
cess capability measurement o requent replace-
ment spherical so contact lenses. Cont. Lens
Anterior Eye, 22, 127–135.
67.e 1
 6
So ft Le ns O p t ics
W NEIL CHARMAN
Int ro d uct io n
Single-vision so contact lenses have a number o optically
attractive eatures. T ey centre well on the cornea with only
small amounts o lateral movement and hence introduce little
additional asymmetric aberration into the lens–eye system.
T e diameter o their optic zone normally exceeds that o the
entrance pupil o the eye under all lighting conditions; thus,
the ‘haloes’ around light sources that are observed at night ol-
lowing excimer re ractive surgery or during wear o some rigid
lenses are avoided. T eir large overall diameter, greater than that
o the cornea, ensures the absence o the discontinuities, are
and stray light e ects that can arise with smaller-diameter rigid
lenses in the peripheral visual eld, which are due to re ractive
and scattering e ects at the lens edges. T eir re ractive index
(about 1.37–1.48) is quite close to that o the cornea, so that
Fresnel re ection losses are comparable with those in the natural
eye. T ey shape themselves so that their back sur ace con orms
closely to the anterior sur ace o the cornea, thus minimizing
tting problems.
On the other hand, the tendency to drape to con orm to the
corneal sur ace and the consequent near-elimination o tear lens
e ects mean that, unlike rigid lenses, so lenses cannot com-
pensate or modest amounts o corneal astigmatism. Only by
using a well-stabilized toric lens can the latter be corrected (see
Chapter 9). Other possible disadvantages rom the optical point
o view include lens exure and hydration variations, which,
together with spatial non-uni ormities in the thickness o any
post-lens tear lm, may result in on-eye power changes. T is
chapter is primarily concerned with such on-eye power changes
and the interaction o the higher-order aberrations o the lens
and the eye, inso ar as they apply to the optic zone o spherical
corrections.
O n-e ye Po w e r Chang e s
Be ore being placed on the eye, the back vertex power o a so
lens is normally checked when the lens is at room temperature
in a ully hydrated state (see Chapter 7). As has already been
noted, when the so lens is worn, its inherent exibility allows it
to ‘drape’, so that the shape o the posterior sur ace approximates
closely to that o the anterior cornea. While this greatly simpli-
es tting, any associated changes in the curvatures o the lens
sur aces and lens thickness may result in the on-eye power o
the lens di ering slightly rom that measured o -eye.
Although draping implies that the tear lens between the con-
tact lens and the cornea ought to have zero power, this may not
always be the case. Wechsler et al. (1979) ound no evidence or
a signi cant tear lens, and several subsequent authors agreed
with this result (Chaston and Fatt, 1980; Holden and Zantos,
1981; Plainis and Charman, 1998). However, Weissman and
68
Zisman (1979) and Michaels and Weissman (1982) suggested
that a tear lens about 10 µl in volume may sometimes exist and
contribute about −0.15 D o power to the combined lens–eye
system. Weissman and Gardner (1984) went on to propose that,
although low-minus lenses may entrap only a small volume o
tears (about 5.5 µl), thicker, low-plus lenses may entrap a greater
volume (about 9.5 µl l), giving a correspondingly greater tear
lens e ect (up to −2.00 D).
Changes in hydration, which are a unction o the lens design
and material (Andrasko and Schoessler, 1980; Andrasko, 1983;
Brennan and E ron, 1987), the wearer, the visual task and the
environmental conditions (E ron et al., 1987; Brennan et al.,
1988) will a ect the re ractive index and geometry o any so
lens, and hence its power. ypically, hydration may all by
around 5–10% a er the rst hour o lens wear (Wechsler et al.,
1982; Andrasko, 1983; E ron and Morgan, 1999). T inner lenses
reach equilibrium a er about 5 minutes, whereas thicker, high-
power positive lenses may continue to dehydrate or 30 minutes
or more a er insertion. E ects appear to be material dependent
(Brennan and E ron, 1987); in particular, high-water-content
lenses dehydrate more and reach equilibrium sooner than lower-
water-content lenses o comparable thickness. T ere is a strong
suggestion that greater dehydration may occur during near work,
due to reduced blinking, and when atmospheric humidity is low.
Water loss can occur by several pathways, including evaporation
into the atmosphere, drainage into the nasolacrimal system and,
possibly, absorption into the conjunctival capillaries.
As the corneal temperature is around 32–35°C (E ron et al.,
1989), while the room temperature is normally about 20°C,
there is a change in temperature when the lens is put on the eye;
this a ects all the lens parameters (Fatt and Chaston, 1980a, b;
Purslow et al., 2005) including hydration and re ractive index.
T e measurements made on a variety o so lens materials by
Fatt and Chaston (1980b), however, suggest that the maximum
increase in (n L − 1), where n L is the lens re ractive index, is only
about 1 part in 40 or a temperature rise o 14°C, so that the
associated power change in a lens o this material would be only
about 0.25 D or a ±10 D lens.
Many authors have attempted to develop either theoretical
or empirical models to allow overall on-eye power changes to
be predicted (Ford and Stone, 1997; Patel et al., 1998; Plainis
and Charman, 1998). Among the more mathematically sophis-
ticated models o exure alone are those based on the concept
that the exed lens always retains constant volume (Bennett,
1976) or that the arc length o the back optic zone o the lens
remains constant (Holden et al., 1976). Experimental studies,
whose results include the e ects o all the actors mentioned,
not just those o exure, agree in indicating that any power
changes are small or negative lenses but that larger, clinically
signi cant changes, which increase with the lens power, occur
or positive lenses.

T is can be seen in Fig. 6.1, which compares a smooth con-
tinuous curve derived rom best ts to a substantial body o
experimental data by Holden et al. (1976), with other experi-
mental data obtained by Plainis and Charman (1998) and Koll-
baum et al. (2013). Also shown (dashed) is a curve based on the
empirical equation proposed by Weissman (1984), that is:
Δr 1 /Δr 2 = 1 − 0.05F
where Δr 1 and Δr 2 are the on-eye changes in the ront and back
sur ace radii o the contact lens and F is the un exed back ver-
tex power. For the purpose o Fig. 6.1 it has been assumed that
the initial value o r 2 is 0.8 mm atter than the corneal radius
o 7.8 mm, and that the lens index is 1.43. It can be seen that,
although there is reasonable agreement, to within about 0.25 D,
between the ormula’s predictions or corrections up to about
±6 D, those or high-powered corrections are less consistent.
Dietze and Cox (2003) interpret such results in a di erent
way. T ey suggest that the paraxial power o contemporary
thin, disposable, so lenses does not change when the lens is
placed on the eye, and that any small apparent discrepancies
in the expected subjective correcting e ect are associated with
the spherical aberration o the lens and eye. T is would be
expected to shi the optimal ocus away rom the paraxial value
towards the marginal ocus in a way that depended upon the
pupil diameter and the sign and magnitude o the aberration.
T is view has, however, been challenged by some later work
(Kollbaum et al., 2013), which indicates that although the o -
eye powers generally agree with manu acturer labelling, small
on-eye changes occur in both the paraxial spherical power and
the spherical aberration o so lenses. T e exact e ects vary in
an unpredictable way with the details o the materials and lens
design used by di erent manu acturers. In general, the results
o this study are broadly in line with those o earlier authors and
show that the largest on-eye changes occur or higher-powered
positive lenses, which lose power (see Fig. 6.1).
It should be mentioned that unusually thick (up to 0.6 mm)
so lenses have occasionally been suggested or the correction
Fig . 6.1 Sup p le me ntal le ns p owe r (i.e . d i e re nce b e twe e n on-e ye
p owe r and in vitro p owe r) as a unction o in vitro p owe r. (The smooth
curve s are rom Hold e n e t al. (1976; b lue continuous line ), We issman
(1984; b lack d ashe d line ) and Kollb aum e t al. (2013, re d d ashe d line );
the g re e n d o t symb ols are e xp e rime ntal d ata ob taine d b y Plainis and
Charman (1998).)
6 So ft Le ns O p t ics 69
o keratoconus (Kau man et al., 1970; Koliopoulos and ragakis,
1981; Campbell and Caroline, 1995). T ese show less draping
during wear and might be expected to be accompanied by sub-
stantial tear lens e ects and e ective on-eye power changes.
At the present time neither modelling nor experimental data
provide ully convincing predictions or on-eye power changes.
All the earlier models involve inadequately justi ed assump-
tions and it is probable that additional actors such as material,
lens design, tting philosophy, patient tear ow and lens–lid
interactions also in uence the results occurring in practice. It
may be that the greater thickness o the rst generation o so
lenses unduly in uenced the early results. Although predictions
based on Fig. 6.1 should give a general guide to the magnitude
o the on-eye power changes to be expected, or practical work it
still seems more sensible to ollow the conventional approach o
trial lens tting, as a er suitable equilibration the trial lens will
display on-eye e ects similar to those o the ordered lens o the
same design and power (E ron, 1991).
Ab e rrat io n
Westheimer (1961) pointed out that, or oveal vision and well-
centred, rotationally symmetric contact lenses having steeply
curved sur aces, the classical lens aberration o greatest poten-
tial importance would be spherical aberration, in which the
power o the contact lens varies with distance rom its axis. T is
is in contrast to spectacle lenses where, as the eye moves with
respect to the lens, oblique astigmatism, distortion and eld
curvature are all introduced whenever the visual axis moves
away rom the optical centre o the lens. Indeed, spherical aber-
ration is o little importance in spectacle lenses, whereas con-
trol o the o -axis aberrations is a major design aim. As or
primary spherical aberration the wave ront aberration varies
with the ourth power o the radius in the pupil and the change
in zonal power with the square o the radius, the greatest opti-
cal impact o spherical aberration is likely to occur when the
pupil diameter is large, that is, under mesopic and scotopic
conditions.
With the exception o di ractive lenses or presbyopes (see
Chapter 23), longitudinal chromatic aberration is normally o
negligible importance in either spectacle or contact lens design,
as any contribution rom the correcting lens is much smaller
than that o the eye itsel (see Chapter 3). Although transverse
chromatic aberration associated with prismatic e ects during
oblique viewing is o great signi cance in relation to spectacle
lens materials and their dispersion, it plays little role in relation
to well-centred contact lenses.
Early work in this area concentrated on exploration o the
bene ts o aspheric lens sur aces in reducing the spherical aber-
ration o the contact lens in isolation (Bauer and Lechner, 1979;
Bauer, 1980). More recently, it has been realized that what mat-
ters is the combined aberration o the lens–eye system and that
a contact lens with minimal spherical aberration does not nec-
essarily lead to the best visual per ormance (Campbell, 1981). In
principle, ideally the aberration o the lens should balance that
o the eye, so that the combined system has minimal aberration
(Fig. 6.2).
It is clear that, i any series o aspheric lenses designed to
have a xed level o spherical aberration or all lens powers is to
o er use ul improvements in the vision o patients by compen-
sating or the eye’s own spherical aberration, several conditions
must be ul lled:
70 PART 2 So ft Co nt act Le nse s
Fig . 6.2 Conce p t o b alancing the p ositive sp he rical ab e rration o a
myop ic e ye with a ne g ative le ns having ne g ative sp he rical ab e rration.
(A) Eye alone ; (B) le ns alone ; (C) comb ine d co rre cte d le ns–e ye syste m.
•T e spherical aberration o the eye should be consistent
rom patient to patient.
• Spherical aberration should be the major ocular aberra-
tion, so that its neutralization produces a substantial re-
duction in root mean square (RMS) wave ront error.
• T e on-eye spherical aberration introduced by the lenses
should not di er rom the o -eye aberration due to exure
or other actors, or i it does, it should vary in a systematic,
predictable way.
• Lens wear should not induce any change in the ocular ab-
errations, or example through corneal warpage.
• Any decentration o the aspheric contact lens with respect
to the axis o the eye should not itsel introduce signi cant
aberration.
• T e neural components o the visual system should be ca-
pable o appreciating any bene ts in optical image quality
that correction might provide.
Although various early attempts were made to assess the
impact on visual per ormance o so lenses designed to have
di erent levels o spherical aberration (Cox, 1990; Cox and
Holden, 1990; Chateau et al., 1998; De Brabander et al., 1998),
they produced somewhat mixed results, with some patients
showing improvements, some no change and others a loss in
visual per ormance. Under photopic conditions, with relatively
small pupils, mean high- and low-contrast visual acuities pro-
duced with spherical and aspherical versions o the same lens
showed no signi cant di erences (Vaz and Gundel, 2003).
Chateau et al. (1998) were, however, able to demonstrate that
i the aberration o the lens was systematically varied then
mesopic contrast sensitivity at 12 c / ° passed through a peak
or each patient: the optimal spherical aberration o the cor-
recting lens tended to become more negative with age. wo
groups o subjects aged between 20 and 45 years were used; one
consisted o emmetropes and the other o myopes with correc-
tions between −5.00 and −10.00 D. T e range o lenses used
was designed to display varying amounts o primary spherical
aberration o the orm:
P (r) = P0 + Ar 2
where P0 is the paraxial power, P(r) is the power at a distance r
mm rom the lens axis and A is a constant (D / mm 2). T e values
o A used ranged rom −0.27 to +0.19 D / mm 2. For comparison,
the values o A can be converted to the Zernike coef cient C04
used to describe primary spherical aberration (see Chapter 3),
or any pupil radius, R, by substitution
( √in )the equation:
C04 = AR4 / 24 5
Use o the parameter A to describe the spherical aberration has
the advantage that it is independent o pupil diameter. Under
the conditions o the visual measurements o Chateau et al.
(1998), pupil diameters were typically around 6 mm.
Fig. 6.3A gives examples o the way in which the contrast
sensitivity or individual subjects varied with the value o A,
whereas Fig. 6.3B plots the variation in the value o A or opti-
mal contrast sensitivity, AOP , against the age o the subjects in
the emmetropic and myopic groups.
It appears that AOP becomes more negative with age, with
the value always being more negative or myopes at any age. In
subjects o all ages, the average value o AOP was −0.16 D / mm 2
in myopes and −0.054 D / mm 2 in emmetropes. It is o interest
that these values are similar in magnitude but o opposite sign
to the mean values o ocular spherical aberration o about +0.05
D / mm 2 ound by Charman and Walsh (1985) or +0.07 D / mm 2
ound by Radhakrishnan and Charman (2007) as a result o
averaging available ocular wave ront aberration data across all
meridians rom various studies. T is suggests that best visual
per ormance may indeed involve a balance between lens and
ocular aberration.
Un ortunately, interpretation o these earlier studies was
hampered by the lack o in ormation on the ocular aberra-
tions o the individual subjects. Such in ormation would have
allowed each subject’s visual results to be interpreted in terms o
the combination o their ocular aberration with that o the lens.
In recent years, the growing availability o e ective aberrom-
eters capable o rapidly estimating a patient’s ocular aberration
under clinical conditions has trans ormed this situation. As a
result, a much clearer picture o the possible bene ts o lenses
designed to have a speci c level o spherical aberration can now
be obtained (E ron et al., 2008).
Summarizing this recent work in relation to the conditions
discussed earlier:
• As outlined in Chapter 3, individual eyes show substantial
variation in their levels o spherical aberration and in their
overall higher-order aberrations. Although Chateau et al.
(1998) appeared to nd di erences between myopes and
emmetropes, the consensus view is now that mean spheri-
cal aberration does not seem to change systematically with
re ractive error (Fig. 6.4A). However, it does change with
age, the mean value becoming progressively more positive
(Fig. 6.4B; Salmon and van de Pol, 2006). T is evidently
explains the nding o Chateau et al. (1998) that the op-
timal aberration o the correcting contact lens became
more negative with age. At any particular age there is a
wide spread in the individual levels o spherical aberration
 6 So ft Le ns O p t ics 71

Fig . 6.4 (A) Root me an sq uare p rimary sp he rical ab e rration, , or

a 6 mm p up il as a unction o re ractive error. (B) Primary sp herical ab e r-
ratio n, e xp re sse d in D / mm 2, or a 4.5 mm p up il as a unction o ag e .
In b oth p lots rig ht-e ye d ata are shown. ((A) Ad ap te d rom Che ng , X.,
Brad le y, A., Hong , X. & Thib os, L. N. (2003). Re lationship b e twe e n re -
ractive e rror and monochromatic ab e rrations o the e ye . O p tom. Vis.
Sci., 80, 43–49. (B) Ad ap te d rom Rad hakrishnan, H. & Charman, W. N.
(2007). Ag e -re late d chang e s in ocular ab e rrations with accommod ation.
J. Vis.,7, 1–21.)

diameter rom the meta-analysis by Salmon and van de Pol

Fig . 6.3 (A) Contrast se nsitivity (CS) at 12 c / ° or our myop e s cor-
re cte d b y so t le nse s having d i e re nt amounts o sp he rical ab e rration
(SA), as sp e cif e d b y the third -ord e r coe f cie nt A. (B) Variation in the
value o the op timal SA coe f cie nt AO PT or the corre cting so t le ns, as
a unction o ag e or e mme trop ic and myop ic sub je cts. (Ad ap te d rom
Chate au, N., Blanchard , A. & Baud e , D. (1998). Inf ue nce o myop ia and
ag ing on the op timal sp he rical ab e rration o so t contact le nse s. J. O p t.
Soc. Am. A, 15, 2589–2596.)
(Fig. 6.4B; see also Chapter 3). No aspheric lens series
with a xed level o spherical aberration can then correct
the spherical aberration o all patients. Although nega-
tive spherical aberration in the contact lens may bene t
the majority o patents, a er ‘correction’ the minority o
younger eyes with negative aberration will have that level
increased.
• Even i spherical aberration is corrected, substantial lev-
els o other higher-order wave ront aberrations remain, as
well as additional blur due to chromatic aberration and re-
sidual spherocylindrical re ractive errors. I , or example,
we take RMS wave ront aberration values or a 6 mm pupil
(2006), the mean RMS in the ourth-order Zernike spheri-
cal aberration mode, Z04, is 0.128 µm, in comparison with
a total RMS aberration (third- to sixth-order) o 0.327 µm.
T us eliminating the spherical aberration would reduce
the total RMS only to 0.301 µm, a relatively small improve-
ment. For comparison, or this pupil diameter, an RMS
wave ront error o 0.327 µm corresponds to an equivalent
spherical de ocus o about 0.25 D, which is about the level
o reliability or clinical re raction techniques. In act, as
a generalization in so lens work, it is o en assumed that
astigmatism needs to be corrected only when it exceeds
0.75 D, so that RMS wave ront errors due to uncorrected
residual spherocylindrical errors o en exceed those due to
higher-order aberrations.
• It appears that the on-eye spherical aberration o thin so
contact lenses is similar but not identical to that ound o -
eye. Changes due to lens exure, change in hydration, or
post-lens tear lm e ects are small (Lopez-Gil et al., 2002;
Dietze and Cox, 2003) but detectable, with the e ective
spherical aberration being reduced or higher-powered
positive lenses (Kollbaum et al., 2013). Comparative stud-
ies in which the same subjects wore either standard so
or rigid gas-permeable contact lenses suggest that levels
o total lens–eye wave ront aberration are generally lower
with rigid lenses (Hong et al., 2001; Lu et al., 2003).
• Hydrogel lenses can undoubtedly, over time, cause marked
corneal warpage and consequently changes in aberration
(Schornack, 2003) in a minority o patients. As yet, the
72 PART 2 So ft Co nt act Le nse s
question o whether more subtle levels o change occur in
the majority o patients or with di erent lens materials re-
mains to be explored.
• I an aspheric lens with signi cant levels o spherical aber-
ration decentres, it will introduce coma (Dietze and Cox,
2004). It may, however, be possible to modi y aspheric de-
sign to minimize the aberrations associated with decentra-
tion (Suzaki et al., 2007).
• T e greatest optical improvements associated with correc-
tion o any orm o monochromatic wave ront aberration
are likely to be obtained when the pupil is large – that is,
under natural mesopic and scotopic conditions. However,
under such conditions, much o the observed degradation
o spatial vision is caused by neural rather than optical
actors. T us even an ideal correction can improve visual
per ormance to only a limited extent; such improvement
is likely to be primarily in contrast sensitivity rather than
high-contrast acuity (Charman and Chateau, 2003).
Overall, then, any claim that all normal patients would bene t
markedly rom an aspheric lens series with some xed ‘average’
level o spherical aberration, compared with standard spheri-
cal lenses, is unlikely to be valid. T is does not mean o course
that the vision o speci c individual patients, particularly those
with unusually high levels o aberration, might not be use-
ully improved by some orm o customized correction. T e
improvements in individual mesopic contrast sensitivity given
by selecting the optimal lenticular spherical aberration in Fig.
6.3 illustrate this, although the improvement in contrast sensi-
tivity over that or a lens with zero spherical aberration rarely
exceeds about 0.2 log units (1.6×).
It seems likely that, in uture, aberrometry will be a standard
procedure in many clinical practices, since relatively low-cost,
multirole instruments capable o aberrometry, topography
and autore raction are becoming increasingly available. As
discussed, true customization o lenses to correct individual
aberrations raises a number o problems. It may be that aber-
rometry ollowed by the selection o a suitable lens rom a
commercial series with several levels o spherical aberration
or each paraxial power might allow practitioners to o er use-
ul improvements in vision to at least some patients, particu-
larly at mesopic levels where the pupil is large. T is, however,
demands larger lens inventories and perhaps a better solution
may be simply to minimize any possible increase in aberra-
tion by making the contact lens have zero spherical aberration,
rather than some average level o spherical aberration, which
may increase the overall aberration when worn by some indi-
viduals (Kollbaum and Bradley, 2007).
As discussed brie y in Chapter 3, there is, in act, continu-
ing scienti c and commercial interest in the possibility o ully
customized so contact lens corrections, particularly or those
patients having high levels o ocular aberration. T e optical
thickness o the lens would be varied across its area in such a way
as to compensate or all the higher-order aberrations o the eye,
not just the spherical aberration. Although the required lenses
lack rotational symmetry, their production by suitable excimer
laser or asymmetric lathe-cutting techniques has already been
success ully demonstrated (Lopez-Gil et al., 2002; Chernyak
and Campbell, 2003; Jeong et al., 2005). T e major problem
is, however, that to be e ective, any wave ront-correcting lens
must undergo minimal rotation or translation on the eye (Bara
et al., 2000; Guirao et al., 2001). T e tolerances get smaller as
the pupil diameter increases. Bara et al. (2000) suggest that, or
a 6.5 mm pupil, permissible limits to rotation and translation
are about 10° and 0.5 mm, respectively. T e tolerances are larger
or abnormal eyes, such as those o keratoconics (De Brabander
et al., 2003; Jinabhai et al., 2012).
Preliminary trials with customized so contact lenses sug-
gest that rst-generation customized lenses can match the acu-
ity achieved with their habitual rigid lens correction (Marsack
et al., 2008). No use ul gains have been ound or normal or
post-penetrating keratoplasty patients, perhaps because o the
dif culties in maintaining lens registration with the eye (Lopez-
Gil et al., 2003; Sabesan et al., 2007). Nevertheless, this is an area
where rapid developments may be expected to occur within the
next ew years.
In addition to their impact on axial re raction and aberra-
tions, so lenses a ect re raction and aberration in the periph-
eral eld (Shen et al., 2010; Shen and T ibos, 2011). T is may be
o signi cance i it is con rmed that imagery in the periphery o
the younger eye in uences the development o myopia (Smith,
2011).
Co nclusio n
T e advent o clinical aberrometers is leading to rapid progress
in our understanding o the way in which the optical design o
so contact lenses interacts with the second-order spherocylin-
drical re ractive error and higher-order aberrations o the eye.
At present it appears that, or photopic vision, making proper
allowance or the possibility o on-eye power change is more
important than concern about correcting aberration. Aspheric
lens series o ering a xed ‘average’ level o spherical aberration
appear to o er little general optical advantage over conven-
tional designs with spherical sur aces. However, the availability
o aberrometry, combined with aspheric lenses with di erent
levels o spherical aberration, could allow a near-optimal lens
to be o ered to each patient and hence yield use ul visual ben-
e ts under mesopic conditions i the lens remains well centred.
Fully customized lenses based on aberrometric measurements
may be particularly use ul or keratoconic and other eyes with
unusually high levels o aberration.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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72.e 1
 7
So ft Le ns Me asure me nt
KLAUS EHRMANN

Int ro d uct io n cell, whereby the lens remains immersed in a saline solu-
tion. Even then, the pH and osmolality o the solution need
T e vast majority o so contact lenses are today mass produced to all within narrow ranges as speci ed in ISO 18369-3 to
by a double-sided moulding process (see Chapter 5). Using such ensure that correct water content and physical dimensions are
a method o manu acture ensures relatively consistent quality, maintained.
eliminating the need to measure every lens that comes out o T e key optical, material and geometrical parameters o
production. T is standardization also makes it easier or manu- interest are:
acturers to meet regulatory requirements, and or practitioners Optical parameters
and patients to have con dence that every lens that goes on eye Power and power pro les
is o good quality and correct power. Although this reduces the Optical quality
need or the contact lens tter and dispenser to measure key Scattering
lens parameters, manu acturers need to be even more diligent Material properties
with their measurement methods, not only to ensure good Water content
product quality, but also to increase manu acturing productiv- Modulus
ity and gain the trust o practitioners and consumers. Wettability
T e assiduous practitioner might still pre er to carry out Sur ace riction
basic lens measurements when investigating and seeking to Oxygen permeability
resolve cases o unsatis actory lens t, poor com ort, or reduced Re ractive index
visual per ormance. Spectral transmission
Contact lens researchers also have a strong interest in lens Lens geometry
metrology. Within the diverse range o research areas compris- Diameter
ing biological science, clinical research and optical engineering, Sagittal depth
each group has speci c requirements in measuring aspects o T ickness
lens geometry, optical and material properties with great preci- Radius o curvature
sion and accuracy. Edge shape.
o cater or these various applications and demands, a Whereas measurement o some o these parameters requires
wide range o equipment has been developed over the years. specialist instrumentation and expertise, other parameters can
In general, the required level o instrument sophistication and be measured quite easily by clinicians or ‘on the spot’ trouble
accuracy depends on the user group and increases rom prac- shooting in their contact lens practice.
titioners to manu acturers to researchers. A good re erence
guide on measurement methods, procedures and tolerances is Le ns Co nd it io ning Acco rd ing t o ISO
the our-part ISO 18369 (International Organization or Stan-
dardization [ISO], 2006a, b, c, d) and its close US equivalent
18369-3
ANSI Z80.20 (Standard, 2010). T ese standards are o critical Because o the hydrophilic nature o all so lens materials and
importance or manu acturers in demonstrating the sa ety and their sensitivity towards environmental changes, proper condi-
e cacy o their products; they are also a good re erence guide tioning o these lenses prior to any measurements is o critical
or practitioners and researchers. T e our parts o ISO 18369 importance. ISO 18369-3 prescribes that a standard phosphate
cover: bu ered saline (PBS) with a pH o 7.4 ± 0.1 and an osmolarity
Part 1: Vocabulary, classi cation system and recommenda- o 310 ± 5 mOsm / kg is to be used to soak all lenses or at least
tions or labelling speci cations 30 minutes. Generally, measurements are to be taken at a tem-
Part 2: olerances perature o 20 ± 0.5 °C. Standard PBS is prescribed as it closely
Part 3: Measurement methods mimics the osmolarity and pH environment o tears on eye.
Part 4: Physiochemical properties o contact lens materials. In clinical practice, sterile 0.9% saline solution is more readily
T e tolerances as speci ed in ISO 18369 are listed in Appen- available and can also be used.
dix B.
It is in the nature o all hydrogel materials that they dehy-
drate quickly when removed rom their aqueous environ-
O p t ical Parame t e rs
ment. Exposure to air changes all physical and geometrical T e optical parameters are most important or the visual per or-
properties o the lens. Particular care is there ore required mance o a contact lens on eye.
when making measurements in air to minimize these changes. T e visual per ormance o a contact lens is largely deter-
Alternatively, most measurements can be per ormed in a wet mined by the delity o optical parameters and prescription.
73
74 PART 2 So ft Co nt act Le nse s
Light scattering and optical distortions are generally low and o
less signi cance.
PO WER AND PO WER PRO FILES
T e three categories o so lenses – spherical, toric and mul-
ti ocal – require di ering approaches to determine their rel-
evant parameters. For single-vision spherical lenses, a single
power reading or the sphere power is su cient to evaluate
the optical power. oric lenses are rotationally non-symmetric
and require the power measurement along at least two di -
erent meridians. Multi ocal lenses are rotationally symmet-
ric and the most interesting in ormation is contained in the
power pro le along the diameter. T e power pro le deter-
mines the distance and add power, and the blending between
these two powers.
For the contact lens practitioner, the simplest method to
con rm the power o a particular contact lens is to place the
lens on eye and per orm an overre raction (Plainis and Char-
man, 1998) to achieve best distance visual acuity. Although this
technique is a viable method or prescribing contact lenses, its
subjective nature and uncontrolled actors like pupil size and
orientation / centration make this methodology unsuitable or
precise and objective power measurements.
T e ocimeter is a simple optical instrument that is still
widely used by manu acturers and practitioners to measure
back vertex power (BVP) over a 4.5 mm central aperture in
air (Fig. 7.1). A cross-shaped mire is projected through the
lens and the image is brought into ocus by turning the power
drum. T e BVP is then read o a dial connected to the power
drum. oric lens power can also be measured by rst align-
ing the orientation marks on the lens and then rotating the
mire to align with the f at and steep meridian o the toric optic
zone. Focusing the line along the f at meridian will provide
the sphere power. T e cylinder power is the di erence to the
ocus position o the steep meridian. T e axis value is the angle
Fig . 7.1 O p tical ocime te r with 3 mm ap e rture ad ap tor. (Courte sy of
Nikon.)
between the f at meridian and the horizontal line. Most o the
autolensometers work on a similar principle, but the power and
axis measurements are taken automatically and the results dis-
played digitally (Fig. 7.2).
Care ul handling and preparation is required when measur-
ing lens power in air. It is recommended to clean the contact
lens and then dab dry both sur aces be ore centring it on the
lens support. Excessive drying or exposing the lens or too long
(longer than around 10 seconds) will dehydrate the lens and
change the optical power. In a ring test involving ve labora-
tories, Hough et al. (1996) showed that standard deviations o
0.1–0.3 D or sphere and cylinder power can be achieved or
ten repeated measurements o low-powered toric lenses using a
manual ocimeter.
T e current state-o -the-art power-measuring instruments
immerse the lens in a saline- lled cuvette to avoid dehydra-
tion e ects. T ese instruments can also map the power o the
complete optical zone rom which all the optical power param-
eters can be extracted. Power-mapping instruments based on
the Moiré def ectometry, Hartmann–Shack (HS) and the phase-
shi ing Schlieren principles are on the market.
T e Moiré def ectometry instrument rom Rotlex was the
rst commercially available power mapper and the rst to
be included in ISO 18369-3. It utilizes two precision gratings
placed in the optical path o a collimated light beam that also
passes through the contact lens inside the cuvette (Fig. 7.3). T e
ringe pattern generated by the gratings is captured by a cam-
era and analysed. T e local tilt angle o the ringes correlates
to the local power o the lens. T ereby, an entire power map o
the optic zone can be calculated and averaged values or sphere,
cylinder and axis obtained.
Several instrument manu acturers have over the last 15
years utilized the Hartmann–Shack method to generate power
maps o so contact lenses. HS sensors consist o an array o
microlenses and a two-dimensional photo detector array –
generally a charge-coupled device (CCD) or complementary
Fig . 7.2 Auto le nsme te r with so t le ns sup p ort. (Courte sy of Tome y.)
 7 So ft Le ns Me asure me nt 75

Reference
Camera vertical fringes
with no lens

Gratings
Tilted fringes
Test cell with a
perfect lens

Lens
Lens Curved fringes
when the lens
Mirror has spherical
Diode laser aberrations

Fig . 7.3 Princip le o Moiré d e e ctome try.

metal-oxide semiconductor (CMOS) camera to measure the

Aberrated
Video sensor wavefront distortions within a wave ront (Jeong et al., 2005). T e num-
ber o microlenses determines the achievable lateral resolution.
T e sensitivity and measurement range are determined by the
ocal length o the microlenses (Fig. 7.4). T e instrument shown
in Fig. 7.5 eatures a 101 × 101 micro-lenslet array providing a
measurement range o ±20 D and a precision o 0.05 D. T e
instrument per orms well within the ISO speci ed precision
tolerances (Wagner et al., 2015). However, when power pro-
Front view Micro-lenslet
les are extracted, the reliability drops signi cantly towards the
array optical centre o the lens.
Phase-shi ing Schlieren is the most recent technology to
Fig . 7.4 Hartmann–Shack wave ront se nsor.
be implemented in a commercial instrument or the power
mapping o contact lenses. T e Nimo R1504 rom Lambda-
X claims a measurement range o ±30 D and a repeatability o
<±0.05 D. Repeatability is generally good, except or the cen-
tral area close to the optical axis within which the con dence
interval increases to over 0.8 D or some lens types. T e Schlie-
ren principle is explained in detail by Joannes et al. (2003); it
is based on the kni e-edge method, in which the single kni e
edge is replaced by a multiline lter element with sinusoi-
dal transmission. T e wave ront passing through the contact
lens, the Schlieren lens, and the Schlieren lter is ocused on
a CCD camera to capture the Schlieren ringes (Figs. 7.6 and
7.7). By moving the lter laterally in small steps, a set o phase-
shi ed images is acquired rom which the wave ront can be
reconstructed.
T e three methods and instruments used to generate power
maps o so contact lenses have a number o common eatures,
as summarized below.
By measuring and mapping the complete optical zone, local
power de ects or deviations can be detected. Most instruments
have implemented algorithms to generate a single quality num-
ber to quanti y optical quality and use this as an additional
pass / ail criteria.
Besides reporting the lower-order aberrations o sphere and
cylinder power and axis angle, higher-order aberrations such
as coma and spherical aberrations can also be obtained rom
Fig . 7.5 Powe r-map p ing instrume nt b ase d on Hartmann–Shack se n- the power maps. T ese are generally reported in the ormat o
sor. (Courte sy of O p tocraft.) Zernike coe cients. Higher-order spherical aberrations can
76 PART 2 So ft Co nt act Le nse s

f2

CCD

Λ
Schlieren
filter
Schlieren
lens
Fig . 7.6 Schlie re n p rincip le to me asure wave ront ab e rrations.

where Pair : lens power in air, Psaline: lens power in saline, n air :
re ractive index o air = 1, nsaline: re ractive index o PBS = 1.3345,
and n lens: re ractive index o lens material 1.39–1.42.
With most lens material having a re ractive index o around
1.39–1.42 and the re ractive index o saline being 1.3345, mea-
surements in saline need to be about ve times more accu-
rate compared with a corresponding power measurement in
air. T e closeness o the re ractive indices o saline and lens
material also requires that both need to be known or measured
with great accuracy. For example, an error o only 0.0005 or a
1.4100 lens material will lead to a alse power reading o 0.35 D
or a −6.00 D contact lens. Relying on the ISO 18369-2 tol-
erance o 0.005 or the re ractive index o so lens materials
is there ore not su cient when measuring optical power in a
cuvette.
T e back vertex power o a contact lens is re erenced to the
Fig . 7.7 Schlie re n imag e o a multi ocal le ns. apex o the back sur ace. As this axial position is not known
precisely or a lens placed inside the cuvette, instrument manu-
acturers use various methods to approximate that location or
their power calculations using thin or thick lens ormulae. T e
best results can be achieved by entering values or centre thick-
ness and base curve or each particular lens.
T e method o power mapping has the disadvantage that,
close to the optical centre o the lens, even very small errors
in the detection o the incoming wave ront angle can lead to a
very large error in the calculated power. o alleviate this prob-
lem, the data-processing algorithms in most instruments utilize
noise ltering and extrapolation methods to smoothe the power
values around the optical axis.

O PTICAL Q UALITY

Fig . 7.8 Powe r p rof le o a b i ocal contact le ns with conce ntric d is-
tance and ad d ring s.
also be plotted as power pro les, providing use ul in orma-
tion, in particular or bi ocal and multi ocal lenses, as shown
in Fig. 7.8.
Measuring the so lens immersed in saline has the advantage
o avoiding dehydration, but it also has some disadvantages that
can signi cantly a ect the measurement accuracy. T e mea-
sured ‘in saline’ power needs to be converted back to ‘in air’
power using Eq. 7.1:
n lens − n air
Pair = Psaline ×
n lens − n saline
Factors that can compromise the optical quality o a so
contact lens are inhomogeneous material, sur ace scratches
or deposits, lathe marks, material inclusions or air bubbles.
T e more obvious de ects can be picked up with any o the
power-mapping instruments or care ul observations using
a slit lamp. More subtle de ects can only be detected using
more sophisticated equipment like the kni e-edge tester (Ho
and Ehrmann, 2000) (Fig. 7.9) or thickness pro lers (Maiden
et al., 2010).
SCATTERING
Scattering is generally o little concern with so contact lenses. It
Eq. 7.1 might be observed occasionally, caused either by sur ace depos-
its or contamination or by manu acturing de ects a ecting the

Fig . 7.9 Colour-co d e d p owe r map o a p rism b allast, so t toric le ns
cap ture d using a kni e -e d g e op tical q uality te ste r.
bulk o the material. Quantitative assessment is best done using
a dark- eld microscope. In vivo, optical coherence tomography
instruments, such as the one used by Kałużny et al. (2006), can
be employed to determine the degree o back scattering.
Mat e rial Pro p e rt ie s
Properties can vary widely between di erent so lens materi-
als and concomitantly, on-eye per ormance in terms o com ort,
vision, t and ocular health. For traditional hydrogel materials,
most o the properties, including modulus, oxygen permeabil-
ity, re ractive index and wettability are linked to the water con-
tent o the material. With the introduction o silicone hydrogels,
coated lens sur aces and additives in packaging solutions, prop-
erties are less predictable and need to be measured individually
or each material.
WATER CO NTENT
As summarized by Gonzales-Meijome et al. (2006), there is an
almost linear relationship between water content and re ractive
index or hydrogel materials. T is relationship makes it possible
to derive the water content o a material by measuring its re rac-
tive index. Re ractometers such as the CL-1 So Contact Lens
Re ractometer rom Atago (Japan) have a scale that indicates
the water content converted rom the re ractive index reading.
T e accuracy that can be expected rom this method is in the
order o ±5% (Nichols et al., 2003).
T e gravimetric method is applicable to all so lens materials
and is generally more accurate, however, this method is destruc-
tive and requires specialized laboratory equipment. It is based
on the ISO 18369-3 (International Organization or Standard-
ization [ISO], 2006c) de nition o water content as:
mH 2 O hydrated material
ωH 2 O = × 100
mhydrated material
where mH 2 O hydrated material = mass o water in the hydrated mate-
rial, and mhydrated material = mass o the hydrated material.
In this context, dissolved solutes such as sodium chloride
and bu ers contribute to the mass o the hydrated material.
7 So ft Le ns Me asure me nt 77
Fig . 7.10 Stre ss ve rsus strain curve o a typ ical contact le ns mate rial
samp le .
From this overall value, water content is calculated a er mea-
surement o the dry mass and hydrated mass o a contact lens at
room temperature:
mhydrated − mdry
ωH 2 O = × 100
mhydrated
where mhydrated = mass o the hydrated material and mdry = mass
o the dry material.
T e key to achieving good accuracy with this method is the
consistent removal o excess sur ace water by dry blotting. Sam-
ple lenses are then dried in an oven and the weight measured
again using an analytical balance.
MO DULUS
Material sti ness is commonly measured and expressed as
the modulus o elasticity, or Young’s modulus. T is modulus is
de ned as the slope o the stress / strain curve o a material under
tensile or compression de ormation. ‘Strain’ is the elongation or
shortening o the test sample expressed as a percentage. ‘Stress’
is the experienced orce divided by the cross-sectional area o the
sample. In order to make reliable measurements, it is pre erable to
have a consistent cross-section o the sample over the ull length
o the sample. Contact lenses are too thin to make any meaning-
ul modulus measurements in compression mode. For the tensile
measurements, a 3–6 mm wide strip rom the centre o a −1.00
D contact lens is cut and its harmonic mean thickness and width
measured within the central 8 mm o its length to obtain the aver-
age cross-sectional area. T e sample is then loaded into the ten-
sile testing instrument and clamped on either end so that the ree
length between the clamps is no more than the optic zone diam-
eter o the lens. From its initial ree length, the sample is elon-
gated by 10–15% and the corresponding orce / elongation curve
recorded (see Fig. 7.10). T e orce scale is converted to stress by
dividing through the cross-sectional area. Most commonly, the
relatively linear section between 4% and 8% elongation is used to
t a straight line, the slope o which is the Young’s modulus.
Using the same instrumentation and sample preparation, it is
possible to also measure the ultimate tensile strength (U S), the
material toughness, and stress relaxation. T e ultimate tensile
strength is the stress inside the material at the point at which
the sample breaks:
force at breakpoint
UTS=
original cross-sectional area
78 PART 2 So ft Co nt act Le nse s
Material toughness is the area under the stress / strain curve up
to the breakpoint (Fig. 7.10). Stress relaxation determines the
dynamic behaviour o a material under stress.
Most plastic materials show some orm o relaxation over
time in response to applying an initial stress. o measure the
time constant and amplitude o this behaviour, the contact lens
sample is quickly elongated to a predetermined percentage o
its ree length and then held or several minutes while record-
ing the change in the orce required to hold the sample. T e
corresponding stress over time curve is plotted and, by tting
an exponential unction, the time constant and amplitude are
extracted (Fig. 7.11). ‘Creep’ is the inverse o stress relaxation
whereby a constant load is instantly applied to the sample and
the subsequent continuing elongation is recorded.
Several actors need to be considered in terms o instrumen-
tation and methods when measuring the mechanical properties
o so contact lens materials. Mechanical properties o plastic
materials are temperature sensitive and the sample tempera-
ture needs to be maintained and recorded at either room tem-
perature (20°C) or on-eye temperature (34°C). Full hydration
o the contact lens samples needs to be maintained throughout
the measurement procedure. Ideally, all measurements should
be per ormed with the samples ully immersed in saline to avoid
changes in dimension and sti ness. However, there are very ew
commercial instruments that can provide this option.
ranoudis and E ron (2004) demonstrated that modulus
measurements can be made in air when the samples are ully
hydrated be orehand and then monitored to ensure the water
lm on the sur ace remains intact. T e actual orces required
to stretch the contact lens samples are rather small (<500 mN)
and most tensile-testing equipment lacks su cient sensitivity
to resolve the small changes. T e Vitrodyne 2000 was a suitable
commercial instrument, but is no longer available (Fig. 7.12).
Some research groups have developed or modi ed instruments
to make them suitable or so contact lens materials (Ehrmann
et al., 2008; Young et al., 2010).
A di erent approach to measure mechanical properties is
through the method o microindentation. T is method has sev-
eral advantages including being non-destructive, requiring only
a small sample size, and being easily implemented on immersed
samples, but it is an indirect method to obtain modulus values
and there ore relies on assumptions and conversion actors. T e
indentation probes can be as small as the ones used in atomic
Fig . 7.11 Stress relaxation curve showing a d e cre ase in stress over time
in re sp onse to 8% e long ation.
orce microscopy (Selby et al., 2014) or larger spheres as used
by Chen et al. (2007), which can make it di cult to separate
sur ace properties rom those o the bulk material.
WETTABILITY
Sur ace wettability is an important actor a ecting biocompat-
ibility and on-eye com ort. For conventional hydrogel materials
sur ace wettability is closely correlated with the water content
o the material. However, the hydrophobic nature o silicone
made it necessary to sur ace coat the rst generation o silicone
hydrogel contact lenses to make them compatible with the ocu-
lar environment. Meanwhile, additional treatments have been
applied to enhance insertion or all-day wettability by adding
wetting agents to the material or packaging solution (Fonn,
2007). T e easiest way or practitioners to assess and compare
sur ace wettability is on eye, using a tear-scope (Guillon, 1998),
and measuring the tear break-up time. T is tear-scope method
is suitable only as a relative measure because tear quality can
vary considerably between patients. Similar observations o the
pre-lens tear lm can also be made using a slit lamp or keratom-
eter. A tear break-up time o less than 4–8 seconds is likely to
adversely a ect com ort and vision (Guillon, 1998).
For more objective wettability measurements o lens sur-
aces, various in vitro methods have been developed and used
in research laboratories. T e contact angle ormed between the
sur ace and the liquid touching the sur ace is a good indicator
o sur ace wettability. T e angle can be measured either by the
def ection o a laser beam (Bush et al., 1988) or by capturing an
image and analysing the cross-sectional pro le (Ketelson et al.,
2005) (Fig. 7.13). T e standard method (sessile drop) is to place
a drop o saline on the convex side o the contact lens.
o avoid lens dehydration, the inverse method (captive bub-
ble), whereby the lens is immersed in saline and an air bubble is
placed on the lens sur ace, has also been implemented and dem-
onstrated to provide reliable results (Maldonado-Codina and
Morgan, 2007). As an alternative to the contact angle method,
the meniscus height or curvature can also be measured to
quanti y sur ace wettability either in vivo (Doughty et al., 2001;
Nichols and Sinnott, 2006) or ex vivo. T e lens is immersed in
saline, held vertically and slowly pulled out until only the lower
hal remains immersed. A cross-sectional image is taken o the
Fig . 7.12 Vitrod yne 2000 mate rial te ste r.

Fig . 7.13 Se ssile d rop me thod to me asure contact ang le as an ind ica-
tor o sur ace we ttab ility.
liquid and lens sur ace and the meniscus ormed in between.
By image analysis or ruler, the meniscus height or radius can be
determined. T e Wilhelmy plate technique is similar procedur-
ally, but, rather than measuring the meniscus height, the vertical
orce exerted by the meniscus is determined ( onge et al., 2001).
With all our o these methods, measurements can be made
under receding or advancing conditions. Under the receding
condition, the lens sur ace is wet at the point o measurement,
whereas, with the advancing condition, the liquid advances over
an area that has been exposed to air.
SURFACE FRICTIO N
Sur ace riction has been implicated in inf uencing on-eye
com ort but there is no rm evidence to support this hypoth-
esis (Ngai et al., 2005). T is lack o evidence might partly be
due to the di culties in measuring on-eye riction between the
lens and the cornea and lid. Published in vitro riction measure-
ments against various re erences can vary by orders o magni-
tude between lens types as well as between particular studies
and methods (Jones et al., 2013).
T e riction coe cient is the ratio between the orce normal
to the sur ace and the orce parallel to the sur ace when two sur-
aces slide against each other. As there are always two sur aces
involved the choice o re erence sur ace can have a signi cant
e ect on the riction results. For contact lenses, glass has been
used most commonly, but metal, plastic, epithelial cells and
even bovine conjunctival tissue have been used (Rennie et al.,
2005; Dunn et al., 2008; Roba et al., 2011; Zhou et al., 2011;
Samsom et al., 2012). Besides the re erence sur ace, the type o
lubricant also needs to be taken into consideration. Saline or
arti cial tear f uid are most suitable to maintain hydration and
to simulate on-eye conditions. Other f uids can also be used, or
example to speci cally study e ects o enriched packaging solu-
tions or eye drops with wetting agents.
O the two types o riction, static and kinetic, only the
kinetic one is o interest or on-eye per ormance. A so lens is
constantly moving on the eye, a bound lens provides no more
tear exchange and should be removed.
T e simplest way to measure riction is by using the ‘ riction
angle’ method. T e material sample is placed on a f at – usually
glass – plate and the plate is tilted slowly. T e tilt angle at which
the sample starts moving is the riction angle, the tangent o
which is the static riction coe cient. T e kinetic coe cient can
be determined by starting with a steeper angle, and repeatedly
7 So ft Le ns Me asure me nt 79
pushing the sample upwards while lowering the angle. T e angle
at which the sample stops sliding downwards corresponds to
the kinetic riction coe cient. A lens holder and a small weight
may be required to mount and provide support or the contact
lens. Instruments that measure the normal and tangential orces
while the sample is moved along the re erence sur ace have also
been developed and measurement data presented (Dunn et al.,
2008; Roba et al., 2011).
Ebatco (MN, USA) and CSM Instruments (Peseux, Switzer-
land) are two suppliers that o er instruments suitable or so
contact lens riction measurements. Modi ed rheometers have
also been used to measure lens riction by rotating the sample
against the re erence sur ace (dos Santos et al., 2009). T e use
o AFM probes to determine sur ace riction has been reported
(Kim et al., 2001); however, there is no clear evidence that the
measurement results actually represent sur ace riction as it is
generally understood, and that these measurements are una -
ected by other sur ace properties.
T e wide range o kinetic riction coe cients, rom 0.02 to
0.6 (dos Santos et al., 2009; Roba et al., 2011) indicate that the
methodology has a great e ect on the results. Material compari-
sons should be made only within data rom the same study.
O XYGEN PERMEABILITY – TRANSMISSIBILITY
Oxygen permeability is a material property that de nes how
easily oxygen passes through a particular material. T e cor-
responding contact lens property is oxygen transmissibility,
which is the permeability divided by the lens thickness. As the
oxygen f ow can be measured only through an actual contact
lens, it is the oxygen transmissibility that is measured and then
converted to permeability by multiplying it with the average
measured lens thickness (t). T e permeability coe cient (Dk)
can be expressed as the product o di usion (D) and solubil-
ity (k) and its common unit is Barrer. T e transmissibility
thereby becomes Dk / t (ISO, 2006d). ISO 18369-4 prescribes
two di erent methods to be used or di erent types o lenses or
permeability ranges. T e polarographic method is applicable
to all material types having an oxygen permeability rom 0 to
145, while the coulometric method is applicable only to non-
hydrogel materials. However, Morgan et al. (2001) have dem-
onstrated that the coulometric method is also viable or so
lenses i certain conditions are met.
With the polarographic method, the contact lens is in direct
contact with the oxygen-sensing probe, whereas with the coulo-
metric method, the oxygen di used through the contact lens is
carried by nitrogen gas to the oxygen sensor (Fig. 7.14). In both
methods, the central 4–7 mm zone is exposed to 21% O2 satu-
rated saline, which is stirred continuously to minimize bound-
ary layer e ects. emperature o the apparatus, lens and saline is
to be maintained at 35° C. Despite the stirring, boundary layer
e ects can still reduce the oxygen f ux through the lens. o elim-
inate this measurement error, lenses o di erent thickness can
be measured and the resulting o set subtracted (Morgan et al.,
2001). ISO 18369-4 also recommends a correction or the ‘edge
e ect’, which is caused by oxygen f owing in sideways around
the perimeter o the clamped area.
T ere is currently no commercial equipment available or
either o these methods. T e ew manu acturers and laborato-
ries that have oxygen permeability measurement capabilities
either use instruments adapted rom the packaging industry or
have developed their own apparatus.
80 PART 2 So ft Co nt act Le nse s

Polarographic Coulometric

21% O2
saturated
saline

Temperature
controlled 2.0 mm 3.3 mm
wet cell

Carrier gas
N2 purge (N2)
(optional)

Silver Gold Aluminium

anode cathode arbour
Fig . 7.15 Hand -he ld so t le ns re ractome te r. (Courte sy of Atag o.)

Fig . 7.14 Comparison betwe en polarographic and coulometric oxyg en

transmissib ility me asure me nt me thod s. (From Morg an M. F., Bre nnan,
N. A. & Alvord , L. (2001). Comp arison of the coulome tric and p olaro-
g rap hic me asure me nt of a hig h-Dk hyd rog e l. O p tom. Vis. Sci., 78(1),
19–20. ©2001 Ame rican Acad e my of O p tome try.)

o convert the measured oxygen transmissibility into per-

meability, transmissibility needs to be divided by the harmonic
mean radial thickness o the measurement area.
Not only is oxygen transmissibility a critical material prop-
erty when it comes to maintaining good ocular health but, as
Cerretani et al. (2012) have demonstrated, su cient ion perme-
ability is also important, particularly with regard to avoiding lens
binding to the cornea. T e measurement methods or ion per-
meability are similar to those or oxygen, except that the sensing
element responds to ions instead o oxygen (Guan et al., 2011).

REFRACTIVE INDEX – DISPERSIO N

Abbe re ractometers are the pre erred choice o instrument or
measuring the re ractive index o hydrogel contact lenses. T ey
are easy to use and provide the required precision o 0.001. Abbe
re ractometers measure the critical angle o incidence or total
internal ref ection, which is directly correlated to the re ractive
index. Fig . 7.16 CLR12-70 re racto me te r. (Courte sy of Ind e x Instrume nts.)

n = n ′ × sinα Eq. 7.2

where n = re ractive index o test sample, n′ = re ractive index o
re erence sur ace, and α = critical angle o incidence upon re er-
ence sur ace.
For the contact lens practitioner, there are hand-held instru-
ments on the market (Fig. 7.15), some o which have a scale
that converts re ractive index into percentage water content or
hydrogel materials. Bench-top instruments such as the Abbe
Mark III Re ractometer (Reichert, NY, USA) and the Standard
Abbe Re ractometer rom Edmund Optics (Barrington, NJ,
USA) are generally more accurate. Consideration needs to be
given to the illuminating wavelength as some materials can have
noticeable dispersion. White light will give an average over the
ull visible spectrum. ISO 18369-4 speci es a single wavelength
o 546.1 nm or 587.6 nm. he CLR12-70 (Index Instruments
Ltd, Peterborough, UK) is one o the ew dedicated instruments
or contact lens materials (Fig. 7.16).
SPECTRAL AND LUMINO US TRANSMITTANCE
Spectral transmittance is de ned as the ratio o transmitted
spectral radiant f ux to the incident spectral radiant f ux. T e
luminous transmittance o the contact lens is obtained by
measuring and integrating the spectral transmittance over the
280–780 nm wavelength spectrum in small increments (<10
nm) and weighing the radiant f ux spectrally by the relative
spectral luminous e ciency unction o the eye (ISO, 2006c).
Measurements and transmittance are speci ed in saline
condition.
In order to make accurate measurements independent o
the lens power, integrating spheres are used to determine the
total transmitted luminous f ux as prescribed in ISO 18369-3.
Still, many research groups have used standard single- or dual-
beam spectrophotometers and either ignored the lens power
e ect or taken measures to reduce its inf uence (Harris et al.,

Fig . 7.17 Sp e ctral transmission curve or so t le ns with UV b locke r.
(From: ACUVUE® O ASYS® Brand Contact Le nse s with HYDRACLEAR®
PLUS Te chnolog y, with p e rmission.)
2000; Moore and Ferreira, 2006; Rahmani et al., 2014). Mea-
surements with and without the lens in the cuvette allow or
the subtraction o known lens-related actors a ecting the light
transmission (Quesnel et al., 2001). While there is no standard
or the minimum luminous transmittance, unworn lenses are
expected to all within a ±5% tolerance band o the speci ed
value. Speci cations are provided with the packaging insert or
all FDA-approved lenses. For contact lenses that claim ultravio-
let (UV) light absorption, the transmittance must be less than
1% or UVB (280–315 nm) and less than 10% UVA (316–380
nm) or all class 1 absorbers. For class 2 absorbers, the respec-
tive values are 5% and 50%. A typical spectral transmittance
graph or a so contact lens with class 2 UV blocker is shown
in Fig. 7.17.
UV blocking is not to be con used with handling tinting.
Although the tint reduces the transmittance in the blue wave-
length region by a small amount, its sole purpose is to increase
visibility or better lens handling and not to provide protection
against UV exposure.
Although measurement o luminance transmittance is
generally con ined to manu acturers and research laborato-
ries, there is one application or which clinicians may ben-
e it rom this in ormation. It has been shown that deposits
or bio ilms orming on worn lenses a ect the spectral trans-
mission (Osuagwu et al., 2014). By measuring worn lenses,
in ormation on the type and amount o deposits can be
obtained.
7 So ft Le ns Me asure me nt 81
Fig . 7.18 Me asuring microscop e with 1 µm re solution or line ar x, y
and z stag e s. (Courte sy of Nikon.)
Le ns Ge o me t ry
In the early days o so contact lenses (1970–1990), many
manu acturers would lathe cut lenses individually according
to the design speci cation o the contact lens tter. A range
o diameter, sag, thickness, base curve and edge parameters
could be combined to generate an optimized custom- tted
lens design. Care ul inspection was advised, as manu actur-
ing sometimes lacked the precision to produce the ordered
lens shape. With the introduction o mass-produced requent
replacement lenses in the late 1980s, a ‘one size its all’ (in
some cases two sizes) approach was taken whereby the manu-
acturer selects the shape parameters that provide acceptable
t and com ort to the majority o patients. Mass production
shi ed the measurement burden to the manu acturers, as they
have the obligation to comply with regulatory and ISO stan-
dards. Nonetheless, the practitioners may still want to check
certain lens parameters i they observe inadequate lens t,
vision or com ort to ensure that this is not due to a poorly
manu actured lens.
DIAMETER
T e outside lens diameter is one o the easiest dimensions to
measure. On-eye measurement can be per ormed using a slit-
lamp biomicroscope tted with a measurement graticule. In
industry, one o the most commonly used instruments is the
Optimec Model JCF (Malvern, UK). When using this instru-
ment the lens is f oating in a temperature-controlled wet cell and
its plane view is projected under magni cation onto a screen
tted with a ruler. T e accuracy o this instrument is speci ed
to be ±0.025 mm. For more accurate measurement, pro le pro-
jectors or measuring microscopes like the Nikon MM400 (Fig.
7.18) can be used. T e resolution and accuracy o this instru-
ment can be as good as ±2 µm (Gundel et al., 1993). Most o
the power-mapping instruments mentioned above also have an
82 PART 2 So ft Co nt act Le nse s
option to extract the lens diameter based on the captured image
rom the lens centration camera.
Besides the outside diameter, the diameter o the optic zone
can also be o interest. T is diameter is usually not visible by
normal projection or observation, and either power-mapping
instruments or instruments based on the kni e-edge method
(Ho and Ehrmann, 2000) need to be employed.
SAGITTAL DEPTH
Sagittal depth or sag is the height o a contact lens as measured
as the vertical distance rom the lens edge to the apex o either
the ront ( ront sag) or the back (back sag) sur ace. With pro-
jection instruments like the Optimec JCM, sag is measured by
placing the lens in a wet cell and projecting a side elevation onto
a screen with a vertical ruler. It is di cult to see the apex o the
back sur ace o the projected image, so ront sag is measured
and back sag is determined by subtracting the centre thickness
rom the ront sag. Back sag can be measured directly by using a
mechanical, ultrasonic, optical or electrical probe to determine
the height o the posterior apex.
T e lens can be either resting on its edge, or measurements
o total sag, or placed on a cylindrical support that is smaller
than the lens diameter. For the latter, the diameter o the sup-
port needs to be reported with the sag value. T e back sag
value in itsel is o little clinical interest. T e main reason or its
measurement is to calculate the back optical zone radius or the
average base curve o a lens in combination with the respective
diameters.
THICKNESS
T ickness measurements and presentations can range in com-
plexity rom a single point, through a line graph, up to thickness
maps. O most interest is the centre thickness o a contact lens.
It varies with lens power and manu acturers usually speci y its
value or a −3.00 D lens. Centre thickness values or so con-
tact lenses can range between 50 µm and 250 µm, depending
on power, material and lens type. T e corresponding ISO tol-
erances are between 15 µm and 28 µm, necessitating precision
instrumentation to achieve reliable measurements. T ickness
can be measured by mechanical, optical or acoustic methods.
For the last o these, ultrasonic pachymeters have been applied
to measure contact lens thickness on-eye by taking the di er-
ence o thickness readings with and without the lens on the cor-
nea. T e accuracy o this method is a ected by the assumptions
made on the sound velocity in the speci c contact lens mate-
rial (Bachman, 1993). A similar issue arises with optical instru-
ments. T e measured optical thickness needs to be converted to
physical thickness by dividing the measured value through the
re ractive index o the lens material. T ree types o instruments
can readily be applied to measure the centre thickness o so
contact lenses in vivo. Most con ocal microscopes have a Z-scan
option, providing intensity peaks at the air–lens and lens–cor-
nea inter ace. Low-coherence inter erometry instruments like
the IOL Master (Zeiss, Germany) or the Lenstar (Haag Streit,
Switzerland) are designed to measure ocular length, but have
su cient resolution to measure also the centre thickness o
contact lenses (Rohrer et al., 2009). Optical coherence tomogra-
phy (OC ) instruments are based on the same inter erometric
principles. With two scanning mirrors, anterior segment OC s
can scan the entire corneal area and generate thickness maps o
lenses and corneas ( ao et al., 2013). Instruments such as the
R Vue (Optovue, Fremont, CA, USA) can achieve a thickness
resolution o less than 5 µm (Reinstein et al., 2012).
Because o the issues related to converting measured to
physical thickness and the limited resolution o these two
methods, the gold standard in centre thickness measurements
is still the electromechanical thickness gauge. Resolution
and accuracy o ±2 µm can easily be achieved; however, the
measurement orce needs to be care ully controlled to avoid
squashing the lens. ISO 18369-3 limits the measurement orce
to 15 mN. T e Rehder thickness gauge (Rehder Development
Company, W. La ayette, IN, USA) is one such instrument that
complies with the standards and is commonly used by manu-
acturers and research laboratories. Misalignment o the centre
o the lens o the lens is another actor that can lead to signi -
cant measurement errors, in particular or high-plus or -minus
lenses, or lenses with unwanted or wanted prism in the optic
zone, such as prism ballast toric lenses.
For rotationally symmetric lenses, the cross-sectional thick-
ness pro le can be o interest or the lens designer, clinician
and manu acturer. A coarse resolution thickness pro le can be
obtained using the thickness gauge and displacing the lens rom
the centre in xed increments. T e Rehder thickness gauge can
be tted with a ball anvil adaptor that rotates the lens under the
measurement pin. As a destructive method to obtain qualitative
in ormation on the lens thickness pro le, cross-sectional slices
can be cut rom a lens at a selected meridian angle and placed
on a microscope or pro le projector. When measuring and
plotting peripheral thickness, one has to distinguish radial rom
axial thickness. Axial thickness is a thickness measured parallel
to the geometrical axis o the lens. Radial thickness re ers to the
thickness measured along a radius line that passes through the
centre o the base curve and is thereby approximately perpen-
dicular to the back sur ace (Fig. 7.19). T e relationship between
axial and radial thickness is given in Eq. 7.3:
t radial = taxial × cosα Eq. 7.3
or:
y
tradial = taxial × cos sin − 1 Eq. 7.4
BC
T ickness pro les are an e ective method to check or
unwanted lens prism. T is is a common manu acturing prob-
lem or spherical lenses. However, with only one cross-section it
is unlikely that the maximum lens prism will be detected.
New instrumentation is commercially available that can
measure entire thickness maps o so contact lenses with high
precision. T e ptychography method utilized in the Phase ocus
Lens Pro ler (Phase ocus, UK) provides a thickness sensitivity
o ±50 nm and a lateral resolution o 7 µm (Rodenburg, 2011;
Plainis et al., 2013). T e OC -based ENVISU S4410 instrument
rom Bioptigen (USA) has a lower resolution, but the advan-
tage o being able to also measure radii o curvatures o ront
and back sur aces. Besides detecting lens prism, the most use-
ul applications or these instruments is the measurement o the
rather complex geometry o toric lenses. Progress in design and
manu acturing techniques have created lens geometries with
optimized clinical per ormance, requiring equally advanced
measurement methods to ensure consistent product quality.
A typical radial thickness map generated rom the Phase ocus
measurement output o a prism ballast toric lens is shown in
Fig. 7.20. Other applications include the conversion o thickness

y
C
B
α
Fig . 7.19 Re lationship b e twe e n axial and rad ial thickne ss.
Fig . 7.20 3D thickne ss map o a p rism b allast, so t toric le ns.
maps into Dk / t maps, indicating the oxygen transmissibility
through certain areas o the lens.
RADIUS O F CURVATURE
T e three most commonly re erenced radii o curvature on a
so contact lens are the ront optic zone radius (FOZR), the
back optic zone radius (BOZR) and the averaged base curve
(BC) o the back sur ace. O these, the FOZR is o interest only
or the lens designer. For a xed back sur ace, the FOZR deter-
mines the sphere power o a contact lens and can there ore be
derived rom power measurements.
Keratometers have been designed to measure the convex
curvature o corneas, but can be used to measure the concave
BOZR a er some slight modi cations, as illustrated in Fig. 7.21.
T e lens is placed edge down in a wet cell on top o a 45° prism.
T e prism projects the mires upwards onto the back optic zone
7 So ft Le ns Me asure me nt 83
taxial
tradial
rom where they are ref ected and aligned with the target lines
by adjusting the radius dial. For toric back sur aces, two readings
perpendicular to each other need to be obtained to acquire the
steep and f at meridian. Reliable measurements may not always
be possible, in particular or lenses with a low re ractive index or
where ront and back sur ace curvatures are similar and mires
can overlap (Holden, 1977). T e keratometer takes its readings
based on the sur ace slopes at two points, approximately 3 mm
apart. Not only does this make the measurements susceptible to
local variations in the sur ace slopes, but it also e ectively pro-
vides only the central curvature or aspheric sur aces.
T e ‘sag’ method measures and calculates the average radius
o curvature or a speci ed diameter. Based on the circle seg-
ment in Eq. 7.5 the radius o curvature r can be calculated rom
the measured sag s (see also Fig. 7.22) at a speci ed diameter y:
s y2
r= + Eq. 7.5
2 8× s
Many modern lens designs have aspheric curvatures on the
ront and / or back sur ace, usually o elliptical shape. T e term
‘radius’ is there ore inadequate to describe the actual shape o
the sur ace. Either it is used as the central radius in conjunc-
tion with the shape actor p o the ellipse, or it corresponds to
the average radius o curvature over a certain diameter. T ere is
some ambiguity on the suitable choice o diameter. ISO 18369-3
only speci es a minimum diameter o 8 mm and gives an exam-
ple with 10 mm. T e Optimec JCF instrument uses also 10 mm
diameter or the lens support cylinder, whereas the SHS Oph-
thalmic OmniSpect (Optocra , Erlangen, Germany) measures sag
over the ull lens diameter. For the contact lens tter, the most
relevant parameter is the base curve radius measured over the
ull lens diameter, which is around 14.0 mm or most so lenses.
T e Envisu S4410 (Bioptigen, Morrisville, NC, USA) is one o
the ew instruments that can measure the exact shape o the
complete back and ront sur ace in vitro. Spherical or elliptical
sur aces can then be tted over any selected area and the relevant
84 PART 2 So ft Co nt act Le nse s

the back sur ace shape to achieve optimized on-eye it and

Wet cell com ort.
Test lens submerged
in saline
EDGE
45° prism Keratometer
mire T e edge o a contact lens describes the transitional area between
the ront and the back sur ace around the perimeter o the lens. T e
two major aspects o edge inspection are assessment o the cross-
sectional edge pro le and the detection o edge de ects around the
circum erence. For the latter, the inspection can be non-destructive
Keratometer
mire i the lens is viewed in a wet cell rom above, under magni cation.
Most disposable so lenses undergo a 100% edge de ect inspection
Fig . 7.21 Ke ratome te r f tte d with p rism and we t ce ll or b ase curve
be ore being packaged. Inspection is either manually or with the
me asure me nts. assistance o video capturing and image analysis. ypical de ects
include edge f ashing, tears and notched edges (Fig. 7.23).
T e cross-sectional pro le o so lens edges can signi cantly
inf uence the on-eye per ormance, particularly with respect to
com ort and staining (E ron and Veys, 1992; Young et al., 1993;
s Maissa et al., 2012; Ozkan et al., 2013; Wol sohn et al., 2013;
Maki and Ross, 2014). Although there is still some dispute over
what comprises the optimal edge shape (Maissa et al., 2012),
y poorly manu actured or designed edges have o en been impli-
cated in in erior com ort (Phillips and Stone, 1989; Jones et al.,
2013). Con ocal microscopy, OC imaging and other opti-
cal methods have been attempted to visualize the edge pro le
r

non-destructively in vivo and in vitro. O these methods, high-

resolution OC imaging is used most widely to capture the
edge shape (Fig. 7.24); however, the resolution is insu cient to
obtain accurate quantitative parameters.
Improved results can be achieved with the destructive ‘edge-
slicing’ method. In this, the contact lens is pressed f atly on a
Fig . 7.22 Re lationship b e twe e n curvature , sag and d iame te r. sheet o plastic. wo razor blades are held together so that their
cutting edges are lined up parallel. Cutting through the centre
o the lens, a thin cross-sectional slice is obtained. A second cut,
radii and shape actors extracted. In optometry, sur aces with perpendicular to the rst one, provides an additional two slices.
conic cross-sections are described by the central radius o cur- T ese slices are placed in a saline- lled wet cell or petri dish or
vature r 0 and the conic constant p, as de ned by Eqs. 7.6 and 7.7: observation under a microscope or pro le projector (Fig. 7.25).
( ) 2 Edge pro le images can be captured and edge thickness mea-
b surements can be taken at a prescribed distance rom the apex.
p= Eq. 7.6
a From the our slices, a good estimation can be obtained on the
and: amount o edge prism.
b2 Edge shapes are commonly classi ed into three edge types
r0 = Eq. 7.7 (Fig. 7.26) (Maissa et al., 2012): round edge, kni e edge and
a
chisel edge. For the clinician, the apex location may also be o
where a = major axis o ellipse and b = minor axis o ellipse. interest as it may adversely a ect the interaction with either the
T e value o p identi es the ve types o conic sections: eyelids or the conjunctiva. T e apex location can be given as a
Ellipsoid p>1 relative measure o the edge thickness or as an absolute value
Steepening towards the periphery: equivalent to the edge li as shown in Fig. 7.27.
Sphere p=1
Ellipsoid 0<p<1 Co nclusio n
Flattening towards the periphery:
Paraboloid p=0 T e measurement o so contact lenses covers a wide range
Hyperboloid p<0 o optical, mechanical, geometrical and sur ace parameters
An approximate value or the shape actor can be obtained by and generally requires sophisticated equipment and expertise
measuring the central curvature r 0, the lens diameter LD and to achieve reliable results. With the widespread use o mass
the back sag, and applying Eq. 7.8: produced, daily disposable lenses and the tightening o qual-
( )2 ity assurance and regulatory requirements, the measurement
LD
2 × r0 2 responsibilities are now predominantly in the domain o the
p= − 2
Eq. 7.8 contact lens manu acturers. It is in the interest o manu actur-
back sag back sag ers to undertake accurate and comprehensive measurements to
In addition to the average base curve, the shape actor ensure a consistent product quality and avoid costly product
gives lens designers another degree o reedom to optimize recalls, while also achieving a high production yield.
 7 So ft Le ns Me asure me nt 85

Fig . 7.23 Typ ical e d g e d e e cts: (A) notch; (B) te ar; (C) ashing .

Fig . 7.24 Cross-se ctional e d g e p rof le ob taine d b y in vivo O CT im-

ag ing . (Re p rod uce d with p e rmission from Kaluzny, B. J., Kaluzny, J. J.,
Szkulmowska, A. e t al. (2006). Sp e ctral op tical cohe re nce tomog rap hy: a
ne w imag ing te chniq ue in contact le ns p ractice . O p hthal. Physiol. O p t.,
26, 127–132.)

Fig . 7.26 Thre e so t le ns e d g e typ e s: (A) round ; (B) kni e ; (C) chise l.

Radial edge
thickness

Edge
lift
Distance from apex
Fig . 7.25 Ed g e slicing with two razor b lad e s. (Courte sy of Fe athe r
Razorb lad e s.) Fig . 7.27 Ed g e p rof le p arame te rs.

Practitioners may still want to check certain parameters i
they observe otherwise-unexplained poor on-eye per ormance.
A number o suitable tools are available in most practices to
con rm or exclude suspected lens de ects. Research laboratories
o en develop their own instrumentation to e ect more accu-
rate measurements o speci c lens parameters and properties;
however, there are still a number o properties, particularly in
relation to in vivo measurements, that elude accurate quanti -
cation. Among them on-eye dehydration, dynamic riction and
tear lm behaviour. Even more di cult to measure are the unc-
tional e ects and their correlation with certain lens parameters,
such as edge–lid interactions or lens-induced corneal pres-
sure points, as they are highly dependent on individual ocular
conditions.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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 8
So ft Le ns De sig n and Fit t ing
GRAEME YO UNG
Int ro d uct io n
Assessment o so contact lens t is probably the most com-
monly undertaken task in contact lens practice but is also one o
the least discussed, possibly because it is regarded as a relatively
straight orward exercise. However, so lens tting is not just a
process o nding a so lens that ts but also one o determining
the so lens and wearing regimen that will provide the patient
with the most com ortable, convenient and sa e contact lens
wear.
T ere is a traditional view that tting so lenses is a less
technically challenging option than that o tting rigid lenses;
however, the increased choices o materials, wearing regimens,
care systems and lenses themselves make the decision-making
process as complex or so lenses as rigid lenses. Since these
decisions rely on clinical judgement rather than measurement,
so lens tting, when done well, is a skilled activity.
O cular Me asure me nt
Contrary to popular belie , keratometry is o little help in the
tting o so lenses because the curvature o the central cornea
is only one o a number o relevant ocular parameters govern-
ing so lens t. Normal variations in corneal asphericity and
diameter have as much e ect on corneal geometry (e.g. sagit-
tal height) as the normal variation in corneal curvature (Young,
1992, 2014). T us keratometry alone is a poor predictor o the
optimum so contact lens base curve radius. As there is a posi-
tive correlation between corneal diameter and corneal curva-
ture (i.e. a tendency or atter corneas to be larger in diameter),
any change in sagittal height due to varying corneal radius is
nulli ed by corresponding variation in corneal diameter (Gar-
ner, 1982). T is would suggest that corneal asphericity is the
most important determinant o so lens t.
One caveat applies, however, with atypical combinations o
corneal diameter and curvature, which may indicate extremes o
sagittal height. For instance, a large cornea showing a relatively
steep keratometry measurement is likely to have a relatively large
sagittal height and will probably require a so contact lens with
a correspondingly large sagittal depth (i.e. steep). Conversely, a
small at cornea is likely to have a small corneal sagittal height
and require a relatively at base curve. When viewed rom the
side, these corneas o en seem abnormally deep or shallow, even
to the naked eye.
Measurement o the horizontal visible iris diameter (HVID)
provides a use ul guide to whether a large or small lens is
required. However, this is only a rough indicator because the
true corneal diameter is signi cantly larger than the iris diam-
eter. T e horizontal corneal diameter has been shown to be, on
average, 1.5 mm larger than the HVID (Martin and Holden,
1982: Hall et al., 2013). T is can be measured to the nearest
86
hal -millimetre with a pupillary distance (PD) rule or, more
accurately, using a slit-lamp graticule.
Palpebral aperture does not have the same relevance as in
the tting o rigid lenses, but extreme cases are worth noting.
A narrow palpebral aperture may increase dif culties o inser-
tion and so, given the choice, a smaller lens may be appropriate.
Larger palpebral apertures are o en associated with incomplete
blinking. T is might in uence the choice o lens material, par-
ticularly when noted in combination with signs o corneal des-
iccation staining.
Basic Princip le s
FO RCES ACTING O N A SO FT LENS
A range o orces act on a so lens, keeping the lens in place on
the eye but allowing it to move a small amount between blinks
(Fig. 8.1).
So lenses are required to ex in two directions in order to
align to the shape o the cornea and sclera. As so lenses are
usually atter than the central corneal curvature, they steepen
in order to align with the cornea but atten and stretch at the
periphery so as to align with the sclera. A use ul model is to
envisage the lens periphery as a series o concentric elastic bands
that stretch in order to align with the peripheral ocular shape
(Kikkawa, 1979). When a large amount o peripheral stretching
is required, this results in a tight t. Conversely, when the lens
is relatively large and there is no stretching, the lens is relatively
loose and may even show edge stand-o .
T e stresses ormed in the lens are proportional to the
mechanical properties o the material as well as the dimen-
sions o the lens. Due to the viscous nature o the tear uid, this
de ormation o the lens to match the shape o the eye results in
pressures being developed in the post-lens tear lm that Martin
and Holden (1986) have termed ‘squeeze pressure’. T is squeeze
pressure is related to the amount o orce required to move the
lens across the eye and there ore lens t (Martin and Holden,
1986; Martin et al., 1989). T e amount o orce required to move
the lens is also related to the viscosity o the post-lens tear lm
(Martin et al., 1989) and this helps to explain why the so lens
movement can vary markedly during a given wearing period.
So lens retaining orces are relatively large compared with
those o rigid lenses and there ore gravitational orce has less o
an e ect.
IDEAL SO FT LENS FIT
T e appropriate so lens, as ar as possible, should be indiscern-
ible to the patient during wear. In other words, there should be
no discom ort or disturbance o vision throughout the wearing
period. Any e ect on ocular physiology should be minimal and
 8 So ft Le ns De sig n and Fit t ing 87

TABLE
8.1 Re q uire me nt s o a We ll-f t t ing So t Le ns
Re q uire me nt Sig nificance
Good com ort Patie nt satis action
Constant corne al Avoid ance o p e rip he ral corne al staining
cove rag e Com ort
Good ce ntration Corne al cove rag e
Stab le p e rip he ral vision
Move me nt on b link Ad e q uate p ost-le ns lub rication
or ve rsion Exchang e o me tab olic waste
Avoid ance o conjunctival staining
O p timum tig htne ss Avoid ance o d iscom ort throug h e xce s-
on p ush-up sive move me nt or e xce ssive me chani-
cal sq ue e ze orce
Avoid ance o ad he re nce with d e hyd ra-
tion
Avoid ance o conjunctival ind e ntation
Good p e rip he ral f t Avoid ance o conjunctival ind e ntation
(i.e . alig nme nt) Avoid ance o e d g e stand -o ; com ort
Good and stab le Patie nt satis action
vision

• sur ace wetting

Fig . 8.1 Forces acting on a so t lens. CMF = circum e rential memb rane
orce ; ELF = e ye lid orce ; G = g ravity; MMF = me rid ional me mb rane orce ;
TFP = tear uid pressure s; VF = viscous orce s. (Adapted from Martin, D.
K., Boulos, J., Gan, J. et al. (1989). A unifying p arame te r to d escrib e the
clinical mechanics of hyd rog e l contact lenses. O p tom. Vis. Sci., 66, 87–91.)
within acceptable limits. A well- tting so contact lens should
ul l the criteria listed in able 8.1.
So t Le ns De sig n
Contact lens practitioners have little direct control over lens
design. Custom-made so lenses can be ordered rom special-
ist laboratories; however, these are relatively expensive. Never-
theless, these can be use ul or extreme prescriptions or ocular
topographies that prove unsusceptible to stock designs.
Most lenses are o ered in a limited range o speci cations
(e.g. two base curves in a single diameter). Despite the relatively
wide range o corneal diameters in the population, most spheri-
cal so lenses are speci ed within a relatively narrow range o
diameters: 14.0–14.5 mm. T e practitioner is there ore largely
dependent on the judgement o the manu acturer.
T e design o proprietary so lenses is governed by a number
o actors in addition to geometry, including material, method
o manu acture and lens power.
• rigidity (and there ore tting characteristics)
• lubricity.
Nowadays, there is little justi cation or using low-Dk lenses
such as poly(hydroxyethyl methacrylate) (polyHEMA) lenses.
T e e ects o hypoxia with conventional low-water-content (i.e.
<50%) lenses are well documented (Bruce and Brennan, 1990).
Based on estimates o corneal swelling, complications such as
corneal striae can be expected to a ect a high proportion o
wearers (Holden and Mertz, 1984). An exception to this rule is
in those rare cases where it proves impossible to t patients with
higher-Dk products.
T e prime decision, there ore, is whether to use a silicone
hydrogel or conventional hydrogel material in mid- (50–60%)
or high-water-content (>60%) lenses. All silicone hydrogel
lenses will provide superior oxygen transmission compared
with conventional lenses; however, they may incorporate disad-
vantages in relation to mechanical properties and sur ace wet-
ting (see Chapter 4).
Comparing conventional hydrogels, a higher-water-content
material does not necessarily guarantee that the lens will pro-
duce better oxygen transmissibility (Morgan and E ron, 1998).
Di erent material categories (e.g. ionic and non-ionic) have
di ering strengths and weaknesses, which can be taken into
account when selecting a lens type or a given patient.
Higher-water-content lenses tend to be thicker or two rea-
sons. First, higher-water materials have a lower modulus and
there ore tend to be less easy to handle in equivalent thick-
nesses. Second, there is a minimum thickness threshold or any
material below which lenses tend to induce corneal desiccation
staining. T ere is some variation between patients and precise
material types; however, or a 70% water content material, the
critical thickness is approximately 0.12 mm, whereas with mid-
water lenses it would be approximately 0.06 mm.

LENS MATERIAL AND WATER CO NTENT METHO D O F MANUFACTURE

T e selection o contact lens material is relevant to several T e method o lens manu acture can in uence the edge design.
aspects o lens per ormance (Jones et al., 2013): Lathing allows a greater range o parameters, but lathe-cut lenses
• oxygen transmission tend to incorporate a thicker edge design than do moulded
• deposit resistance lenses. Cast moulding is the predominant method o so lens
88 PART 2 So ft Co nt act Le nse s
manu acture owing to the relatively low manu acturing costs,
high reproducibility and the act it allows thin edges to be ormed.
BASE CURVE RADIUS (BACK O PTIC ZO NE
RADIUS)
So lenses are speci ed by base curve radius (BC), total diam-
eter, back vertex power and material. I the lens is available in
only a single speci cation (i.e. a one- t lens), the lens brand
name and power may be enough to speci y the lens prescrip-
tion. However, this apparent simplicity belies the complexity
and importance o so lens design. Lenses with apparently simi-
lar speci cations can show widely di ering tting characteris-
tics (Young et al., 1997), or instance, due to variations in back
sur ace design (Young et al., 1993).
raditionally, BC is the main parameter to be modi ed when
attempting to optimize lens t; a steepening o BC is required
to tighten lens t and vice versa. However, even with relatively
thick polyHEMA lenses, large changes in BC are required in
order to have a signi cant e ect on lens movement (Lowther
and omlinson, 1981). With thinner high-water lenses, changes
in BC have even less e ect. T e labelled BC is there ore o little
help in so lens tting.
BC is also not help ul when comparing di erent brands o
lens. Lenses o similar BC can show widely di ering sagittal
depths because o di erences in back sur ace design (Burki,
1997). T is and di erences in materials’ mechanical proper-
ties means that widely di ering lens ts may be observed rom
seemingly similar lenses. With silicone hydrogel lenses the high
modulus o elasticity o many lenses means that even small (0.2
mm) changes in base curve can have a signi cant impact on lens
t and com ort (Dumbleton et al., 2002).
TO TAL DIAMETER
Un ortunately, the labelled total diameter is o en as unhelp ul
as the labelled BC. T e act that the water content, and there ore
the dimensions, o some lens materials varies with temperature
makes it dif cult to compare the labelled diameter o one lens
with another. Most non-ionic lenses, particularly those contain-
ing N-vinyl pyrrolidone, shrink by approximately 0.5 mm when
raised rom room to eye temperature. Ionic lenses are also tem-
perature sensitive, although they shrink much less than non-
ionic lenses (Young et al., 2011). Some lenses are made larger in
diameter to compensate or this.
A urther complicating actor is that the on-eye diameter
is a ected by the sagittal depth o the lens. Lenses o similar
nominal diameter can vary in sagittal depth by as much as 1 mm
(Burki, 1997) and, as the periphery o a so lens attens to align
with the scleral pro le, the sagittal depth can have a signi cant
e ect on e ective diameter.
BACK VERTEX PO WER
Some modi cations are o en made to the lens design at the
extremes o the power range. At the lower end o the minus
power range (<−1.50 D) the centre thickness is usually increased
to improve lens handling. At the higher end o the power range,
the centre thickness is o en reduced and the optic zone diameter
kept to a minimum in order to maximize oxygen transmission.
T e thickness o high-minus lenses can be urther reduced
and the optical per ormance improved by incorporating
aspheric optics in order to overcome lens spherical aberra-
tion (Cox, 1990). Aspheric optics can also be incorporated
to reduce the spherical aberration o the eye (Kollbaum and
Bradley, 2005). A number o designs are available that claim
to use aspheric optics in order to improve visual per ormance
(e.g. Bausch & Lomb PureVision 2, CooperVision Biomedics
Premier); however, the published data have given con icting
results (Morgan et al., 2005; E ron et al., 2008; Rae et al., 2009;
Lindskoog et al., 2011).
With plus-power lenses, the optic zone diameter is again mini-
mized in order to minimize centre thickness. Some manu actur-
ers have utilized a larger diameter in order to accommodate the
anticipated greater movement; however, hyperopic eyes tend to
be smaller in diameter and there ore this is o doubt ul bene t.
T ere tends to be little di erence in lens t between low-
minus and higher-minus lenses o similar design. However,
plus-power lenses tend to show signi cantly more post-blink
movement than do minus lenses, which is probably due to
greater interaction with the upper lid (Young et al., 1993).
CENTRE THICKNESS
Lens centre thickness is relevant to ease o lens handling and sus-
ceptibility to dehydration. Mid-water-content hydrogel lenses
(50–59%) are generally manu actured with centre thicknesses
in the range 0.06–0.10 mm, whereas high-water-content lenses
(60%) generally have centre thicknesses in the range 0.10–0.18
mm. Silicone hydrogel lenses vary widely in water content but
tend to have centre thicknesses in the range 0.07–0.09 mm.
EDGE THICKNESS AND DESIGN
Due to poor measurement repeatability, so lens peripheral thick-
ness is not the subject o an ISO standard and is not always rou-
tinely veri ed during lens manu acture. Nevertheless, variations in
peripheral thickness can have a signi cant e ect on lens t; con-
trary to expectations, thicker-edged lenses o en show a looser t
than do thinner lenses o similar basic design (Young et al., 1993).
Modern designs generally taper to a thinner edge than many
older designs. Several edge shapes have been identi ed, includ-
ing ‘rounded’, ‘kni e’ and ‘chisel’ edges. T e thinner kni e-and
chisel-edge designs appear to give better com ort, sit closer to
the bulbar conjunctiva, show less movement and have less inter-
action with the lids than do the rounded design (Maissa et al.,
2012; Wang et al., 2009).
So t Le ns Fit t ing O p t io ns
Many so lenses show an acceptable t on a wide range o eyes,
but an acceptable t is not necessarily the optimal or most com-
ortable t. As well as nding the most appropriate lens design,
selecting the optimal lens involves nding the lens material, lens
replacement schedule and wearing regimen that best suit the
individual patient. In order to achieve this, it is necessary to use
a wide range o so lens types and brands.
Trial Le ns Fit t ing
INITIAL LENS SELECTIO N
As discussed earlier, without understanding the material and
design characteristics o a particular lens it is not possible to

predict its clinical tting per ormance. Even with this in orma-
tion, it is dif cult to predict rom keratometry and HVID mea-
surements which lens is likely to be the most suitable.
he selection o a irst trial lens can take into account
HVID, particularly i the cornea appears to be unusually large
or small. he selection o BC is a process o trial and error
unless there is use ul in ormation rom the patient’s previ-
ous lenses. I , or instance, the patient previously required a
steeper- itting lens in order to achieve a success ul it, this
would suggest the need or a lens with relatively tight- itting
characteristics.
Lens material and wearing regimen are also key actors in
the selection o the initial trial lens. Although compromises
occasionally have to be made, these should be selected based
on an assessment o the patient’s requirements rather than on
prescribing habits or practice policy.
SO FT LENS INSERTIO N
1. Be ore inserting a so lens, place it between the index and
middle ngers and rinse with saline to remove any debris.
2. Allow the excess saline to drain be ore placing the lens on
a dry ore nger.
3. With the ore nger o the other hand, hold open the pa-
tient’s top lid while holding open the bottom lid with the
middle nger o the other hand (Fig. 8.2).
Fig . 8.2 Inse rting a so t le ns. (A) Dire ct the g aze o the p atie nt nasally to e xp ose the b ulb ar conjunctiva. Re tract the up p e r e ye lid with your le t
ore f ng e r, and the in e rior e ye lid with the mid d le f ng e r o the rig ht hand . (B) With your rig ht ore f ng e r, ap p ly the le ns to the b ulb ar co njunctiva o
the p atie nt. (C) Slid e the le ns late rally o n to the corne a. O nce the le ns is ce ntre d on the corne a, and without air b ub b le s b e ne ath it, your f ng e r can
b e re mo ve d . (Courte sy of Ad rian Bruce .)
8 So ft Le ns De sig n and Fit t ing 89
4. With the patient looking to the opposite side, place the
lens on the bulbar conjunctiva, allowing it to stick by cap-
illary orce rather than pressure rom the nger.
5. Ask the patient to look towards the lens. Continue to hold
the lids open or a ew seconds to allow the lens to settle.
6. Ask the patient to look down, then let go o the lids. With
thin so lenses the lens can be easily olded or dislodged
i it has not properly settled.
7. I the patient nds the lens uncom ortable, this may be
due to post-lens debris, in which case temporarily dis-
lodging the lens on to the sclera may remove this (Fig.
8.3).
SO FT LENS REMO VAL
1. Ask the patient to look up.
2. Hold down the patient’s bottom lid with the middle nger
o the le hand.
3. Slide the lens onto the lower sclera.
4. Pinch and remove the lens with the thumb and ore nger
(Fig. 8.4).
SETTLING TIME
Lenses alter their tting characteristics during a period o equil-
ibration owing to di erences in temperature, pH and osmolarity
90 PART 2 So ft Co nt act Le nse s
between the lens vial and eye. Lenses tend to show less move-
ment a er this period o settling. In some cases, lenses exhibit
gross tightness immediately a er insertion and are unlikely to
show suf cient improvement on settling. T e post-lens tear lm
appears to settle within minutes, whereas the pre-lens tear lm
can take 30 minutes to thin to its equilibrium state (Nichols and
Fig . 8.3 Disp lacing a so t le ns to d islod g e a ore ig n b od y.
Fig . 8.4 Re moving a so t le ns. (A) The le ns is slid o the corne a on to
the in e rior or te mp oral b ulb ar conjunctiva and lig ht p re ssure is ap p lie d
on to the le ns sur ace using the thumb and ore f ng e r. (B) The f ng e rs are
p inche d tog e the r to li t the le ns o the e ye . (Courte sy of Ad rian Bruce .)
King-Smith, 2004). A ast blink rate appears to quicken lens set-
tling (Golding et al., 1995), possibly because the thickness o
the post-lens tear lm is an important actor in lens movement
(Little and Bruce, 1994).
Many tting guides recommend a long settling period be ore
assessing lens t, particularly in the case o high-water-content
lenses (e.g. 30 minutes); however, this is requently impractical
and unnecessary. Martin and Holden (1983), however, showed
that high-water ionic lenses stabilize within a 10–15-minute
period. Brennan et al. (1994) noted that the most e ective time
to predict the nal tting characteristics was approximately 5
minutes a er lens insertion; however, they also noted that a
proportion o patients show a relatively long settling time (>25
minutes) and hence the importance o reassessing lens t at the
rst a ercare check.
Le ns Fit Charact e rist ics
So lenses rarely show the idealized t described in textbooks
and tting guides (Young, 1996). able 8.2 summarizes the ac-
tors a ecting so lens t.
A summary o the characteristics o tight, loose and opti-
mally tting so lenses can be seen in able 8.3. It should be
noted, however, that so lenses rarely show all o the classic
characteristics o a given type o lens tting. Loose lenses, or
instance, o en show good centration despite excessive move-
ment (Young, 1996).
O PTIMUM SO FT LENS FIT
T e ideal so lens will:
• be com ortable
• be per ectly centred, overlapping the limbus by at least 1
mm
• show approximately 0.3 mm o movement with a blink and
a similar amount o lag on version gaze
• show easy movement on push-up ollowed by smooth re-
centring
• have edges that align with the sclera without indenting the
conjunctiva.
T e minimum requirements o an acceptable- tting so lens
are as ollows:
• ull corneal coverage at all times
• some movement on blink and / or version
• absence o excessive movement
• no conjunctival indentation or edge stand-o .
TIGHT SO FT LENS FIT
A typical tight so lens tting will:
• be initially com ortable but may ache or eel tired later in
the wearing period
TABLE
8.2 Fact o rs A e ct ing So t Le ns Fit
• Corne al g e ome try: corne al asp he ricity, curvature and d iam-
e te r
• Contact le ns g e ome try: b ack op tic zone rad ius, p e rip he ral
thickne ss, ce ntral thickne ss
• Contact le ns mate rial: me chanical p rop e rtie s
• Post-le ns te ar f lm: non-invasive b re ak-up time (NIBUT)
• Extrane ous actors: p ing ue culae , lid te nsion
 8 So ft Le ns De sig n and Fit t ing 91

TABLE
8.3 Typ ical So t Le ns Fit t ing Charact e rist ics
Crit e rio n Tig ht O p t imum Lo o se
Com ort Initially g ood , althoug h e ye s may e e l Good Poor
tire d late r in we aring p e riod
Ce ntration Can b e g ood or p oor Good Possib ly d e ce ntre d
Post-b link move me nt Little or none 0.2–0.4 mm >0.4 mm
Lag on ve rsion or up g aze Little or none 0.2–0.4 mm >0.4 mm
Tig htne ss on p ush-up Di f cult to d islod g e and slow to Easy to d islod g e and smooth Ve ry e asy to d islod g e and
re cove r re cove ry ast re cove ry
Pe rip he ral f t Conjunctival ind e ntation Alig ne d Ed g e stand -o
Vision Stab le or p ossib ly cle are r a te r a b link Stab le Variab le

• display minimal or no movement with a blink
• be dif cult to dislodge by the push-up test and will be slow
to recover.
In extreme cases, there will be indentation o the scleral con-
junctiva. T e centration o the lens is not a help ul indicator o
whether a lens is tight.
LO O SE SO FT LENS FIT
A typical loose- tting so lens will:
• be uncom ortable due to excessive lens movement or de-
centration
• sometimes show decentration and excessive movement on
blinking (≥0.5 mm)
• be easily dislodged on push-up and all quickly when the
lower lid is retracted
• have an edge that may show some stand-o , especially at
the in erior temporal edge.
Asse ssme nt o Fit
T e visual assessment o so lens t should be undertaken
with the aid o a slit lamp rather than a hand-held magni er
(e.g. Burton lamp). Only a slit lamp can give the magni cation
required to view the ner details o so lens t – or instance,
the t o the lens periphery.
CO MFO RT
T e patient’s reaction to the lens in terms o com ort is the rst
clue to the lens t. A well- tting so lens is a com ortable lens.
ight- tting lenses are also usually com ortable, but some dis-
com ort or lens awareness may indicate a loose- tting lens.
One study ound that 63% o loose- tting lenses were graded
as relatively uncom ortable (Young, 1996). Due to the overlap-
ping distribution o corneal nerves, it is dif cult or patients
to locate precisely the source o any discom ort; however, it is
worth asking the patient to describe the discom ort with ques-
tions such as:
• Can you eel the edge o the lens?
• Is the discom ort at the top or bottom edge o the lens?
• Is it more noticeable when you blink?
• Does the lens eel as i it is moving about in your eye?
Also, gauge the severity o any discom ort by observing the
patient. Clearly, excessive lacrimation or blepharospasm would
tend to suggest a more severe reaction.
It is wrong to think that new wearers require a prolonged
adaptation period to the com ort o so lenses in similar ashion
to rigid lenses. Well- tting so lenses, once settled, should be
virtually indiscernible to the patient.
CENTRATIO N
Some decentration is acceptable provided the lens shows cor-
neal coverage at all times and does not appear to compromise
com ort. Remember that the cornea extends beyond the HVID
and that some overlap o the visible iris is necessary, ideally by
about 1 mm.
As expected, loose- tting lenses tend to show greater decen-
tration. In one study, three-quarters o loose- tting lenses
showed decentration greater than 0.3 mm (Young, 1996). ight
lenses show similar centration characteristics to those o well-
tting lenses. In other words, tight lenses do not necessarily
show per ect centration but can vary rom per ect to noticeably
decentred.
With most higher-power lens designs, the optic zone diame-
ter will be reduced in order to minimize lens thickness. In these
cases, it is important to ensure that any decentration does not
compromise peripheral vision.
MO VEMENT
Some lens movement is necessary to maintain post-lens lubrica-
tion and, in turn, ensure a complete post-lens tear lm. Exces-
sive movement can cause unnecessary discom ort and disrupt
vision. Post-blink movement is a more important indicator o
tight rather than loose- tting lenses as virtually all tight- tting
lenses show little or no movement (Young, 1996). Loose- tting
lenses do not necessarily show excessive movement and there-
ore the assessment o lens movement on its own is an inad-
equate measure o lens t.
In a normal t, the lens appears to remain stationary when
the lid moves downward during the rst part o the blink but
then moves upwards by a small amount during the second
part o the blink, returning to its original position immediately
a er the blink – hence the description ‘post-blink movement’.
Some loose ttings show a type o movement reminiscent o lid
attachment with rigid lenses. T e lens shows some downwards
movement as soon as the lid starts to blink be ore showing the
normal up-and-downwards movement. In some cases, the lens
can be seen to move with the lid even during small changes in
lid position.
So lens movement correlates surprisingly poorly with the
pressure that the lens exerts on the eye, except where the lens
exerts pressure above a certain threshold. In these cases, the lens
tends to show no movement (Martin et al., 1989). In addition,
92 PART 2 So ft Co nt act Le nse s

Little and Bruce (1994) have shown that lens movement is

a ected by the state o the post-lens tear lm. Depletion o the
post-lens tear lm due to lens dehydration may even result in
lens adherence. In cases where patients present with lenses
showing no movement, it is there ore wrong to assume that this
is due to the lens geometry and other actors such as the patient’s
tear lm and working environment should be considered.
Movement on sideways gaze (version lag) can be as sensitive
an indicator o t as post-blink movement. T e assessment o
upgaze lag is less use ul and, in act, a large proportion o well-
tting lenses show no movement on upgaze lag (Fig. 8.5).

TIGHTNESS O N PUSH-UP
T e assessment o lens t using the push-up test is the most use-
ul single test o lens t (Fig. 8.6). T is is undertaken by digitally
moving the lens upwards, pushing the lower lid against the lens
edge. T e test consists o an assessment o the amount o orce
necessary to dislodge the lens upwards coupled with the speed
o recentration o the lens rom its dislodged position. As crude
as it sounds, the push-up test has been shown to correlate closely
with ‘squeeze pressure’, which is a measure o the mechanical
properties o the lens and an index o the orce exerted by the
lens on a given eye (Martin et al., 1989). T e test shows high Fig . 8.5 Loose and we ll-f tting le nse s in p rimary g aze and on ve rsion.
predictive value and is equally sensitive or both tight and loose
ts (Young, 1996).
I the lens is already decentred upwards it may be dif cult
to dislodge, thus giving a alse impression o tightness. In this
situation, lens t can be checked by using the top lid to recentre
the lens be ore per orming the push-up test in the normal way.
Lenses can also give the alse impression o tightness because
o post-lens dryness causing the lens to adhere to the eye. T is
is rarely seen during trial lens tting but is occasionally seen in
patients attending a ercare visits, particularly i the patient is
prone to dry eye or has been in a dry atmosphere. In these cases,
once the lens has been orcibly dislodged by push-up and the
post-lens tear lm is able to re orm, the lens resumes its normal
tting appearance.
A variant o the test, the spring-back test, involves digitally
displacing the lens sideways and observing the speed o recen-
tration. However, this test is unnecessarily disruptive and not
recommended.

Fig . 8.6 Asse ssme nt o f t b y the p ush-up te st.

PERIPHERAL FIT
T e peripheral t is an important, but o en overlooked, aspect
o so lens t. A lens can show good centration and tightness
on push-up but still show poor edge alignment. Even slight,
barely visible edge stand-o can cause discom ort due to inter-
action with the lids (Fig. 8.7). Edge stand-o is o en more easily
disclosed by moving the lens closer to the limbus by push-up
(Josephson, 1977).
T e opposite case o excessive peripheral tightness is rarely
seen with conventional hydrogel lenses owing to their relatively
thin edges but is common with higher-modulus silicone hydro-
gel lenses. T e type o constriction described in textbooks as
vessel blanching is extremely rare and would occur only with
a thick lens that was tightly tting in every respect. Particu-
larly with silicone hydrogel lenses, it is use ul to examine the
periphery under magni cation or signs o indentation o the
bulbar conjunctiva. When present, this may also be visible on Fig . 8.7 Gross e d g e stand -o ; e ve n slig ht e d g e stand -o can cause
lens removal through pooling o uorescein in the indentation. d iscom ort.

Even i the lens periphery is not tight, close examination can
be use ul in identi ying relatively thick edges that might cause
discom ort through interaction with the lid wiper, particularly
at the 2 and 10 o’clock positions.
VISIO N
An overre raction is usually unnecessary as part o the tting
procedure. Spherical so lenses, because o their thinness and
exibility, rarely support a tear lens between the lens and cor-
nea. In the case o with-the-rule astigmatism, the required
contact lens power usually corresponds to the vertex distance-
corrected spectacle sphere (assuming minus cylinder); thus no
adjustment is necessary or cylinder power. On the other hand,
with against-the-rule astigmatism, the required power will
incorporate approximately hal o the cylinder power. Where
an overre raction yields an unexpected result, this can usually
be explained by checking the lens power with a ocimeter (see
Chapter 7).
Unstable vision may indicate a loose, relatively mobile t. In
rare cases, unstable vision that clears with a blink indicates a
steep central t. However, this is more common with relatively
thick or high-modulus lens designs, but even then is rarely seen.
O THER METHO DS O F FIT ASSESSMENT
Other techniques or assessing lens t have been suggested;
however, the basic methods described above are usually suf -
cient. Other methods include the ollowing:
• Assessing keratometry mires – the keratometry mires
tend to distort when the lens is not aligned with the lens
sur ace. Mire distortion tends to clear immediately a er
a blink with tight- tting lenses and between blinks with
loose- tting lenses.
• Videokeratoscopy – this gives a more detailed picture than
keratometry. T e nal contour map, however, unlike kera-
tometry is a static assessment.
• Retinoscopy – this can be use ul in con rming that the op-
tic zone gives proper coverage o the pupil, which may be
particularly use ul with some bi ocal designs.
So t Le ns Fit t ing Pro b le ms
DISCO MFO RT
wo aspects o the lens design can a ect com ort: total diameter
and edge design. However, other possibilities should be ruled
out rst, such as:
• oreign body
• lens inside out
• lens damage
• lens spoilation.
As there is a relatively wide transition zone between the cor-
nea and sclera, a so lens may appear to just cover the cornea
when in reality the lens edge is irritating the peripheral cornea.
I the lens decentres so that the edge is close to the limbus, the
patient is usually able to localize the discom ort to that part o
the limbus.
Many larger corneas show marginal corneal coverage with
standard-diameter so lenses. Since most so lens brands are
o ered in one diameter only, the obvious remedy is not avail-
able and it is necessary to try a di erent lens type. However, as
8 So ft Le ns De sig n and Fit t ing 93
lenses with a steeper BC have a slightly larger sur ace area than
do their equivalent atter versions, changing BC can sometimes
overcome the problem. As a rule o thumb, steepening BC by
0.4 mm will result in an increase in diameter o 0.2 mm on the
eye.
Relatively large changes in peripheral thickness can be made
to a lens design without a ecting com ort (Young et al., 1993).
Nevertheless, some thinner-edged designs do appear to give bet-
ter com ort than others. As with rigid lenses, there does appear
to be an adaptation e ect. However, as com ort appears to be
the characteristic that patients most value, the best approach is
to nd a design that is immediately com ortable or a particular
patient. As noted earlier, some cases o edge sensation may be
related to the peripheral t.
In case o dryness-related discom ort, an alternative approach
is to change to a more wettable material and / or dehydration-
resistant material, such as oma lcon A or seno lcon A (Lemp
et al., 1999; Riley et al., 2006).
INAPPRO PRIATE DIAMETER
Too Larg e
Greater than usual coverage o the sclera is not in itsel a clini-
cal problem. However, the act that the lens is required to ex
close to the optic zone junction in order to align with the limbus
and sclera can result in areas o increased mechanical pressure.
When concentrated at the edge, this can result in conjunctival
indentation. When too large a diameter results in poor exure
in the midperiphery, this can lead to superior arcuate staining
(Young and Mirejovsky, 1993).
Another problem with large lenses is that the lens may be
visible on the eye, particularly i the lens has a thick periphery
or incorporates a deep handling tint.
Un ortunately, there are ew so lenses available in diam-
eters smaller than 14.0 mm. Also, as noted earlier, comparing
the labelled diameters o so lenses is not necessarily a reliable
guide to their on-eye per ormance. It is there ore necessary or
practitioners to gain an appreciation o which lenses are rela-
tively small on-eye; current examples are Air Optix Night & Day
(Alcon) and So ens 59 (Bausch & Lomb).
Too Small
Lenses that are too small can cause peripheral corneal staining
as well as discom ort. Again, it is necessary to have an appre-
ciation o which lenses are relatively large once equilibrated on
the eye; current examples o relatively large lenses are Proclear
(CooperVision) Air Optix Aqua (Alcon) and Acuvue Oasys
1·Day (Johnson & Johnson).
INAPPRO PRIATE FIT
Too Loose
Loose- tting lenses can also cause peripheral corneal staining and
symptoms o discom ort and variable vision. Patients may also
complain o lenses being displaced rom the cornea during wear.
T e rst possibility to consider is whether the lens is inside
out. Switching to a similar lens o steeper BC may not always
overcome the problem, particularly with thin lens designs. It
may be necessary there ore to change to a lens with a tendency
towards tight tting.
94 PART 2 So ft Co nt act Le nse s
Too Tig ht
ight lenses induce greater levels o staining than do well- tting
lenses and the prevalence o staining increases with increasing
degree o tightness. ight- tting lenses tend to be com ortable
but patients occasionally complain o aching eyes later in the
wearing period.
PO O R VISUAL ACUITY
Occasionally, so lenses ail to give acceptable vision even when
the optimum power appears to have been selected.
Possible reasons or poor vision include the ollowing:
• uncorrected astigmatism
• lens deposits
• poor sur ace wetting
• lens imper ections.
Slit-lamp inspection o the lens on the eye will indicate whether
the problem is poor sur ace wetting as a result o spoilation
or merely poor tear quality is to blame. Generally, i these are
severe enough to a ect vision, they will be easily visible on slit-
lamp examination.
As with spectacle lenses, contact lenses very occasionally
show optical imper ections that, in turn, a ect vision. T ese
include waves, distorted optics and multiple zones o power. T e
ocimeter image may give an indication, but the lens optics can
also be inspected by dabbing the lens dry with a tissue wipe and
viewing through the lens with the naked eye while holding it
towards a light source.
In the event o no obvious cause, the best remedy is to replace
the lens to see whether this overcomes the problem.
VARIABLE VISIO N
When the visual acuity is normal but the patient complains o
variable vision, the ollowing causes may be suspected:
• incorrect back vertex power, e.g. over-minus, under-plus
• poor binocular balance
• excessive lens movement, i.e. loose t
• poor pre-lens tear lm.
Fit t ing Caucasian ve rsus O rie nt al e ye s
Di erences in ocular anatomy between Caucasian and Ori-
ental eyes can potentially impact so contact lens tting. In
a UK-resident Chinese population, Lam and Loran (1991)
observed that corneas o UK-resident Chinese people were
steeper and smaller than Caucasian eyes. However, Hickson-
Curran et al. (2014) noted that Chinese and Japanese corneas
tended to be slightly atter but to show similar asphericity in the
atter meridian than did Caucasian. Also, Oriental eyes tend to
show a narrower palpebral aperture: on average, about 1.0 mm
smaller than Caucasian eyes (Lam and Loran, 1991; Hickson-
Curran et al., 2014). A comparison o Caucasian and British
Asian eyes noted smaller corneas in the British Asian popula-
tion but no di erence in curvature or asphericity (Hall et al.,
2013).
Hickson-Curran et al. (2016) evaluated the e ect o ocular
topography on so contact lens t 547 subjects rom two eth-
nic groups – Caucasian (n = 250) and Chinese (n = 297). Sub-
jects were tted with a 1-Day ACUVUE spherical lens in two
base curves – 8.50 and 9.00 mm. T ey observed that the steeper
base curve (8.50 mm) spherical lenses gave an acceptable overall
lens t with 98% or more o subjects in both groups, while the
atter lens (9.00 mm) was acceptable in a signi cantly higher
proportion o the Chinese compared with the Caucasian group
(96 versus 82%, p < 0.0001). T e main di erence in t between
groups was or centration; there was signi cantly less decentra-
tion with the Chinese group (8.50 base curve: 39 versus 72%,
p < 0.0001; 9.0 base curve: 63 versus 85%, p = 0.02). T e 8.5 mm
base curve showed good centration or 97% o Caucasian eyes
and 96% o Chinese eyes. Overall, they concluded that the lens
tested in this study tted a large proportion o both Chinese and
Caucasian eyes and is robust to the di erences in ocular dimen-
sions between the two ethnic groups examined.
Co nclusio n
As has been seen rom reading this chapter, the tting o so
contact lenses is not a simple ormulaic task. Care ul thought
needs to be given to selecting a lens o appropriate material,
dimensions and wearing modality to match the ocular char-
acteristics and li estyle pre erences o the individual patient.
Using a wide range o lens brands gives greater exibil-
ity and increases the chance o arriving at the best solution
expeditiously.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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94.e 1
9
So ft To ric Le ns De sig n and Fit t ing
RICHARD G LINDSAY
Int ro d uct io n
T e use o so toric lenses (in pre erence to spherical so
lenses) is indicated when there is ocular astigmatism present, be
it corneal or non-corneal, that warrants correction. Unlike rigid
lenses, so lenses do not mask corneal astigmatism but rather
con orm to the shape o the cornea. Consequently, correcting
ocular astigmatism with so lenses requires that cylinder be
incorporated into the back vertex power (BVP) o the lens.
Numerous manu acturers o so contact lenses have made
extremely optimistic claims o their spherical lenses being able
to correct satis actorily astigmatism o between 1.00 and 2.00 D.
Only rarely is this achieved. Bernstein et al. (1991) showed that
there was no statistically signi cant masking o corneal cylinder
with standard-thickness so spherical lenses. Indeed, the most
help ul indication o the likely residual astigmatism ound while
wearing a spherical so contact lens is the ocular astigmatism
determined rom an accurate subjective spectacle re raction.
For many years it was held that prospective contact lens
wearers with clinically signi cant astigmatism could not be suc-
cess ully tted with so lenses. Since the early 1980s, however,
notable advances in so toric lens technology have been made
such that the correction o astigmatism with so lenses is now a
viable option or the majority o these patients. Indeed, annual
contact lens tting surveys over the last 10 years have consis-
tently demonstrated a commensurate increase in toric lens t-
ting as a proportion o all so lenses tted. T is is evident rom
Fig. 9.1, which shows the extent o toric so lens tting as a per-
centage o all so spherical and toric lenses prescribed in seven
nations between 2000 and 2015 (Morgan et al., 2016).
Based on the distribution o astigmatism in prospective con-
tact lens wearers, Holden (1975) determined that, i all astig-
matism o 0.75 D or more were corrected, 45% o lens wearers
would need toric lenses. T is threshold is shown as a dotted line
in Fig. 9.1. It is evident rom Fig. 9.1 that so toric lens tting
has evolved to the point where nearly all those with clinically
signi cant astigmatism are being corrected with toric lenses.
Crit e ria fo r Use o f So ft To ric Le nse s
When deciding whether or not to prescribe a so toric lens,
practitioners should avoid using criteria such as ‘all patients
with cylinders greater than a certain amount should be tted
with so toric lenses’. Instead, each patient should be assessed
separately, taking into account the ollowing actors.
DEGREE O F ASTIGMATISM
As a generalization, 1.00 D or more o astigmatism should be cor-
rected, although there will be signi cant variability between patients.
Holden (1975), in discussing the criteria or the prescribing o toric
lenses, showed that 45% o the population required a cylindrical
correction o up to 0.75 D and 25% o the population required a
correction o 1.00 D or more. A more recent study by Young et al.
(2011) revealed that the prevalence o patients showing astigma-
tism o 0.75 and 1.00 D or greater in at least one eye was 47% and
32%, respectively. As mentioned previously, the current so toric
lens prescribing rate suggests that almost all cases o astigmatism
0.75D D or more are now being tted with so toric lenses.
CYLINDER AXIS
T e axis o the ocular cylinder is also an important actor. For
example, an uncorrected cylinder with an oblique axis will cause
greater degradation o visual image compared with an equiva-
lent amount o uncorrected with-the-rule or against-the-rule
astigmatism (Lindsay, 1998).
O CULAR DO MINANCE
Uncorrected astigmatism is ar more likely to be accepted by the
patient i it is in the non-dominant eye. For example, patients
may tolerate uncorrected cylinder o up to 2.00 D in their non-
dominant eye, while at the same time requiring that cylinder as
small as 0.50 D be corrected in their dominant eye. Related to
this is the situation where a patient has unequal visual acuities.
In this case, higher degrees o uncorrected astigmatism will
usually be tolerated in the eye with the poorer acuity.
VIABILITY O F O THER ALTERNATIVES
T e practitioner also needs to consider whether so toric lenses
are the best option or whether the patient would be better o
with spectacles or rigid lenses. For example, a patient with high
degrees (>5.00 D) o both corneal and spectacle astigmatism
would most likely achieve better acuities with a rigid toric lens.
VISUAL NEEDS O F THE PATIENT
Usually, the less critical the visual task the greater is the amount
o astigmatism that can be le uncorrected (and vice versa).
For example, a musician may require that a cylinder as small
as 0.50D be corrected to enable music to be read. In contrast, a
person with no speci c critical visual tasks may be happy with a
cylinder as high as 2.00 D le uncorrected so long as the spheri-
cal component o the re ractive error is corrected.
De sig n o f So ft To ric Le nse s
Satis actory visual per ormance with so toric lenses is depen-
dent upon two key design components – sur ace optics and lens
stabilization.
95
96 PART 2 So ft Co nt act Le nse s
SURFACE O PTICS
T e two principal categories o sur ace optics are as ollows:
1. oroidal back sur ace with a spherical ront sur ace
2. Spherical back sur ace with toroidal ront sur ace.
With so toric lenses, regardless o which o the above optical
con gurations is prescribed, the end result on the eye will be a
bitoric lens orm owing to the wrapping o the ront and back
sur ace o the lens onto the cornea.
T e optical considerations or so toric lenses are di erent
rom those encountered when using rigid lenses. T is is primar-
ily because a so toric lens will tend to wrap onto the cornea
such that a negligible tear lens orms between the back sur ace
o the lens and the ront sur ace o the cornea. Consequently, the
optical principles o rigid toric lenses do not apply. T ere are no
tear lens calculations to per orm and all the ocular astigmatism
will usually be corrected by incorporation o cylinder into the
BVP o the so toric lens.
T e choice o design (i.e. toric back sur ace versus toric ront
sur ace) is generally based more on considerations relating to
manu acture, lens stability and physiological per ormance.
Currently, the majority o so toric lenses prescribed globally
are o a planned-replacement orm and virtually all o these
lenses are mass-produced by a process o cast moulding. All
other so toric lenses are custom made or the patient by a pro-
cess o either crimping or generating, the latter being a spe-
ci c orm o lathe cutting devoted to the production o toric
sur aces. As a general rule, generated toric lenses will be thin-
ner and show better reproducibility than do those made rom
crimping techniques.
STABILIZATIO N TECHNIQ UES
All orms o so toric lenses need to be stabilized so that the
toric optics o the lens can be maintained in the desired orienta-
tion in order to correct the ocular astigmatism. T e aim is to
minimize rotation rom the ideal in-eye orientation. T e ori-
entation o a so toric lens on the eye must be predictable and
Fig . 9.1 Exte nt o toric so t contact
le ns f tting as a p e rce ntag e o all so t
sp he rical and toric le nse s p re scrib e d in
se ve n nations b e twe e n 2000 and 2015.
consistent, otherwise suboptimal vision will result. T e devel-
opment o the technique o dynamic stabilization in the 1980s
has resulted in an overall improvement in the per ormance o
so toric lenses.
Toroid al Back Surface
Some practitioners and laboratories believe that a so toric
lens with a toric back sur ace will generally locate better than a
ront sur ace toric lens, because it is believed that the back toric
sur ace is more likely to align with, or ‘lock onto’, the match-
ing toroidal corneal sur ace. However, experience has shown
that a toroidal back sur ace alone is insu cient to achieve lens
stabilization.
Prism Ballast
T e theory o prism ballast is that base-down prism is incorpo-
rated into the lens so that the lens will be heavier at the prism
base (due to excess lens mass). Gravity then acts to cause the
prism base to locate in eriorly.
Prism ballast has long been used as a technique or stabi-
lizing toric orms o lenses, but it does have certain disadvan-
tages when applied to so lens designs. T e additional thickness
brought about by the use o a prism can be a problem in that it
reduces oxygen transmissibility in the thick prism zone and can
also cause physical discom ort in patients with sensitive lids.
In addition, so toric lenses incorporating prism ballast o en
show excessive downward mislocation on the eye. T e thicker
edge in the region o the prism base can be thinned during the
manu acturing stage to orm a ‘com ort’ cham er (Edwards,
1999), although this will slightly negate the intended thickness
di erential along the vertical axis o the lens. T e problem here
is nding an acceptable compromise between com ort and lens
stability.
One o the di culties that arises with the use o prism ballast
is that, i it is going to be prescribed monocularly, it may cause
vertical prismatic e ects that can make the patient uncom ort-
able. T is then requires the use o a similar prism or the other

eye, which can prove di cult i the other eye requires a spherical
lens or is emmetropic. Fortunately, however, prism ballast does
not o en give rise to binocular problems (Gasson, 1977).
T is design eature is perhaps considered in erior to dynamic
stabilization (see below) or maintaining the orientation o a so
toric lens on the eye; nevertheless, prism ballast is the method
o stabilization that is used predominantly in disposable toric
lens designs, which have proved to be reasonably success ul in
clinical practice.
Pe ri-b allast
T is method o lens stabilization eatures a lens with a minus
carrier (peripheral zone), with the carrier being thicker in eri-
orly. In other words, the prismatic thickness pro le changes are
con ned to the lens carrier, where the carrier is thicker in e-
riorly (prism base-down). T is design is abricated simply by
removing the high-minus lenticular carrier rom the superior
portion o the lens. In e ect, it is similar to prism ballast except
that with peri-ballast all the prism is outside the region o the
optic zone.
Truncation
runcation re ers to the technique o slicing o the bottom o
the lens so as to orm a ‘shel ’ that will rest upon – and there ore
align with – the lower lid. T is is a reasonably success ul method
o stabilizing lenses with thick edges, especially when combined
with prism ballast (Fig. 9.2). Either a single lower truncation or
a double truncation (where both the top and bottom o the lens
are sliced o ) can be used (Strachan, 1975). With the ormer,
the truncated section o the lens that is removed can be any-
where between a sag o 0.5 and one o 1.5 mm.
T ere are problems with the use o truncation in so toric
lens tting. T e truncated edge can make the so lens uncom-
ortable to wear. T e measurement o the lid angle can be di -
cult and imprecise. Quite o en the truncation does not work,
with the lid angle appearing to have no e ect on the positioning
or location o the truncated lens. Another di culty with trunca-
tions (and prism ballasting) is the instability that can occur with
oblique cylinders. T e uneven thickness produced by oblique
cylinders can make lens stabilization very di cult. For these
reasons, so toric lens truncation is rarely used today.
Dynamic Stab ilization
T e technique o dynamic stabilization was initially developed
by Fanti (1975) and this is currently the most commonly used
method o stabilization or so toric lenses. With this technique,
the dominant lens orientation e ect is achieved by pressure rom
the upper lid (primarily) and the lower lid. Hanks (1983) used
the analogy o the ‘watermelon seed’ to illustrate how dynamic
stabilization works. Simply put, pressure applied to the thin end
o a watermelon seed by the ngers (i.e. the pressure exerted on
a thin zone o a lens between the upper lid and globe) causes the
watermelon seed to move away rom the ngers (i.e. causes the
lens to orient away rom the squeezing orce o the eyelid and
globe). Hanks (1983) demonstrated that the e ect o gravity is
insigni cant, and that the e ect o the thickness pro le inter-
action with the upper lid as described above is the dominant
stabilizing component.
With dynamic stabilization, the contact lens toricity is con-
ned to the central portion o the lens. T e superior and in e-
rior (‘dynamic stabilization’) zones o the lens incorporate a
thickness di erential. T e action o the lids on these superior
9 So ft To ric Le ns De sig n and Fit t ing 97
Fig . 9.2 A p rism-b allaste d so t toric le ns with a sing le (in e rior) trun-
cation. The truncation has b e e n cut at the ang le o the mid d le third
o the lowe r lid , b ut in this p hotog rap h the p atie nt had to look up in
ord e r to b ring the truncation ne ar the lowe r lid . The lid marg in may
thus only have a limite d e e ct on the truncation in this p atie nt. Note
the p romine nt b ub b le und e r the le ns ne ar the truncation – a common
p rob le m with the se le nse s. (Ad ap te d from Tan, J., Pap as, E., Carnt, N.
e t al. (2007). Pe rformance stand ard s for to ric soft co ntact le nse s. O p tom.
Vis. Sci., 84, 422–428.)
and in erior lens cham ers serves to stabilize the lens in the
correct orientation. Such a design is shown in Fig. 9.3. Many
similar approaches, re erred to as ‘double slab-o ’, ‘thin-zone’ or
‘reverse prism’ designs, are manu actured throughout the world.
Dynamic stabilization avoids the complications o trunca-
tion and prism ballast. Oxygen transmissibility is not reduced
as additional thickness is generally not incorporated into the
lens. Indeed, the excessive thickness o prism ballast lenses can
be avoided and, by producing toroidal back sur aces, the aver-
age lens thickness is only slightly greater than that o equivalent
spherical designs. T e main disadvantage o this design is that
the thickness di erential that can be achieved at the edge o the
lens is dependent on the spherical power o the lens. Lower-
powered lenses will have a reduced thickness di erential and,
or this reason, a design incorporating prism ballast is o en
more e ective in stabilizing a so toric lens that has a low spher-
ical power component (Snyder, 1998).
T e orientation in which a lens incorporating dynamic sta-
bilization is inserted into the eye is generally not important
since the action o the lids during blinking will quickly stabilize
the lens in the correct orientation. With some designs, a larger,
thinned zone is provided superiorly to utilize the act that most
o the blink action is per ormed by the upper eyelid. With these
designs it is more important that the lens is inserted the cor-
rect way up. o acilitate this – and to assist the practitioner
in determining the degree o in-eye lens rotation – such lenses
will generally have some orm o marking at the 6 or 12 o’clock
position.
Princip le s o f Co rre ct io n
It is clear that to produce a stable ocular correction or the astig-
matic eye the lens must align closely over the central cornea in
ront o the pupil. It must provide the correct power while it is in
situ and must stabilize e ectively to prevent the rotation o the
meridional powers away rom their intended orientation.
98 PART 2 So ft Co nt act Le nse s
Fig . 9.3 Desig n eature s o a so t toric le ns that he lp to minimize lens
rotation. Note the prism- ree optic zone in the toroidal reg ion o the le ns.
FITTING
T e tting principles or so toric lenses are very similar to those
or so spherical lenses, as outlined in Chapter 8. A well- tting
lens is com ortable in all directions o gaze, gives complete cor-
neal coverage and appears properly centred. On blinking there
should be about 0.25–0.5 mm o vertical movement when the
eye is in the primary position. On upwards gaze or lateral move-
ments o the eye, the lens should lag by no more than 0.5 mm.
T e total diameter o the lens is very important because this
parameter will inf uence both lens centration and lens stability.
Generally, when speci ying the lens diameter the practitioner
should err on the large side, as a larger diameter means that
more area is available or the stabilization zones to take e ect in
the periphery o the lens.
Some practitioners advocate tting so toric lenses that are very
steep (tight) with minimal lens movement, on the assumption that
this will aid stability and reduce lens rotation. With the designs
available today, however, this is not necessary. I a lens is too tightly
adherent to the eye, it will not be a ected by the locating orces
designed to stabilize lens orientation (Holden, 1976). Consequently,
a steeply tting lens may decrease stability and lead to undesirable
actors such as limbal indentation and f uctuating vision – the latter
being caused by the so lens vaulting the corneal apex.
A well- tting lens will reveal stable lens orientation with a
quick return to axis i mislocated. A tight- tting lens will show
stable lens orientation but a slow return to axis i mislocated. A
loose- tting lens will demonstrate an unstable and inconsistent
lens orientation (Hanks and Weisbarth, 1983).
BACK VERTEX PO WER DETERMINATIO N
T e determination o BVP or a so toric lens is much easier
than that or a rigid toric lens. Due to the absence o a tear lens,
the BVP or a so toric lens should be similar to the spectacle
re raction (or ocular re raction i the vertex distance e ect is
signi cant).
T e BVP o the lens can be determined either empirically or
by per orming a spherocylindrical overre raction (SCO) over a
diagnostic lens. With empirical prescribing, the BVP ordered
or the so toric lens will be equal to the ocular re raction o
the patient, based on the assumption o an a ocal tear layer
under the so toric lens. For the latter method, an SCO may be
per ormed over either a spherical or a toric trial lens. Use o a
spherical trial lens is generally pre erred, as an SCO with a toric
trial lens may require complex calculations involving oblique
cylinders in order to determine the required lens power. When
using a spherical trial lens, the resultant toric lens power is sim-
ply calculated by adding the SCO to the BVP o the trial lens.
With both methods, some arbitrary allowance or lens rotation
may have to be incorporated into the nal lens prescription.
EFFECT O F LENS RO TATIO N
A considerable degree o cylindrical error can be induced when
a lens does not stabilize satis actorily and rotates away rom the
intended orientation (Lindsay et al., 1997); this phenomenon
is demonstrated in Appendix I. For example, i the contact lens
correction incorporates a power o plano / −2.00 DC × 180,
Appendix I reveals that a mislocation o the axis by 10° results
in a spherocylindrical error o +0.35 / −0.69 DC × 40. A use ul
rule o thumb here is that a lens made to speci cation but mislo-
cating on the eye will produce an overre raction with a spherical
equivalent equal to zero. Where the sphere or cylinder power
is incorrect, the spherical equivalent o the re raction will not
equal zero (Long, 1991).
PREDICTING LENS RO TATIO N
Hanks and Weisbarth (1983) showed that, on average, so toric
lenses will tend to rotate nasally by about 5–10°, where nasal
rotation is designated as rotation o the in erior aspect o the
lens towards the nose. T ey also showed, however, that there
was signi cant variability between so toric lens wearers in the
actual amount and direction o lens rotation; variations also
occur between di erent lens designs.
T e nature o both contact lens materials and their associ-
ated designs is continually changing; per ormance characteris-
tics that were typical or toric so contact lenses o a decade
ago may be o questionable relevance today. an et al. (2007)
have examined the per ormance o several lenses with di er-
ing methods o stabilization and have developed recommended
per ormance standards or toric so contact lenses ( able 9.1).
T e variability in per ormance o so toric lenses can be due
to the ollowing actors.
Lid Anatomy
Variation in lid tension (tightness), lid location, lid angle, lid
symmetry and palpebral aperture size can all have a signi cant
e ect on the location and stability o a toric lens on the eye.
ight lids are more likely than loose lids to a ect lens move-
ment and location (Lindsay, 1998) and it has been shown that

TABLE
9.1 Re co mme nd e d Pe rfo rmance St and ard s
Exce lle nt Acce p t ab le
Comfort (1–100) ≥90 80–89
Me an le ns mislocation ≤± 6° ± 7° to ± 10°
SD of le ns location <± 6° ± 6° to ± 10°
Rotational re cov- >10° 6–10°
e ry / 10 b links
% Le nse s within ± 10° ≥90 70–89
(Re p rod uce d from Tan, J., Pap as, E., Carnt, N. e t al. (2007). Pe rfor-
mance stand ard s for toric so ft contact le nse s. O p tom. Vis. Sci., 84,
422–428.)
– or prism-stabilized lenses – a smaller palpebral aperture
size is associated with a more stable lens orientation (Young
et al., 2002).
Le ns–Eye Re lationship
he optimal itting relationship between the lens and the eye
may vary rom one patient to the next. he type o it (steep,
alignment or lat) will, in turn, have a signi icant bearing on
lens position. For example, the degree o adherence between
lens and eye is a very important actor (Holden, 1976). I a
lens is too tightly adherent to the eye it will not be a ected
by the locating orces designed to stabilize lens orientation.
Conversely, Young et al. (2002) have shown that less lens
movement is associated with more stable lens orientation;
however, increased tightness is associated with slower reori-
entation speed.
Le ns Thickne ss Profile
It has been noted previously that with dynamic stabilization the
thickness pro le interaction with the upper lid is the dominant
stabilizing component. Although most so toric lenses manu-
actured today have the contact lens toricity con ned to the
central portion o the lens, a thickness di erential due to the
astigmatic correction can still have a signi cant e ect on lens
location.
T e lens thickness pro le is determined by the power o
the lens, in particular the axis and magnitude o the astigmatic
correction. For so toric lenses incorporating dynamic stabi-
lization, Gundel (1989) showed that rotational inf uence is
greatest or lenses with cylinders at oblique axes (either 30–60°
or 120–150°), ollowed by lenses incorporating correction or
with-the-rule astigmatism (150–30°), and is least or lenses with
against-the-rule axes (60–120°).
Gundel (1989) postulated that the principal actor a ect-
ing lens rotation is the initial point o contact between the
upper lid and the thicker meridian o the lens. For toric lenses
with oblique axes, the implication is that there will be notable
rotational e ects as contact rom the upper lid will always
a ect one edge o the thicker meridian be ore the other. As
the upper lid comes down, it will orce the lens down at this
irst point o contact, causing it to rotate in a certain direc-
tion. his principle is illustrated by the example shown in
Fig. 9.4. A mislocating e ect also occurs with lenses correct-
ing or with-the-rule astigmatism as the lid contraction angle
will usually be at a slight angle to the thickest axis o the lens
(Holden, 1975). For toric lenses incorporating a correction
or against-the-rule astigmatism, upper-lid contact with the
thicker (horizontal) meridian will be airly symmetrical and
so the rotational e ect is minimal. However, the in luence
9 So ft To ric Le ns De sig n and Fit t ing 99
Po o r
<80
>10°
>± 10°
<6°
<70
Fig . 9.4 The e ect o lid action on lens rotation or a so t toric lens with
the prescription o −1.00 / −2.00 × 45 being worn in the right eye. As the
upper lid comes down, it will f rst act on the lens (and the 135° meridian)
at around the 10 o’clock position on the cornea. The downward motion on
the lens at this point will cause it to rotate nasally. BVP = back vertex power.
o the lower lid can override that o the upper lid depending
on its position, tightness and amount o lateral movement
(Young, 2003).
ALLO WING FO R LENS RO TATIO N
I it is expected that the so toric lens to be ordered will rotate when
placed on the eye o the patient, then an allowance must be made
or this rotation, otherwise the cylinder axis o the lens in situ will
not adopt the correct orientation or the ocular correction. When
allowing or nasal rotation in the right eye, the amount o rotation
should be subtracted rom the required cylinder axis and vice versa
or the le eye. When allowing or temporal rotation in the right
eye, the amount o rotation should be added to the required cylin-
der axis and vice versa or the le eye. Hence:
• I le eye and nasal rotation: add.
• I le eye and temporal rotation: subtract.
• I right eye and nasal rotation: subtract.
• I right eye and temporal rotation: add.
T e acronym LARS (le add, right subtract) – relating to nasal
rotation o the in erior aspect o the lens – can be quite use ul.
Many practitioners work on the principle that clockwise
rotation necessitates adding the allowance or rotation to the
required cylinder axis, and anticlockwise rotation requires sub-
tracting the allowance or rotation to determine the nal cylin-
der axis. Hence:
• I clockwise rotation: add.
• I anticlockwise rotation: subtract.
I , at the dispensing or a ercare visit, the lens rotation is not
what was expected (but the lens location is stable), simply reor-
der the lens with the revised allowance or lens rotation. Gen-
erally, rotational stability is a more important actor than the
degree o rotation. Lenses that give suboptimal but stable acuity
are more likely to be acceptable than those that give moments
o clear vision ollowed by moments o poor vision as the lens
rotates.
MEASUREMENT O F LENS RO TATIO N
So toric lenses will usually have markings on the lens at a speci c
re erence point so the degree o rotation can be assessed when the
100 PART 2 So ft Co nt act Le nse s
lens is on the eye. T e markings may be in the orm o laser trace,
scribe lines (Fig. 9.5), engraved dots or ink dots (Fig. 9.6).
he lens markings do not represent the cylinder axis; they
are simply a point o re erence with regard to which the rota-
tion o the lens can be assessed. hey may either be at the 6
o’clock position o the lens or in the horizontal lens meridian
at the 3 and 9 o’clock positions. he latter situation is pre -
erable as the markings can then be observed without hav-
ing to retract the lower eyelid (which would inter ere with
the dynamic stabilizing orces that normally act to orient the
lens). In addition, having two widely spaced markings about
14 mm apart at the 3 and 9 o’clock positions, as opposed to
one mark or a set o marks at the 6 o’clock position, makes
Fig . 9.5 Scrib e line on so t toric le ns. This le ns has two scrib e line s as
marke rs, with the re e re nce p oints b e ing at the 3 and 9 o ’clock locations
(only the 9 o’clock mark is visib le he re ). De b ris has accumulate d in the
scrib e line – a common site or d e p osit ormation.
Fig . 9.6 So t toric le ns with two ink d ots, one ab ove the othe r, as mark-
e rs or the 6 o’clock re e re nce p oint. The up p e r ink d ot is only just visib le
ag ainst the d ark iris. Two d ots are use d to he lp with le ns id e ntif cation;
the le ns in the othe r e ye has just one ink d ot. This le ns is e xhib iting
ab out 10° nasal rotation.
it easier to quanti y the angle o rotation. Many laboratories
that opt or the 6 o’clock indication provide three lines on
their lenses, each separated by the same known angle, thus
also acilitating a determination o lens rotation. Generally,
lenses with markings at the 6 o’clock position are those with
asymmetrical dynamic stabilization where it is important or
the larger, thinner peripheral zone to be oriented superiorly
or optimal lid interaction.
Estimation is a straight orward and reasonable technique or
assessing the degree o lens rotation, made simpler i the prac-
titioner remembers that there is 30° between each hour on a
clock ace. Clinical experience has shown that this is a satis ac-
tory method o assessing lens rotation, with errors more likely
to occur when evaluating higher amounts o lens rotation (Sny-
der and Daum, 1989).
When assessing lens rotation, it is important to realize that it is
the angular orientation o the marker on the lens that is signi cant
and not the position o the marker on the cornea. Fig. 9.7 shows a
so toric lens on a le eye with the marker indicating that the lens
is rotating nasally by about 20° (given that the re erence point or
the marker is the 6 o’clock position). However, a closer look at the
marker reveals that it is vertically oriented, the expected orientation
i the lens was not rotating. In this case, the apparent nasal rotation
is due to a nasal decentration o the contact lens.
DETERMINING LENS MISALIGNMENT
T e usual method o determining lens misalignment is simply
to estimate the degree o lens rotation by observing the location
o the so toric lens on the eye. T is value is then compared
with the expected lens rotation that has been incorporated into
the BVP o the contact lens. T e di erence between the actual
and expected values represents the degree o lens misalignment.
An SCO can also be used to determine the degree o lens mis-
alignment. T e lens misalignment is deduced by calculating the
e ective BVP o the lens on the eye (BVPin situ). T e SCO obtained
over the mislocating so toric lens is subtracted rom the ocular
re raction (Oc Rx) o the patient (Lindsay et al., 1997). T at is:
BVPin situ = Oc Rx − SCO
Fig . 9.7 False ap p e arance o le ns rotation re sulting rom a d e ce ntre d
co ntact le ns that has not actually rotate d .
 9 So ft To ric Le ns De sig n and Fit t ing 101

Calculating the BVPin situ will require the resolving o T e minus sign be ore the radical symbol simply means that
obliquely crossed cylinders and this is best done by matrix the nal solution will be in minus cylinder orm.
optics (Long, 1976; Keating, 1980) using the ollowing method: T ese ormulae can easily be incorporated into a spreadsheet
1. Express both the spherocylindrical ocular re raction and ( able 9.2) that can then be quickly utilized in clinical practice.
the SCO in dioptric power matrix orm (F), whereby: Once the BVPin situ has been determined, any degree o lens
misalignment can then be identi ed, along with any errors in
S+ C sin 2 θ −C sin θ cos θ the power o the manu actured lens, by comparing the BVPin situ
F=
−C sin θ cos θ S+ C cos2 θ with the BVP speci ed or the contact lens.
For example, consider a so toric lens being tted to the le
where S is the sphere power, C is the cylinder power and θ eye o a patient. T e ocular re raction is −3.00 / −2.00 × 10. T e
is the axis (in radians) o the cylinder. speci ed BVP o the contact lens is −3.00 / −2.00 × 20, so this
2. Subtract the dioptric power matrix or the re raction rom prescription incorporates an allowance or 10° nasal rotation.
the dioptric power matrix or the ocular re raction, to ob- An SCO with this lens yields +0.50 / −1.00 × 47.5. Solving or
tain the dioptric power matrix, Fr, or the BVPin situ: BVPin situ gives −3.00 / −2.00 × 175. T e speci ed cylinder axis
was 20°; however the e ective cylinder axis on the eye is 175°.
Sr + Cr sin 2 θr −Cr sin θr cos θr T ere ore the lens is exhibiting 25° nasal rotation on the eye
Fr =
−Cr sin θr cos θr Sr + Cr cos2 θr (instead o the expected 10° nasal rotation). o allow or this 25°
nasal rotation, the contact lens would now have to be reordered
3. Convert the matrix orm o the BVPin situ back to sphero- with a cylinder axis o 35° to achieve the target cylinder axis on
cylindrical notation using the ollowing ormulae: the eye o 10°.
I visual acuity is not improved by the SCO, the cause o the
a 11 a 12 suboptimal acuity may be a poorly tting lens, a lens o poor
I the lens power matrix is a 21 a 22 quality (possibly due to signi cant deposition on the lens sur-
ace) or some orm o ocular pathology (Myers et al., 1990).
trace (t) = a 11 + a 22 and
Planne d Re p lace me nt o f So ft To ric
determinant (d) = (a 11 a 22 ) − (a 12 a 21 ) Le nse s
o convert the matrix orm o the BVPin situ back to sphe- Many clinicians initially treated planned replacement (i.e. dis-
rocylindrical notation, the sphere power, cylinder power posable) so toric lenses with scepticism because o concerns
and cylinder axis o the BVPin situ, Sr, Cr and θr, can be about on-eye per ormance and reproducibility (Lindsay, 2006);
determined as ollows: however, presently most so toric contact lenses are prescribed
on a disposable basis, with a recent survey revealing that less
(t − Cr ) than 1% o new so toric lens ts did not involve any planned
Sr =
2 lens replacement (Morgan et al., 2016). T e majority o dispos-
able lenses are replaced at monthly, two-weekly or daily inter-
(Sr − a 11 ) 180 vals and disposable so toric lenses are available in these three
θr = a tan × (where θr is in degrees) modalities, as well as in both conventional hydrogel and silicone
a 12 π hydrogel materials. As noted in Chapter 20, the rationale or the
√ planned replacement o so contact lenses is based on the tenet
Cr = − t 2 − 4d that cleaner lenses should produce ewer adverse ocular e ects.

TABLE
9.2 Sp re ad she e t fo r De t e rmining So ft To ric Le ns Misalig nme nt
A B C D E
1 SPHERE CYLINDER AXIS
2
3 O c Rx −3 −2 10 =D3 / 57.2958
4 MATRIX = B3+C3*(SIN(E3)^ 2) =−C3*SIN(E3)*CO S(E3)
5 = −C3*SIN(E3)*CO S(E3) =B3+C3*(CO S(E3)^ 2)
6 OR 0.5 −1 47.5 =D6 / 57.2958
7 MATRIX = B61C6*(SIN(E6)^ 2) = −C6*SIN(E6)*CO S(E6)
8 = −C6*SIN(E6)*CO S(E6) =B6+C6*(CO S(E6)^ 2)
9 SU = B4-B7 =C4-C7
10 = B5-B8 =C5-C8
11 TRACE = B9+C10
12 DET = (B9*C10)−(B10*C9)
13 BVPin situ = (B11-C13) / 2 =−SQ RT((B11^ 2)−4*B12) =IF(57.2958*ATAN((B13-B9) / C9) > 0,
57.2958*ATAN((B13-B9) / C9),
180+ 57.2958*ATAN((B13-B9) / C9))
14
102 PART 2 So ft Co nt act Le nse s
Virtually all disposable so toric lenses are produced as a
stock range o lenses encompassing a certain number o cylin-
drical powers (such as −0.75, −1.25 and −1.75 D), a set choice o
spherical powers ( or example, rom +6.00 to −9.00) and cylin-
der axes in 5° or 10° steps – usually the latter – most o en cover-
ing the complete spectrum rom 0° to 180°. T e choice o back
optic zone radius and total lens diameter or these lenses is also
usually limited; hence, given that the contact lens practitioner
has chosen to use a particular type o disposable so toric lens,
the main decision in tting and prescribing these lenses gener-
ally relates to the speci cation o BVP.
One o the advantages associated with the use o disposable
so toric lenses is that it is usually possible to undertake a lens-
wearing trial on a prospective patient using a disposable so
toric lens with the appropriate BVP. T is allows the practitioner
to ascertain more accurately whether the cylinder axis o the
so toric lens in situ will adopt the correct orientation or the
ocular correction. At the same time, the practitioner is also able
to determine whether the patient can wear the lens com ortably
without any adverse e ect on the eye.
Limit at io ns o f To ric So ft Le nse s
T ere will be a certain number o cases encountered in clinical
practice where so toric lenses are either less likely to be suc-
cess ul or do not represent the best option or the prospective
contact lens patient. In these situations, the practitioner should
take extra care when prescribing so toric lenses.
LO W SPHERICAL CO MPO NENTS
Patients who are tted with so toric lenses that contain a low
spherical component, or example +0.25 / −2.50 × 180, are o en
very critical o axis alignment because the astigmatism is the
most signi cant component o their re ractive error. In addi-
tion, with some o the older so toric lens designs, the thickness
di erentials (to aid lens location) that can usually be achieved
are reduced with small spherical components (Hanks and Weis-
barth, 1983).
O BLIQ UE CYLINDERS
As previously discussed (Holden, 1975; Gundel, 1989), so
toric lenses incorporating oblique cylinders, or example
−2.00 / −2.00 × 45, may show poorer stability due to complex lid
lens interactions.
LARGE CYLINDRICAL CO MPO NENTS
Lens rotation becomes more signi cant as the degree o cylinder
is increased. For example, a patient with a toric lens incorporat-
ing a 1.25 D cylinder may be able to tolerate a 5° rotation rom
the expected lens location, whereas a toric lens patient with a
3.50 D cylinder will probably notice a signi cant drop in vision
or the same degree o rotation o -axis.
IRREGULAR ASTIGMATISM
No orm o so toric lens is able to correct irregular astigma-
tism. Patients with astigmatic errors o this nature are usually
corrected with some orm o rigid contact lens.
PHYSIO LO GICAL CO NSIDERATIO NS
Improvements in toric lens design have led to an overall reduc-
tion in the thickness o most so toric lenses. T is decrease in
lens thickness has led to a reduction in the number o physi-
ological problems encountered with so toric hydrogel lenses.
Despite this, the overall thickness o a so toric lens can be sig-
ni cantly greater than that o a so spherical lens because o the
addition o a cylinder and the creation o thickness di erentials
throughout the toric lens orm. Consequently, oxygen transmis-
sibility will be reduced – especially i the lens has not been made
up in a silicone hydrogel material – and mechanical irritation
increased in the thicker regions o the lens, with the result that
compromises to ocular health are more likely to occur.
Conditions seen quite o en with so toric lens wear include
the ollowing:
• corneal oedema – especially in patients with hyperopic
astigmatism wearing hydrogel lenses
• corneal neovascularization – usually in erior and superior
and more likely in myopic patients wearing hydrogel lenses
• superior limbic keratoconjunctivitis – especially with large
lenses
• conjunctival indentation – especially with tight- tting
lenses.
I corneal hypoxia is a suspected cause o any ocular changes
seen with so toric lens wear, then a sensible strategy would be
to re t the patient with a so toric lens incorporating a silicone
hydrogel material so as to improve the oxygen transmissibility
o the lens.
Co nclusio n
A large variety o so toric lens designs are available today,
incorporating a number o di erent stabilization techniques. As
a result, the visual requirements o most astigmatic patients are
readily satis ed. T e act that these products are o en supplied
in requent replacement and disposable modalities means that
it is also possible to make so toric lens wear convenient and
tailored to the li estyle requirements o the patient.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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Lindsay, R. G., Bruce, A. S., Brennan, N. A., et al.
(1997). Determining axis misalignment and
power errors o toric so lenses. Int. Contact Lens
Clin., 24, 101–107.
Long, W. F. (1976). A matrix ormalism or decen-
tration problems. Am. J. Optom. Physiol. Opt., 53,
27–33.
Long, W. F. (1991). Lens power matrices and the
sum o equivalent spheres. Optom. Vis. Sci., 68,
821–822.
Morgan, P. B., Woods, C. A., ranoudis, I. G., et al.
(2016). International contact lens prescribing in
2015. CL Spectrum, 31(1), 28–33.
Myers, R. I., Jones, D. H., & Meinell, P. (1990). Using
over-re raction or problem solving in so toric
tting. Int. Contact Lens Clin., 17, 232–234.
Snyder, C. (1998). Overcoming toric so lens chal-
lenges. CL Spectrum, 13(Suppl.), 2–4.
Snyder, C., & Daum, K. D. (1989). Rotational posi-
tion o toric so contact lenses on the eye – clinical
judgements. Int. Contact Lens Clin., 16, 146–151.
Strachan, J. P. F. (1975). Correction o astigmatism
with hydrophilic lenses. Optician, 170(4402),
8–11.
an, J., Papas, E., Carnt, N., et al. (2007). Per or-
mance standards or toric so contact lenses. Op-
tom. Vis. Sci., 84, 422–428.
Young, G. (2003). oric contact lens designs in
hyper-oxygen materials. Eye Contact Lens, 29,
S171–S173. discussion S190–S191, S192–S194.
Young, G., Hunt, C., & Covey, M. (2002). Clinical
evaluation o actors inf uencing toric so contact
lens t. Optom. Vis. Sci., 79(1), 11–19.
Young, G., Sulley, A., & Hunt, C. (2011). Prevalence
o astigmatism in relation to so contact lens t-
ting. Eye Contact Lens, 37(1), 20–25.
102.e 1
10
So ft Le ns Care Syst e ms
PHILIP B MO RGAN
Int ro d uct io n
With the very notable exceptions o daily disposable lenses
and extended-wear lenses that are discarded a er each period
o continuous wear, all contact lenses must be subjected to
some orm o maintenance procedure a er each use. T e key
elements o lens maintenance are cleaning and disin ection.
Contact lenses must also be sa ely stored in solution until they
are next worn. T is chapter explores the rationale or under-
taking these tasks, and reviews current lens care maintenance
options.
THE RATIO NALE FO R DISINFECTING CO NTACT
LENSES
Contact lens practitioners are acutely aware that an eye wear-
ing a contact lens is more likely to become in ected than an eye
not wearing a contact lens. Brennan and Coles (1997) estimated
the risk o contact lens-associated in ection as being 60 times
greater in a contact lens wearer than in a non-lens wearer. T e
reasons or this increase in risk are multi actorial, and it is worth
considering these actors in the rst instance as they essentially
orm the rationale or contact lens disin ection.
T e eye has a number o inherent protective mechanisms to
resist in ection. T ese are generally success ul, as can be seen in
the light o work by Fleiszig and E ron (1992), who estimated
that potential pathogens are present in the tear lm o 5% o
a population at any time, yet the prevalence o ocular-sur ace
in ection alls ar short o this value. T e tear lm and the blink-
ing process play an important role in the resistance o in ection.
Basal tear production is o the order o 1–2 µl / min and the
overall tear volume is about 7 µl, which con rms the rapid turn-
over o tears at the ocular sur ace with the consequent removal
o microorganisms.
Bacteria in the tear lm must also breach the de ence pro-
vided by proteins in the tear lm such as lysozyme, lacto errin
and sur actant protein D. Furthermore, immunoglobulins such
as secretory IgA, IgG, IgE and IgM can act to resist in ection.
A microorganism that is able to de eat all the above systems
is still hampered in its quest to invade and in ect the cornea
because o the various de ences o the corneal epithelium. T ese
include: tight junctions, which prevent the migration o micro-
organisms between epithelial cells; sloughing o cells rom the
epithelial sur ace to remove in ected cells be ore any urther
harm is caused to the rest o the cornea; the active release o
antibacterial actors rom the corneal epithelium; and the ‘ lter-
like’ barrier provided by the basal lamina, which prevents bac-
teria reaching the underlying stroma (Fleiszig and Evans, 2010).
Contact lens wear adversely a ects a number o these de ence
mechanisms. Perhaps the most signi cant e ect is the preven-
tion o clearance o debris and microorganisms rom the ocular
sur ace by the blinking mechanism owing to the protection
o ered by the contact lens. It has also been postulated that the
level o bronectin is reduced during contact lens wear, thereby
increasing the likelihood o bacterial attachment to the epithe-
lium (Fleiszig et al., 1992).
A key reason or the increase in ocular in ections amongst
contact lens wearers is the bioburden o microorganisms intro-
duced to the ocular sur ace when lenses are applied. Indirect
evidence or this is provided by the work o Rad ord et al.
(1998), who analysed the risk actors associated with contact
lens-related in ections. T ey ound that the risk o in ection
was signi cantly increased in those wearers undertaking only
irregular disin ection with their contact lenses. T e association
o inappropriate use o the contact lens storage case (Seal et al.,
1999) and a lack o handwashing (Stapleton et al., 2007) with
an increased risk o contact-lens-related in ections also sup-
ports the notion that contact lens wear presents an increased
microbial challenge to the ocular-sur ace de ence systems. As
such, it seems clear that whilst contact lens wear renders the
eye at greater risk o in ection, there is good evidence that the
appropriate use o suitable contact lens disin ection systems will
reduce the magnitude o this increased risk.
THE RATIO NALE FO R CLEANING CO NTACT
LENSES
T ere are two key reasons why a contact lens should be cleaned
prior to disin ection. First, a wide variety o intrinsic and extrin-
sic debris can adhere to the sur ace o a contact lens. T is can lead
to lens distortion, discom ort, an unsightly cosmetic appearance
(as soiled lenses can show marked discoloration clearly visible
to an onlooker), ocular-sur ace and eyelid pathology and vision
loss (Gellatly et al., 1988). Lens cleaning can mitigate against
these problems. Cho et al. (2009) ound rinsing to be ine ective
in removing loosely bound deposits on lenses compared with
rubbing. Lens deposits are discussed in depth in Chapter 19.
Second, cleaning acts to enhance the disin ection process by
reducing the levels o microorganisms on the contact lens. Shih
et al. (1985) demonstrated this by contaminating contact lenses
with an organic load plus live cells o Pseudomonas aeruginosa
or Staphylococcus epidermidis. When lenses were rinsed or 10
seconds, contamination was reduced rom 1 million colony-
orming units (c u) per lens to less than 3000 c u per lens. When
the lenses were rubbed with the index nger in the palm o the
hand or 10 seconds with three drops o cleaner on each side
be ore the rinsing process, there was a reduction to less than 300
c u per lens (Fig. 10.1). T e importance o contact lens clean-
ing is supported by the epidemiological work o Rad ord et al.
(1995), who demonstrated that the risk o in ection was about
three times greater in patients who cleaned their lenses less than
twice per week compared with those who achieved at least this
103
104 PART 2 So ft Co nt act Le nse s
Fig . 10.1 E e ct o le ns rinsing and cle aning on b acte rial b iob urd e n.
(Ad ap te d rom Shih, K. L., Hu, J. & Sib le y, M. (1985). The microb iolog ical
b e ne t o cle aning and rinsing contact le nse s. Int. Contact Le ns Clin., 12,
235–242.)
requency o cleaning. Zhu and co-workers (2011) have dem-
onstrated that ‘rubbing and rinsing’ with a contact lens solu-
tion is more e ective in removing pathogenic microbes rom a
lens sur ace than rinsing alone or indeed when no treatment is
employed. Accordingly, it would seem prudent to recommend
that all contact lens care systems include a rub and rinse step as
part o the hygiene regimen.
THE EVO LUTIO N O F SO FT LENS CARE SYSTEMS
Historically, the care o a so contact lens was a complex and
time-consuming activity or the wearer. T e various steps o
the lens care process were divided into separate activities with
a di erent bottle or tablet or each. T is has changed over time
or two reasons: rst, the introduction o multipurpose prod-
ucts has meant that more than one component o the lens care
process could be undertaken with a single solution. Second, the
commercial success o disposable and planned-replacement so
lenses in the 1990s – with the associated emphasis on patient
convenience – acted as a power ul incentive or the lens care
industry to reduce the complexity o the lens care process as
much as possible. In some respects, such as a reduced require-
ment or regular enzymatic cleaning o so lenses, this was jus-
ti ed. In others, such as the omission o any orm o lens sur ace
cleaning, there appeared to be a related increase in the incidence
o microbial keratitis (Sarwar et al., 1993).
T e great majority o so contact lens wearers are prescribed
multipurpose products. A survey in 2015 o about 23 000 con-
tact lens ts in 34 countries demonstrated that 90% o so lens
wearers were prescribed a multipurpose product, with the
remaining care systems mainly peroxide based (Morgan et al.,
2016). Interestingly, evidence rom the United States market
points to a small upsurge in the use o peroxide care systems in
recent times (E ron et al., 2015).
Le ns Care Syst e ms
PHYSICAL METHO DS
T e various physical methods o so lens disin ection rely on
energy being imparted to microorganisms to cause lethal cell
changes. Heating was the rst so lens disin ection method
approved by the US Food and Drug Administration (FDA) in
1972. Disin ection using this approach requires a temperature o
80°C to be maintained or at least 10 minutes. A representative
Fig . 10.2 The Bausch & Lomb le ns he at unit. (Co urte sy o Bausch &
Lomb .)
example o one o the heating units available at this time was
the Bausch & Lomb system (Fig. 10.2), which reached 96°C or
a period o about 20 minutes (Mote et al., 1972). In terms o
lens disin ection, the heating systems were recognized as being
highly e ective (Busschaert et al., 1978), even against the pro-
tozoan Acanthamoeba (Ludwig et al., 1986). Furthermore, a er
the initial purchase o the heat unit, the ongoing costs o opera-
tion were minimal.
However, there were a number o disadvantages associated
with heat disin ection. In normal circumstances, the protein
that spoils the sur ace o a so contact lens does not denature
or does so slowly; however, heating the lens will immediately
denature protein with adverse clinical consequences such as
reduced acuity, the potential or ocular sur ace reactions such as
giant papillary conjunctivitis and altered physical lens parame-
ters. With the popularity o low-water-content, non-ionic lenses
in the early and mid 1970s, this was not as signi cant a problem
as with the use o these systems with more modern, high-water-
content and ionic materials that absorb much greater quantities
o proteins (Maissa et al., 1998). Fig. 10.3 demonstrates how a
standard single heat disin ection cycle – per ormed on an ionic,
high-water-content lens that had been worn or 8 hours – causes
the lens to turn yellow and become de ormed.
T e heating process was also inconvenient or many wearers.
Not only did this method require a nearby source o electric-
ity, but also the system used unpreserved saline, which did not
o er any antimicrobial activity. T e opportunity or microbial
contamination arose i the lenses remained in the cooled saline
or a prolonged period, so this disin ection system required the
process to be repeated each day with resh solution i the lenses
were not used.
With the advent o planned-replacement lenses, which were
generally o high water content and o en manu actured rom
ionic materials more prone to parameter changes, the popular-
ity o heat disin ection waned, and this technique is rarely used
today.

Fig . 10.3 Pro le vie w o an ionic, hig h-wate r-conte nt contact le ns. (A)
Following 1 we e k o e xte nd e d we ar. (B) Same le ns as shown in (A) a te r
o ne cycle o he at d isin e ction, which has re sulte d in d iscolouration and
d istortion.
Microwave irradiation has been proposed as a potentially
cheap and e ective method o so lens disin ection. Harris et al.
(1993a) demonstrated that, although there are some parameter
changes when lenses are repeatedly irradiated with a standard
650 W microwave oven, none o these changes are clinically sig-
ni cant. However, as patients o en need to care or their lenses
in locations remote rom a microwave oven, this approach is
o en impractical or inconvenient.
Studies on the e cacy o ultraviolet radiation or contact
lens disin ection have provided equivocal results. Using radia-
tion at 253.7 nm at an energy o 44.3 µW / cm 2, Kilvington and
Scanlon (1991) ound that pathogenic Acanthamoeba cysts and
trophozoites survived irradiation o 22 minutes duration. Simi-
larly, Palmer et al. (1991), using an identical system, concluded
that, although the numbers o microorganisms were reduced by
ultraviolet irradiation, the level o survivors was unacceptably
high. On the other hand, Harris et al. (1993b) demonstrated
that disin ection could be achieved at the same wavelength
or a panel o bacteria using an ultraviolet lamp with a higher
energy output o 950 µW / cm 2. Harris et al. (1993c) concluded
that any parameter changes with this method were not clinically
important.
T e use o ultrasound systems or lens disin ection has also
been proposed. Although such devices can be shown to have a
limited disin ection e ect (E ron et al., 1991a), the e cacy o
ultrasound energy is limited by the physical similarity between
lens material and solution, meaning that the relatively large
amount o energy required to clean the lens success ully would
probably damage its sur ace (Fatt, 1991).
CHLO RHEXIDINE- AND THIO MERSAL-
PRESERVED SYSTEMS
A er the problems associated with heat systems became known,
alternative disin ection systems were required that allowed or
10 So ft Le ns Care Syst e ms 105
the simple storage o contact lenses without a ecting the lens
or causing irritation to the eye. Suitable early candidates were
products that contained chlorhexidine gluconate or thiomersal.
Chlorhexidine is probably the most widely used biocide in
antiseptics, especially or handwashing and oral products. Its
action has been closely studied, and it is believed that its uptake
by both bacteria and yeast is extremely rapid. Chlorhexidine
damages cell walls and subsequently attacks the bacterial cyto-
plasmic or inner membrane, or the yeast plasma membrane
(McDonnell and Russell, 1999).
T iomersal is considered to be a less e ective antimicrobial
agent overall, although its action against ungi is better than that
o chlorhexidine. Due to this, a combination o chlorhexidine
gluconate and thiomersal became common in disin ectants or
so contact lenses. However, due to the absorption o these
agents onto so lenses, toxic and hypersensitivity reactions
were reported when they were used clinically (Wilson et al.,
1981). T e build-up o these preservatives, and the subsequent
leaching onto the ocular sur ace over time, had the potential
to cause discom ort and discontinuation o lens wear (Hind,
1975). T ese products were ultimately superseded by others that
o ered a similar level o convenience and antimicrobial e cacy,
and a lower adverse reaction rate.
Anthony et al. (1991) described a novel approach or a
chlorhexidine system, known as OptimEyes (Bausch & Lomb).
T ey developed a tablet that, when dissolved in tap water, pro-
vided a solution with a chlorhexidine concentration o 0.004%.
T e solution was shown to be e ective against a panel o chal-
lenge microorganisms and also against most o the microorgan-
isms ound in tap water. T is was a controversial development
because this product was speci cally designed or use with tap
water and practitioners were concerned that contact lens wear-
ers would consider standard tap water as an acceptable compo-
nent o lens care generally. T e product was simple and cheap to
use, and it provided action against Acanthamoeba. Its disadvan-
tages included the reliance on a supply o rising mains tap water
and, importantly, it was contraindicated or use with FDA group
IV lenses because the action o chlorhexidine is reduced with
ionic lenses. With the increasing popularity o group IV lenses
throughout the 1990s, the OptimEyes product did not become a
mainstream so lens care product.
CHLO RINE
Chlorine-releasing agents are long established as disin ec-
tion systems or swimming pools, baby eeding equipment
and medical instrumentation. In the 1980s, chlorine-releasing
systems were developed or the disin ection o contact lenses.
T ese were seen as being highly convenient owing to their
ease o use, portability and low adverse reaction rate. In mar-
kets that did not have access to multipurpose solutions (MPS)
when planned-replacement lenses were introduced at the end o
the 1980s, these systems became very popular. Pearson (1992)
reported that 26% o so lens wearers in the UK used chlorine
systems in 1991. No chlorine-releasing products are available
today in the UK.
wo chlorine-releasing systems achieved market success.
Alcon introduced the So ab product in the early 1980s (Fig.
10.4). T is was a tablet o sodium dichloroisocyanurate that was
dissolved in saline to orm 3 parts per million (ppm) o chlo-
rine. In the mid 1980s Sauf on developed the Aerotab product,
which released 8 ppm chlorine. Laboratory studies suggested
106 PART 2 So ft Co nt act Le nse s
Fig . 10.4 The So tab chlorine syste m. (Courte sy o Alcon.)
that these solutions were e ective at destroying a range o
microorganisms, including bacteria and ungi (Rosenthal et al.,
1992). T e killing action was thought to be due to the direct
e ect o the chlorine on some vital constituent o the cell o the
microorganism, such as its protoplasm or enzyme system (Cop-
ley, 1989). However, these products became associated with an
increase in contact-lens-related microbial keratitis (Rad ord
et al., 1995, 1998). For example, the optimal use o a chlorine
system was associated with about a 15- old increase in the likeli-
hood o Acanthamoeba keratitis compared with hydrogen per-
oxide or other solutions.
T e association o ocular in ections with chlorine solutions,
despite satis actory laboratory per ormance, suggests that there
were problems with the e cacy o these systems with normal
day-to-day usage. One issue was that the overnight dissipation
o chlorine resulted in a loss o disin ecting power, so prolonged
storage was not appropriate with these products. T ere was
also evidence that the antimicrobial per ormance was severely
reduced when lenses were soiled (Copley, 1989); this actor
would not have been addressed when antimicrobial e cacy
was determined by the licensing authorities. Overall, there was
little margin or error when using these products; or example,
E ron et al. (1991b) and Sarwar et al. (1993) reported a number
o cases o corneal in ection in patients who had ailed to use
sur actant cleaning solutions prior to chlorine disin ection. T e
negative publicity generated by such cases o microbial keratitis,
and the widespread availability o MPS, which were also very
easy to use, led to a great reduction in the use o chlorine-releas-
ing systems throughout the 1990s.
HYDRO GEN PERO XIDE
Hydrogen peroxide has been used as an antimicrobial agent or
about 200 years. It is widely used medically or disin ection and
sterilization and is generally available in concentrations rom
3% to 90%, depending on its purpose. Hydrogen peroxide has
a broad-spectrum e cacy against bacteria, viruses and yeast
by producing hydroxyl- ree radicals that attach to essential cell
components such as lipid and proteins (McDonnell and Russell,
1999), and is o en considered to be the ‘gold standard’ in terms
o so contact lens disin ection. For example, 3% hydrogen per-
oxide will kill trophozoites and cysts o Acanthamoeba castel-
lanii in 3 minutes and 9 hours o soaking, respectively (Zanetti
et al., 1995). It can be chemically broken down into oxygen
and water, and is there ore considered to be environmentally
riendly. Hydrogen peroxide tends to decompose on standing,
and it there ore needs to be stabilized, typically with phosphates
or phosphorates. T e use o stannate as a stabilizer has been
associated with hazing o ionic lenses owing to an interaction
between the stannate ions, methacrylic acid groups in the lens
material and tear-derived lysozyme (Sack et al., 1989).
Although hydrogen peroxide has a high e cacy in terms
o its antimicrobial action, it is toxic to the eye, and requires
neutralization be ore a lens that has been placed in hydrogen
peroxide can be worn com ortably. Paugh et al. (1988) dem-
onstrated that conjunctival hyperaemia was induced by levels
o hydrogen peroxide greater than 200 ppm and that concen-
trations in excess o 100 ppm were associated with subjective
stinging. Interestingly, these authors could not demonstrate any
corneal or conjunctival staining with the highest concentration
o hydrogen peroxide studied in their study (800 ppm). Changes
in epithelial cell activity have been noted in the presence o con-
centrations as low as 30 ppm ( ripathi and ripathi, 1989).
Storage in hydrogen peroxide has been reported to alter lens
parameters. Bruce (1989) noted a temporary reduction in lens
hydration a er prolonged lens storage in hydrogen peroxide.
High-water ionic lenses (FDA group IV) appear to be most
susceptible to changes in diameter and base curve (McKenney,
1990), although the clinical consequences o these changes are
generally not signi cant because o their temporary nature; or
example, a soaking period o 20 minutes in neutralizer returns
lens parameters to their original speci cation within 1 hour o
lens wear (Jones et al., 1993).
T e approaches to neutralization have varied since the intro-
duction o hydrogen peroxide as a contact lens disin ectant.
T e initial approach was to allow or the storage o the lenses in
hydrogen peroxide with neutralization undertaken as a secondary
process be ore lens application. T ese two-step systems were con-
sidered to provide good antimicrobial action, especially when the
lens was exposed to 3% hydrogen peroxide overnight; however, the
complexity o using these systems has led to a cessation o their use
in many markets and they are now generally not available.
T e most popular approaches or the second stage o the two-
step hydrogen peroxide systems were to add a solution o either
catalase or sodium pyruvate to the lens storage case a er the
hydrogen peroxide had been discarded to neutralize any remain-
ing peroxide (Gyulai et al., 1987; Christie and Meyler, 1997).
T e more recently popular one-step hydrogen peroxide
systems negate the requirement or a separate neutralization
process by the contact lens user. A er the lens storage case is
closed, the disin ection and neutralization steps take place
without urther intervention. wo approaches are common. In
the rst, such as in the Oxysept 1-step system (Abbott Medical
Optics), the lens case is lled with hydrogen peroxide, and a
coated tablet containing catalase is added. As the coating o the
tablet dissolves, catalase is released into the solution, leading to
neutralization o the hydrogen peroxide within about 2 hours
(Christie and Meyler, 1997). A number o products use a second
method o neutralization: a platinum disc. In this approach, the
disc is either attached as an integral part o the lens holder or is
permanently lodged in the base o the storage case (Fig. 10.5).
T ere is a rapid neutralization over the rst 2 minutes – rom
the original 30 000 ppm, or 3% concentration, to about 9000
ppm – ollowed by a slower phase to 50 ppm a er 3 hours (Gyu-
lai et al., 1987), and 15 ppm a er 6 hours (Christie and Meyler,
1997) (Fig. 10.6).

Fig . 10.5 Pe roxid e solutions includ ing o ne ne utralize d with a tab le t
(le t) and othe rs ne utralize d with a p latinum-co ate d d isc (Courte sy o
Ab b ott Me d ical O p tics, Alcon and Sauf on Pharmace uticals).
Fig . 10.6 Hyd rog e n p e roxid e is ne utralize d more rap id ly with p lati-
num d isc syste ms than with tab le t syste ms. (Ad ap te d rom Christie , C. L.
& Me yle r, J. G. (1997) Conte mp orary contact le ns care p rod ucts. Cont.
Le ns Ante rior Eye , 20, S11–17.)
T e trade-o or the increased convenience o a one-step sys-
tem is two old. First, as the lenses are held in neutralized solution
only within a ew hours o entering the case, long-term storage is
not advisable as the residual solution has no antimicrobial prop-
erties. Second, the reduced time in relatively high-concentration
hydrogen peroxide compared with the two-step systems a ords
a reduced antimicrobial power to the system. Furthermore, the
speed o hydrogen peroxide neutralization di ers between the tab-
let systems and the platinum disc systems (see Fig. 10.6). Although
activity against bacteria is likely to be adequate with these systems
(Stokes and Morton, 1987), the storage period is unlikely to be
su cient or e cacy against Acanthamoeba cysts (Zanetti et al.,
1995). However, antimicrobial e cacy can be enhanced by appro-
priate lens cleaning and rinsing (Cancrini et al., 1998). It is note-
worthy that the use o one-step hydrogen peroxide systems has
not been associated with an increased risk o Acanthamoeba kera-
titis in case–control studies (Rad ord et al., 1995).
LENS CLEANING
One-step hydrogen peroxide systems are used with either a sepa-
rate cleaning solution or an integrated sur actant cleaner, which
rids the lens sur ace o mucus, proteins and lipids rom the tear
lm and o other debris, such as pollutants and cosmetics, rom
10 So ft Le ns Care Syst e ms 107
Fig . 10.7 Sche matic re p re se ntation o the actio n o a sur actant cle an-
e r on a so t le ns.
the environment. Lens cleaning o this type has numerous clini-
cal bene ts, and wearers should be advised to clean their lenses
a er each use.
Such sur actant agents solubilize debris rom the lens sur-
ace. Furthermore, because the sur actant molecules have
a hydrophilic end and a hydrophobic end, a monolayer is
ormed around lipid droplets created a er physical dispersion
o any lipid spoilation, creating a micelle. With the hydropho-
bic end o the sur actant molecule ‘buried’ in the lipid drop-
let, and the hydrophobic end exposed, recoalescence o the
lipid due to repulsion o the electrical charges is prevented.
As the hydrophilic region is water soluble, the lipid spoila-
tion can be emulsi ed (Fig. 10.7). Sur actants also act to wet
hydrophobic sur aces. T is is an important consideration or
silicone hydrogel lenses as they are typically less wettable than
conventional hydrogels. For contact lens care, non-ionic sur-
actants rom either the poloxamer or poloxamine amily are
employed. Few separate (‘stand-alone’) sur actants are cur-
rently available owing to the popularity o multipurpose con-
tact lens solutions.
Historically, lenses were o en subjected to enzymatic clean-
ing, which required the use o tablets or solutions that attempted
to remove protein rom so lenses. With the domination o daily
disposable and requent-replacement lenses worldwide, the use
o such products is very limited.
MULTIPURPO SE SO LUTIO NS
MPS account or around 90% o prescribed care regimens in
Europe, Canada and Australia (Morgan et al., 2016). By de -
nition, these products ( able 10.1) do not require the use o
other auxiliary components in the lens care process. T e rst
such products were made available or use with contact lenses
in the 1980s and their popularity has increased steadily since
that time.
Polyhe xanid e -b ase d MPS
Most MPS contain polyhexanide (polyhexamethylene bigua-
nide, PHMB), which was originally developed as a presurgery
antimicrobial scrub and then marketed or the sanitization o
swimming pools and spas. Polyhexanide is part o the same
pharmaceutical amily as chlorhexidine, and is active against a
wide range o bacteria. T e action o polyhexanide is thought
to be due to its rapid attraction towards the negatively charged
phospholipids at the bacterial cell sur ace, ollowed by impair-
ment o membrane activity with the loss o potassium ions
108 PART 2 So ft Co nt act Le nse s

TABLE
10.1 Co nst it ue nt s o f So ft Le ns Mult ip urp o se So lut io ns (MPS)
Co mp any Pro d uct Pre se rvat ive (p p m) Surfact ant Cle ane r Buffe r O t he r Co mp o ne nt s
Ab atron Q uattro Polyhe xanid e (1) Lub ricare Phosp hate EDTA
Ad vance d Re g ard Sod ium chlorite Pluronic Hyd roxyp rop yl me thylce llulose
Eye care Hyd rog e n p e roxid e (100) (we tting ag e nt)
Re se arch
Ab b ott Me d ical Comp le te Ale xid ine (1.6) Te tronic 904 Borate EDTA
O p tics Re vitale ns Polyq uad (3)
Alcon O p ti-Fre e Polyq uad (10) Poloxamine Citrate EDTA
Exp re ss MAPD (5)
Alcon O p ti-Fre e Polyq uad (11) Te tronic 1304 Borate , citrate Prop yle ne g lycol
Re p le nish MAPD (5)
Alcon O p ti-Fre e Polyq uad (10) Te tronic 1304 Borate , citrate Sorb itol
Pure Moist MAPD (6) Hyd raGlyd e Aminome thylp rop anolol
EDTA
Bausch & Lomb Re Nu Polyhe xanid e (0.5) Poloxamine Borate EDTA
Bausch & Lomb Re Nu Polyhe xanid e (1) Poloxamine Borate Hyd ranate
MultiPlus EDTA
Bausch & Lomb Biotrue Polyhe xanid e (1.3) Poloxamine Borate Hyaluronate
Polyq uad (1) Sul ob e taine
EDTA
Sauf on All-in-O ne Lig ht Polyhe xanid e (1) Poloxamine Borate EDTA
Sauf on Syne rg i O xip ol Poloxame r Phosp hate Hyd roxyp rop yl me thylce llulose
(we tting ag e nt)

EDTA = e thyle ne d iamine te traace tic acid ; MAPD = myristamid op rop yl d ime thylamine .

Fig . 10.8 Some active ag e nts are smalle r than a typ ical so t le ns p ore Fig . 10.9 So t le ns solutions with p olyhe xanid e as the sole d isin e c-
size whe re as othe rs are larg e r. tant. (Co urte sy o Bausch & Lomb and Sauf on Pharmace uticals.)

and the precipitation o intracellular constituents. Poly-
hexanide has a larger molecular weight than chlorhexidine,
which means that it is not able to enter the matrix o so lens
materials. In turn, this reduces the likelihood o the preserva-
tive reaching the ocular sur ace, with the potential or toxic
or hypersensitivity reactions (Fig. 10.8). MPS contain poly-
hexanide at a range o concentrations rom 0.5 to 1.0 ppm
(Fig. 10.9).
Solutions using polyhexanide as their sole disin ecting agent
may also contain other key components. For example, Renu
Multiplus (Bausch & Lomb) contains hydranate as a seques-
tering agent to reduce protein deposition. T is chemical orms
complexes with calcium, which can act as a bridge between the
lens sur ace and proteins. Cyclean (Sauf on Pharmaceuticals)
contains a viscosity agent and uses a novel design o lens case
that allows the lens baskets to be rotated within the case to pro-
vide a cleaning action.
Polyq uate rnium-1-b ase d MPS
Some MPS have polyquaternium-1 or polyquad as the preserva-
tive. T is compound is derived rom the same pharmaceutical
amily as polyhexanide – the polyquats. It is a large molecule,
and has a long history o use in the cosmetics industry.
T e most widely used polyquad products are the Opti-Free
amily, which contains polyquad and another antimicrobial
agent, myristamidopropyl dimethylamine (MAPD). T is con-
tains a citrate bu er instead o the phosphate or borate bu ers
that are generally ound in polyhexanide-based MPS. T is nega-
tively charged bu er is included in the polyquad products to
reduce the adherence o polyquad to the sur ace o some ionic
lens materials; this same property can reduce the protein depo-
sition on so lenses because positively charged proteins, such
as lysozyme, can bind with the citrate rather than with the lens
sur ace (Hong et al., 1994). However, citrate is not e ective
against lipid spoilation (Franklin et al., 1995). T e antimicrobial
per ormance o this product is claimed to be similar to disin-
ection with a one-step hydrogen peroxide system (Rosenthal
et al., 1999).
A sur actant is typically included in MPS (both polyhexanide
and polyquad based) so that they can o er a cleaning action
in addition to their disin ection properties. T ese solutions also
contain ethylenediamine tetraacetic acid (ED A), or one o

Fig . 10.10 Sche matic action o a che lating ag e nt.
Fig . 10.11 So t le ns solutions with two d isin e ctants. (Courte sy o
Ab b ott Me d ical O p tics, Alcon and Bausch & Lomb .)
its salts, as a chelating agent. A chelating agent is a substance
comprised o molecules that can orm several coordinate bonds
to a single metal ion (Fig. 10.10). In the case o contact lens
care, ED A removes ions such as calcium, resulting in a lens-
cleaning e ect (protein can bind to calcium on the lens sur-
ace, and there ore increase deposition) and an antimicrobial
e ect (calcium ions are required or cell wall metabolism by
microorganisms).
‘Dual Disinfe ction’ MPS
Whilst historically MPS have included a single active disin ec-
tant agent, more recently launched products have tended to ea-
ture two such agents and this has led to the coining o the term
‘dual disin ection’. With any single antimicrobial agent demon-
strating a particular range o per ormance across various micro-
organisms, the presence o two disin ectants o ers the potential
or synergistic action and enhanced per ormance. Good exam-
ples here include Complete Revitalens (Abbott Medical Optics),
which includes both polyquad and alexidine; Opti-Free Pure-
Moist (Alcon), with polyquad and MAPD, and Biotrue (Bausch
& Lomb), which incorporates polyhexanide and polyquad) (Fig.
10. 11).
MULTIPURPO SE SO LUTIO NS AND SILICO NE
HYDRO GEL LENSES
T e MPS products discussed above were all developed and
launched when conventional hydrogels dominated the daily-
wear contact lens market. Since the launch o the rst silicone
hydrogels speci cally marketed or daily wear in 2004, there has
10 So ft Le ns Care Syst e ms 109
Fig . 10.12 So t le ns solutions containing sod ium chlo rite . (Courte sy o
Ad vance d Vision Re se arch and Sauf on Pharmace uticals.)
been a dramatic increase in their use or this modality – rom
3% o so contact lenses prescribed or monthly replacement
daily-wear lenses in the UK in 2004 to about 90% in 2014. Over
a similar time period, there was a strong move towards recom-
mending to contact lens wearers that lens rubbing or rinsing is
no longer required, such that a majority o wearers do neither
step (Morgan et al., 2011).
A silicone hydrogel material presents di erent challenges
compared with conventional hydrogels or lens cleaning. T e
non-ionic nature o silicone hydrogels means that the lenses
attract increased amounts o lipid and reduced quantities o
protein compared with conventional hydrogels (the majority o
which are ionic in nature) (Jones et al., 2003). Additionally, there
have been reports o asymptomatic corneal staining when some
MPS have been used with daily-wear silicone hydrogels (Jones
et al., 2002), although the clinical signi cance o such staining
is not clear. However, all the main MPS products on the market
are approved or us with silicone hydrogel lenses. wo MPS with
di erent chemistries that some practitioners pre er or silicone
hydrogel lenses are Regard (Advanced Vision Research) and
Synergi (Sauf on Pharmaceuticals). Regard contains sodium
chlorite and low-concentration hydrogen peroxide (100 ppm)
or disin ection, a wetting agent and a sur actant cleaner. When
exposed to light, sodium chlorite breaks down to sodium chlo-
ride and oxygen, thereby making this product autoneutralizing.
Synergi is based around the oxochlorite complex, which is used
in other industries or disin ection. T is complex has appro-
priate disin ection properties or use with contact lenses and
breaks down in light into sodium chloride and oxygen. Synergi
also contains a sur actant cleaner and hydroxypropyl methylcel-
lulose as a wetting agent (Fig. 10.12).
Re w e t t ing So lut io ns
Contact lens wearers may complain o numerous symptoms,
including dryness and general discom ort; such symptoms are
the primary reasons or the discontinuation o contact lens wear
(Dumbleton et al., 2013). A common method o clinical man-
agement o ocular discom ort is the prescription o so lens
rewetting solutions, which are also known by the synonyms o
‘lubricants’ and ‘com ort drops’ (Fig. 10.13). E ron et al. (1991c)
ound that, although these products were o en well received
by wearers and com ort was improved or at least 6 hours a er
their instillation, there was little evidence that their e ect was
110 PART 2 So ft Co nt act Le nse s
Fig . 10.13 Contact le ns re we tting solutions (Courte sy o Ab b ott
Me d ical O p tics, Ad vance d Eye care Re se arch and Bausch & Lomb ).
Fig . 10.14 Dryne ss symp toms imp rove with b oth saline and p re -
scrib e d re we tting solutions. (Ad ap te d rom E ron, N., Go ld ing , T. R. &
Bre nnan, N. A. (1991c) The e e ct o so t le ns lub ricants on symp toms
and le ns d e hyd ration. CLAO . J., 17, 114–119.)
greater than that o saline (Fig. 10.14). Furthermore, the mecha-
nism o symptomatic relie is not clear; Golding et al. (1990)
demonstrated that this was not due to an enhancement o the
pre-lens tear lm.
A number o products contain viscosity-increasing agents
such as methylcellulose that increase the adherence o the solu-
tion to the lens and enhance the contact time o the solution at the
ocular sur ace. Other components commonly ound in rewetting
solutions include sodium chloride and bu ering agents.
Saline So lut io ns
Some contact lens wearers are prescribed a saline rinsing solu-
tion when they rst commence contact lens wear. T ese prod-
ucts are particularly help ul to new wearers, who tend to handle
lenses more requently, and require more attempts at lens appli-
cation, leading to increased contamination rom the ngers.
Some hydrogen peroxide users remove any residual hydrogen
peroxide with a rinsing product to reduce any stinging on appli-
cation. T e rinsing process can also play a signi cant role in
the removal o microorganisms rom the lens sur ace (Cancrini
et al., 1998).
Homemade and unpreserved saline have been associ-
ated with serious ocular-sur ace in ections and is not rec-
ommended (Sweeney et al., 1992). Previously, contact lens
solution manu acturers provided saline primarily in aerosol
canisters with the pressure within the canisters preventing
contamination, although it was recommended that the user
ejects a small amount o saline be ore use as contamination
o the spray tip has been associated with corneal in ections
(Donzis, 1997). However, this was an expensive approach to
supplying saline and preserved saline solutions have gained
popularity in their ‘squeezy’ bottle ormat. With these prod-
ucts, the active ingredient serves only to prevent contamina-
tion o the solution, rather than play any active role in contact
lens disin ection. One example o these products is Bausch &
Lomb saline, which is preserved with a low concentration o
polyhexanide (0.3 ppm).
Re lat ive Pe rfo rmance Me asure s
An important consideration or the contact lens practitioner
when dispensing a care product is its per ormance in terms
o cleaning and, perhaps more importantly in terms o wearer
sa ety, disin ection e cacy.
T e rst sa eguard or the practitioner is that, in many parts
o the world, contact lens disin ectants are required to meet
a number o criteria be ore they can be labelled and sold as
such. For example, in the European Union, all such products
are required to display the CE mark, which indicates that the
product has displayed a minimum level o disin ecting per or-
mance and that a number o other criteria (such as satis ac-
tory manu acturing conditions) have been met. T e CE mark
requires a contact lens disin ectant to meet the per ormance
requirements o the international standard ISO 14729:3 (Micro-
biological Requirements for Products and Regimens for Hygienic
Management of Contact Lenses; ISO, 2012). o achieve this, the
product must show activity against three bacteria (Pseudomo-
nas aeruginosa, Staphylococcus aureus and Serratia marcescens)
and two orms o yeast (Candida albicans and Fusarium solani)
(Fig. 10.15).
Products are rst tested on a stand-alone basis. Here, the dis-
in ectant must be able to reduce the population o each o the
bacteria by 99.9% (or a three-log reduction) and the yeast by
90% (a one-log reduction). T is testing is per ormed in labora-
tory conditions without the use o contact lenses; that is, there
is a mixing o the test organisms with a xed quantity o the
solution under test.
I the product ails to meet the stand-alone criteria, the regi-
men procedure can be invoked whereby the per ormance o the
product in a more ‘real-world’ situation is analysed. However, to
proceed to this stage, solutions must at least have demonstrated
that they are able to achieve stasis or yeast in the stand-alone
test, and an overall combined ve-log reduction or the three
bacteria, with at least one-log reduction or each o the bacteria.
In the regimen procedure, contact lenses are inoculated with
the panel o test organisms, and then treated according to the
instructions provided by the manu acturer or cleaning, rinsing
and soaking. o satis y the criteria, there must be at least a our-
log reduction or all the test organisms.
In order to reach the marketplace, there ore, contact lens
solutions are required to achieve a set standard o per ormance.
However, o urther interest is the relative per ormance o the
various products that are available. Although this might seem to
require simply generating comparative data or a range o care
products, this area is raught with problems. For example, an
approach that has been used in the past to demonstrate the dis-
in ection capabilities o disin ectant systems is the D-value. T is
parameter denotes the time taken or a disin ectant product to
reduce the population o an organism to 10% o its original level
(a one-log reduction).

Fig . 10.15 Flow chart ind icating the p ath b y which d isin e ctant p rod ucts are te ste d or ISO 14729:3.
Although this appears to be a use ul indication o solution
per ormance, there are a number o problems with its use. T e
D-value assumes a linear relationship between the logarithm o
the number o survivors and time. However, the action o contact
lens disin ectants tends to be non-linear, which suggests that the
use o D-values is inappropriate and can lead to misleading repre-
sentations o product per ormance (Sutton et al., 1991).
Another drawback to the D-value approach is that no
account is made o the minimum recommended disin ection
time (MRD ) recommended by the manu acturer. For example,
a product may o er a one-log reduction in 20 minutes, and a
three-log reduction in 1 hour; the clinical success o this prod-
uct, however, must depend to some extent on the MRD , which
could be 10 minutes or 6 hours. Lowe et al. (1992) proposed a
new measure o solution potency – solution power – to over-
come this problem. T is parameter was de ned as the MRD
divided by the D-value.
A di culty with this sort o approach is that no account is
made o any cleaning or rinsing (as distinct rom disin ecting)
that may be employed as part o the overall care system. Some
wearers may tend to omit these steps with some systems and not
with others; this must have an impact on the overall disin ecting
capabilities o the regimen.
Another signi cant problem when assessing di erences
between products is that di erent laboratory conditions and
techniques can be employed. A relevant example here is the e -
cacy o disin ectants against Acanthamoeba. A number o vari-
ables exist when analysing the per ormance o products against
Acanthamoeba, including the strain o Acanthamoeba used,
growth conditions and contact time o the disin ectant. Indeed
the results in this area are highly dependent on methodology,
which has led, in part, to the e cacy o contact lens disin ec-
tants against Acanthamoeba being omitted rom ISO 14729:3.
10 So ft Le ns Care Syst e ms 111
Despite this, the e ectiveness o contact lens disin ectants
against Acanthamoeba is o considerable interest to contact
lens practitioners. On a stand-alone basis, hydrogen peroxide
is e ective at destroying both Acanthamoeba trophozoites and
cysts, with overnight storage in 3% hydrogen peroxide providing
better per ormance in this regard than the shorter contact time
with a one-step system (Zanetti et al., 1995). MPS have poorer
antiacanthamoebal e cacy (Davies et al., 1990), although the
combination o MAPD and polyquad may improve this (Rosen-
thal et al., 2000). In a clinical setting, cleaning and rinsing are
likely to remove some Acanthamoeba (Cancrini et al., 1998).
Furthermore, Acanthamoeba is thought to require the presence
o bacteria to survive and grow, so antibacterial e cacy o a
contact lens disin ectant will have an e ect on acanthamoebal
contamination.
The Le ns St o rag e Case
An important component o the complete lens care system
is the case in which the lenses and disin ecting solutions are
stored. Surveys have reported that up to 77% o lens cases
are contaminated with bacteria and 8% with Acanthamoeba
(Gray et al., 1995). Contamination appears to be unrelated
to solution type, and it is now clear that the development
o microbial bio ilms in contact lens cases can reduce the
e ect o a disin ecting solution (Fig. 10.16). Indeed, it has
been speculated that long-term use o a solution might select
a naturally resistant population o microbes that adapt to
survive exposure to a disin ectant (Gray et al., 1995). Inter-
estingly, some bacteria release catalase when their cell mem-
branes are disrupted; this release could potentially act to
neutralize local hydrogen peroxide and protect other bacte-
ria within the bio ilm.
112 PART 2 So ft Co nt act Le nse s
Fig . 10.16 The corre ct use o p re scrib e d care syste ms is ve ry imp or-
tant or e cie nt cle aning and d isin e cting .
T e care ul cleaning o lens cases is important or contact
lens wearers. Wu and co-workers (2010a) ound that digital
rubbing o a lens case with rising with a MPS was e ective at
removing microbial contamination. T erea er, the lens case
should be allowed to air-dry and be stored ace down between
uses (Wu et al., 2010b). Many manu acturers urther assist prac-
titioners and patients by supplying a new contact lens case with
each bottle o disin ecting solution.
Co nclusio n
With the growing popularity o daily disposable and
extended-wear lenses, there has been a commensurate reduc-
tion in the use o contact lens solutions. Nevertheless, the
majority o lenses prescribed still require lens care systems,
and various options are available to satis y the needs o
patients. In the current climate o strict regulatory control in
most markets, practitioners and patients can use these prod-
ucts with con idence. An important caveat is that patients
use these lens care systems – as simple as they may appear
– in precise accordance with the instructions supplied by the
manu acturer. As discussed in Chapter 43, the prevalence o
non-compliance with contact lens care systems is uncom-
ortably high, and practitioners are obliged to encourage
patients constantly to use these systems as directed, in order
to maximize their e icacy.
ACKNO WLEDGEMENT
T e author acknowledges the assistance o Kayleigh Walda or photog-
raphy in Figures 10.5, 10.9, 10.11, 10.12 and 10.13.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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Rosenthal, R. A., McAnally, B. S., McNamee, L. S.,
et al. (2000). Broad spectrum antimicrobial activ-
ity o a new multipurpose disin ecting solution.
CLAO J., 26, 120–126.
Sack, R. A., Harvey, H., & Nunnes, I. (1989). Disin-
ection associated spoilage o high water content
ionic matrix hydrogels. CLAO J., 15, 138–145.
Sarwar, N., Gri th, G. A. P., Loudon, K., et al.
(1993). Acanthamoeba keratitis associated with
disposable hydrogel contact lenses disin ected
daily with a chlorine-based care system. J. Br. Con-
tact Lens Assoc., 16, 15–18.
Seal, D. V., Kirkness, C. M., Bennett, H. G. B., et al.
(1999). Acanthamoeba keratitis in Scotland: risk
actors or contact lens wearers. Contact Lens An-
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Shih, K. L., Hu, J., & Sibley, M. (1985). T e micro-
biological bene t o cleaning and rinsing contact
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112.e 1
112.e 2 Re fe re nce s
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Delayed hypersensitivity to thimerosal in
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 PART

3
Rig id Co nt act Le nse s

PART O UTLINE
11 Rig id Le ns Mate rials 115
Nathan E ron
12 Rig id Le ns Manufacture 123
Nathan E ron
13 Rig id Le ns O p tics 130
W Ne il Charman
14 Rig id Le ns Me asure me nt 136
Klaus Ehrmann
15 Rig id Le ns De sig n and Fitting 143
Grae me Young
16 Rig id Toric Le ns De sig n and Fitting 156
Richard G Lind say
17 Rig id Le ns Care Syste ms 163
Philip B Morg an
This pa ge inte ntiona lly le ft bla nk
11
Rig id Le ns Mat e rials
NATHAN EFRO N
Int ro d uct io n
It is interesting to speculate whether the present rigid lens mate-
rials would be invented and brought to market now i they did
not already exist. Given the competitive situation that exists in
relation to production costs and pricing policy, against the high
background costs o product development in the biomedical
eld, the answer is probably no. T ey have, however, played an
important role in the development o contact lens materials and
occupy a small but signi cant place in the range o currently
available products. Much o the relevant in ormation is con-
tained in the patent literature, which is analysed in some detail
elsewhere (Kishi and ighe, 1988; Künzler and McGee, 1995;
ighe, 1997).
PO LYMETHYL METHACRYLATE
o appreciate the way in which rigid, as distinct rom so ,
materials have developed it is necessary to go back to the period
ollowing World War II. T e new availability o plastics materi-
als, speci cally polymethyl methacrylate (commonly known as
PMMA), led to the design and development o the rst corneal
lens as a replacement or glass corneo-scleral lenses. T e PMMA
lenses were prepared by polymerization o methyl methacrylate
with a ree-radical initiation system (Fig. 11.1) to orm rods or
buttons rom which a lens was obtained by lathing and polish-
ing. Fig. 11.1 represents the assembly o n methyl methacrylate
units to orm a PMMA chain n units long. PMMA was an ideal
candidate or use as a hard contact lens material because it had
similar appearance and ease o abrication to glass, acceptable
sur ace wettability and excellent durability. T e lenses com-
pared avourably with scleral lenses in that they were thin and
lightweight, could be worn more com ortably and gave excellent
visual correction.
THE NEED FO R O XYGEN
By the 1960s a greater appreciation o the e ects o contact
lens wear on the anterior eye was developing and the act that
PMMA is essentially a barrier to oxygen transport became
widely recognized. Corneal physiologists at that time were not
only able to carry out theoretical calculations on the e ect o
contact lenses on corneal respiration, but were also able to carry
out well-di erentiated experiments using PMMA and a very
di erent material, silicone rubber (Fig. 11.2).
Some aspects o the structure and behaviour o polymers,
including these two materials, have been outlined in Chapter 4.
T e most important property to consider in the context o the
present discussion is the di erence in their oxygen permeabili-
ties. PMMA is a glassy thermoplastic material, which has advan-
tageous optical clarity, processability and ease o sterilization,
but the disadvantage, as a contact lens material, o virtual
impermeability to oxygen. Silicone rubber, on the other hand,
belongs to a group o materials known as synthetic elastomers,
which are not only exible but also show rubber-like behaviour
(i.e. they are capable o being compressed or stretched and when
the de orming orce is removed they instantaneously return to
their original shape). T ey consist o polymer chains that pos-
sess high mobility and are cross-linked at intervals along the
polymer backbones. Because o this chain mobility, oxygen is
able to di use rapidly through the structure. T ese polymers
have oxygen permeabilities more than 100 times greater than
that o PMMA. Silicone rubber is the most signi cant member
o the group, with an oxygen permeability around 1000 times
greater than that o PMMA. T is extremely high oxygen perme-
ability arises rom the backbone o alternate silicone and oxygen
atoms, which con ers not only great reedom o rotation but also
a much higher solubility or oxygen than is possessed by rub-
bery polymers with simple carbon backbones.
Silicone rubber lenses, sur ace treated to give acceptable
wettability, were developed in the mid 1960s (McVannel et al.,
1967) and ound clinically to have little deleterious e ect on
corneal respiration (Hill and Schoessler, 1967). T e problems
o maintaining adequate sur ace properties, which were initially
encountered in its routine clinical use, have never been ully
overcome, however, and silicone rubber lenses are used only
rarely. T e uniquely high oxygen permeability o the silicon–
oxygen backbone has, however, been harnessed in two distinct
types o contact lens material: silicone hydrogels (Chapter 4) and
the so-called rigid gas-permeable (RGP) materials described
here. Because PMMA is now essentially redundant as a contact
lens material, the term ‘rigid gas-permeable’ is equally redun-
dant. All rigid lenses manu actured today (aside rom PMMA)
are gas permeable. For this reason, the term ‘rigid lens’ is used
throughout this book, and is intended to re er to all rigid lenses
apart rom PMMA, unless the latter is speci cally designated.
THE PRO BLEM O F HYDRO PHO BIC SURFACES
Elastomers, such as silicone rubber, are in many ways intermedi-
ate between thermoplastics such as PMMA and hydrogels such
as poly(hydroxyethyl methacrylate) (polyHEMA). T us, they
possess to a degree the toughness associated with the ormer
group o materials and the so ness o the latter, and in this sense
they are ideal candidates or contact lens usage. Un ortunately,
however, they all possess the same inherent disadvantage: the
molecular eatures required or true elastic behaviour invariably
produce polymers with hydrophobic sur aces. All polymers in
this group – not only the silicone-based materials – require
some orm o sur ace treatment to render them suf ciently
hydrophilic or use as contact lenses, but because o the ease
o chain rotation the sur aces slowly revert to their untreated
115
116 PART 3 Rig id Co nt act Le nse s
Fig . 11.1 Sche matic re p re se ntation o re e rad ical p olyme rization o
me thyl me thacrylate .
Fig . 11.2 Structure o silicone rub b e r. Me = CH3.
state. T is problem is made worse by the virtually instantaneous
elastic recovery o the materials, which causes them to ‘grab’ the
cornea a er being de ormed by the blink. T is in turn displaces
the posterior tear lm and leads to lens binding. Despite the
attempts to harness almost every available elastomeric material,
as witnessed by the patent literature, no true elastomer has been
success ully used as a commercial contact lens material.
THE SEARCH FO R BETTER MATERIALS
Once the need or a contact lens material with higher oxygen
permeability than PMMA was established, a wide-ranging
search began. T ere was, additionally, some belie that a more
exible material than PMMA would con er enhanced com ort.
At rst sight the task o nding an improved material would
not seem too dif cult as almost all thermoplastics are less rigid
and more oxygen permeable than PMMA. Several exible
thermoplastics materials have been suggested as being suitable
or contact lens manu acture in the patent literature, but none
o these has achieved clinical signi cance. T e most promising
results were obtained with poly (4-methylpent-l-ene), a orm
o which is known commercially as PX, and with cellulose
esters such as cellulose acetate butyrate (CAB). PX and CAB
resemble each other in many ways. Both polymers are less
rigid and less brittle than PMMA – they can conveniently be
described as ‘tougher’. T e oxygen permeability o both mate-
rials is appreciably (o the order o 20 times) greater than that
o PMMA (Kamath, 1969; Re ojo et al., 1977) and both were
capable o being abricated by moulding techniques, which are
inherently cheaper than lathe cutting, this still being the most
widely used method o contact lens abrication in the 1970s.
Even the act that PX required a sur ace treatment step and
that both materials (especially CAB) lacked the dimensional
stability o PMMA did not seem to be inhibitors to their com-
mercial uture. T e act that they became, airly quickly, curi-
osity materials was largely due to the appearance, and almost
instant success, o the silicone acrylates.
Hyb rid Rig id Gas-p e rme ab le
Mat e rials
T e logic o silicone acrylate materials is inescapable. T ey com-
bine, to a degree, the ease o preparation o PMMA and the oxy-
gen permeability o silicone rubber. When the need to modi y
PMMA to improve its oxygen permeability arose, there was,
there ore, no dif culty in recognizing that act. T e problem lay
in combining such polymers to achieve a balance o properties.
T e origin o the problem is the act that di erent types o reac-
tion are used in the ormation o the two materials. T is can
be illustrated by using the picture o polymers such as PMMA
and hydrogels as ‘washing line’ polymers. T e principle is that
polymers o this type have a long backbone (i.e. the string or
‘washing line’) rom which a variety o chemical groups may be
suspended (the ‘washing’).
Other types o polymer, o which silicone rubber is one
example, can be regarded as ‘poppet bead’ polymers. T e indi-
vidual units are joined just like the individual beads on a ‘pop-
pet bead’ necklace. T ere is no ‘washing’ hanging rom the chain
and the properties o the polymer are controlled by the struc-
ture o the poppet beads themselves. T e undamental problem
that prevented simple PMMA–silicone rubber combinations
rom being prepared is that the ‘washing line’ and ‘poppet bead’
chemistries are incompatible and beads cannot be inserted into
the washing line. T e requirement is that, in order to insert an
individual monomer unit into an acrylate or methacrylate poly-
mer such as PMMA, it is necessary that the monomer should
have a carbon-to-carbon double bond (as shown in Fig. 11.1).
Without the double bond the washing cannot be pegged onto
the washing line. T e siloxy-methacrylates that orm the basis
o current gas-permeable technology get round this problem
in a well-recognized, but nevertheless quite ingenious, way.
Short segments o the poppet bead chain are turned into ‘wash-
ing’ by attaching them to a chemical intermediate that contains
the necessary double bond. T is can be seen in the structure o
the siloxy-methacrylate monomer (Fig. 11.3), which in essence
consists o the individual units o silicone rubber structure
pasted onto a modi ed methyl methacrylate molecule. On the
basis o this simple picture, the story o gas-permeable lenses
can be un olded.
The Gaylo rd Pat e nt s – Harne ssing
Silico n
T e major advance that enabled the development o rigid con-
tact lens materials is ound in the work o Norman Gaylord at
Polycon Laboratories, described in a series o patents (Gay-
lord, 1974, 1978). T ere are two distinct aspects o this work
that are worth noting. T e rst is the development o what has
become the industry standard siloxy-methacrylate monomer,
tris(trimethyl-siloxy)–methacryloxy-propylsilane (Fig. 11.3),
commonly re erred to as RIS. T e second is the recognition
o the value o incorporating uoroalkyl methacrylates (e.g.
1,1,9-trihydroper uoro-nonyl methacrylate; Fig. 11.4), princi-
pally to enhance oxygen permeability. It is important to recog-
nize that the bonds between individual carbon atoms are not
disposed at right angles to each other and that molecules are
not at but rather have three-dimensional shapes. Although this
point, which has been discussed in Chapter 4, is re ected in Fig.
11.1, it is impractical to do so in the representation o more com-
plicated molecules such as the siloxy- and uoromethacrylates

Fig . 11.3 Tris(trime thyl-siloxy)-me thacryloxy-p rop ylsilane (TRIS)
monome r. Me = CH3.
Fig . 11.4 1,1,9-trihyd rop e rf uoro-nonyl me thacrylate monome r.
Me = CH3.
shown in Figs. 11.3 and 11.4. Both these aspects o the work
o Gaylord have been subsequently developed, and together
orm the basis o most existing commercial rigid contact lens
materials. Although RIS is still the most widely used siloxy-
methacrylate monomer in rigid lens manu acture, the uo-
romethacrylate monomers employed in current commercial
materials are much simpler than that initially used by Gaylord.
It is important to note that the concept o a uorine-con-
taining contact lens was not new. Fluorocarbons dissolve more
oxygen than do hydrocarbons and give rise to polymers with
somewhat higher oxygen permeabilities than their hydrocar-
bon equivalents. It was over 10 years a er the rst description
o the advantages o contact lenses prepared rom polymers
derived rom per uoroalkylethyl methacrylates, in a series o
DuPont patents, that signi cant commercial use was made o
uorocarbon-based contact lenses ( ighe, 1997). T e reason
is straight orward: there is a huge advantage in oxygen perme-
ability o the siloxy-methacrylates over uorocarbon methacry-
lates, which on their own do not produce a clinically signi cant
balance o advantages over PMMA. T e great advantage o the
11 Rig id Le ns Mat e rials 117
Fig . 11.5 Me thacrylic acid monome r. Me = CH3.
uorinated methacrylates comes when they are used partially
to replace methyl methacrylate in copolymers with RIS. T e
balance o the three components ( uoromethacrylate, methyl
methacrylate and RIS) is adjusted to optimize oxygen perme-
ability, hardness (which in uences processability) and wettabil-
ity. Although the Gaylord patents marked the beginning o the
inventive thread, several other workers made signi cant contri-
butions to the development o lenses with advantages in clinical
practice by identi ying ways o optimizing the balance o oxygen
permeability, wettability and mechanical behaviour.
Within a 12-month period in 1978 and early 1979, at about
the time o appearance o the third patent o Gaylord’s, three
workers began to le their separate series o patents related to
siloxy-methacrylate-based contact lens materials. T ese were,
in advancing order o the priority date or the rst written l-
ing, Kyoichi anaka ( oyo Contact Lens), Edward Ellis (Poly-
mer echnology) and Nick Novicky, whose later patents (and
presumably rights to the earlier patent) were assigned to Syn-
tex (USA). T e Ellis and Novicky patents orm a clear line o
continuation rom the early work o Gaylord and, because o
this, are best considered together (Ellis and Salamone, 1979;
Novicky, 1980). T e work o anaka – or which parallel lings
exist in Japan and the USA – has some slight and signi cant
di erences mainly concerned with the inclusion o a hydroxyl
group into the siloxy monomer to improve wettability ( anaka
et al., 1979). T is was a signi cant early step in overcoming the
technical obstacles to the development o silicone hydrogels, as
separately discussed in Chapter 4.
T e Ellis and Salamone patents used the basic concept o
Gaylord with slight but signi cant modi cations. T e more
important o these uses the basic composition – described by
Gaylord – based on RIS, but claiming novelty in the additional
use o methacrylic acid (Fig. 11.5 – a hydrophilic monomer
re erred to but not exempli ed by Gaylord) to improve sur ace
wettability, and by the incorporation o an itaconate ester (e.g.
dimethyl itaconate; Fig. 11.6). T is composition ormed the
basis o the in uential early range o Boston rigid lens materials.
T e early Japanese patent o anaka marked the beginning o
a rapid growth in Japanese patent activity, principally as a result
o work assigned to Hoya Lens and oyo Contact Lens. T e sub-
sequent clinical interest in the use o rigid lenses or extended
wear in Japan stimulated particular interest in means o enhanc-
ing Dk. T is interest was paralleled by a series o patents, which
provide valuable in ormation on the use o uoroalkyl methac-
rylates in conjunction with siloxy-methacrylates, and the prop-
erties o uoroalkyl methacrylates themselves. T e properties,
118 PART 3 Rig id Co nt act Le nse s
Fig . 11.6 Dime thyl itaconate monome r. Me = CH3.
Fig . 11.7 Trif uoroe thyl me thacrylate monome r. Me = CH3.
speci cally the permeabilities o the individual homopolymers,
are care ully described. It is in the Japanese patent literature, or
example, that the relative permeability along the series o homo-
polymers o methyl methacrylate, tri uoroethyl methacrylate
(Fig. 11.7) and hexa uoroisopropyl methacrylate (Fig. 11.8),
is disclosed (1 : 60 : 100). T is indicates the relative advantage,
in terms o permeability, o replacing methyl methacrylate by
either o these two uoro monomers. T e ground is clearly seen
in this patent or the development o uorine-containing siloxy-
methacrylate gas-permeable materials (e.g. Equalens, Fluo-
roperm, Menicon SP) which penetrated the UK and US markets
towards the mid 1980s. It is in the Japanese patents, however,
that the relationship between composition and permeability o
these materials is described ( arumi and Komiya, 1982).
T e readily discernible trend in the development o rigid
contact lens materials described in the patent literature and dis-
cussed here is one o increasing oxygen permeability balanced
against the retention o acceptable dimensional stability and
ocular compatibility (characterized by wettability and deposit
Fig . 11.8 He xaf uo roisop rop yl me thacrylate monome r. Me = CH3.
resistance). T e essential structural developments have centred
around our areas:
1. T e RIS component, characterized by attempts to incor-
porate higher proportions o more highly branched siloxy
derivatives.
2. T e use o uorocarbon co-monomers in the place o hy-
drocarbon-based components such as methyl methacrylate.
3. T e improvement o wettability by incorporation o hy-
drophilic co-monomers, or subsequent sur ace modi ca-
tion o the ormed lens.
4. T e development o cross-linking technology; rigid lens
materials necessarily contain much higher levels o cross-
linking agents than do so lenses.
Much attention has been paid in the patent literature to the
comprehensive coverage o all possible structural variants dis-
closed in the original patents won by Gaylord, published in
1974. Despite this, little that is truly new has appeared since
then, and certainly nothing to match the leap orward brought
by the identi cation o RIS as a means o producing rigid
contact lens materials with Dk values many times greater than
PMMA. T e process since that time has been one o re nement
and improvement, based on the underlying principles that are
contained in the patents described above.
One important re nement to increase both oxygen permea-
bility and material strength was the introduction by Menicon o
novel siloxanylstyrene monomers into the polymer backbone.
Unlike its previous lenses (SFP and EX), which relied on sili-
cone-containing methacrylate compounds or enhanced oxygen
permeability, the Menicon Z material eatures tris (trimethylsi-
loxy) silyl styrene as the key monomer to uoromethacrylate.
T is chemical structure results in excellent mechanical proper-
ties, allowing the lens to be signi cantly thinner than a typical
rigid lens (Szczotka, 2004). It was the rst rigid lens material
classi ed in the ‘hyperoxygen transmissibility’ category with a
Dk o 175, and is the only rigid lens that is approved by the US
Food and Drug Administration or 30 days o continuous wear.
T is is a variation o the styrene–HEMA polymer used in the
So perm hybrid lens. T e use o styrene adds a greater resis-
tance to exure and a lower speci c gravity.
Plasma coating has been used to good e ect in silicone
hydrogel materials to overcome inherent hydrophobicity. T e
lenses are enclosed in an ionized gas with an equal number o
positively and negatively charged species. T e highly charged
species within the gas plasma bombard the sur ace o the mate-
rial, and the resulting energy causes a number o changes on the
sur ace o the material. It is used in a wide variety o applications,

including highly ef cient sur ace cleaning, or increasing hydro-
philicity and even hydrophobicity. A plasma oxidation sur ace
treatment process has been developed or the treatment o rigid
contact lenses produced rom the Optimum range o materi-
als (Contamac). T e manu acturers claim the processes have
been optimized to produce signi cant improvements in the
wetting characteristics, without requiring a lengthy treatment
procedure.
Silicone hydrogel polymers have been very success ul
in the orm o so t lenses but can be made with a range o
water contents rom 0 to 60%. At low water contents (<10%),
the polymers are rigid. here are two types o rigid silicone
hydrogel materials. In one type, the water content and expan-
sion are constrained by decreasing the ratio o hydrophilic
monomers and increasing the cross-link density. hus the
polymer cannot absorb water into the interior o the matrix,
but the sur ace can hydrate like a hydrogel lens. In the second
type, a reactive hydrolysable monomer is included in the or-
mulation. his means that, when the lens is placed in water,
the reactive monomer hydrolyses, producing a hydrophilic
sur ace like a hydrogel lens. he reaction cannot proceed
into the interior as expansion is constrained by cross-link-
ing. his type also has the novel property o regenerating the
hydrophilic sur ace i the lens sur ace is damaged or the lens
is repolished.
Co mme rcial Rig id Mat e rials and t he ir
Pro p e rt ie s
able 11.1 lists rigid contact lens materials that are commer-
cially available at the time o writing. T ere has been some
movement in recent years towards the standardization o
experimental procedures or measuring material oxygen per-
meability (Dk). It is by no means certain, however, that all mea-
surements quoted by manu acturers have been made to such
standards. T is is particularly true o the wide range o rigid
lenses supplied, as they are rom such a variety o sources. T is
act presents a problem to the clinician in selecting materials
on the basis o oxygen per ormance. Some cautionary com-
ments are included here.
O XYGEN PERMEABILITY
Several di erent experimental procedures or determining
oxygen permeability may be distinguished. In each case, oxy-
gen at a known e ective concentration passes rom the donor
side o the cell through the membrane (o known thickness
and cross-sectional area) to a receiver side, also o known vol-
ume, where it is sensed. In the case o rigid polymers it is pos-
sible to use both gas-to-gas and liquid-to-liquid systems. T is
has the advantage that re erence values or standard materi-
als can be obtained in the gas-to-gas system, which does not
su er rom some o the shortcomings o the liquid-to-liquid
cell, in which the liquid is ideally stirred on both sides o the
membrane.
T e polarographic electrode technique, which is usually used
or lens measurement, has several shortcomings. First, the cell
is unstirred (thereby giving rise to boundary layer problems);
secondly, the thickness o the contact lens normally shows a
centre-to-edge variation (which produces uncertainties in the
calculation); thirdly, because the lenses vary in curvature, the
volume o the receiver side is not accurately xed. In principle,
11 Rig id Le ns Mat e rials 119
this last point should be less important, because the technique
is not usually operated in the manner that measures rate o
increase in oxygen concentration o the receiver side o the cell,
but rather the resultant equilibrium oxygen consumption by the
electrode. T e ability to do this relies on the assumption that
oxygen transported to the receiver side is ef ciently consumed
by the electrode sensor and that, as a result, the partial pres-
sure o oxygen on the receiver side is always e ectively zero.
With very permeable samples, however, these assumptions are
not justi ed. In all cell con gurations, it is important to have
an oxygen-tight seal o the membrane separating donor and
receiver chambers, but this again is dif cult to achieve with the
ormat and samples involved in contact lens measurement and
edge-e ect corrections must be made. A great deal o e ort has
gone into standardization o procedures and cross-correlation
o results, but only when results have come rom specialist labo-
ratories can they be relied upon (Holden et al., 1990; Weissman
and Fatt, 1991; ranoudis and E ron, 1995; Benjamin and Cap-
pelli, 2002).
Because in hydrogels, water is the oxygen transport medium
through the lens, boundary layer e ects are more readily ana-
lysed and eliminated. In rigid lenses, however, although mea-
surements are easily made, the deviations rom ideal behaviour
increase with increasing permeability and are dependent upon
the sur ace properties o the individual lens. It has been recog-
nized or many years that, even in stirred cells, boundary layer
e ects produce greater problems with non-hydrophilic materi-
als (Hwang et al., 1971). As a result o the various actors identi-
ed here, wide variations exist between reported Dk values or
the same lens material. T is is particularly problematical or the
clinician, as there is no readily measured property (such as the
water content o a hydrogel) that gives an independent guide
to the permeability value. T ese issues have been discussed at
length by Brennan et al. (1987).
MECHANICAL PRO PERTIES
T e problems associated with the use o increasing quantities
o siloxy-methacrylates to achieve high oxygen permeabilities
are two old. First, incompatibility, phase separation and dete-
rioration in mechanical properties – particularly dimensional
stability – limit the proportion o such monomers that can be
incorporated. Second, their use requires the incorporation o
hydrophilic monomers containing hydroxyl, carboxyl, amide
or lactam groups to improve wettability. T ese monomers tend
to reduce oxygen permeability and produce low levels o water
uptake that in turn reduce dimensional stability. It is well rec-
ognized that developments that have produced higher oxygen
permeabilities have led to problems with mechanical properties,
and that such problems are quite common. Despite this, the cur-
rently used mechanical property measurements, such as hard-
ness, do not indicate any clear distinction between materials.
Although materials are recognized to ail because o inadequate
mechanical behaviour, there is certainly no accepted basis upon
which the per ormance o lenses in a clinical setting can be cor-
related with presently used test measurements (Kerr and Dilly
1988; Jones et al., 1996).
Fle xure
Lens exure causes induced residual astigmatism on toric cor-
neas. Silicone acrylate lenses have been shown to undergo sig-
ni cantly more exure, and alter residual astigmatism more,
120 PART 3 Rig id Co nt act Le nse s

TABLE
11.1 Rig id Co nt act Le ns Mat e rials
Manufact ure r Trad e Name Co lo ur Mat e rial Dk 1
Bausch & Lomb Boston II Cle ar, b lue , g re e n Silicone acrylate 12
Boston IV Cle ar, b lue , e le ctric b lue Silicone acrylate 19
Boston Eq uale ns 2 Cle ar, b lue , e le ctric b lue Fluorosilicone acrylate 47 3
Boston ES2 Blue , ice b lue , g re e n, g re y, b rown, cle ar Fluorosilicone acrylate 18
Boston EO 2 Blue , ice b lue , g re e n, g re y, b rown, ice Fluorosilicone acrylate 58
g re e n, e le ctric b lue
Boston Eq uale ns II2 Cle ar, b lue , g re e n, re d , ye llow Fluorosilicone acrylate 85 3
Boston XO 2 Blue , ice b lue , viole t, g re e n, re d , ye llow, Fluorosilicone acrylate 100
cle ar
Boston XO 2 2 Visib ility tint, b lue , ice b lue , viole t, g re e n, Fluorosilicone acrylate 141
re d , ye llow
Contamac US Hyb rid FS Cle ar, b lue , g lacie r b lue , g re e n, g re y Fluorosilicone acrylate 31
Hyb rid FS F / R Mould Cle ar Fluorosilicone acrylate 31
O p timum Classic Blue , g lacie r b lue , g re e n, g re y Fluorosilicone acrylate 26
O p timum Comfort Blue , b rown, fore st g re e n, g lacie r b lue , Fluorosilicone acrylate 65
g re e n, g re y
O p timum Extra Cle ar, b lue , g lacie r b lue , g re e n, g re y Fluorosilicone acrylate 100
O p timum Extre me Blue , g re e n, g lacie r b lue , g re y Fluorosilicone acrylate 125
O p timum GP Syste m Blue , g re e n, g lacie r b lue , g re y Fluorosilicone acrylate 26, 65, 100, 125
O p timum HR 1.51 Blue Fluorosilicone acrylate 50
O p timum HR 1.53 Blue Fluorosilicone acrylate 26
G.T. Lab oratorie s Fluore x 300 2 Cle ar, b lue , g re e n, g re y, aq ua, rose b rown Fluorosilicate acrylic 30
Fluore x 500 2 Cle ar, b lue , g re e n, g re y, aq ua, rose b rown Fluorosilicate acrylic 50
Fluore x 700 2 Cle ar, b lue , g re e n, g re y, aq ua, rose b rown Fluorosilicate acrylic 70
InnoVision Accu-Con Cle ar, b lue , g re e n, g re y, b rown, d ark b lue Fluorosilicone acrylate 25
Hyd rO 2 Soft b lue , soft g re e n, oce an b lue Fluorosilicone acrylate 50
Lag ad o Corp ora- SA 18 2 Cle ar, b lue , g re y, g re e n, b rown, d ark b lue , Silicone acrylate 18
tion d ark g re e n
SA 32 2 Cle ar, b lue , g re y, g re e n, b rown, d ark b lue , Silicone acrylate 32
d ark g re e n
FLO SI2 Cle ar, b lue , g re y, g re e n, b rown, d ark b lue , Fluorosilicone acrylate 26
d ark g re e n
O NSI-56 2 Blue , g re e n, g re y, b lue -viole t, cle ar Fluorosilicone acrylate 56
TYRO -97 2 Cle ar, b lue , g re e n, g re y, b lue -g re e n Fluorosilicone acrylate 97
The Life Style SGP Blue , g re e n, b rown, g re y Siloxane acrylate 22
Comp any SGP II Cle ar, b lue , g re e n, b rown, g re y Siloxane acrylate 43.5
SGP 3 Cle ar, b lue , g re e n Fluorosiloxane acrylate 43.5
Me nicon Me nicon Z2 Lig ht b lue and cle ar Fluorosiloxanyl styre ne 163 4
Parag on Vision Fluorop e rm 2 Cle ar, b lue , g re e n, g re y, maje stic b lue , Fluorosilicone acrylate 30
Scie nce s crystal b lue
Fluorop e rm 60 2 Cle ar, b lue , g re e n, b rown, crystal b lue Fluorosilicone acrylate 60 3
Fluorop e rm 92 2 Cle ar, b lue , g re e n Fluorosilicone acrylate 92 3
Fluorop e rm 151 2 Blue , crystal b lue Fluorosilicone acrylate 151 3
O p tacryl 60 Blue Silicone acrylate 18
Parag on HDS2 Fore st g re e n, e me rald g re e n, sap p hire Fluorosilicone acrylate 58 3
b lue , crystal b lue
Parag on HDS NO N- Blue , g re e n Fluorosilicone acrylate 58
UV
Parag on HDS 100 1 Blue , g re e n Fluorosilicone acrylate 100 3
Parag on HDS HI 1.54 Blue , g re e n Fluorosilicone acrylate 22
Parap e rm O 2 Cle ar, b lue , g re e n, e le ctric b lue Silicone acrylate 15.6
Parap e rm EW Cle ar, b lue , g re e n Silicone acrylate 56 3
Parag on THIN 2 Blue , g re e n Fluorosilicone acrylate 29
Ste llar O P-2 Cle ar, b lue , b rown, g re y, g re e n Fluorosilicone acrylate 15
O P-3 2 Cle ar, b lue , b rown, g re y, g re e n, d ark b lue , Fluorosilicone acrylate 30
d ark g re e n
O P-6 2 Cle ar, b lue , b rown, g re y, g re e n Fluorosilicone acrylate 60
1IS0 /Fatt me thod .
2UV ab sorb e r /
inhib itors availab le .
3FDA ap p rove d or 7-d ay e xte nd e d we ar.
4Ap p rove d or 30-d ay e xte nd e d we ar

than do PMMA lenses at all centre thicknesses (Harris et al.,
1982). For both lens types, lenses thinner than 0.15 mm exed
signi cantly more than thicker lenses. T is critical centre thick-
ness should be considered when tting these lens types on toric
corneas (Harris et al., 1987). However, it is not correct to assume
that all gas-permeable lenses ex more than PMMA. Lin and
Snyder (1999) compared exure in low-(15), medium-(60) and
high-(150)Dk materials, as measured by keratometry over the
lenses. No signi cant di erences were ound within or between
lens materials when comparing magnitude o exure. T e ex-
ure o both PMMA and Boston XO materials were investigated
by Collins et al. (2001) in three centre thicknesses (0.05, 0.10

and 0.15 mm) using a videokeratoscope; they also ound no sig-
ni cant di erences in exure. Methods o exure measurement
are discussed in Chapter 14.
Hard ne ss
Little work is carried out on the measurement o clinically rel-
evant mechanical properties, and the values quoted are almost
invariably related to the hardness o the material. Although
hardness tests have some place in contact lens characterization,
they do not re ect the type o mechanical ailure or problems
that normally arise, which are usually associated with racture,
chipping or splitting, or distortion. In the absence o agreed
standards or suitable methods, manu acturers’ quoted data are
usually obtained with one or other o the standard hardness test
methods.
Hardness can be de ned as resistance to penetration. In
a hardness test, an indenter is pressed on the sur ace o the
material under test, and the extent to which it sinks into the
material or a given pressure and time is an inverse measure o
the hardness. T ere are many hardness testers available com-
mercially that are suitable or plastics and rubbers, including
the Vickers indenter, the Rockwell hardness tester and the
Shore durometers. T ese may be divided into three categories:
1. Hardness tests that measure the resistance o a material
to indentation by an indenting probe (e.g. Brinell, Vickers
and Shore durometers): some tests measure the indenta-
tion with the load applied and some measure the residual
indentation a er the load is removed.
2. Hardness tests that measure the resistance o a material to
scratching by another material (e.g. the Bierbaum scratch
test, the Moh hardness test): similar techniques are com-
monly used in paint testing and involve pulling the sam-
ple beneath a loaded indenter.
3. Hardness tests that measure recovery ef ciency or resil-
ience (e.g. the various Rockwell testers).
T ere is no common method o measurement in these tests. For
example, the Rockwell A-scale hardness test measures the depth
o penetration with the load applied, whereas the Rockwell R-,
L-, M- and E-scale tests measure depth caused by a spheri-
cal indenter a er most o the load has been removed. In these
methods the amount o rebound or recoverable de ormation is
important. T e Vickers Microhardness test di ers again, in that
a microscope is used to measure the diagonals o the pits le by
a diamond-shaped indenter on a square base. T ere is a linear
relationship between the depth o impression and the hardness
number. Each o the hardness methods uses an arbitrary scale
and, although the scales can be approximately compared, pre-
cise correlation is not possible.
T e extent o scratching o rigid contact lens materials was
evaluated by ranoudis and E ron (1996) and this property was
related to material oxygen permeability and re ractive index.
One hundred and orty lenses made rom 28 di erent rigid
materials were evaluated in a masked and randomized manner.
Scratches were created on the ront sur ace o the lenses using
an apparatus that was speci cally designed and constructed or
this experiment. T e extent o scratching was quantitatively
evaluated using a computer-based scanning and image analysis
system. T e oxygen permeability o all materials was measured
using the polarographic method. An Atago N3000 hand-held
re ractometer was used to measure the re ractive index o
these materials. T ree signi cant correlations were revealed:
an inverse relationship (r = −0.813, P < 0.0001) between the
11 Rig id Le ns Mat e rials 121
oxygen permeability and the re ractive index, a positive rela-
tionship (r = 0.511, P < 0.008) between oxygen permeability and
the extent o scratching, and an inverse relationship (r = −0.539,
P < 0.0058) between the re ractive index and the extent o
scratching.
SURFACE PRO PERTIES
Similar problems arise with the measurement o wettability by
contact angle techniques. In this case, the e ect o soaking on
water uptake and thus the wettability o materials, coupled with
the use o the inverted or captive air bubble technique in solu-
tions other than water, combine to produce wide variations,
because o the di erent methodologies, in the reported values
or a given material. T e eld o contact lens sur ace properties
has also become more complex with the passage o time. T e
water wettability o materials provides a good primary indica-
tion o the ability o tears to orm a coherent and stable layer on
the sur ace o the material. It tells nothing o the compatibility
o the material with tears.
Un ortunately, the inverted (captive) air bubble tech-
nique has been identi ed as a standard in contact lens work.
T e measurement is made a er an air bubble is allowed to
impinge, rom underneath, onto the sur ace o the sample,
which is suspended in an aqueous liquid. T is is the most di -
cult type o contact angle to measure correctly as it involves
judging where the base o a distorted sphere just impinges on a
sur ace. More importantly, the air bubble has to displace water
rom the sur ace o the sample, which is requently presoaked.
As all the siloxy-methacrylate materials contain appreciable
amounts o hydrophilic monomer to improve sur ace wettabil-
ity, they all retain a strongly adsorbed water layer at the sur ace
under these conditions. Not surprisingly, there ore, with this
method very similar and very low so-called wetting angles are
obtained with current rigid lens materials. What is measured
in each case is the value or a di use layer o water on a poly-
mer sur ace. T e values are similar to those obtained by this
technique with hydrogels. T e biological and biochemical sur-
ace events, on the other hand, occur at a molecular level and
do not recognize the di use water layer barrier that is sensed
by macroscopic droplet techniques. T is is the underlying rea-
son or the lack o relevance to clinical practice o the wetting
angle, as presently measured.
Well-established techniques exist which enable the wetting
hysteresis and the detailed sur ace energy components, rather
than a single wetting angle, to be determined. Biomaterials sci-
ence makes widespread use o such methods; the contact lens
community could pro tably do the same.
O PTICAL PRO PERTIES
Domínguez-Vicent et al. (2016) assessed the optical quality o
our Boston contact lens materials with an optical device based
on Schlieren inter erometry. Speci cally, they measured higher-
order aberrations and their corresponding root mean square
values o our di erent rigid gas-permeable contact lenses made
rom our di erent Boston materials: EO, ES, XO and XO2. For
each lens, 30 measurements were per ormed with two optical
apertures: 3.0 mm and 6.0 mm.
T e root mean square error o higher-order aberrations was
ound to vary signi cantly with material type or both opti-
cal apertures (p < 0.01). T e largest di erence was obtained
122 PART 3 Rig id Co nt act Le nse s
between the Boston EO and the Boston ES materials ( or a 6.0
mm aperture), the mean di erence being (8.3 ± 0.2) × 10−2 µm.
T e modulation trans er unctions, point spread unctions and
Strehl ratio values were similar among all Boston materials
at the smaller optical aperture; however, di erences between
each material were more apparent or the 6.0 mm aper-
ture, with the Boston ES material exhibiting the best optical
quality.
REFRACTIVE INDEX
Fluorosilicone acrylate lenses are likely to have a re ractive
index between 1.420 and 1.460, whereas an index o 1.460
or greater usually indicates a silicone acrylate material. T e
re ractive index o PMMA is 1.49. Unlike in spectacle lens dis-
pensing, re ractive index has rarely been a actor in the choice
o rigid lens material. However, manu acturers are starting to
introduce lenses with higher re ractive indices. Contamac’s
Optimum HR material and Paragon Vision Sciences’ Paragon
HDS HI material have re ractive index values ranging rom
1.51 to 1.54. A bene t o these higher-index materials is the
enhanced re ractive e ect the materials might have when
used in aspheric multi ocal designs. With the same amount o
asphericity, a higher-index material will produce an increased
add e ect (Pence, 2009).
Co nclusio n
T is chapter provided an outline o the basic chemistry o rigid
plastics used in the contact lens industry, and has traced the
successive developments in rigid lens materials primarily with
re erence to the patent literature. All stages o development have
been driven by a parallel growth o in ormation relating to the
biocompatibility (the need or oxygen permeability and sur ace
wettability) and the clinical per ormance o the lenses.
Predicting compatibility in vivo rom tests in vitro is never
entirely success ul. Increasingly, however, it enables di erences
between the per ormance o materials to be success ully pre-
dicted. In addition the use o biological probes, such as ani-
mal cells, and interaction with biological sera, provide use ul
in ormation in the development o new biomaterials. T e area
is complex, but o ers several approaches that will improve con-
siderably on current techniques, and will have some relevance
to the clinical per ormance o rigid contact lenses.
Ackno wle d g e me nt s
T e author would like to acknowledge Brian J. ighe as the
author o this chapter in the previous edition.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
REFERENCES
Benjamin, W. J., & Cappelli, Q. A. (2002). Oxygen
permeability (Dk) o thirty-seven rigid contact
lens materials. Optom. Vis. Sci., 79, 103–111.
Brennan, N. A., E ron, N., Holden, B. A., et al. (1987).
A review o the theoretical concepts, measurement
systems and application o contact lens oxygen per-
meability. Ophthal. Physiol. Opt., 7, 485–490.
Collins, M. J., Franklin, R., Carney, L. G., et al.
(2001). Flexure o thin rigid contact lenses. Cont.
Lens Anterior Eye, 24, 59–64.
Domínguez-Vicent, A., Esteve- aboada, J. J., &
Ferrer-Blasco, . (2016). Optical quality compari-
son among di erent Boston contact lens materi-
als. Clin. Exp. Optom., 99, 39–46.
Ellis, E. J., & Salamone, J. C. (1979). (to Polymer
Technology Corp). Silicone-containing hard contact
lens material. US patent 4 152 508.
Gaylord, N. G. (1974). (to Polycon Lab Inc.) Oxygen-
permeable contact lens composition methods and
article of manufacture. US patent 3 808 178.
Gaylord, N. G. (1978). (to Syntex USA Inc.) Methods
of correcting visual defects: compositions and articles
of manufacture useful therein. US patent 4 120 570.
Harris, M. G., Kadoya, J., Nomura, J., et al. (1982).
Flexure and residual astigmatism with Polycon
and polymethyl methacrylate lenses on toric cor-
neas. Am. J. Optom. Physiol. Opt., 59, 263–266.
Harris, M. G., Gale, B., Gansel, K., et al. (1987). Flex-
ure and residual astigmatism with Paraperm O2
and Boston II lenses on toric corneas. Am. J. Op-
tom. Physiol. Opt., 64, 269–273.
Hill, R. M., & Schoessler, J. (1967). Optical mem-
branes o silicone rubber. J. Am. Optom. Assoc.,
38, 480–483.
Holden, B. A., Newton-Howes, J., Winterton, L.,
et al. (1990). T e DK project – an interlaboratory
comparison o DK / L measurements. Optom. Vis.
Sci., 67, 476–481.
Hwang, S. ., Kammermeyer, K., & ang, . E.
(1971). ransport o dissolved oxygen through
silicone rubber membrane. J. Macromol. Sci. Phys.
(B), 5, 1–10.
Jones, L., Woods, C. A., & E ron, N. (1996). Li e ex-
pectancy o rigid gas permeable and high water
content contact lenses. CLAO J., 22, 258–260.
Kamath, P. M. (1969). Physical and chemical at-
tributes o an ideal contact lens. Contacto, 13,
29–34.
Kerr, C., & Dilly, P. N. (1988). Problems o dimen-
sional stability in RGPs. Optician, 195(5134),
21–23.
Kishi, M., & ighe, B. J. (1988). RGP materials: a re-
view o the patent literature. Optician, 195(5134),
21–23.
Künzler, J. F., & McGee, J. A. (1995). Contact lens
materials. Chem. Ind., 21, 651–653.
Lin, M. C., & Snyder, C. (1999). Flexure and residual
astigmatism with RGP lenses o low, medium, and
high oxygen permeability. Int. Contact Lens Clin.,
26, 5–9.
McVannel, D. E., Mishler, J. L., & Polmanteer, K. E.
(1967). (to Dow Corning Corp) Hydrophilic con-
tact lens and method of making same. US patent
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Novicky, N. N. (1980). Oxygen permeable hard
and semi-hard contact lens compositions, meth-
ods and articles of manufacture. US patent 4 242
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Pence, N. (2009). GP materials o er new options
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Re ojo, M. F., Holly, F. J., & Leong, F. L. (1977). Per-
meability o dissolved oxygen through contact
lenses I. Cellulose acetate butyrate. Contact In-
traoc. Lens Med. J., 3, 27–33.
Szczotka, L. B. (2004). T e uture o GP continuous
wear. CL Spectrum, 19(2), 21.
anaka, K., akahashi, K., Kanada, M., et al. (1979).
(to Toyo contact Lens Co Ltd, Japan) Methyl
di(trimethylsiloxy)silylpropyl glycerol methacry-
late. US patent 4 139 548.
arumi, N., & Komiya, S. (1982). (to Hoya Lens
KK) Contact lens with high oxygen permeability.
Jap Kokai. 57–182718.
ighe, B. J. (1997). Contact lens materials. In
A. J. Phillips, & I. L. Speedwell (Eds.), Contact
Lenses (4th ed. Ch. 3, pp. 50–92). Ox ord: Butter-
worth-Heinemann.
ranoudis, I., & E ron, N. (1995). Oxygen permea-
bility o rigid contact lens materials. J. Br. Contact
Lens Assoc., 18, 49–53.
ranoudis, I., & E ron, N. (1996). Scratch resistance
o rigid contact lens materials. Ophthal. Physiol.
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Opin. Ophthalmol., 2, 88–94.
122.e 1
12
Rig id Le ns Manufact ure
NATHAN EFRO N
Int ro d uct io n
Although lathing technology has been used to abricate contact
lenses since their invention over 130 years ago, developments
over the past quarter o a century in precision engineer-
ing, materials technology and computer control systems have
resulted in a capability to manu acture lenses o almost any
imaginable shape – rom basic spherical lens orms to highly
complex aspheric designs. T ese developments have resulted in
renewed interest in rigid lenses, and in particular miniscleral
lenses, which despite representing a small minority o lenses
sold are still a very important alternative orm o vision correc-
tion – and indeed the only orm o contact lens that will provide
adequate vision in cases o corneal distortion (as occurs in kera-
toconus). T e type o use or design o rigid lenses prescribed has
shi ed substantially over time. In 1996, 80% o rigid lenses were
o spherical design (Morgan and E ron, 2008); this had dropped
to 44% in 2015 (Morgan et al., 2016). T e proportion o lenses
requiring more specialized manu acturing techniques has risen
accordingly, as is evident rom worldwide rigid lens prescribing
data or 2015 (Morgan et al., 2016) (Fig. 12.1).
T is chapter will explain the process o rigid lens manu ac-
ture and presents an analysis o the impact o regulatory con-
straints on the rigid lens sector.
Rig id Le ns Manufact ure
T e process o lathe cutting so lenses has already been outlined
in Chapter 5. Here, a more comprehensive illustrative account
o the process o lathe cutting will be presented in the context o
rigid lens manu acture.
RAW MATERIALS
T e raw material is supplied to the lens manu acturer in the orm
o at cylindrical buttons o 12.7 mm diameter and circa 4.3
mm thickness. Some types are sold with a concave depression
in one sur ace as preparation or base curve cutting. T ese are
supplied in various colours and the tradename o the product is
typically imprinted on one sur ace o the button (Fig. 12.2). T e
choice o material is largely dictated by clinical needs, with oxy-
gen permeability being a key consideration. T e latest range o
rigid materials is designed as ‘super’ gas permeable with Dk val-
ues o over 150 Barrers. T ese materials typically require some
postproduction sur ace treatment in order to ensure a wettable
sur ace. Manu acturers o en seek extended-wear approvals or
lenses made rom these polymers, or use in overnight orthoker-
atology. From the standpoint o the manu acturing laboratory,
however, consideration needs to be given to the ‘machinability’
o the material, as some materials are more susceptible to sur-
ace deterioration and degradation o optical quality compared
with other materials when subjected to the same manu actur-
ing processes (Meyers, 1997). Manu acturing laboratories that
wish to make lenses rom the latest rigid materials need to use
only the best types o lathes available. ypically these lathes will
use hydrostatic X,Y slides and air-bearing spindles, all under
sophisticated computer control.
GENERATING THE LENS BACK SURFACE
Some lathes are con gured so that they can be used to generate
both the ront and back sur ace o the lens; however, in practice,
separate lathes are used in order to optimize the lens production
process. Fig. 12.3A shows a lathe con gured or generating the
lens back sur ace.
T e button is rst secured in a carrier, or dolly, which is a
small hollow cylinder lined with plastic (Fig. 12.3B). T is assem-
bly is secured to a back sur ace lathe in a clamp, or collet (Fig.
12.3C) and this assembly is set spinning at a high rate about its
central axis. Orssengo et al. (1997a) have demonstrated that the
accuracy in achieving the desired back optic zone radius can
be increased by minimizing the pressure applied to the button
when xing it into the collet o the lathe.
A ‘rough’ or preparation diamond-tipped tool is automati-
cally advanced towards the spinning button and the pos-
terior sur ace lens shape is cut by advancing the diamond
cutter rom the edge to the centre o the button (because the
button is spinning around its central axis, a cut on only one
side o the button will result in the ull width o the button
being cut) (Fig. 12.3D). he waste plastic that is lathed away
(swar ) is extracted via an air vacuum tube mounted above
the lathe assembly. Some laboratories will strive to improve
swar and sur ace management by the use o suitable cutting
luids. hese cutting luids or sprays maintain a cooler sur-
ace and assist the swar to peel away cleanly rom the button
sur ace. Any clogging o swar around the diamond tool will
very quickly result in a pitted and overheated sur ace. A ine
diamond tool is used to make the inal sur ace cut so as to
render a smooth, high-quality inish. With some lathes, the
ine cut can be so precise as to obviate the need or polishing.
his can be achieved with the use o gem-quality diamond
tools, air-bearing spindles and slides and nanometer sur ace
control. he best o these lathes can achieve a sur ace rough-
ness (Ra) close to 3–8 nm.
A diamond tool advances rom the side to reduce the button
diameter to the required size o the nished lens. T e button
is released rom the lathe and the cut sur ace is given a brie
polish – typically or about 5–30 seconds, depending on the
lathe / material combination (Fig. 12.3E). T e thickness o the
button is measured at its thinnest point (centrally) and this
in ormation is programmed into the ront sur ace lathe so that
the nal lens will be cut to the desired thickness.
123
124 PART 3 Rig id Co nt act Le nse s
Fig . 12.1 Rig id le ns p re scrib ing . (Afte r Morg an e t al., 2016.)
Fig . 12.2 Rig id le ns b uttons. (Courte sy of Polyme r Te chnolog y Boston
XO .)
In the process o lathing and polishing, care must be taken
to avoid overheating the lens material, because the generation
o excess heat can result in warpage, sur ace crazing (San ord,
1987) (Fig. 12.4) and errors in generating the desired sur ace
curvature (Orssengo et al., 1997b).
Strategies employed to avoid this problem include program-
ming the lathe to make incremental cuts rather than one contin-
uous cutting action, and passing a constant ow o air / cutting
uid over the lathing assembly to keep it cool.
GENERATING THE LENS FRO NT SURFACE
In order to generate the lens ront sur ace, the button needs to
be xed onto a mount, or arbour (which will later be secured to
a ront sur ace lathe). T is process o mounting the button onto
the arbour is known as blocking. T e arbour can be a metal or
plastic cylindrical tool, one end o which is dome shaped so that
the curve o the dome approximately matches the orm o the
posterior lens sur ace that has previously been generated. T e
operator heats the arbour to approximately 80°C and applies
low-melting-point wax to the dome end or, in the case o a plas-
tic tool, applies a UV-sensitive glue that can be cure to a hard
orm a er centering. T e newly cut back sur ace o the button is
mounted on to the wax-sur aced dome o the arbour and care-
ully centred (Fig. 12.5A) via either a centri ugal means or by
some orm o precision alignment jig.
T e arbour–button assembly is clamped into a ront sur ace
lathe (Fig. 12.5B) and the button is inspected under magni ca-
tion while spinning at low speed to con rm that it is properly
centred; i this were not the case, the ront and back sur aces
would not be co-concentric, and both prism power and uneven
edge thicknesses would inadvertently be introduced into the
lens. Once centration is con rmed, the thickness o the but-
ton is determined by a computer-controlled thickness gauge. A
series o incremental cuts is made rom the edge to the centre
with a rough preparation diamond-tipped cutter, then with a
ne diamond-tipped cutter, in precisely the same manner as or
the back sur ace (Fig. 12.5C). As ront sur ace cutting requires
that the spindle spins in the opposite direction o back sur ace
ace cutting, however, the diamond holders are mounted on
the ront sur ace lathe in di erent con gurations to the back.
T is speci c con guration allows or optimal swar and sur-
ace management. T e ront sur ace is cut to a depth that will
result in a nished lens o desired thickness. T e arbour–button
assembly is released rom the lathe and mounted in a support in
a polishing machine. T e ront sur ace is polished or about 30
seconds to 2 minutes with a so pad impregnated with a water-
based polishing compound (Fig. 12.5D).
ENGRAVING, MARKING AND FENESTRATIO N
At this juncture in the manu acturing process – with the near-
nished lens still mounted on the arbour (Fig. 12.6A) – the lens
can be engraved or marked. Engraving can be undertaken using
a pantographic device, whereby the operator traces the desired
letters to be engraved on the lens against a stainless-steel master
template into which the letter orms are impressed; such a device
is illustrated in Fig. 12.6B. ypical engravings might include ‘R’
and ‘L’ to indicate the right and le eyes, the back optic zone
radius, total lens diameter or a lens identi cation code.
I requested by a practitioner, enestrations (small holes) can
be introduced into the lens using a laser (Fig. 12.6C). T is pro-
cedure is usually done to the nished lens. Both lens sur aces are
given a light manual polish ollowing these procedures.
EDGE PO LISHING AND FINAL INSPECTIO N
T e lens is released by either ultrasonic or manual means rom
the arbour and washed in detergent to remove any excess wax
remaining on the lens sur ace. Edge polishing can be carried out
using a polishing machine such as that illustrated in Fig. 12.7A.
(With certain lens designs and lathes, the lens edge can be n-
ished with a smooth, ne cut so that polishing is not required.)
T e lenses are xed to a support arm by placing the lens ront
sur ace onto a concave rubber cup support, through which air
is drawn to ‘suck’ the lens rmly in place. T e spindle rotates
around its long axis, and the spinning lens is lowered onto a
at rotating polishing pad and moved slowly rom side to side.
By doing this, the polishing pad alternately brushes towards the
anterior and posterior edges, creating a smooth, rounded edge.
A er polishing, the lens is supported in a small suction
holder and the edges are inspected using a 10× hand magni er
 12 Rig id Le ns Manufact ure 125

Fig . 12.3 Ge ne rating the rig id le ns b ack sur ace . (A) Back sur ace lathe . (B) Button ab o ut to b e mounte d in d olly. (C) Button–d olly asse mb ly is col-
le cte d in lathe . (D) Back sur ace curve b e ing cut into the b utton with a d iamond -tip p e d tool. (E) Back sur ace p olishing . (Courte sy of Ste rling Ultra
Pre cision.)
126 PART 3 Rig id Co nt act Le nse s

(Fig. 12.7B). Any irregularities can be recti ed manually by pol-

ishing the lens – again supported in a suction holder – against a
small rotating polishing pad (Fig. 12.7C). Ehrmann et al. (1999)
have described an optical pro lometer that can accurately por-
tray the edge pro le o rigid lenses; such a system may pave
the way to a more exact approach to the edge nishing o rigid
lenses in the uture. Modern digital optical inspection devices
can also provide a highly accurate and detailed image o the lens
edge and sur ace.
T e key parameters o the lens – power, back optic zone
radius, total diameter, optic zone diameter and thickness –
are checked (see Chapter 14), to ensure that these all within
expected tolerances (see Appendix B). I all is well, the lens is
cleaned and dispatched to the customer. Proctor (1997) advises
that rigid lenses should be soaked or 24 hours prior to checking
the lens parameters because certain lens orms may display a
small amount o attening upon hydration (Proctor and E ron,
Fig . 12.4 Crazing and cracking ap p e aring in a rig id le ns that has b e e n
imp rop e rly manu acture d ; this could b e d ue to ove rhe ating d uring lath-
1997).
ing or use o an inap p rop riate solve nt. Lenses may be dispatched in solution or dry. I supplied dry,
the practitioner should soak the lenses or at least 4 hours be ore

Fig . 12.5 Ge ne rating the rig id le ns ront sur ace . (A) Blocking the b utton o n to a b rass arb our. (B) Fro nt sur ace lathe . (C) Front sur ace curve b e ing
cut into the b utton with a d iamond -tip p e d kni e . (D) Front sur ace p olishing .
 12 Rig id Le ns Manufact ure 127

Fig . 12.6 Custom mod if catio n. (A) Ne ar-f nishe d le ns orm wax-
mounte d on the b rass arb our. (B) Pantog rap hic syste m or le ns e n-
g raving . (C) Lase r syste m or toric le ns scrib e marking and introd uc-
ing e ne strations.

dispensing them to the patient, to ensure optimal lens sur ace
wettability.
Merindano et al. (1998) used the techniques o inter erential
shi ing-phase microscopy and scanning electron microscopy
to examine the sur aces o unworn rigid lenses manu actured
using lathe cutting. T ey ound a higher degree o sur ace irreg-
ularities in lenses made rom materials o higher oxygen per-
meability. T ese results may give insights into actors such as
sur ace wettability and propensity or deposit ormation, but are
unrelated to lens com ort as the irregularities were measured on
a nanometre scale and there ore could not be detected by the
human cornea.
Sp e cialt y Rig id Le ns Manufact ure
Computer numerically controlled lathes have ushered in a
new era in which virtually any curve a practitioner wants can
be cut. T e lathes are controlled rom a centre point to achieve
the desired rate o change rom centre to edge. T ey have also
reduced the need or excessive polishing. T is helps to ensure
that the lenses produced are consistent and easily duplicated.
From the desired base curve, the computer mathematically cal-
culates the spline curve, which starts at the optical zone and
ends at the tip o the lens.
TO RIC RIGID LENS MANUFACTURE
Either sur ace o a rigid lens will sometimes require a toric orm
or the correction o astigmatism and / or to achieve rotational
stabilization. T is can be achieved by directly lathing a toric sur-
ace on to the button, or by a technique known as crimping.
T e process o directly lathing a toric back sur ace on to the
lens button is achieved by using a y-cutter, which is a diamond
tool that has its cutting tip set at right angles to the axis o its
support shank. T e positions o the y-cutter and lens blank
are reversed, so that the lathe manoeuvres the lens button in
an arc around the y-cutter, which spins in a xed position. A
similar principle is applied or generating a ront toric sur ace.
128 PART 3 Rig id Co nt act Le nse s

Fig . 12.7 Ed g e p olishing and insp e ction.

(A) Two le nse s suction-mounte d to the
sp ind le s o an e d g e -p olishing machine ,
re ad y to b e lo we re d on to rotating p ad s.
(B) Insp e cting the le ns e d g e s using a 10×
hand mag nif e r. (C) Manual p olishing o the
le ns e d g e .

An alternative direct-cutting technique involves the principle o
pulsing either the diamond tool or the spindle containing the
lens itsel in an orthogonal axis to the lens sur ace that is to be
cut. By adjusting the stroke length o the pulses in conjunction
with the spindle revolution and eed rate, rotationally non-sym-
metrical shapes can be generated.
o generate a toric back sur ace using the technique o
crimping, a spherical back curve is cut into the button in the
usual way, except that a stepped rim is also engraved into the
base o the blank. T e curvature o this sur ace is the average
o the required toric radii o the nished lens. T e button is
machined down to about 0.20 mm thick so that it can be exed
to the desired amount. T e button is placed in a crimping tool
with the concave sur ace acing upwards; this tool is a orm o
clamp that allows pressure to be incrementally applied to the
rim o the button until it bends by a measured amount. T e
extent o bending is monitored optically using a conventional
radiuscope.
T e crimping assembly containing the exed button is xed
to the spindle o a lathe and set spinning. A spherical sur ace
is cut into the rotating exed button. When the button is even-
tually released rom the crimping tool, it reverts to its natural
shape and the lathed sur ace assumes a toric orm. T e lens is
blocked and a spherical curve can be generated on the ront
sur ace. Crimping is used again to generate a toric ront sur-
ace i required. Orssengo et al. (1997c) have described how
variations in crimping pressure and the preliminary radius o
curvature o the back lens sur ace prior to crimping can in u-
ence the average back sur ace curvature and degree o toricity
achieved.
ASPHERIC RIGID LENS MANUFACTURE
Aspheric sur aces can be generated or two main purposes:
1. o provide an enhanced lens t, by more closely matching
the aspheric sur ace o the cornea.
2. o provide a progressively changing power pro le across
the lens to correct longitudinal spherical aberration or
presbyopia.
Modern lathing techniques enable these complex curves to be
generated accurately and in a consistent manner.
REVERSE-GEO METRY LENS MANUFACTURE
Reverse-geometry designs, in which the peripheral curves are
steeper rather than atter than the base curve, were not pos-
sible with older lathe technology. T e ability to generate such
pro les is required to produce lenses suitable or modern ortho-
keratology, where the atter central curve is used to atten the
cornea, but the steeper periphery aids centration (see Chapter
32). It is now possible to generate steeper or atter curves just in
the periphery o the in erior quadrant to minimize or eliminate

edge stand-o . Previously this might have been done manually,
but the lenses were inherently almost impossible to reproduce.
Ind ust ry Re g ulat io n
In Europe, the control o contact lenses and contact lens care
products is regulated by the European Medical Devices Directive.
T is directive sets out requirements to which each device must
con orm – there are thousands o medical devices covered by the
directive – and the associated trade then devises appropriate man-
agement mechanisms to ensure the con ormity o its products.
Devices con orming to the directive should carry the European
standard CE mark. Since June 1998, it has been illegal either to sell
or buy a contact lens that does not have the CE mark af xed to it.
T e CE marks are dispensed through what are called noti-
ed bodies. Companies wishing to af x the CE mark to their
products must be registered as an approved manu acturer with
a noti ed body, which will provide them with authority to use
the mark. In order to get on the approved list o a noti ed body,
manu acturers o contact lenses are generally required to have:
(1) implemented a quality system, typically ISO 9002, and then
(2) applied the medical device-speci c CE requirements in the
orm o a urther layer o bureaucratic controls set out in EN
46002. T is procedure has become the de facto approach used
by UK contact lens manu acturers who have obtained the CE
mark or their products, and looks set to be the normal pathway
or complying with the regulations. A principal activity o the
noti ed bodies is to audit the device manu acturer to make sure
that the procedures in use are such that devices made in the
system comply with the directive.
An un ortunate outcome o working within a regulated
industry is that new product development is a slower and
more expensive process. Such regulations do not provide or
the ‘ ast-track’ approach o the 1980s, when new materials and
designs moved rapidly rom research and development to the
clinic. Certainly, there has been a noticeable decline in the pat-
tern o requent releases o new highly permeable materials
and innovative back sur ace designs into the marketplace since
the new European regulatory ramework came into being
(Hough, 1997).
12 Rig id Le ns Manufact ure 129
Co nclusio n
T ere is ever-increasing commercial pressure in the average
optical practice to prescribe so contact lenses, and a certain
amount o peer pressure to do the same (E ron, 2010). Mass
media consumer advertising by major so lens manu acturers
rein orces this trend by continuously highlighting the clear ben-
e ts o the com ort and convenience o disposable so lenses.
Modern contact lens lathes based on the latest developments
in computer control systems and precision engineering have
resulted in sophisticated designs that can address the most com-
plex o ocular disorders.
T e huge numbers o so lenses produced to meet the
requirements o disposable and requent-replacement wear-
ing modalities could easily give the impression that rigid lenses
orm a very minor part o contact lens practice; indeed, in the
UK between 1996 and 2005, rigid lens new ts decreased rom
22% to 4% (Morgan and E ron, 2006), and this low level o rigid
lens prescribing has remained low, being 6% in 2015 (Morgan
et al., 2016). However, even though rigid lens manu acture is
labour intensive and expensive, the survival o this sector attests
to the act that there is an ongoing clinical requirement or rigid
lenses. Other orces serving to preserve rigid lens sales include
inertia in the prescribing habits o more traditional practitio-
ners, demand rom existing wearers who are satis ed with the
product, trends towards requent rigid lens replacement (see
Chapter 20) and, perhaps most importantly, the willingness
o some practitioners to embrace the challenges o specialty
rigid lens tting to achieve the best possible outcomes or their
patients. Fortunately there appears to be a suf cient market or
rigid lenses to enable the small, specialized manu acturers to
survive.
ACKNO WLEDGEMENTS
T e authors would like to thank Joe anner, Bruce Workman and Steve
Newman or their assistance in writing and illustrating this chapter.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
REFERENCES
E ron, N. (2010). Obituary – rigid contact lenses.
Cont. Lens Anterior Eye, 33, 245–252.
Ehrmann, K., Ho, A., & Schindhelm, K. (1999). A
novel method to quanti y the edge contour o
RGP contact lenses. Cont. Lens Anterior Eye, 22,
19–25.
Hough, . (1997). Rigid lens manu acture in the
1990s. Optician, 214(5612), 24–28.
Merindano, M. D., Canals, M., Saona, C., et al.
(1998). Rigid gas permeable contact lenses sur-
ace roughness examined by inter erential shi ing
phase and scanning electron microscopies. Oph-
thal. Physiol. Opt., 18, 75–82.
Meyers, W. E. (1997). T e clinical implications o
contact lens machinability. CL Spectrum, 12,
36–40.
Morgan, P. B., & E ron, N. (2006). A decade o con-
tact lens prescribing trends in the United Kingdom
(1996–2005). Cont. Lens Anterior Eye, 29, 59–68.
Morgan, P. B., & E ron, N. (2008). T e evolution o
rigid contact lens prescribing. Cont. Lens Anterior
Eye, 31, 213–214.
Morgan, P. B., Woods, C. A., ranoudis, I. G., et al.
(2016). International contact lens prescribing in
2015. CL Spectrum, 31(1), 28–33.
Orssengo, G. J., Pye, D. C., & Ho, A. (1997a). Analy-
sis o the colleting method o producing spheri-
cal sur aces in contact lens blanks using nite
element and experimental methods. Cont. Lens
Anterior Eye, 20, 41–48.
Orssengo, G. J., Pye, D. C., & Ho, A. (1997b). Varia-
tion in optic zone radii o a contact lens during
manu acturing and the e ects o temperature on
this variation. Cont. Lens Anterior Eye, 20, 143–151.
Orssengo, G. J., Pye, D. C., & Ho, A. (1997c). Analy-
sis o the crimping method o producing toric sur-
aces in contact lens blanks using nite element
and experimental methods. Cont. Lens Anterior
Eye, 20, 49–55.
Proctor, E. (1997). Contact lens manu acturing. In
A. J. Phillips, & L. Speedwell (Eds.), Contact Lens-
es (4th ed., pp. 777–800). Ox ord: Butterworth-
Heinemann.
Proctor, E., & E ron, N. (1997). Radical changes to
back optic zone radii o rigid gas permeable con-
tact lenses. Cont. Lens Anterior Eye, 20, 172.
San ord, M. (1987). Crazing acts and opinions.
Contact Lens Forum, 12(7), 54.
129.e 1
13
Rig id Le ns O p t ics
W NEIL CHARMAN
Int ro d uct io n
Unlike so lenses, which drape to t the cornea so that on the
eye the geometry o the back sur ace closely con orms to that o
the anterior cornea, the back sur ace o a rigid lens maintains its
shape. As a result, a tear lens o predictable orm and power is
generated between the contact lens and the cornea. T e overall
optical system producing the retinal image there ore e ectively
contains three elements: the rigid lens, the tear lens and the eye
itsel . We can imagine each o these elements as being separated
rom its neighbour by an in nitely thin lm o air (Fig. 13.1A).
T is chapter is largely concerned with the role o the tear lens
and the actors that in uence its properties. Aberration will also
be discussed. Questions o e ectivity, spectacle magni cation
and related matters are addressed in Chapter 3.
Basic Te ar Le ns Pro p e rt ie s
T e power o the tear lens, sometimes called the liquid, uid
or lacrimal lens, depends on the relative geometry o the optic
zone o the back sur ace o the rigid lens and the anterior sur-
ace o the cornea. Fig. 13.1B shows possible variations on the
basic tear lens orm. T e tear lens may contribute negative, zero
Fig . 13.1 (A) The b asic te ar le ns conce p t. Althoug h e xag g e rate d o r
clarity, the air g ap s b e twe e n the contact and te ar le nse s and te ar le ns
and corne a are e e ctive ly ne g lig ib le . Se e te xt or d e f nitions o r1, r2 and
rC. (B) Ge ome try o the te ar le ns as a unction o f t.
130
or positive power to the overall lens–eye system, depending on
whether the tting o the rigid lens is at, in alignment or steep,
respectively.
From a clinical perspective it is important to determine the
likely magnitude o the power o the tear lens and how it varies
as the back optic zone radius (BOZR) o the lens is changed. I
r 1 and r 2 are the ront optic zone radius (FOZR) and BOZR o
the rigid lens and r C is the radius o the anterior cornea, then the
ront and back radii o the tear lens are r 2 and r C, respectively.
With corneal lenses it is reasonable to consider that the thick-
ness o the tear lens can be neglected, so that its power, F , will
there ore be:
FT = (n T − 1) (1/r 2 − 1/r C ) = (n T − 1) (r C − r 2 ) /r 2 r C (Eq. 13.1)
where n is the re ractive index o the tears (1.336). Both r 2
and rC will normally be about 8 mm. T is gives, with adequate
accuracy:
( −6
)
FT = (1.336 − 1) (r C − r2 ) / 64 × 10
where the radii are in metres. Setting, as an example, r C − r 2 = 0.05
mm, we nd:
( −3
)
FT ≈ (0.336) · 0.05 × 10 /64 × 10 − 6 ≈ + 0.25D
T us, as an approximate rule o thumb, or a rigid lens the tear
lens power increases by about +0.25 D or each 0.05 mm that
the BOZR o the lens is steeper than the corneal radius. Cor-
respondingly, on any cornea the back vertex power (BVP) o
the rigid contact lens needs to be changed by −0.25 D or each
0.05 mm that the BOZR is made steeper, to compensate or the
extra positive power o the liquid lens. I the lens BOZR is made
atter by 0.05 mm, the BVP needs to be changed by +0.25 D.
More exact calculation o F can, o course, be carried
through using Eq. 13.1. T e approximation is less acceptable or
corneas that are much steeper or atter than the normal value o
about 7.8 mm. T is can be seen i we note that, or small changes
δr2 in r 2, we can write or the change, δF , in tear lens power:
δFT = (δFT /δr 2 ) δr 2 = − [ (n T − 1) /r 2 2 ] δr 2
T at is, or a given change in r 2, the change in tear lens power is
actually inversely proportional to r 22.
The Te ar Le ns During Trial Le ns Fit
rial or diagnostic lenses are o en used to nd the BOZR that
gives the required t with a particular lens design – an over-
re raction then being carried out to determine any additional
power needed in combination with the trial lens used to give the
patient clear vision. In this case the ordered lens power is sim-
ply the sum o the BVP o the trial lens and the overre raction
(assuming that the power o the latter is small enough or e ec-
tivity to be ignored; see Chapter 3). T is is because the BOZR

and corneal radii, r2 and r C, with the nal lens will be exactly the
same as with the trial lens, so that the tear lens has equal power
in both cases (Fig. 13.2).
Re q uire d BVP w he n t he Le ns t o Be
O rd e re d has a Diffe re nt BO ZR fro m
t he Trial Le ns Use d
T e situation may arise where a trial lens with a given BOZR
is not available, in which case it may be necessary to order a
lens with a BOZR that di ers rom that o the trial lens actually
used. Since the BOZR, r 2, in the two cases di ers, so also will
the power o the tear lens, and this in turn will in uence the
required BVP o the ordered lens. T is e ect is best illustrated
by an example (Fig. 13.3).
Suppose that the trial lens giving a t that is closest to that
desired has a BOZR o 8.10 mm and a BVP o −3.00 D. With
this lens, an overre raction o +1.00 D is ound. Consideration
o uorescein patterns and the corneal radius, however, suggests
that trial lens t is too steep and that the ordered lens should
have a BOZR (r2) = 8.25 mm. Qualitatively, it can be seen rom
Fig. 13.3 that this attens the ront sur ace o the tear lens and
hence tends to make its power less positive. o compensate or
this, the nal contact lens must have relatively more positive
power. What is the required BVP or the ordered lens?
Fig . 13.2 Ge ome try o the rig id le ns and the te ar le ns whe n a trial le ns
with the same b ack op tic zone rad ius (BO ZR) as the f nal le ns is use d .
BVP = b ack ve rte x p owe r.
Fig . 13.3 Chang e in te ar le ns g e ome try and re q uire d b ack ve rte x
p owe r (BVP) whe n the b ack op tic zone rad ius (BO ZR) o the ord e re d
le ns d i e rs rom that o the trial le ns.
13 Rig id Le ns O p t ics 131
Evidently, taking into account the BVPs o the trial lens and
the overre raction, the ideal BVP or a lens o the original 8.10
mm BOZR would be:
F'V = − 3.00 + 1.00 = − 2.00 D
T us light would leave the back sur ace o the correcting lens o
8.10 mm BOZR with a vergence o −2.00 D. T e power o the
anterior sur ace o the original tear lens (in air) is:
( −3
)
(1.336 − 1) / 8.10 × 10 = + 41.48 D
Using the general vergence equation,
L' − L= F
where L and L′ are the object and image vergences, respectively
and F is the sur ace power, we nd that, a er passing through
the anterior sur ace o the tear lens, the vergence o the light
would be:
− 2.00 + 41.48 = + 39.48 D
I we assume that the tear lens has negligible thickness, this ver-
gence incident upon the rear sur ace o the tear lens will correct
the eye.
Now consider the ordered lens with a BOZR o 8.25 mm.
Since the rear sur ace o the tear lens is unchanged, we again
require that the vergence o the light leaving the anterior sur ace
o the tear lens be +39.48 D. T e power o the anterior sur ace
o the new tear lens is:
( −3
)
(1.336 − 1) / 8.25 × 10 = + 40.73 D
T us the vergence, L, incident upon the anterior sur ace o the
tear lens must be:
L= L' − F = 39.48 − 40.73 = − 1.25 D
As this vergence is provided by the correcting lens, the required
BVP or the ordered lens o BOZR 8.25 mm is −1.25 D (as
compared with the value o −2.00 D or a lens o BOZR 8.10
mm). T is agrees well with our earlier rule o thumb, which sug-
gests that, as the BOZR is 0.15 mm (or 3 × 0.05 mm) atter, the
required BVP must be +0.75 D (or 3 × 0.25 D) more positive
than its original value o −2.00 D – i.e. the required BVP is −1.25
D, as also ound by the more exact approach.
Calculat io n o f Re q uire d Surface Rad ii
fro m a Trial Le ns Fit
Assuming that the BOZR that gives the desired t has been
determined by the use o trial lenses, it is o interest to deter-
mine what value o FOZR, r 1, is needed to give the required
BVP, given values or the centre thickness and re ractive index
or the lens. Again, it is help ul to give an illustrative example to
demonstrate the thick lens calculation involved.
Let us suppose that it is ound that a good t is achieved with
a trial lens o BVP −7.00 D and a BOZR o 8.00 mm. T e overre-
raction is −1.00 D at a vertex distance o 13 mm. T e lens index
is 1.49 and its centre thickness is to be 0.30 mm.
We are justi ed in ignoring tear lens e ects as these are iden-
tical or the initial and nal lens. As the overre raction is small,
e ectivity can be ignored and the required BVP or our nal
lens is −8.00 D.
T e power o the back sur ace o the nal lens is:
( −3
)
F2 = (1 − 1.49) / 8.00 × 10 = − 61.25 D
132 PART 3 Rig id Co nt act Le nse s

As we require the emergent vergence at the back sur ace to be:

F 'V = L2 ' = − 8.00 D
the incident vergence at that sur ace, L2, must be:
L2 = L2 ' − F2 = − 8.00 − (− 61.25) = + 53.25 D
But L2 = 1.49 / l2, so that the object distance, l2, or the second
sur ace is:
l2 = 1.49/L2 = 1.49/(+ 53.25)m = + 27.98 mm
T us, or a centre thickness o 0.30 mm, the image distance or
the rst sur ace is:
l1 ' = 27.98 + 0.30 = 28.28 mm
and the corresponding image vergence is:
( −3
) than the anterior radii (i.e. r 180 = 6.93 mm, and r 90 = 6.24 mm),
L1 ' = 1.49/l1 ' = 1.49/ 28.28 × 10 = 52.69 D
As, or a distant object, the incident vergence at the rst sur ace
is zero, the exiting vergence L1’ must correspond to the power
o the sur ace, that is:
F1 = (1.49 − 1) /r1 = 52.69 D
where r 1 is in metres. T is gives r 1 = 9.30 mm. I a toric lens is
required, the same process can be repeated in each principal
meridian.
Ne ut ralizat io n o f Co rne al
Ast ig mat ism b y a Rig id Le ns o f
Sp he rical Po w e r
We can see qualitatively that, in air, the astigmatism arising
rom a di erence in the radii r C1 and r C2 in the two principal
meridians o the anterior cornea is:
(n C − 1) (1/r C1 − 1/r C2 )
where n C is the corneal index. I , however, the anterior cornea
is in contact with the tears rather than air, this astigmatism is
reduced to:
(n C − n T ) (1/r C1 − 1/r C2 )
aking nC as 1.376 and n as 1.336, we see that the astigmatism
is likely to be reduced by a actor:
(n C − n T ) / (n C − 1) = 0.040/0.036 ≈ 0.1 ×
In act the situation is slightly more complex than this
because o the contribution o the rear sur ace o the cornea to
the overall corneal astigmatism, but this does not alter the basic
conclusion that corneal astigmatism can be almost completely
neutralized by the use o a spherical rigid lens. An example will
illustrate this (Fig. 13.4).
Suppose that the anterior sur ace o the cornea shows with-
the-rule astigmatism, with:
r 180 = 7.70 mm, giving power
( −3
)
F180 = (1.376 − 1) / 7.70 × 10 = 48.83 D
r90 = 6.93 mm, giving power
( −3
)
F90 = (1.376 − 1) / 6.93 × 10 = 54.26 D
Hence the astigmatism o the anterior sur ace o the cornea is:
F90 − F180 = 54.26 − 48.83 = 5.43 DC (with-the-rule)
Fig . 13.4 Situation with a sp he rical contact le ns on an astig matic cor-
ne a. (A) Basic le ns g e ome try; (B) ante rior corne al and p oste rior te ar le ns
rad ii (mm); (C) p oste rior corne al rad ii.
Now suppose that the posterior corneal radii are 10% smaller
and that the re ractive index o the aqueous humour is 1.336.
T e posterior meridional powers will be:
( −3
)
F180 = (1.336 − 1.376) / 6.93 × 10 = − 5.77 D
( −3
)
F90 = (1.336 − 1.376) / 6.24 × 10 = − 6.41D
T us the astigmatism o the posterior sur ace is:
F90 − F180 = − 6.41 + 5.77 = − 0.64 DC
T e total uncorrected corneal astigmatism is thus slightly lower
than that due to the anterior sur ace alone, i.e.:
5.43 − 0.64 = 4.79 DC (with-the-rule)
What is the e ect o a spherical rigid contact lens? As the lens
itsel and the anterior sur ace o the tear lens can contribute only
spherical power, they do not a ect the astigmatism. T e powers
o the posterior sur ace o the tear lens are:
( −3
)
F180 = (1 − 1.336) / 7.70 × 10 = − 43.64 D
( −3
)
F90 = (1 − 1.336) / 6.93 × 10 = − 48.48 D
i.e. F90 − F180 = − 4.84 DC
When balanced against the astigmatism o the cornea, this
leaves a mere 4.79 − 4.84 = −0.05 DC o uncorrected astigma-
tism o corneal origin, so that the original corneal astigmatism
has been almost completely neutralized. Note that this does not
depend in any way upon the re ractive index o the correcting
lens. Any residual astigmatism due to the crystalline lens will,
o course, remain uncorrected. Very occasionally a patient may
be encountered who has a spherical re ractive error but non-
zero corneal astigmatism. T is there ore implies that the resid-
ual (lenticular) astigmatism is o opposite sign to the corneal
astigmatism and that correcting the corneal astigmatism with a
spherical rigid lens will leave the residual astigmatism mani est.
In such cases a spherical so lens will result in better visual acu-
ity, as the ailure o the so lens to correct the corneal astigma-
tism will allow the balance between the corneal and lenticular
astigmatism to be maintained.
Although the above discussion has concerned regular astig-
matism, it is obvious that irregular astigmatism and, indeed,
general corneal irregularity will similarly be masked by a spher-
ical lens and its accompanying tear lens (see below).
It is, however, important to note that, although nominally a
spherical rigid lens will neutralize any value o corneal astig-
matism, the tting relationship is likely to be unsatis actory
 13 Rig id Le ns O p t ics 133

or corneal astigmatism greater than about 2.00 DC. T us or +

higher levels o astigmatism some orm o toroidal correction is
required (see Chapter 16).
Excellent expositions o urther rigid and so lens calcula-
tions o this type, together with many numerical examples, are
given by Ford and Stone (1997) and Douthwaite (2005).

Ab e rrat io ns o f Rig id Co nt act Le nse s

As in the case o so lenses, the steep sur ace curvatures o rigid
lenses mean that, i they remain well centred, their major aber-
ration in relation to oveal imagery ought to be spherical aberra-
tion (Westheimer, 1961). Early calculations by Campbell (1981)
emphasized that it was the aberration o the combined lens–
eye system that was o importance, rather than that o the lens
alone in air; it appeared that the dominant actor was the orm
+
o the ront sur ace o the lens, although amounts o spherical
aberration were likely to be low. Cox (1990) went on to demon-
strate that levels o spherical aberration started to reduce visual
per ormance signi cantly only or pupils larger than 6 mm
and when rigid lens powers were more positive than −3.00 D.
Hammer and Holden (1994) broadly agreed with these results
and pointed out that, or conicoidally aspheric lens sur aces, on-
eye aberration became more positive as the p-value o the ront
sur ace was increased and, to a lesser extent, more negative as
the p-value o the back sur ace was increased.
Atchison (1995) made the important point that, although
a well-centred aspheric contact lens might reduce the overall
spherical aberration with respect to a lens with spherical sur aces,
this advantage could break down i the lens decentred by more
than about 1 mm, when substantial amounts o coma and de ocus
could be introduced, depending upon the exact lens parameters Fig . 13.5 Sp ot d iag rams or a + 6.00 D le ns comb ine d with a sp he rical
involved. Image quality with a spherical lens is generally more co rne a, as a unction o d e ocus and d e ce ntration. Le ns d isp lace me nts
are 0 mm (top row), 1.0 mm (mid d le row) and 1.5 mm (b ottom row).
robust against decentration. T is is illustrated in Fig. 13.5, which Each row shows various p lane s o ocus. The g aussian imag e p lane is
shows spot diagrams (i.e. retinal images o a point as calculated by at 0.0 mm and ne g ative value s corre sp ond to move me nt o the imag e
ray optics) or the case o a +6.00 D lens and a 5 mm pupil. Vari- p lane toward s the corne a. (A) Sp he rical contact le ns. (B) Rig id contact
ous combinations o de ocus and decentration are shown. le ns with an asp he ric ront sur ace (p = + 0.6): the chose n p -value ne arly
e liminate s sp he rical ab e rration, g iving minimal b lur in the g aussian im-
Relatively ew earlier experimental studies explored the ag e p lane (0.0 mm). (Ad ap te d from Atchison, D. A. (1995) Ab e rrations
possible impact o the spherical aberration o rigid contact associate d with rig id contact le nse s. J. O p t. Soc. Am. A, 12, 2267–2273.)
lenses on visual per ormance. Collins et al. (1992), however,
ound that when a group o 12 subjects was tted with rigid
lenses with ront-sur ace asphericities corresponding to p = 1.0 associated with the crystalline lens remains uncorrected, how-
(sphere), 0.74 and 0.49 ( attening ellipsoids), both high- and ever. In broad terms, it can be seen that similar compensation
low-contrast photopic visual acuities were statistically identical is likely to occur or the other higher-order aberrations asso-
with all lenses. In mesopic conditions, when pupils were larger, ciated with the asymmetries and irregularities o the cornea
low-contrast visual acuity was signi cantly worse with the (Grif ths et al., 1998). T e result is that, as ar as the earlier
p = 0.49 lenses, but only by one line. Interestingly, when asked parts o the contact lens–eye system are concerned, the origi-
which lens they pre erred, all except three subjects chose the nal corneal aberrations become relatively unimportant and it
lenses with a spherical (p = 1.0) ront sur ace. T ose who chose is the aberrations associated with the anterior sur ace o the
the lenses with p = 0.74 had demonstrably better visual per or- contact lens that dominate. However, the part o the original
mance with them than with the other lenses. T us, although the ocular wave ront aberration that was contributed by the crys-
e ects o rigid lens spherical aberration on visual per ormance talline lens will not be a ected by the presence o the contact
at photopic levels were generally small, there was some evidence lens. T us the overall wave ront aberration o the rigid contact
that asphericities that optimized vision or the individual were lens–eye system will approximate to the sum o that due to the
appreciated by the wearer. anterior sur ace o the contact lens and that due to the crystal-
More recent work using wave ront aberrometry has clari ed line lens o the eye.
some aspects o the e ects o rigid lenses on the combined lens– T e impact o these rigid lens-induced changes will depend
eye aberration in individual patients. upon the balance between the contributions to the ocular wave-
As discussed earlier, the e ect o a spherical rigid lens ront aberration made by the cornea and the crystalline lens.
and the associated tear lens is to neutralize almost all o the How do these contributions compare? Intriguingly, recent stud-
eye’s original corneal astigmatism (i.e. the cornea’s second- ies con rm what had been suspected rom earlier work (El Hage
order astigmatic wave ront errors). T e residual astigmatism and Berny, 1973; Millodot and Sivak, 1979): in young adult eyes
134 PART 3 Rig id Co nt act Le nse s
the aberrations o the cornea, particularly spherical aberration,
tend to be o similar magnitude but opposite sign to those o
the lens, so that the aberrations o the total eye are o en smaller
than those o its component parts (Artal et al., 2002; Kelly et al.,
2004). However, the degree o balance between corneal and len-
ticular aberration varies between individuals and tends to dete-
riorate with age, largely as a result o increases in the wave ront
errors o the crystalline lens. It appears likely that aberration-
balancing occurs passively as a result o the basic optical design
o the eye, rather than being an active process like emmetropiza-
tion (Artal et al., 2006).
T e key point is that elimination o corneal aberrations by a
suitable design o contact lens does not necessarily reduce the
wave ront aberration o the complete contact lens–eye system.
Practical measurements o aberrations with eyes wearing rigid
lens support this conclusion (Lu et al., 2003; Choi et al., 2007).
Contact lenses may either reduce or increase the higher-order
wave ront aberration compared with that o the original eye.
T ose subjects whose aberrations are dominated by high levels
o corneal aberration are likely to have reduced aberrations
with rigid lens wear, whereas those with low initial levels o
both corneal and total aberrations may su er rom an increase
in aberrations during lens wear. Rigid lens wear is, then, likely
to be help ul in reducing the e ect o higher-order aberrations
in corneal conditions such as keratoconus (Grif ths et al.,
1998; Dorronsorro et al., 2003; Choi et al., 2007; Jinabhai et al.,
2012)
It is important to note that contact lens wear does not simply
introduce changes in spherical aberration; it also a ects coma
and other asymmetric aberrations, presumably as a result o ac-
tors such as the lack o rotational symmetry in the cornea and
decentration o the contact lens. What is not clear at the pres-
ent time is the longer-term e ect o rigid lens wear on lens–eye
aberrations. Gross corneal warpage has long been recognized as
a possible problem o rigid-lens wear (E ron, 2004) and it may
be that some corneal change occurs in all eyes. Associated aber-
rational changes may be small, however, owing to the masking
e ect o the tear lens.
All recent authors (Hong et al., 2001; Dorronsorro et al.,
2003; Lu et al., 2003; Choi et al., 2007) agree that aberrome-
try can provide a better understanding o the on-eye e ects o
rigid lenses on the vision o individual patients. Undoubtedly
urther studies will clari y the bene ts o particular materials,
lens designs and tting philosophies in reducing aberration and
increasing visual per ormance.
O t he r Rig id Le ns Effe ct s
Certain optical e ects occur when rigid lenses move during
wear, or are distorted over time, via interactions between the
lids, the lens and the cornea. Disturbing optical e ects can also
result rom re ections o the lens edge or optical zone junc-
tions. T ese phenomena are considered here.
PRISMATIC EFFECTS DUE TO DECENTRED O R
TILTED LENSES
Prismatic e ects may arise as a result o the lens either decen-
tring or tilting, the latter o en being due to pressure rom the
upper lid. o a reasonable approximation, the corneal lens and
the associated tear lens will both become decentred by the same
amount with respect to the pupil centre, so that, applying the
Prentice rule, P = Fc, where P dioptres is the prism power result-
ing rom a decentration o c centimetres and F is the combined
dioptric power o the contact lens and tear lens. I , or example,
F = ±10 D and there is 1 mm o lens decentration, a 1 dioptre
prism can be induced. T is will be o little importance i simi-
lar e ects occur in both eyes – that is, i the correcting pow-
ers are similar and tting has ensured that similar amounts o
movement occur in the two eyes. Fuller discussions o prismatic
e ects are ound in Ford and Stone (1997) and Douthwaite
(2005).
FLEXURE EFFECTS WITH RIGID CO RNEAL
LENSES
Although the basic assumption o this discussion has been that
a spherically powered rigid lens remains so when placed on the
eye, these lenses may ex on strongly toroidal corneas, particu-
larly when the lenses are thin (Harris and Chu, 1972). T is leads
to a ailure to correct the corneal astigmatism. Steps that may
be taken to minimize exure in such cases include tting the
BOZR as at as possible and minimizing the back optic zone
diameter. Flexure e ects are dif cult to predict and tend to vary
as the lens moves on the eye; they are there ore best assessed
empirically by direct objective and subjective determination o
the e ectiveness o the correction.
VISUALLY DISTURBING EFFECTS WITH RIGID
LENSES
A number o disturbing visual e ects may arise with some
designs o rigid lens (Fig. 13.6). I the optic zone is small and
the eye pupil is large, the outer zones o the pupil will be imper-
ectly corrected, leading to a ‘halo’ under dim lighting condi-
tions. Similar e ects may occur with smaller pupils i the lenses
are badly decentred, so that the whole eye pupil no longer lies
within the optic zone o the lens. In cases where the overall
diameter o the lens is less than that o the cornea, discontinui-
ties and are light e ects may arise in the peripheral eld. Other
Fig . 13.6 Possib le d isturb ing e e cts arising with rig id le nse s. (A) ‘Ha-
loe s’ arising rom the op tic zone b e ing smalle r than the d ilate d p up il.
(B) Asymme tric re tinal p oint imag e s d ue to a hig h-rid ing le ns. (C) Distur-
b ance o visio n in the p e rip he ral f e ld d ue to scatte ring and re raction at
the le ns e d g e . (D) Scatte ring rom le ns d e p osits.

disturbing e ects may result rom lens deposits or, in the case o
scleral lenses, rom bubbles.
Co nclusio n
From the purely optical point o view, spherical-powered rigid
lenses have the merit o correcting modest amounts o corneal
13 Rig id Le ns O p t ics 135
astigmatism as well as any spherical re ractive errors. As exure
e ects are relatively slight, their per ormance is, perhaps, more
predictable than their so lens counterparts.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
REFERENCES
Artal, A., Berrio, E., Guirao, A., et al. (2002). Contri-
bution o the cornea and internal sur aces to the
change in ocular aberrations with age. J. Opt. Soc.
Am. A, 19, 137–143.
Artal, P., Benito, A., & abernero, J. (2006). T e hu-
man eye is an example o robust optical design.
J. Vis., 6, 1–7.
Atchison, D. A. (1995). Aberrations associated
with rigid contact lenses. J. Opt. Soc. Am. A, 12,
2267–2273.
Campbell, C. E. (1981). T e e ect o spherical aber-
ration o contact lens to the wearer. Am. J. Optom.
Physiol. Opt., 58, 212–217.
Choi, J., Wee, W. R., Lee, J. H., et al. (2007). Changes
o ocular higher-order aberration in on- and o -
eye o rigid and gas permeable contact lenses.
Optom. Vis. Sci., 84, 42–51.
Collins, M. J., Brown, B., Atchison, D. A., et al.
(1992). olerance to spherical aberration induced
by rigid contact lenses. Ophthal. Physiol. Opt., 12,
24–28.
Cox, I. (1990). T eoretical calculation o the longitu-
dinal spherical aberration o rigid and so lenses.
Am. J. Optom. Physiol. Opt., 67, 277–282.
Dorronsorro, C., Barberos, S., Llorente, L., et al.
(2003). On-eye measurement o optical per or-
mance o rigid gas permeable contact lenses based
on ocular and corneal aberrometry. Optom. Vis.
Sci., 80, 115–125.
Douthwaite, W. A. (2005). Contact Lens Optics and Lens
Design (3rd ed.). Ox ord: Butterworth-Heinemann.
E ron, N. (2004). Contact Lens Complications (2nd ed.,
pp. 187–197). Ox ord: Butterworth-Heinemann.
El Hage, S. G., & Berny, F. (1973). Contribution o
the crystalline lens to the spherical aberration o
the eye. J. Opt. Soc. Am., 63, 205–211.
Ford, M. W., & Stone, J. (1997). Practical optics and
computer design o contact lenses. In A. J. Phillips,
& L. Speedwell (Eds.), Contact Lenses (4th ed.,
pp. 154–231). London: Butterworth-Heinemann.
Grif ths, M., Zahner, K., Collins, M., et al. (1998).
Masking o irregular corneal topography with
contact lenses. CLAO J., 24, 76–81.
Hammer, R. M., & Holden, B. A. (1994). Spherical
aberration o aspheric contact lenses on eye. Op-
tom. Vis. Sci., 71, 522–528.
Harris, M. G., & Chu, C. S. (1972). T e e ect o con-
tact lens thickness and corneal toricity on exure
and residual astigmatism. Am. J. Optom. Physiol.
Opt., 49, 304–307.
Hong, X., Himebaugh, N., & T ibos, L. N. (2001).
On-eye evaluation o optical per ormance o
rigid and so contact lenses. Optom. Vis. Sci., 78,
872–880.
Jinabhai, A., Charman, W. N., O’Donnell, C., et al.
(2012). Optical quality or keratoconic eyes with
conventional RGP and simulated customised
contact lens corrections. Ophthal. Physiol. Opt.,
32, 200–212.
Kelly, J. E., Mihashi, ., & Howland, H. C. (2004).
Compensation o corneal horizontal / vertical
astigmatism, lateral coma, and spherical aberra-
tion by internal optics o the eye. J. Vis., 4, 262–271.
Lu, F., Mao, X., Qu, J., et al. (2003). Monochromatic
wave ront aberration in the human eye with con-
tact lenses. Optom. Vis. Sci., 80, 135–141.
Millodot, M., & Sivak, J. (1979). Contribution o the
cornea and lens to the spherical aberration o the
eye. Vision Res., 19, 685–687.
Westheimer, G. (1961). Aberrations o contact lens-
es. Am. J. Optom. Arch. Am. Acad. Optom., 38,
445–448.
135.e 1
14
Rig id Le ns Me asure me nt
KLAUS EHRMANN

Most rigid lens materials are relatively insensitive to ambient

Int ro d uct io n
In contrast to so lenses, rigid contact lenses are individually
tted and then lathe cut to meet particular optical, geometrical
and material speci cations (see Chapter 12). Although the man-
u acturing precision has improved signi cantly over the years,
in particular with the introduction o computer numerical-con-
trolled lathes, such improvements do not eliminate the need or
care ul lens inspection and measurements to ensure that only
good quality lenses are tted on the eye. T is quality assurance
rests predominantly with the lens laboratories, but contact lens
practitioners should also be able to con rm basic lens param-
eters and detect aulty lenses.
T e more experienced contact lens tters occasionally
modi y rigid lenses to adjust the optical power, remove sur ace
scratches or smoothen the edge pro les. Subsequent inspection
is recommended to ensure that the modi cation was success-
ul. T e identi cation o unknown materials might be a urther
reason why practitioners and laboratories need to measure
material related properties. Most aspects o contact lens quality
are covered by ISO 18369 Parts 1–4 (International Organiza-
tion or Standardization [ISO], 2006a, b, c, d) and laboratories
are obliged to deliver only lenses that do not exceed allowable
tolerances.
Based on shape, rigid contact lenses can be divided into
scleral lenses (including corneo-scleral and miniscleral lenses)
and corneal lenses. Optical eatures can include aberration con-
trol, astigmatic correction, or translating or simultaneous add
powers or treating presbyopia. Orthokeratology lenses correct
vision by reshaping the corneal sur ace. Each o these lenses has
its own critical set o parameters and requires speci c methods
o inspection to ensure good vision and patient satis action.
T e list o parameters that need to be checked on rigid lenses
can be grouped into three main categories:
Lens geometry:
Lens and optic zone diameters
Centre and edge thickness
Back and ront sur ace radius o curvature
Edge pro les
Optical properties:
Power and power pro les
Optical quality and sur ace de ects
Material properties:
Wettability
Friction
Oxygen permeability
Re ractive index
Modulus
Luminance transmittance
Sur ace hardness.
136
temperature and relative humidity, and can be measured under
normal laboratory or practice environment conditions.
Le ns Ge o me t ry
Despite being called ‘rigid’, nished rigid lenses can be very
exible and can de orm permanently or temporarily when
put under stress. It is there ore important to keep the lens ree
rom external orces when measuring geometrical parameters
(McMonnies, 1989). T ere have been reports to suggest that
uptake o water or disin ection solution can also alter the shape
o rigid lenses (Piccolo et al., 1990), but these e ects appear to
be minor and generally o no concern.
LENS AND O PTIC ZO NE DIAMETERS
T e V-gauge is a simple and easy-to-use method with adequate
accuracy to measure the outside diameter o rigid lenses. A
tapered channel is cut into a strip o plastic with diameter mark-
ings along the channel. Fig. 14.1 illustrates the use o such a device.
T e lens is placed in the wider opening on the right hand side and
then gently notched towards the le until it touches the opposite
side o the channel. T e diameter value o the precalibrated scale
is read rom the position at which the lens touches the channel.
Projection systems such as calibrated loupes or slit lamps tted
with measuring graticules can also be used to measure lens diame-
ters. T ey are reported to achieve a tolerance limit o 0.1 mm (Port,
1987) and have the advantage o being able to measure the diam-
eter across several meridians, identi ying possible lens warpage.
Fig . 14.1 Che cking rig id le ns ove rall d iame te r with a V-g aug e . The
le ns is inse rte d into the wid e op e ning o the V-shap e d g roove on the
rig ht, and allowe d to slid e d own to the le t until the g aug e b e come s too
narrow or the le ns to slid e any urthe r. The total d iame te r o the le ns is
re ad o the scale that runs alo ng the lowe r b ord e r o the g roove . In this
case , the le ns has a d iame te r o 9.0 mm.
 14 Rig id Le ns Me asure me nt 137

With the correct illumination, distinct zones across the lens
area can also be visualized and measured with projection sys-
tems. For more precise measurements, measuring microscopes
or pro le projectors can be used, providing a resolution o up
to 1 µm.
CENTRE AND EDGE THICKNESS
T e measurement o centre thickness provides key in orma-
tion on the rigidity o a lens and is also used to calculate oxy-
gen transmissibility. Central, peripheral, and edge thickness
can be measured using dial or digital gauges (Fig. 14.2). T e
gauges should have a readout resolution o 1 µm and a speci-
ed accuracy o ±3 µm. T e anvil and the plunger need to be
tted with spherical ball tips with a radius between 1.2 and
5 mm. o minimize sur ace indentation and alse thickness
readings the measurement orce should not exceed 1.4 N (ISO,
2006c). By moving the lens away rom its central position,
radial thickness readings can be obtained at selected periph-
eral and edge locations.
Optical and acoustic methods have also been used or
measuring lens thickness on eye or on the bench. Ultrasound
pachymeters are commonly used to measure axial length and
corneal thickness. However, these instruments are limited
in their resolution and acoustical properties o lens materi-
als need to be known to correct the measured thicknesses.
Optical methods ace a similar constraints, but the conver-
sion is made easier as the re ractive index o lens materials
is generally known. he two most commonly used optical
methods are Scheimp lug photography and optical coher-
ence tomography (OC ) imaging. For both methods, clinical
instruments are commonly used or anterior segment imag-
ing – or example, the Pentacam (Oculus, Germany) and the
R Vue (Optovue, US), respectively. Either instrument can
be employed to measure cross-sectional thickness pro iles
as well as complete thickness maps. he built-in analysis
so tware converts the measured optical thickness into physi-
cal thickness using the corneal re ractive index o 1.377. o
obtain the actual thickness or a rigid lens, Eq. 14.1 is to be
applied:
1.377
ta = tm × Eq. 14.1
RI1
where ta = actual thickness o rigid lens, t m = measured thick-
ness o rigid lens as displayed by instrument and RIl = re ractive
index o rigid lens material.
By obtaining thickness pro les across several meridians,
the amount o unwanted lens prism can be determined. Lens
prism is a common de ciency with lathe-cut lenses. T is
de ect is caused by a decentration o the ront sur ace relative
to the back sur ace due to inaccurate re-blocking o the button
on the lathe.
BACK AND FRO NT SURFACE RADIUS O F
CURVATURE
T e standard instrument with which to measure the radius o
concave or convex sur aces on rigid lenses is the radiuscope.
T e operating principle o the radiuscope is explained in Fig.
14.3. Rays rom the illuminated target are projected onto the
sur ace via a beam splitter. At the in- ocus position A, the
re ected target is seen through the eyepiece as a clear, sharp
image. In position B, the rays are re ected perpendicularly to
the lens sur ace and also generate a sharp image. T e relative
distance between A and B corresponds to the radius o cur-
vature. T is operating principle applies to convex as well as
concave sur aces.
T e steep and at radii o toric sur aces can also be mea-
sured by orienting the respective meridians with the verti-
cal and horizontal line o the target and bringing each one in
ocus alternately. As many sur aces are now manu actured as
aspheric ellipsoids or paraboloids, the target images in posi-
tion B won’t be in sharp ocus and only an average radius can
be determined. Should more detailed sur ace in ormation be

To microscope

From
illuminated
target
Beam splitter

Condenser lens

B
Convex surface
(position 2)

Concave surface A
(position 1)
Convex surface
(position 1)

Concave surface B
(position 2)
Fig . 14.2 Me asuring rig id le ns thickne ss using an e le ctrome chanical Fig . 14.3 O p e rating p rincip le o the rad iuscop e or me asuring conve x
g aug e . or concave curvature s.
138 PART 3 Rig id Co nt act Le nse s
required, radii analysers such as the Brass 2000 (Rotlex, Israel)
that utilize Moiré de ectometry can generate topographic
maps and extract sur ace pro les with tted mathematical
unctions. T is methodology is particularly use ul or manu-
acturers o orthokeratology lenses. T e precise cutting o the
complex back sur ace pro le is critical to achieve the targeted
corneal reshaping.
T e keratometer is a clinical instrument that can also be
used to measure ront and back radii o rigid lenses. o mini-
mize inter ering re ections it is best to use a olding mirror
and place the rigid lens horizontally, with a drop o water on
the sur ace acing downwards (Fig. 14.4). Keratometers mea-
sure the curvature at only two de ned points, usually about 3
mm apart. Any asphericity cannot be captured, but toric sur-
aces can be measured by rotating either the instrument or
the lens to determine the steep and at meridians. Kumbar
et al. (2012) showed that keratometer measurements agree
well with results obtained by a radiuscope, with the mean di -
erence being less than 0.03 mm.
Corneal topographers like the Humphrey Atlas (Carl
Zeiss Meditec, Germany) have success ully been used to
measure the curvatures o rigid lenses, including aspheric
and toric sur aces (Elder and Benjamin, 2009). Elder and
Benjamin ound that this instrument measures within the
base curve tolerance o 0.05 mm. However, not all topogra-
pher instruments are suitable to measure concave sur aces.
When an appropriate instrument is lacking, an impression
can be taken rom the back sur ace and then measured as a
convex sur ace.
Complete cross-sectional sur ace pro les can also be
obtained by Scheimp ug and OC based imaging instruments
(see T ickness section above). Some instruments have built-
in curve tting algorithms or provide data export options or
external analysis. T e sharpness o junctions between di erent
zones on the lens can also be determined using the appropri-
ate analysis tools. o avoid optical distortions, the sur ace to be
measured should ace the instrument.
Fig . 14.4 Use o the ke ratome te r or me asuring the concave (b ack)
sur ace o a rig id le ns.
EDGE PRO FILES
T e edge shape can be o critical importance or rigid lenses with
respect to on-eye com ort (La Hood, 1988). T e relative position
o the apex, the sharpness o the anterior and posterior edge radii
and edge thickness are eatures that can be inspected by practi-
tioners using readily available equipment. Henry and Barr (1990)
used a simple projection magni er with graticule to check the
edge pro le. o better visualize the posterior edge shape, a slit
lamp can be used to illuminate and observe a narrow section o
the entire edge pro le. A lens-holding device as used by Caroline
et al. (1991) assists with the rotation o the lens to observe pro les
around the circum erence o the lens (Fig. 14.5). T is ability to
rotate the lens is a critical aspect, as most lenses are made with
some degree o unwanted prism, which has a major impact on
edge thickness and edge shape. Full inspection is also required to
detect any chipping and dents or other localized de ects.
La Hood (1988) also recognized the importance o checking
edge shape at di erent meridians when she developed a mould-
ing technique to obtain impressions o edge pro les. T e entire
edge o the rigid lens was pressed into a blob o quick-setting
dental mould material. A er setting, the lens was popped out
and the mould sliced in our quadrants with two razor blades
pressed against each other. T e slices obtained could be viewed
under a microscope and images taken or urther analysis and
documentation. La Hood (1988) classi ed edges as sharp, blunt,
round or square.
For ull edge shape quanti cation, Ehrmann et al. (1998)
developed an optical pro ler that measures complete cross-
sectional lens pro les along several meridians, including high-
resolution edge pro les. T e sel -guided optical sensor moves
along the lens pro le, recording data points with micron preci-
sion. Mathematical algorithms are then used to analyse the pro-
les and extract numerical parameters or quality assessment
and classi cation.
By measuring edge pro le and back sur ace with this instru-
ment, the axial and radial edge li can also be obtained rom the
collected data sets. As shown in Fig. 14.6, edge li is the distance
between the extended back optic zone radius and the apex o the
edge, in either radial or axial direction, and can be calculated
using measured parameters o lens diameter, back sag and back
optic radius:
Fig . 14.5 Le ns e d g e -vie wing d e vice .
 14 Rig id Le ns Me asure me nt 139

Fig . 14.6 The orm o the e d g e o a rig id le ns can b e d e ne d in te rms

o e ithe r axial e d g e li t (AEL) or rad ial e d g e li t (REL). This nome nclature
ap p lie s to all le ns p owe rs and d e sig ns. BO ZR = b ack op tic zone rad ius.

√
REL= [(r − s2 ) + y2 ] − r Eq. 14.2

Fig . 14.7 Manual ocime te r with contact le ns sup p ort. (Courte sy of

AEL= s1 − s2 Eq. 14.3 Nikon.)
where:
√
s1 = r − r 2 − y2

For lenses with an aspheric back optic sur aces, r needs to be

replaced with the average back optic zone radius to obtain a
meaning ul edge li value. For certain lens tting philosophies,
such as the lid attachment method (Korb and Korb, 1970), edge
li is a critical parameter and needs to be determined to trou-
bleshoot poorly tting lenses.

O p t ical Pro p e rt ie s
In clinical practice, the optical per ormance o a rigid lens can
be assessed in vivo, either subjectively by means o overre rac-
tion or objectively with the use o autore ractors or double-pass
wave ront analysis. T is in vivo testing has the advantage o
taking into account patient-speci c actors such as lens centra-
tion and tear lens e ects, making it a good measure or visual
satis action. However, to track manu acturing quality and to
troubleshoot poor visual per ormance, objective methods are
required to quanti y the optical parameters. Fig . 14.8 Colour-cod e d p owe r map ob taine d with Nimo TR1504 (co-
lour scale is in D).

PO WER AND PO WER PRO FILES

T e standard ocimeter is a suitable tool with which to measure the
sphere and cylinder power o rigid lenses (Fig. 14.7). As described
in ISO 18369-3 (ISO, 2006c), a 4.5 mm aperture stop should be
used to minimize errors due to the highly curved back sur ace
o rigid lenses. In particular, in order to obtain the correct back
vertex power or high-powered lenses, correction actors might be
required i the back sur ace curvature di ers signi cantly rom a
standard 8.00 mm radius. T e cylinder power and axis can also be
determined by measuring the steep and the at meridian power,
either turning the lens or the mire with re erence to the lens mark-
ing. T e amount o optical prism can also be estimated using the
ocimeter. T e instrument should be calibrated using a series o
certi ed calibration lenses with 8.00 mm base curve.
T e quality o the projected target image provides some
indication on the optical design o the lens or its sur ace qual-
ity. In particular, simultaneous multi ocal lenses will gener-
ate a target image that cannot be brought into sharp ocus. o
measure these lens types accurately, or even translating bi o-
cal lenses, wave ront-sensing instruments are required. T e
three common methods implemented in commercial lens
mapping instruments are Hartmann–Shack (SHSOphthalmic,
Optocra ), Moiré de ectometry (Contest Plus II, Rotlex) and
phase-shi ing Schlieren (Nimo R1504, Lambda-X). All o
these instruments map the re ractive power o the entire opti-
cal zone, rom which numerical parameters such as lower-and
higher-order aberrations (Zernike coe cients), power pro les
and optical de ects can be extracted (Fig. 14.8). Depending on
140 PART 3 Rig id Co nt act Le nse s
the selected method employed to convert the measured power
into back vertex power, additional measured or assumed lens
parameters o centre thickness, base curve radius, sag or re rac-
tive index might have to be provided.
O PTICAL Q UALITY AND SURFACE DEFECTS
T e power-mapping instruments listed above also calculate a
relative optical quality number based on the optical irregulari-
ties within the optic zone. However, this optical quality number
is based on standard single-vision designs. More complex toric,
multi ocal or orthokeratology lenses should be inspected man-
ually by examining the colour-coded power maps or averaged
power pro les to detect optical distortions. Optical distortions
can be caused by uneven sur aces or local changes in re ractive
index due to overpolishing (Walker, 1989; Ho and Ehrmann,
2000). Finer sur ace de ects such as lathe marks or scratches can
best be visualized under the dark- eld microscope. ranoudis
and E ron (1996) used the Optimec Contact Lens Analyser
(Optimec, UK) to capture images o scratched sur aces and then
quanti ed the scratching using image analysis so ware. Instru-
ments based on the kni e-edge principle (Ho and Ehrmann,
2000) visualize both power and sur ace de ects although they
cannot distinguish whether the de ect is on the ront or back
sur ace. None o these instruments, dedicated or examining
either so or rigid contact lenses, is yet commercially available.
Mat e rial Pro p e rt ie s
T e measurement o material properties is generally outside the
realm o practitioners. Material manu acturers publish all the
relevant in ormation and there is little scope or these param-
eters to change rom their nominal values. With the exception
o wettability, riction and modulus, ISO 18369 Parts 2, 3 and 4
prescribe the measurement methods and tolerances or material
properties. Because o the specialized nature o these measure-
ments, laboratories o en develop their own instrumentation in
compliance with the ISO recommendations.
WETTABILITY
Good sur ace wettability is required to maintain a stable
pre-lens tear lm and with it, good vision and ocular health.
In vivo observations using a slit lamp or tearscope (Keeler,
USA) are the clinically most relevant assessments (Guillon,
1998), although they lack the quanti cation o the material
property itsel . Measuring the contact angle o a sessile drop
as described by Bush et al. (1988) is the most common in vitro
method to establish wettability, not only o contact lens materi-
als. Whereas Bush used a laser beam as optical pointer to read
the contact angle, commercial instruments such as the T eta
Optical ensiometer (Biolin Scienti c, USA) capture a magni-
ed image o bubble and lens sur ace and automated image
analysis determines the contact angle. T ese instruments also
have the advantage o precise control over the size o the water
or saline drop, which can a ect the measured contact angle.
Further re nements include the measurement o the receding
or advancing angles.
Shiraf an et al. (1995) took a di erent approach by measur-
ing the adherent mass o the drop o liquid on the ront sur ace
o a rigid lens a er immersing and removing the sur ace rom
the liquid. T ey ound that there are signi cant di erences
3 rigid lenses,
attached to triangular plastic plate
Glass plate,
wetted with saline
Friction angle
Fig . 14.9 De te rmining le ns riction using the riction ang le me thod .
not only between materials, but also within the same mate-
rial depending on its conditioning, whether stored dry in
air, or soaked in water. Maldonado-Codina and E ron (2006)
expanded on this method by measuring the adherence orce
o the meniscus as well as the maximum length the menis-
cus could be stretched be ore breaking. Although they tested
only hydrogel lenses, the same method can be applied to rigid
materials.
FRICTIO N
Friction is a sur ace and material property that determines how
easily two sur aces slide against each other when an external
orce is applied. Friction is de ned as the ratio o the orce tan-
gential to the sur ace to the orce normal to the sur ace. T is
ratio implies that the riction coe cient is independent o the
magnitude o the actual orces and the area o contact. It can
however, be signi cantly a ected by the sur ace texture and the
type o lubricant applied between the two sur aces. Static ric-
tion applies under conditions or which the two sur aces are at
rest and then start moving relative to each other. Kinetic ric-
tion is the measured orce ratio when one sur ace moves at a
constant speed relative to the other. T is coe cient is generally
lower than the static riction and applicable to the on-eye condi-
tion. T e rigid lens is constantly moving relative to the cornea
and eyelid.
Attempts have been made to measure riction coe cients
in vivo or in vitro using corneal or conjunctival tissues. Although
clinically most relevant, the results are generally highly variable
and strongly in uenced by co ounding and uncontrolled actors
(Robinson, 1964; Rennie et al., 2005). A more objective way to
determine material speci c riction coe cients is to move the
lens or a polished button along a glass plate and measure normal
and tangential orces.
A very simple procedure to conduct riction measurements
in the laboratory or clinical practice utilizes the concept o
riction angle. As illustrated in Fig. 14.9, the lens sample is
placed on a glass plate, which is then tilted until the sample
starts sliding down the plate. T e angle against the horizontal
is measured and the tangent o that angle represents the static
riction coe cient. o measure the kinetic riction, one starts
with a steeper angle and pushes the lens downwards. Gradually
reducing the angle, a point will be reached at which the lens
will stop sliding. T e tangent o that angle is the kinetic ric-
tion coe cient o that lens material against glass. A suitable
lubricant such as saline or arti cial tear uid can be applied
to the glass plate to simulate more realistic on-eye conditions.
o prevent lenses rom tipping over, three lenses o the same
material can be attached to a small triangular piece o plastic
with double-sided sticky tape and then placed onto the glass
plate with the anterior sur aces down.

O XYGEN PERMEABILITY
A comprehensive review o the Dk measurement methods is
given in Chapter 7 with respect to so lens materials. O the two
methods described in ISO 18369-4 (ISO, 2006d), the polaro-
graphic one is applicable only to Dk values o up to 145 Barrer,
while the coulometric method can be used or all non-hydrogel
materials. With a Dk value o around 80–140 Barrer, most mod-
ern rigid lens materials can be measured with either method.
However, it is known that the two methods can produce di er-
ent results (Morgan et al., 2001) and speci cs o the methodol-
ogy should accompany any reported Dk values; these include:
the method, the particular instrument used and the applied
edge and boundary layer corrections.
REFRACTIVE INDEX
T e Abbe re ractometer is the standard instrument or mea-
suring re ractive index o rigid lens materials. T is instru-
ment determines the critical incidence angle o a light beam to
achieve total internal re ection. T e internal re ection is cor-
related to the re ractive index o the optical material. Reliable
measurements can be made only i the contact area between the
measurement prism and the test material is at least 3 mm 2. T e
curved sur ace o rigid contact lenses is di cult to be measured
directly, although Hodur et al. (1992) reported that with a drop
o saline as contact uid, reliable readings can be obtained with
the hand-held N3000 re ractometer (Atago, Japan). More suit-
able or re ractive index measurements are material samples
with one at polished sur ace.
ISO 18369-4 (ISO, 2006d) speci es that a wavelength o 546
or 588 nm is to be used. T e CLR 12-70 re ractometer (Index
Instruments, UK) is a dedicated instrument or rigid and so
contact lens materials that is ully automated, eliminating oper-
ator skills and the subjective variability o en reported with
manual re ractometers.
MO DULUS AND FLEXURE
As with the re ractive index, the material sti ness cannot be
measured using a nished contact lens. T e tensile Young’s
modulus is the most commonly cited sti ness value and can be
measured using a general tensile instrument such as the model
5948 Micro ester (Instron, USA). From the material button, a
thin strip with a constant and known cross-section needs to be
prepared. T e strip is clamped on either end and then stretched.
From the recorded stress over strain curve, the Young’s modulus
is determined as the slope o the tted straight line within the
linear region o the material de ormation.
Lens exure is a combined property o material sti ness and
lens geometry. It speci cally relates to the elastic de ormation,
which is di erent rom the permanent de ormation, usually
re erred to as lens warpage. Lens exure is a clinically relevant
measure that indicates what de ormation it might experience
on the eye or how easily a lens might break with handling. ISO
18369-4 (ISO, 2006d) describes in some detail how to per orm
this measurement. As shown in Fig. 14.10, the lens is clamped
at its diameter between two jaws and slowly compressed until
the lens breaks while the exural de ormation and orce are
recorded. Force and de ormation at the point o rapture and at
30% o de ormation are reported. As this is a destructive test, it
is not much use or practitioners.
14 Rig id Le ns Me asure me nt 141
Force and
displacement
recorder
Lens flexure
Undeformed lens
Lens under load
Fig . 14.10 De vice to d e te rmine f e xure o a rig id le ns.
Lens laboratories or material manu acturers may be able to
obtain some use ul in ormation on how thin they can make
lenses in a speci c material be ore it becomes too ragile or
de orms on eye. O all the actors that contribute, lens exure is
most sensitive to changes in lens thickness. T us it is di cult to
apply empirically established exure data to any one particular
lens, given the thickness variability with lens powers, manu ac-
turing tolerances or centre thickness and unwanted lens prism
(McMonnies, 1989; Ehrmann et al., 1999).
LUMINANCE TRANSMITTANCE
T e luminance transmittance o optical materials can be a ected
by light scattering or absorption, both o which are generally not
o concern in rigid materials where transmittance values range
rom 94% to 97% within the visible spectrum, as speci ed in
the material data sheets rom the various manu acturers. Scat-
tering can occur, but in most cases that would be due to sur ace
roughness or scratches. Only rarely can microbubbles or other
inclusions be ound within the material. Similarly, absorption is
generally negligibly small, with the exception where manu actur-
ers deliberately add light-absorbing compounds to the material
either to block UV light or to provide a handling tint. In this case,
the luminance transmittance needs to be measured with a spec-
trometer, covering the wavelength range rom 200 to 800 nm.
Measurements are best per ormed using three polished but-
tons o di erent thicknesses. By plotting the absorption versus
thickness and extrapolation to zero thickness, any sur ace e ects
can be eliminated and the actual material absorption obtained.
ISO 18369-3 describes a mathematical method to remove sur-
ace e ects rom rigid lens transmissibility measured in air, but
this method only partially addressed the issue o sur ace re ec-
tions. Quesnel and Simonet (1995) immersed the rigid lens in
saline to minimize sur ace, power and prism e ects and were
able to reproduce transmittance curves published by manu ac-
turers. T is method can also be used to identi y unknown rigid
materials, as demonstrated by Dain and Pye (1993).
SURFACE HARDNESS
Hardness is a sur ace property that describes the resistance
against permanent indentation by another body. With respect
to rigid contact lenses, it is the key parameter that determines
the scratch resistance o a material. Relative scratch resistance
can be determined with methods similar to the one described
142 PART 3 Rig id Co nt act Le nse s
by ranoudis and E ron (1996), in which they rst used an
apparatus to scratch one sur ace o the lens and then applied
image analysis tools to quanti y the amount o scratching.
Manu acturers usually speci y their material hardness in
Shore D units. T is is measured as the indentation depth o a
conical metal tip with a 30° cone angle when a 44.5 N orce is
applied. ypical values or PMMA are 89 Shore D, with most
other gas-permeable materials being up to 30% lower. Sur ace
coatings have been applied to rigid lenses to improve their
scratch resistance, but this has the disadvantage that they can-
not be repolished and may compromise sur ace wettability.
Co nclusio n
Ensuring correct geometrical shape and optical power is critical
or clinicians in achieving a success ul rigid lens t. Although
manu acturers are obliged to supply only lenses that all within
ISO-allowed tolerances, the contact lens tter is still advised to
scrutinize critical parameters, in particular when patients com-
plain about poor vision or discom ort. Rigid lens tolerances are
summarized in Appendix B. Even ollowing success ul dispens-
ing, rigid lenses should be regularly inspected throughout their
li etime to check or sur ace and edge de ects as well as lens
warping. In most contact lens practices, the required equipment
is readily available. For more specialized measurements, the
lenses may have to be returned to the lens or material manu-
acturer. With their dedicated instrumentation, they can ully
characterize all aspects related to rigid contact lens design and
per ormance.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
REFERENCES
Bush, J. F., Hu , J. W., & Mackeen, D. L. (1988).
Laser-assisted contact angle measurements. Am.
J. Optom. Physiol. Opt., 65, 722–728.
Caroline, P., Norman, C., & Martin, R. (1991). RGP
edge analysis and modi cation. CL Spectrum, 6,
39–49.
Dain, S. J., & Pye, D. C. (1993). Identi cation o rigid
gas permeable contact lens materials by means
o ultraviolet-visible spectrophotometry. Optom.
Vis. Sci., 70, 517–521.
Ehrmann, K., Ho, A., & Schindhelm, K. (1998). A
3D optical pro lometer using a compact disc
reading head. Measurement Sci. Tech., 9, 1259.
Ehrmann, K., Ho, A., & Schindhelm, K. (1999). A
novel method to quanti y the edge contour o
RGP contact lenses. Cont. Lens Anterior Eye, 22,
19–25.
Elder, K. S., & Benjamin, W. J. (2009). Prototype base
curve attachment or the topographer: What will
replace the vanishing radiuscope? Optometry, 80,
131–137.
Guillon, J. P. (1998). Non-invasive tearscope plus
routine or contact lens tting. Cont. Lens Anterior
Eye, 21(Suppl. 1), S31–S40.
Henry, V. A., & Barr, J. . (1990). Veri cation, modi-
cation and care. CL Spectrum, 5, 57–67.
Ho, A., & Ehrmann, K. (2000). A kni e-edge
system or evaluating contact lens. In F. S. P.
Manns, & A. Ho (Eds.), SPIE – Ophthalmic
Technologies X, 2000 (pp. 102–107). San Jose:
SPIE.
Hodur, N. R., Jurkus, J., & Gunderson, G. (1992).
Rigid gas permeable lens identi cation using re-
ractometry. Int. Contact Lens Clin., 19, 71–75.
International Organization or Standardization (ISO).
(2006a). ISO 18369-1. Ophthalmic Optics – Contact
Lenses – Part 1: Vocabulary, classif cation system
and recommendations or labelling specif cations.
Geneva: ISO.
International Organization or Standardization
(ISO). (2006b). ISO 18369-2. Ophthalmic Optics –
Contact Lenses – Part 2: Tolerances. Geneva: ISO.
International Organization or Standardization
(ISO). (2006c). ISO 18369-3. Ophthalmic Optics
– Contact Lenses – Part 3: Measurement methods.
Geneva: ISO.
International Organization or Standardization
(ISO). (2006d). ISO 18369-4. Ophthalmic Optics
– Contact Lenses – Part 4: Physicochemical proper-
ties o contact lens materials. Geneva: ISO.
Korb, D. R., & Korb, J. E. (1970). A new concept in
contact lens design – parts I and II. J Am. Optom.
Assoc., 41, 1023–1032.
Kumbar, ., Shyam Sunder, ., Swati, J., et al. (2012).
Correlation o back optic zone radius measure-
ment o rigid contact lenses with radiuscope and
keratometer. Cont. Lens Anterior Eye, 35, 282–284.
La Hood, D. (1988). Edge shape and com ort o rigid
lenses. Am. J. Optom. Physiol. Opt., 65, 613–618.
Maldonado-Codina, C., & E ron, N. (2006). Dy-
namic wettability o pHEMA-based hydrogel
contact lenses. Ophth. Physiol. Opt., 26, 408–418.
McMonnies, C. W. (1989). Quality control or gas
permeable hard lens manu acture. Clin. Exp. Op-
tom., 72, 15–18.
Morgan, C. F., Brennan, N. A., & Alvord, L. (2001).
Comparison o the coulometric and polarograph-
ic measurement o a high-Dk hydrogel. Optom.
Vis. Sci., 78, 19–29.
Piccolo, M. G., Leach, N. E., & Boltz, R. L. (1990).
Rigid lens base curve stability upon hydrogen
peroxide disin ection. Optom. Vis. Sci., 67, 19–21.
Port, M. (1987). Measurement rigid lens diameters.
J. Br. Contact Lens Assoc., 10, 23–26.
Quesnel, N. M., & Simonet, P. (1995). Spectral trans-
mittance o UV-absorbing so and rigid gas per-
meable contact lenses. Optom. Vis. Sci., 72, 2–10.
Rennie, A. C., Dickrell, P. L., & Sawyer, W. G. (2005).
Friction coe cient o so contact lenses: mea-
surements and modeling. Tribol. Lett., 18, 499–504.
Robinson, D. A. (1964). T e mechanics o human
saccadic eye movement. J. Physiol., 174, 245–264.
Shira kan, A., Woodward, E. G., & Hull, C. C.
(1995). A novel approach to measuring the wet-
tability o rigid contact lenses. Mass measure-
ment o the adherent liquid on the rigid lens
sur ace (1). Ophthal. Physiol Opt., 15, 575–583.
ranoudis, I., & E ron, N. (1996). Scratch resistance
o rigid contact lens materials. Ophthal. Physiol
Opt., 16, 303–309.
Walker, J. (1989). Overpolishing uorosilicone-
acrylates – the consequence and the cure. J. Br.
Contact Lens Assoc., 12(Suppl. 2), 29–32.
142.e 1
15
Rig id Le ns De sig n and Fit t ing
GRAEME YO UNG
Int ro d uct io n
Fitting rigid lenses is an improbable achievement. Essentially it
involves constructing a complex three-dimensional structure to
sit, without the aid o any supplementary adhesive, on a verti-
cally inclined sur ace while being repeatedly dislodged by a cov-
ering structure. Fortunately, the task is made easier by a number
o mitigating actors:
• T e lids help to prevent the lens alling rom the eye.
• T e change in curvature at the limbal junction helps to
prevent sideways dri .
• T e capillary orces in the pre-lens tear lm are usually
strong enough to hold the lens in place but weak enough
to avoid adherence.
On the other hand, a number o actors can make rigid lens t-
ting di cult:
• No two eyes have precisely the same dimensions.
• T e worse the re ractive error, the less predictable is the t.
• Re ex tearing during adaptation can alter the lens t.
• Rigid lenses can be very uncom ortable, no matter how
good the t.
T e t o a rigid lens is af ected by a range o actors, many o
which are not easily quanti able, such as corneal and limbal
anatomy, lid geometry and mechanics, and extraneous actors
such as pterygia. As a result, many practitioners consider rigid
lens tting to be more o a cra than a science. T ere is, there-
ore, a wide variation in competence between practitioners,
which primarily relates to experience. Practitioners new to rigid
lens tting can bene t greatly in the initial stages rom being
overseen by a more experienced colleague.
O cular To p o g rap hy
A number o ocular dimensions are relevant to the selection
o rigid lenses. hese are summarized in able 15.1, along
with typical population variations. Precise measurement
o each o these dimensions is not essential to success ul
rigid lens itting; however, or a given patient, it is help ul
to assess whether the eye is close to average or atypical, or
instance, whether the corneal diameter is larger or smaller
than average.
CO RNEA
T e cornea is generally aspheric in shape and is requently
described as ellipsoid (Kiely et al., 1982). In most cases, a cor-
neal section can be approximated to a prolate ellipse – that is,
one that gradually attens towards the periphery. Conventional
keratometers give readings corresponding to points approxi-
mately 1.5 mm either side o the corneal apex. Given that cor-
neas with similar keratometer readings (K-readings) can show
widely dif ering peripheral curvature (asphericity), keratometry
alone does not always indicate the optimum rigid lens t.
T e degree o corneal asphericity is o en expressed as either
corneal eccentricity or corneal shape actor. With eccentric-
ity (e) a spherical sur ace equals zero, while a attening ellipse
equates to a positive value. Shape actor (SF) is a unction o
eccentricity, whereby:
SF = 1 − e2
Using shape actor, a spherical sur ace equals 1.0, a attening
ellipse is <1.0, while a steepening ellipse is >1.0.
With-the-rule astigmatic corneas are steeper in the vertical
meridian and are generally easier to t than against-the-rule
astigmatic corneas, on which rigid lenses tend to show sideways
decentration. With-the-rule astigmatic corneas o en show
greater corneal astigmatism in the in erior cornea compared
with the superior cornea. As a rule o thumb, 1.00 D o cor-
neal astigmatism corresponds to a dif erence in K-readings o
approximately 0.2 mm. T e peripheral cornea tends to show less
toricity than does the central cornea (Read et al., 2006).
T ere is no correlation in the population between corneal
asphericity and central corneal curvature (Guillon et al., 1986;
Hall et al., 2013). However, there is a correlation between
K-readings and corneal diameter such that larger corneas tend
to be atter in curvature whereas smaller corneas tend to be
steeper (Mandell, 1989). Also, there is a correlation between
asphericity and the degree o myopia; higher myopes show less
peripheral corneal attening, which is consistent with the lon-
ger axial length o the myopic eye (Carney et al., 1997a).
T e cornea is invariably larger in the horizontal meridian
than in the vertical. It is not easy to measure the true diameter
o the cornea owing to the gradual change in transparency at
the limbus. In practice, the width o the visible iris (horizontal
visible iris diameter, HVID) is used as a gauge o corneal diam-
eter. T e HVID is approximately 1.5 mm smaller than the actual
corneal diameter (Martin and Holden, 1982; Hall et al., 2013).
TABLE O cular Dime nsio ns and Typ ical Po p ulat io n
15.1 Variat io ns
Me an (mm) ± 2 SD (mm)
Flatte st corne al 7.85 7.25–8.45
curvature – ke ratome try
Corne al shap e actor 0.67 0.40–0.95
Corne al d iame te r 13.3 11.7–14.1
Horizontal visib le iris d iame te r 11.7 10.7–12.7
Palp e b ral ap e rture 10.2 7.4–13.0
SD = stand ard d e viatio n.
(Data from Hall, L., Hunt, C., Young , G. & Wolffsohn, J. (2013). Factors
affe cting corne o scle ral top og rap hy. Inve st. O p hthalmol. Vis. Sci., 54,
3691–3701.)
143
144 PART 3 Rig id Co nt act Le nse s

Corneal diameter in uences the choice o lens diameter. T e

typical variation in corneal diameter o 2.4 mm (see able 15.1)
is mirrored by a similar variation in typical rigid lens diameter,
that is, 8.30–9.80 mm.

LIDS
T e lower lid usually aligns with the lower limbus while the
upper lid tends to cover the limbus and overlap by approxi-
mately 1 mm. Both o the eyelids can help to position the lens
high enough to cover the pupil and, in many cases, the lens is
ef ectively passed rom one lid to the other between blinks.
T e maximum vertical distance between the lids (palpebral
aperture) is generally measured prior to tting. Smaller palpe-
bral apertures tend to require smaller-diameter lenses; however,
the relationship o the lids to the superior and in erior limbus
is also relevant, and there ore there is no simple relationship
between palpebral aperture and optimum lens diameter. Rigid
lens wear itsel can cause a reduction in palpebral aperture. Fonn
et al. (1996) noted that the palpebral aperture in rigid lens wear-
ers is, on average, 0.5 mm smaller than that in so lens wearers.
When the upper lid is relatively high, the lens tends to decen-
tre low and a large-diameter lens is o en required to encourage
the upper lid to grip the lens and hold it in place; this is known
as lid attachment. A relatively low upper lid and narrow palpe-
bral aperture tends to result in upwards decentration (Carney
et al., 1997b).
In cases where the lower lid is positioned higher than the
limbus, a smaller lens may be required. On the other hand,
when the lower lid is low or inef ective owing to ectropion, a
large-diameter lens is o en required, again to encourage lid
attachment.
Fig . 15.1 Force s acting on a lid -attache d rig id le ns. ELF = e ye lid orce ;
T ere is a correlation between palpebral aperture and cor- ESTF = e d g e sur ace te nsion orce ; G = g ravity, TFP = te ar uid p re ssure ;
neal diameter. Larger corneas, as well as being relatively at, VF = viscous orce s. (Ad ap te d from Guillon, M. & Sammons, W. A. (1994)
tend to be accompanied by a wider palpebral aperture. Contact le ns d e sig n. In M. Rub e n & M. G. Guillon (e d s) Contact Le ns
Practice (Ch. 5, p p . 87–112). Lond on: Chap man & Hall.)

ETHNIC VARIATIO NS IN O CULAR DIMENSIO NS

Some ethnic variations in ocular topography have been noted
in the literature. In a UK-resident Chinese population, corneas
have been noted to be steeper and smaller and to show less cor-
neal attening than Caucasian eyes (Lam and Loran, 1991). T is
suggests a requirement or smaller rigid lenses showing less
peripheral attening or such patients. In a more recent study,
however, Chinese and Japanese corneas tended to be slightly
atter but to show similar asphericity in the atter meridian
(Hickson-Curran et al., 2014). It is likely that environmental
actors, such as nutrition, as well as ethnic dif erences in uence
corneal topography and probably account or the mean atten-
ing in corneal curvature noted in the Japanese population over a
20-year period (Hirotsuji, 1990). As expected, oriental eyes tend
to show a narrower palpebral aperture: on average, about 1.0
mm smaller than Caucasian eyes (Lam and Loran, 1991; Hick-
son-Curran et al., 2014). A comparison o Caucasian and British
Asian eyes noted smaller corneas in the British Asian population
but no dif erence in curvature or asphericity (Hall et al., 2011).
T ere is less in ormation on ethnic variations in A ro-Carib-
bean populations, although there is some evidence that these
corneas tend to be larger and atter than corneas o Chinese or
Japanese populations (Babalola and Szajnicht, 1960). One study
noted that A rican-American corneas tended to be more prolate
than in Caucasians (Fuller and Alperin, 2013).
Fo rce s Act ing o n t he Rig id Le ns
A number o orces act on the rigid lens and have to be suitably
balanced in order to achieve a satis actory t (Fig. 15.1). T e
gravitational orce o the lens and pre-lens tear lm cause the
lens to drop. T e ef ect will be greater, and the lens less stable,
the urther orwards the centre o gravity lies. T e centre o grav-
ity is urther orward in plus lenses compared with minus lenses
(Fig. 15.2). It is shi ed posteriorly by increasing the diameter,
steepening the back optic zone radius (BOZR), or decreasing
the thickness o the lens. With both plus and minus lenses,
the greatest shi and most ef ective stabilization are achieved
through changing the lens diameter (Carney and Hill, 1987).
T e lens is held in place by the capillary orces in the post-
lens tear lm and the sur ace tensional orce in the tear meniscus
at the lens edge. T e capillary orce increases with increasingly
closer alignment o the lens and the cornea. T e orce is there-
ore greater with spherical corneas compared with astigmatic
corneas. Fig. 15.3 shows the change in apparent alignment with
increasing astigmatism.
Sur ace tension orces act at the lens edge where the edge
meniscus is not covered by the lid. T ere will be no sur ace ten-
sion where a meniscus is absent owing to excessive edge clear-
ance. T is orce can be increased by reducing edge clearance
and edge thickness (Khorassani and Peterson, 1988).

Fig . 15.2 Rig id le ns ce ntre o g ravity (CO G) in a p lus (le t) and minus
(rig ht) p owe r le ns.
Fig . 15.3 Ap p are nt p e rce ntag e corne al alig nme nt (PCA) and ave rag e
te ar laye r thickne ss (TLTav) with incre asing corne al astig matism.
Eyelid orces (primarily the upper lid) act to move the lens
in a vertical direction during the blink. Between blinks, these
orces help to stabilize the lens in the case o a lid attachment t
but have no ef ect in the case o an interpalpebral t.
Rig id Le ns De sig n
BACK O PTIC ZO NE DIAMETER
T e back optic zone diameter (BOZD) is usually xed or a given
design in a given total diameter ( D) and is generally 1–1.5 mm
smaller than the D. T e BOZD should be large enough to
cover the pupil in most conditions, including low illumination.
With toroidal corneas, using a smaller BOZD can increase
the area o alignment and there ore improve the t. However,
i the BOZD is reduced while maintaining the same D, this
results in a wider periphery and atter peripheral curves are
required in order to maintain edge clearance.
I the BOZD is changed, it is usually necessary to change the
BOZR in order to maintain a clinically equivalent t. Reduc-
ing the BOZD without reducing the BOZR results in a sagittal
depth that is shallower and there ore a atter t. As a rule o
thumb, an increase in BOZD o 0.5 mm requires an increase in
BOZR o 0.05 mm.
15 Rig id Le ns De sig n and Fit t ing 145
TABLE
15.2 Sug g e st e d Ce nt re Thickne sse s
Le ns Po we r (D) Ce nt re Thickne ss (mm)
−1.00 0.18
−2.00 0.17
−3.00 0.16
−4.00 0.15
≥− 5.00 0.14
Ad d 0.02 mm or co rne al astig matism ≥2.00 D.
Fig . 15.4 Axial e d g e li t (EL) and e d g e cle arance (EC).
FRO NT O PTIC ZO NE DIAMETER
T e ront optic zone diameter (FOZD) should be at least 0.5
mm larger than the BOZD. Except in low powers, most rigid
lenses are lenticulated so as to reduce thickness and weight.
Lenses occasionally incorporate a negative carrier in order to
encourage lid attachment and to centre the lens. A negative car-
rier is a peripheral zone that is thinner at the optic zone junction
than at the lens periphery. A positive carrier or tapered-edge
design – where the peripheral zone is thicker at the optic zone
junction than the lens periphery – is occasionally used to dis-
courage lid attachment in a high-riding lens.
CENTRE THICKNESS
I lenses are made too thin, not only is there a greater risk o
breakage but also the lenses tend to ex on astigmatic corneas,
leaving residual astigmatism. As exure is a unction o lens
thickness, it is worse with low-minus-powered lenses. For a
given amily o materials, exure tends to increase with increas-
ing Dk. It is there ore necessary to increase lens centre thick-
ness with higher-Dk materials. able 15.2 gives suggested centre
thickness values or lenses o varying power.
EDGE LIFT AND EDGE CLEARANCE
Without a peripheral gap between the edge o the lens and the
cornea, mechanical pressure leads to super cial corneal dam-
age. Such a gap is also important or tear exchange and to enable
lens removal using the lids. T is gap is termed the edge clear-
ance and can be speci ed axially or radially. A minimum axial
edge clearance o 60–80 µm when the lens is centred is consid-
ered to be the optimal value (Atkinson, 1984).
Whereas edge clearance relates to the lens and cornea, edge
li relates to the lens only (Fig. 15.4).
146 PART 3 Rig id Co nt act Le nse s

Some rigid lens designs ollow a concept o constant edge
li throughout the range o BOZRs; however, this tends to
result in greater edge clearance at the atter end o the range.
A superior design is one that gives constant edge clearance or
corneas o similar asphericity. Constant edge clearance designs
based on those proposed by Guillon et al. (1983) are given in
Appendix H.
EDGE FO RM
T e shape o the lens edge is one o the most important actors in
minimizing any discom ort. Poor edge rounding, in particular,
can result in greater edge awareness by the upper eyelid. Good
rounding o the ront sur ace edge has been shown to be more
important than rounding o the posterior edge (La Hood, 1988).
T is suggests that the interaction o the edge o the lens with the
eyelid is more important in relation to com ort than the interac-
tion with the cornea. Fig. 15.5 shows examples o edge shapes.
SPHERICAL VERSUS ASPHERIC DESIGNS
A wide variety o sur ace shapes have been used in rigid lenses.
T ese can be broadly categorized as: spherical, aspheric or
a combination o the two (e.g. spherical centre with aspheric
periphery). An aspheric back sur ace design is theoretically
capable o providing better alignment to the cornea (which is
aspheric), although there are a number o advantages and dis-
advantages to both types ( able 15.3).
Fig . 15.5 Rig id le ns cross-se ctions showing variations in e d g e orm.
(A) We ll-round e d e d g e ; (B) sharp p oste rior e d g e ; (C) sharp ante rior
e d g e ; (D) at e d g e .
SPHERICAL DESIGNS
Spherical designs incorporating a spherical back optic zone
with a number o atter spherical peripheral zones are the most
widely used and readily understood orm o rigid lens. T e
peripheral zone is generally 1–2 mm in width and composed
o one to our peripheral curves. ricurve designs (i.e. a central
curve plus two peripheral zones) are probably the most com-
monly used lens orm. Bicurve designs are occasionally used
with small lenses (e.g. <8.5 mm). etracurve and other multi-
curve designs are used with larger lenses or where a smoother
transition is required between the peripheral zones.
T e ront sur aces o most spherical designs are bicurve,
incorporating an optic zone that is slightly larger than the
BOZD and a ront-sur ace peripheral zone. T e curvature o the
optic zone is governed by the required lens power and that o the
peripheral zone governed by the edge thickness, the power and
FOZD o the lens; these parameters are invariably calculated
by the manu acturing laboratory. Monocurve ront-sur ace
designs (single-cut) are occasionally used in small, low-power
lenses but most lenses are lenticulated (i.e. made with a thinner
peripheral zone) in order to reduce mass and overall thickness.
Multicurve ront-sur ace designs are occasionally used with
higher-power lenses in order to reduce peripheral thickness.
ASPHERIC DESIGNS
From a mathematical point o view, the choice o spherical
geometry is almost arbitrary as the sphere is merely one o an
in nite number o conic sections. As noted earlier, ew i any
corneas are spherical in shape and there ore a spherical back
sur ace is not the obvious choice. However, aspheric rigid lenses
have two important disadvantages compared with spherical
lenses: (1) they are more di cult to manu acture, particularly
using conventional lathes; and (2) they cannot easily be checked
using a radiuscope or keratometer. Nevertheless, they of er a
number o advantages that arguably outweigh their disadvan-
tages (see able 15.3).
T e main advantages o aspheric designs relate to com ort.
Aspheric designs tend to show less edge clearance and there-
ore induce less edge sensation rom contact with the palpebral
conjunctiva. Poor blending o back-sur ace junctions in spheri-
cal lenses can cause irritation on version when the lens moves

TABLE
15.3 Ad vant ag e s and Disad vant ag e s o Asp he ric ve rsus Sp he rical Rig id Le nse s
Sp he rical Asp he ric
Manu act ure Re lative ly e asy Easy with comp ute r-controlle d lathe s
Not e asy with conve ntional lathe s
Ve rif cat io n Easy Di f cult
Ind uce d Ast ig mat ism None Small amount with d e ce ntration
Pre sb yo p ic Co rre ct io n None Small amount
Co rne al Alig nme nt Ad e q uate Slig htly g re ate r
Ed g e Cle arance Usually 80–120 µm Usually 60–90 µm
Back Sur ace J unct io ns Can b e a p rob le m i not b le nd e d Rare ly a p rob le m
Thickne ss Can b e minimize d b y le ns d e sig n Thinne r p e rip he ry p ossib le
Co m o rt Slig ht to mod e rate d iscom ort Some time s b e tte r owing to re d uce d
thickne ss and e d g e cle arance

of -centre and the peripheral zones come into contact with the
cornea. T is is generally avoided with aspheric lenses unless the
periphery is poorly blended. T e gradual attening o aspheric
lens sur aces results in a thinner periphery, which may also help
reduce edge sensation.
Optically, aspheric designs can both improve and degrade
image quality. When not aligned with the visual axis, aspheric
lenses will induce astigmatism. On the other hand, with higher-
power lenses, aspheric optics can reduce spherical aberration.
In myopic early presbyopes, the reduced minus power in the
periphery o aspheric lenses can help with near vision and delay
the need or a presbyopic correction.
Aspheric designs take dif erent orms but these dif erences
are usually too subtle to be evident other than rom the product
literature o the manu acturer. T e simplest aspheric design is
an elliptical shape selected to be close to, or slightly atter than,
the average cornea. More complex aspheric designs change their
degree o attening (or eccentricity) rom centre to edge. Some
designs are spherical in the centre, changing to aspheric geom-
etry towards the periphery. Most aspheric designs incorporate
a much atter, o en spherical, peripheral zone about 0.2 mm
wide. T is peripheral zone serves to avoid mechanical irritation
when the lens decentres to the peripheral cornea.
PMMA VERSUS RGP LENS DESIGN
Given the risk o corneal exhaustion syndrome and other chronic
hypoxic ef ects o the cornea, there is little or no justi cation or
tting polymethyl methacrylate (PMMA) lenses (Sweeney, 1992).
However, it is use ul to have an appreciation o dif erences in design
between non-gas-permeable PMMA lenses and rigid gas-perme-
able (RGP) lenses so that, when PMMA lenses are being re tted,
these dif erences can be taken into account. Because o the reli-
ance on trans er o oxygen through the tears to the post-lens cor-
nea, PMMA lens designs generally incorporate a wider and atter
periphery. T is results in a narrower optic zone and greater edge
clearance (Khorassani and Peterson, 1988). In comparison, RGP
lens designs usually incorporate the ollowing eatures:
• larger D
• larger BOZD
• narrower periphery
• steeper peripheral curves (resulting in less edge clearance).
Trial Fit t ing O p t io ns
T e traditional method o tting rigid lenses is by way o reus-
able trial lenses, although other options such as empirical t-
ting have become increasingly popular. With the theoretical risk
o transmission o in ection by contact lenses, the use o trial
lenses has been questioned, although Hogan (2003) showed the
chance o obtaining prion disease through contact lens use to
be negligible.
TRIAL FITTING SET
T e use o trial lens (or diagnostic) tting sets in a range o BOZRs
and Ds was once the standard method or tting rigid lenses.
A set o lenses in a given trial tting set generally ollows a
single design concept – or instance, constant edge clearance.
Lenses in a standard trial tting set are typically available in a
single diameter and back vertex power (BVP) with a range o
BOZRs in 0.1 mm steps; however, it is pre erable to use tting
15 Rig id Le ns De sig n and Fit t ing 147
sets that have lenses available in two diameters (e.g. 9.2 and 9.8
mm). Examples o additional use ul tting sets include:
• plus power, e.g. +3.00 D, smaller diameter
• high minus, e.g. −8.00 D, larger diameter
• small diameter or interpalpebral tting, e.g. 8.6 mm
• keratoconic, diameter varying with BOZR.
Sodium hypochlorite (Milton) in 20 000 ppm solution has been
suggested as an ef ective method o disin ecting rigid trial lenses.
EMPIRICAL FITTING
A high degree o success can be achieved by empirical tting
(i.e. ordering initial lenses based on keratometry and re rac-
tion). In one study, 91% o eyes were success ully tted by this
method (Back et al., 1996).
Most contact lens laboratories will supply lenses on a per-
case basis – that is, a xed cost or an unlimited number o
lens exchanges or a given patient until a nal satis actory t is
obtained. T is is an attractive option, especially in avoiding con-
cerns about cross-in ection. Furthermore, there are occasions
when this method is the only practical method, or example
when wishing to t a design not covered by available tting sets
or when an initial trial tting is simply not convenient or the
patient.
CO RNEAL TO PO GRAPHY (VIDEO KERATO SCO PY)
FITTING
Most corneal topographers incorporate rigid lens tting so -
ware (Fig. 15.6). T is enables practitioners to model dif erent
rigid lenses designs on an accurate representation o the cor-
nea o the patient (Caroline et al., 1994). T e tting success
rates are relatively low when relying solely on using the de ault
settings o the corneal topographer but can be relatively high
(77–93%) when an experienced practitioner uses the so ware
to select an appropriate lens (Jani and Szczotka, 2000).
Most corneal topographers use a Placido disc image re ected
rom the cornea, which is automatically measured and inter-
preted to produce corneal topography maps or videokerato-
grams. T ese maps can be presented as corneal curvature maps
or corneal elevation maps. From the point o view o rigid lens
tting, elevation maps are the most use ul. Conventionally,
Fig . 15.6 An e xamp le o vid e oke ratoscop e rig id le ns f tting so tware .
148 PART 3 Rig id Co nt act Le nse s

TABLE
15.4 Guid e line s o r t he Init ial Se le ct io n o a Rig id Le ns
A. SELECTIO N O F LENS TO TAL DIAMETER
HVID (mm) Small PA < 9.5 mm Ave rag e > 10.7 mm Larg e PA
< 11.2 8.2 8.6 9.2
11.2–11.6 8.6 9.2 9.6
11.6–12.0 9.2 9.6 10.0
> 12.0 9.6 10.0 10.0

B. SELECTIO N O F LENS BACK O PTICAL ZO NE RADIUS (BO ZR)

Le ns Diame t e r (mm) BO ZR (mm) BVP (D)
8.2 K−0.05 S
8.6 K−0.05 S− 0.25*
9.2 K−0.05 S− 0.25*
9.6 K−0.05 S− 0.25*
10.0 K S

HVID = horizontal visib le iris d iame te r; PA = p alp e b ral ap e rture ; BVP = b ack ve rte x p owe r; K= atte st K-re ad ing ; S = ve rte x-corre cte d sp he re rom
minus-cylind e r sp e ctacle p re scrip tion.
*Ad d − 0.25D.

steeper parts o the cornea are presented as ‘hotter’ colours such
as red and orange (see Chapter 41). With-the-rule astigmatism
corneal maps show a vertically oriented ‘bow-tie’ pattern. Kera-
toconic corneas show a rapid change in colour (or curvature)
near the corneal apex.
T e main advantages o corneal topographer elevation maps
in rigid lens tting are that they:
• indicate whether the corneal apex is decentred
• show atypical corneal shapes, e.g. extremes o corneal
asphericity
• allow the practitioner to monitor changes in corneal shape
• allow virtual trial tting o rigid lenses.
T ere is an apparent trend or rigid lens tting to be used more
or specialist ts (Morgan and E ron, 2008), in which case eleva-
tion maps are likely to prove increasingly use ul. T e obvious
limitation o elevation maps in trial lens tting is that they ail
to take into account the in uence o the lids.
Se le ct io n o Init ial Le nse s
TRIAL FITTING SET
T e procedure or selecting an initial tting o spherical lenses
using a trial tting set is as ollows:
1. Select a lens diameter based on corneal diameter, palpe-
bral aperture and lid con guration ( able 15.4).
2. Select the BOZR based on attest keratometer (K) reading,
adjusting the BOZR to be atter or steeper than K depend-
ing on BOZD. Since relatively steep- tting lenses are easier
to visualize with uorescein, err on the steep side.
3. I more than one power is available, select a lens power
closest to the re raction o the patient.
EMPIRICAL FITTING
T e procedure or empirical tting o spherical lenses is as
ollows:
1. Select a lens diameter based on corneal diameter, palpe-
bral aperture and lid con guration (see able 15.4).
2. Select the BOZR based on attest K-reading (K), adjust-
ing the BOZR to be atter or steeper than K depending
on BOZD. Flatter radii tend to be used with larger BOZD
and vice versa.
3. I the lens is an average diameter, select the BVP based
on the sphere power rom the re raction (minus cylinder
orm) corrected or vertex distance. With an average-diam-
eter lens, no adjustment is necessary; however, an adjust-
ment is necessary i the BOZR is steeper or atter than K.
4. Order the lens and use this ef ectively as a trial tting lens,
being prepared to modi y or reorder be ore dispensing.
Le ns Inse rt io n, Re mo val and Se t t ling
LENS INSERTIO N
Whether the initial lens is selected empirically, by corneal
topographer or rom a trial tting set, it is necessary to assess
the lens on the eye. With experienced rigid lens wearers, hav-
ing the patient insert the lens enables the practitioner to assess
the patient’s technique. Some patients all into bad habits such
as licking lenses or inserting them on to the sclera. With new
patients, it is pre erable or the practitioner to insert the lenses
rather than adding to the patient’s anxiety.
Be ore inserting the rst lens in new wearers, it is help ul to
prepare the patient or some initial discom ort, to advise that
this will recede and to suggest that any discom ort will be mini-
mized by looking downwards. Anxiety may also be reduced by
explaining that any discom ort will be to the eyelid rather than
the eye itsel , which will be unaf ected. Applying wetting solu-
tion to the lens be ore insertion will tend to make the lens more
com ortable and trans er more readily to the eye, but avoid
applying more than a small drop as too much can make uores-
cein assessment more di cult.
o minimize initial discom ort in new wearers the use o a
topical anaesthetic has been advocated. By reducing re ex lac-
rimation it is possible that a more accurate assessment o lens
t may be made. Although controversial, Bennett et al. (1998)
showed that the use o a topical anaesthetic at the tting and
dispensing visits or rst-time wearers o rigid lenses resulted in
signi cantly ewer dropouts, improved initial com ort and gave
an enhanced perception o the adaptation process and greater
overall satis action a er 1 month o lens wear.
 15 Rig id Le ns De sig n and Fit t ing 149

Fig . 15.7 Inse rting a rig id le ns. (A) Dire ct the g aze o the p atie nt
straig ht ahe ad . Re strain the p atie nt’s up p e r e ye lid with yo ur le t
thumb o r ore f ng e r. (B) With the le ns on the ore f ng e r o your rig ht
hand , move the le ns in close to the corne a, and re tract the in e rior
e yelid with the mid d le f ng e r. (C) Touch the le ns to the ce ntre o the
co rne a, the n g e ntly re le ase the lid s and ask the p atie nt to b link g e n-
tly. (Courte sy of Ad rian Bruce .)

o insert a rigid lens:

1. Ask the patient to xate a distant object to steady the eyes.
2. Place the lens on the index nger o the hand that will be
holding the patient’s bottom lid.
3. Hold the patient’s top lid using the index nger or thumb
o the other hand (Fig. 15.7A). I this proves di cult, have
the patient rst look down until the lid is securely held.
4. Hold the bottom lid using the middle nger o the hand
holding the lens (Fig. 15.7B) and place the lens directly
onto the centre o the cornea (Fig. 15.7C).
5. Release the bottom lid but continue to hold the top lid and
ask the patient to look down.
6. At this point, the lens is o en quite com ortable. Warn the
patient that once you let go o the lid, the patient will be
more aware o the lens.
I the lens locates onto the sclera, the lens will probably not be
uncom ortable. Have the patient look in the opposite direction
to where the lens is located (e.g. upwards i the lens is located on
the lower sclera). With two ngers, manipulate the lens towards
Fig . 15.8 Re p ositioning a mislocate d rig id le ns.
the cornea using the lids (Fig. 15.8). I this proves di cult,
remove the lens using the patient’s lids or a suction holder.

2. I necessary pull the lids apart in order to position the lid

LENS REMO VAL
o remove a rigid lens:
1. Place the index ngers o each hand on the lids o the pa-
tient above and below the centre o the lens (Fig. 15.9A).
margins at the lens edges.
3. Gently press the eyelid margins on to the eye and towards
each other (Fig. 15.9B).
4. T e lens may then be grasped and removed (Fig. 15.9C).
150 PART 3 Rig id Co nt act Le nse s

Fig . 15.9 Re moving a rig id le ns. (A) Place the ore f ng e rs o e ach
hand on the lid s o the p atie nt ab ove and b e low the ce ntre o the
le ns. (B) I ne ce ssary move the e ye lid s slig htly ap art in ord e r to p osi-
tion the lid marg ins at the le ns e d g e s. Ge ntly p re ss the e ye lid mar-
g ins on to the e ye and toward s e ach othe r. (C) The le ns may the n
b e g rasp e d and re move d b y the p ractitione r. (Courte sy of Ad rian
Bruce .)

SETTLING TIME
With new wearers, the patient’s initial reaction to rigid lenses
is use ul and can give an indication o how easily the patient
will adapt to rigid lens wear. Clearly, those showing little or no
lacrimation and who are able to move the eyes without apparent
discom ort are the most promising candidates. In these cases,
the lens t can be assessed immediately. However, in most cases,
it will be necessary to wait 5–10 minutes or any lacrimation to
subside. T is period can be used to discuss aspects o the pro-
cess, such as costs and hygiene and to answer any questions.
In a ew cases it may be some time be ore lacrimation subsides
enough to allow examination. It is necessary, however, to consider
other possible reasons or the discom ort. T is might be due to a
oreign body attached to the lens (the tears usually clear any loose
oreign bodies) or, alternatively, the t might be so poor as to be
causing some mechanical trauma to the cornea or conjunctiva.
Having ruled out other causes o discom ort, it might be necessary
to give a longer settling period (e.g. 10–30 minutes). It is pre erable
that the patient does not leave the practice during this period.
lens should position within the limbal boundary. In the case
o a lid attachment t the lens edge will be positioned under
the top lid, whereas with an interpalpebral t the lens will
be positioned between the lids. Also, lenses are occasionally
designed with thicker edges incorporating a negative carrier
in order to encourage lid attachment and lens centration. T e
requirements o a well- tting rigid lens are summarized in
able 15.5.
SATISFACTO RY LENS FIT
A lens with less than optimum itting may dri t downwards
between blinks, but not so ast as to disrupt vision or irri-
tate the bottom lid or lower limbus. It will move vertically
with a blink, being irst pushed as ar as the lower limbus
and then li ted by the lid almost to the upper limbus. In the
case o with-the-rule astigmatism, the lens will pivot along
the horizontal meridian or, i there is apical clearance, at the
edge o the optic zone at the 3 and 9 o’clock corneal locations
(Caroline et al., 1994).

Le ns Fit Charact e rist ics Asse ssme nt o Le ns Fit

O PTIMUM LENS FIT
T ere is a temptation to assess rigid lens tting purely in terms
A well- tting rigid lens will centre in such a way that the pupil o whether the lens is steep or at; however, this approach ails
is ully covered by the optic zone while the eye is open. T e to consider other aspects o rigid lens t. In particular, when

TABLE
15.5 Re q uire me nt s o a We ll-f t t ing Rig id Le ns
Re q uire me nt Imp o rt ance
Com ort Patie nt satis action
Good ce ntration Corne al cove rag e
Stab le p e rip he ral vision
Move me nt on b link or ve rsion Ad e q uate p ost-le ns lub rication
Avoid ance o le ns ad he re nce
Sup p ly o oxyg e n (low-Dk mate rials)
Constant p up il cove rag e Stab le vision
Ad e q uate corne al alig nme nt Avoid ance o e xce ssive me chanical p re ssure
O p timum e d g e cle arance Avoid ance o me chanical d isrup tion
Com ort
Avoid ance o 3 and 9 o’clock staining
BO ZR = b ack o p tical zone rad ius; BO ZD = b ack op tical zone d iame te r.
new to rigid lens tting, it is help ul to work through the ollow-
ing checklist o tting characteristics:
• diameter acceptability
• centration
• movement
• central t
• edge clearance.
T ere is also a tendency to assess rigid lenses in only one posi-
tion. However, during normal wear, rigid lenses move to all
positions on the cornea and it is there ore necessary to assess
the lens in a variety o positions, where necessary manipulating
the lens through the lids to move it to dif erent corneal loca-
tions. In particular, it is important to assess the peripheral t o
the lens when it decentres along the attest meridian (e.g. at 3
and 9 o’clock in with-the-rule astigmatism).
Hand-held ultraviolet (UV)-illuminated magni ers (Bur-
ton lamps) can be used or the assessment o rigid lens t and
have the advantage o allowing the patient to maintain normal
head posture. T is type o assessment is also relatively quick and
allows the two eyes to be easily compared. On the other hand,
the magni cation is not good enough to evaluate some impor-
tant aspects o t, such as edge clearance. For this reason alone,
slit-lamp evaluation is the method o choice or properly assess-
ing rigid lens t.
Some rigid lens materials contain a UV inhibitor that absorbs
wavelengths corresponding to that emitted by Burton lamps,
making uorescein evaluation impossible. T e blue lters on
most slit lamps have a wider spectral range, which overcomes
this problem.
WHITE LIGHT ASSESSMENT O F FIT
T e position o the lens may change when uorescein is added
to the tear lm. o avoid this con ounding in uence, the lens
should rst be assessed in white light prior to the instillation
o uorescein. It is necessary to ensure that the illumination
setting o the slit-lamp biomicroscope is not so bright as to
induce re ex tearing or an aversion re ex, which could cause
the patient to adjust lid position.
Diame te r
T e lens should appear to be the appropriate size or the eye.
With a relatively small lens, problems will tend to arise rom
15 Rig id Le ns De sig n and Fit t ing 151
Re le vant Rig id Le ns Parame t e rs
Ed g e thickne ss
Ed g e orm
Ed g e cle arance
Back sur ace junctions
Ed g e cle arance
BO ZR
Diame te r
Diame te r
BO ZD
BO ZR
Pe rip he ral curve rad ii
Pe rip he ral curve wid th
decentration. T e lens may ail to cover the cornea through sit-
ting high or resting on the bottom lid. It may also be less com-
ortable because o greater interaction between the upper lid
margin and the lens edge. Alternatively, the lens may irritate the
bottom lid by dropping between blinks.
Lenses that are larger than the palpebral aperture can result
in problems through interacting with the bottom lid as well as
the top lid. In some cases, the lens will be pushed into a high-
riding position by occasional interaction with the bottom lid,
whereas in other cases the lens may rest on the bottom lid.
Ce ntration
T e lens diameter may appear to be appropriate or the corneal
diameter and palpebral aperture but nevertheless show some
decentration. T e position o the lens between blinks is important.
Some decentration may be acceptable i the optic zone maintains
pupil coverage, but this may also indicate poor central or peripheral
t. Flat- tting lenses, or example, can show decentration in any
direction, depending on actors such as lid position or tightness.
Move me nt
All rigid lenses, however steep, show some movement. T e
task, there ore, is to assess the extent, speed and direction o
movement. T is should be observed in normal primary gaze.
Sluggish, limited post-blink movement may indicate a relatively
steep- tting lens. Fast movement sometimes indicates a at- t-
ting lens but may also be due to strong interaction with the top
lid, perhaps due to excessive edge clearance.
In addition, it is sometimes use ul to retract the lids and
observe the lens moving under gravity alone. Hold the lids
apart and manoeuvre the lens upwards. On releasing the lens, it
should drop slowly. I the lens shows less movement without the
in uence o the lids, this would suggest excessive lid interaction.
A true at- tting lens o en shows downward movement in an
arcuate direction.
Pe rip he ral Fit
Instances o markedly excessive edge clearance can be observed
with white light. T e peripheral tear meniscus may be absent,
particularly in the steeper meridian. In severe cases, this results
in bubbles orming behind the lens, which in turn can lead to
dimple staining. Patients also tend to nd such lenses uncom ort-
able owing to excessive interaction with the sensitive lid margins.
152 PART 3 Rig id Co nt act Le nse s

Fig . 15.10 Fluore sce in we d g e . Two conve rg ing g lass p late s are f lle d
with uore sce in; the p late s are touching at the rig ht sid e o the we d g e .

FLUO RESCEIN ASSESSMENT O F FIT

Inte rp re tation of Fluore sce nce
Fluorescein sodium is soluble in water. It absorbs most light in
the blue part o the spectrum but most o its emitted light is
in the yellow part o the spectrum and some in the green. T e
intensity o light emitted is governed by the concentration and
pH o the solution, and, critically in rigid lens tting, the thick-
ness o the uorescein sample. T e ef ect o concentration and
thickness o uorescein can be analysed using wedges o uo-
rescein (Fig. 15.10). At the thinner end o the wedge, uorescein
is not visible until a critical thickness o about 15 µm is reached.
T e intensity can be seen to increase towards the thicker end
o the wedge until another critical thickness o about 60 µm
is reached, beyond which the uorescein is seen as a uni orm
bright-yellow colour (Young, 1988).
In rigid lens tting, the uorescein pattern is a simple two-
dimensional representation o a complex three-dimensional
shape. T is provides use ul in ormation about the relationship
o the lens with the shape o the eye. Areas o tear pooling appear
bright yellow. Where the tear layer is absent or extremely thin,
there is no visible uorescence and the area appears dark blue
or black. Between these extremes, varying thicknesses o post-
lens tear lm are seen in varying intensities o yellow / green.
Fluorescein there ore provides a contour map o the thickness
o the tear lm.
Fluore sce in Instillation
As noted earlier, excessive uorescein will disrupt the lens t and
it is there ore best to instil a minimal amount, pre erably rom
a uorescein strip. Placing a drop o uorescein on the superior
sclera will maximize the length o time the dye remains in the
eye. In particularly sensitive patients, the process can be simpli-
ed by touching the uorescein strip against the ront o the lens.
A thick uorescein-stained pre-lens tear lm may con ound
interpretation o the true post-lens uorescein pattern (the
object o interest), so it may be necessary to wait until this has
dissipated be ore assessing the pattern.
T ree primary annular regions o the uorescein t should
be evaluated systematically: the central t, the peripheral t and
the edge clearance. In the case o a tricurve lens, these three
annular zones essentially correspond to the three back sur ace
zones o the lens. It is important to note areas showing no uo-
rescence as well as those that do.
As with the assessment o corneal staining, it is help ul to use
a yellow lter to enhance the visualization o the uorescein.
Fig . 15.11 Asse ssing ce ntral uore sce in f t having ce ntre d the le ns
and re tracte d the top lid .
Fig . 15.12 Typ ical uore sce in p atte rn with we ll-f tting le ns on astig -
matic (1.00 D) corne as o similar K-re ad ing s b ut varying corne al asp he -
ricity (corne al shap e actors = 0.60, 0.85 and 1.10).
Ce ntral Fit
I the lens is hal covered by the top lid, or the lens is decen-
tred, it may not be possible to observe the central t without
retracting the lid and repositioning the lens. T is is achieved
by gently holding the top and bottom lids with the index n-
ger and thumb, respectively (Fig. 15.11). T e lids can be used
to manoeuvre the lens into a central position and also to pump
extra uorescein beneath the lens.
T e uorescein pattern or well- tting lenses will vary
according to corneal asphericity and astigmatism. As one would
expect, spherical corneas show the simplest uorescein pat-
terns. T e optimum t is one that shows central alignment or
just a trace o uorescein indicating minimal central clearance.
With astigmatic corneas, in the steeper meridian the central
uorescein pattern will show increasing thickness towards the
edge. T e most recognizable uorescein pattern is the ‘dumb-
bell’ pattern seen with spherical lenses on astigmatic corneas
(see Fig. 15.11); however, the pattern varies according to the:
• asphericity o the cornea (Fig. 15.12)
• amount o corneal astigmatism (Fig. 15.13)
• lens design
• tting relationship, i.e. whether the lens is relatively steep
or at.

Fig . 15.13 Fluore sce in p atte rns o rig id le ns o varying b ack op tic
zone rad ius on with-the -rule corne as o varying astig matism.
With steep- tting lenses, uorescein assessment will show a
central pool o uorescein. T is pool will appear brighter the
steeper the t. In extreme cases, an air bubble may be present.
With at- tting lenses, central touch will be visible as an area
o dark blue or black. T e atter the t, the smaller the area o
touch. Fluorescein will be present in the mid-periphery and
may be continuous with the peripheral band o uorescein.
Mid -p e rip he ral Fit
Spherical lenses, particularly on astigmatic eyes, make contact
with the cornea at the edge o the optic zone. I the lens is poorly
blended or makes contact at a sharp angle, it may be uncom ort-
able and cause epithelial disruption. I a narrow line o contact
between optic zones can be seen upon lens inspection, it is likely
that there is a sharp junction rom poor blending. A band o
contact corresponding to the rst peripheral zone may indicate
relatively steep peripheral curves and the need or peripheral
lens attening.
In the case o a at- tting lens, the mid-peripheral band o
uorescein may merge with that o the central zone, even in the
attest meridian.
Ed g e Fit
T e width and the brightness o the peripheral band o uores-
cein give an indication o the extent o edge clearance. Where
the edge clearance is small, the tear lm thickness may be less
than the critical thickness above which the uorescein appears
with a saturated yellow colour. T is is generally less than the
desired clearance o 80 µm or more. A less-than-bright yellow
peripheral ring there ore indicates suboptimal edge clearance.
T is will be con rmed by an apparent break in the periph-
eral band o uorescein when the lens decentres towards the
limbus.
In the case o excessive edge clearance, bubbles may be seen
orming under the lens periphery. T e peripheral band may also
be wider than expected and show the saturated yellow appear-
ance over much o the peripheral band.
15 Rig id Le ns De sig n and Fit t ing 153
Fig . 15.14 Hig h-rid ing rig id le ns.
O VERREFRACTIO N
Measuring the overre raction during a rigid lens trial tting
not only helps to determine the nal lens power but also gives
an indication o whether the optimum t has been obtained.
An unexpected overre raction suggests that either the lens is
wrongly labelled or the t is not per ect. T e steeper the lens
t, the more minus power will be required in order to compen-
sate or a relatively plus-powered tear lens. Variable vision may
indicate a decentred or at- tting and relatively mobile lens t.
As a rule o thumb, a change in BOZR o 0.05 mm requires a
change in BVP o 0.25 D in order to compensate or the change
in tear lens. For instance, i a lens requires steepening by 0.10
mm and the overre raction is plano, then the minus power o
the lens will need to be increased by −0.50 D.
Rig id Le ns Fit t ing Pro b le ms
DECENTRATIO N
Poor centration is more common with higher levels o astigma-
tism. In the case o with-the-rule astigmatism the decentration
tends to be upwards (Fig. 15.14), whereas in the case o against-
the-rule astigmatism it tends to be sideways.
Decentration can be investigated as ollows:
1. Check whether the central t is relatively at. A change
in BOZR o 0.05 or 0.10 mm is unlikely to have much e -
ect on centration; however, larger changes than this may
make a critical dif erence.
2. Check that the edge clearance and edge thickness are not
excessive and resulting in undue lid in uence. In particu-
lar, this is o en the case with a high-riding lens.
3. Assuming no undamental errors in t, the next approach is
to consider an increase in overall diameter and optic zone di-
ameter. T e lens may still show some decentration, but this is
acceptable so long as there is pupil coverage by the optic zone.
4. I the decentration is deemed to be due to corneal astig-
matism, consider re tting with a back-sur ace toric de-
sign (see Chapter 16).
154 PART 3 Rig id Co nt act Le nse s
Fig . 15.15 Mild 3 and 9 o’clock staining (shown he re in the 3 o’clock
location).
PERIPHERAL CO RNEAL DESICCATIO N
T e appearance o 3 and 9 o’clock corneal staining can arise
due to either mechanical trauma or, more commonly, desic-
cation. T e extent o staining does not correlate with patient
symptoms (van der Worp et al., 2009). Some minimal 3 and 9
o’clock desiccation staining is considered acceptable; however,
coalescent or widespread staining can lead to vascularization,
scarring and corneal thinning (dellen) – conditions that o en
require remedial attention. T e characteristic appearance o 3
and 9 o’clock staining is a triangular shape delineating those
areas not wetted by the action o the upper lid. T e apex o
the triangle corresponds to the location o the widest part o
the lens (Fig. 15.15). Research suggests that the incidence o
3 and 9 o’clock staining is lower with larger lenses (>9.5 mm)
incorporating a moderately wide tear reservoir (Schnider
et al., 1997).
A number o actors can contribute to 3 and 9 o’clock desic-
cation staining including:
• in requent blinking
• poor tear quality
• in erior lens decentration
• excessive lid clearance due to lens edge clearance or edge
thickness (Schnider et al., 1996).
A diverse range o possible treatment options has been pro-
posed to overcome this type o staining (van der Worp et al.,
2003). T e ollowing are the most use ul options:
• Encourage blink awareness i the patient demonstrates
partial or in requent blinking.
• Modi y the lens to reduce edge thickness.
• Blend the back-sur ace junctions, i appropriate, to reduce
edge clearance.
• Re nish the lens edge to reduce the diameter and there ore
reduce edge clearance.
• Redesign the lens to reduce edge clearance.
• Increase the diameter, incorporating a wide peripheral
band.
• Re t with so lenses – this can be surprisingly success ul
even when tear lm quality is a contributing actor.
Fig . 15.16 Poor e d g e cle arance with a rig id le ns with re sultant con u-
e nt staining .
PERIPHERAL CO RNEAL MECHANICAL TRAUMA
Desiccation 3 and 9 o’clock staining can be mistaken or
mechanically induced staining resulting rom poor edge clear-
ance. A lens may show adequate edge clearance when centred
but exert mechanical pressure when decentred towards the lim-
bus. On examination o the uorescein t, the staining coin-
cides with an arcuate area o contact (Fig. 15.16). T is problem
may be remedied as ollows:
• Modi y the existing lens to increase edge clearance, assum-
ing that the lens periphery is thick enough.
• Redesign the lens with increased edge clearance.
Substantial changes in peripheral curve radii are required to
ef ect a signi cant change in edge clearance (Young, 1998).
For instance, with a 9.5 mm diameter tricurve design, atten-
ing both peripheral curves by 0.25 mm is required to achieve a
minimal signi cant change in edge clearance o about 10 µm.
DISCO MFO RT
T e most common reason or discontinuing rigid lens wear is dis-
com ort. T e description o symptoms of ered by (or elicited rom)
the patient can be help ul in determining the cause o the problem,
such as whether the discom ort arises rom the cornea, palpebral
conjunctiva or lid margin; whether it arises rom symptoms o
dryness, edge sensation or mechanical pressure on the cornea; or
whether it is connected with any particular activity or environment.
Possible modi cations to rigid lens designs that might
improve com ort include:
• reblending the back-sur ace optic zone transitions
• rerounding and / or thinning the edges
• reducing edge clearance by reducing the D
• increasing the D
• re tting with an aspheric design.
T e rst three o the strategies described above can be under-
taken by modi ying an existing lens as opposed to making a
new lens. Such modi cations can be undertaken in the practice
i suitable equipment is available; however, lens modi cation
requires some skill (Phillips, 2007) and most practitioners pre-
er to instruct a lens laboratory to undertake such tasks.

I the problem can be alleviated by modi cation, redesign
or some change in lens wearing habits, then clearly these steps
should be ollowed. However, a er taking such actions and
allowing or a reasonable period o adaptation to rigid lens wear,
some patients report that the discom ort remains unacceptable.
Such patients may never adapt to com ortable rigid lens wear
and other options should be considered, the obvious one being
a change to so lenses. Alternatively a hybrid lens design may be
pre erable in the case o an irregular cornea.
PO O R O R UNSTABLE VISIO N
T e accepted tolerances in rigid lens manu acture are relatively
wide. Because errors in BOZR and BOZD as well as BVP af ect
the re ractive correction, a rigid lens can be within tolerance
but still under- or overcorrect by nearly 1.00 D. In this case, an
overre raction will bring the visual acuity back to normal. I ,
however, the vision quality is still poor, the ollowing actors
should be considered:
• poor sur ace wetting – i new, the lens may not have been
su ciently hydrated
• optical distortion – occasionally waves in the polymer or
on the sur ace o the lens can disturb vision; these can be
observed by cleaning the lens and looking through it with
the naked eye
• sur ace scratches – can usually be polished out o the lens
• sur ace deposits – normally removable with a sur ace
cleaner, particularly an abrasive sur ace cleaner.
Variable vision can arise either through inadequate pupil cov-
erage (small BOZD or decentration) or poor sur ace quality
(scratches, deposits or poor wetting).
LENS LO SS
Rigid lens wearers who do not have spare lenses are at a dis-
advantage compared with most so lens wearers, or whom
15 Rig id Le ns De sig n and Fit t ing 155
the loss o an occasional disposable lens is not a problem. T e
repeated loss o a rigid lens may relate to the lens design. ight
lids combined with generous edge clearance can result in a lens
being ipped out o the eye. Apart rom optimizing the edge
clearance, increasing the lens diameter can also help to make
lenses more secure. In the case o signi cant corneal astigma-
tism, it may also be necessary to consider a back-sur ace toric
design.
Practitioners should be cognizant o the act that reports
o lost lenses may be due to the lens becoming mislocated and
sometimes embedded beneath the upper eyelid, unknown to
the patient. Numerous reports have appeared in the literature
describing this phenomenon, the most astonishing being that o
Kelly (1994), who described the case o a emale patient who had
reported losing numerous rigid lenses over a 3-month period. A
mucus-coated pellet was eventually removed rom beneath her
upper eyelid: this comprised eight PMMA lenses and one rigid
gas-permeable lens.
Co nclusio n
Although most lenses prescribed today are so lenses, there is
still a role or rigid lenses. Advances in lens material technology
have enabled rigid lenses that inter ere minimally with ocular
physiology. In some cases o poor corneal optics, rigid lenses
are the only optical solution short o keratoplasty. However, as
has been demonstrated above, rigid lenses are ar less orgiving
than so lenses in terms o tting characteristics and com ort.
Success ul rigid lens tting there ore demands patience, care-
ul patient management and good skill levels on the part o the
practitioner, coupled with perseverance and understanding on
the part o the patient.
Acce ss t he co mp le t e re e re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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IV rigid lenses. Int. Contact Lens Clin., 15, 311–315. in 3- and 9-o’clock staining. Optom. Vis. Sci., 86,
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Kiely, P. M., Smith, G., & Carney, L. G. (1982). T e 260–265.
667–673.
mean shape o the human cornea. Optica Acta, 29, Young, G. (1988). Fluorescein in rigid lens t evalua-
Guillon, M., Lydon, D. P. M., & Sammons, W. A.
1027–1040. tion. Int. Contact Lens Clin., 15, 95–100.
(1983). Designing rigid gas-permeable contact
La Hood, D. (1988). Edge shape and com ort o rigid Young, G. (1998). T e ef ect o rigid lens design on
lenses using the edge clearance technique. J. Br.
lenses. Am. J. Optom. Physiol. Opt., 65, 613–618. uorescein t. Cont. Lens Anterior Eye, 21, 41–46.
Contact Lens Assoc., 6, 19–25.

155.e 1
16
Rig id To ric Le ns De sig n and Fit t ing
RICHARD G LINDSAY
Int ro d uct io n
T e use o rigid toric lenses (in pre erence to rigid spherical
lenses) is indicated under the ollowing circumstances:
1. to improve the vision in cases where a lens employing
spherical ront and back optic zone radii is unable to pro-
vide adequate re ractive correction
2. to improve the physical t in cases where a lens with a
spherical back optic zone radius (BOZR) and spherical
back peripheral zone radii ails to provide an adequate
physical t.
T ese two main uses o toroidal sur aces on contact lenses are
not always distinct, such that occasionally a toric lens will be
used or both physical and optical reasons. For example, when
tting an eye with both a high degree o residual astigmatism
and a large amount o corneal toricity, a toric lens is required
optically (to correct the residual astigmatism) as well as physi-
cally (to optimize the t o the lens) (Lindsay, 1996).
Fo rms o f To ric Le ns
T ere are many varieties o rigid toric lens available to the
practitioner. Most commonly, a lens will have both a toroidal
back optic zone and peripheral zone. T ese lenses are gen-
erally used in attempting to obtain a good physical t on a
cornea that is too toroidal to allow a good t with a lens hav-
ing a spherical BOZR and spherical peripheral radii. Lenses
with toroidal back optic and peripheral zones can be produced
with or without a toroidal ront optic sur ace. A lens that has
a toroidal back optic zone and a toroidal ront sur ace is said
to have a bitoric construction. I the principal meridians are
not parallel, then the lens is designated as having an oblique
bitoric construction.
Occasionally, a rigid toric lens may be prescribed, consisting
o a spherical back optic zone and a toroidal peripheral zone.
T is type o lens can also be produced with or without a toroi-
dal ront sur ace, the latter usually being the pre erred option.
Lenses with spherical back optic zones and toroidal peripheral
zones are used as a means o attempting to improve the physical
t o a lens on an astigmatic cornea without the optical com-
plications inherent in the use o lenses with toroidal back optic
zones.
Very rarely, a rigid toric lens is produced with a toroidal back
optic zone and a spherical peripheral zone, with the intention
o improving the circulation o tears beneath the lens. How-
ever, when this is done, it is possible that the lens may become
less stable with regard to resisting rotation. One limitation o
employing a spherical periphery is that the peripheral radius
must be greater than, or equal to, the atter radius o the toroi-
dal back central optic zone. Once again, this orm o lens can be
made with or without a toroidal ront sur ace.
156
T e only other rigid toric lens orm consists o a spherical
back optic zone and spherical peripheral zone combined with
a toroidal ront optic sur ace. T is type o lens is required in
the situation where there is signi cant residual (non-corneal)
astigmatism but minimal corneal astigmatism. In this case, the
residual astigmatism needs to be corrected by means o a toroi-
dal ront sur ace, with a spherical optic zone indicated or the
back sur ace owing to the negligible corneal astigmatism.
Crit e ria fo r Use
Since rigid lenses with both spherical BOZR and peripheral radii
are o en used success ully on corneas with medium to high
degrees o astigmatism, it is important to decide what degree
o corneal astigmatism should indicate the use o toroidal back
optic zones. In general, these lenses should be used only when a
lens with a spherical BOZR cannot be made to t success ully. It
is rare to nd that toroidal back optic zones are necessary unless
the corneal astigmatism exceeds 2.50 D (i.e. the di erence in the
corneal radii, as measured with a keratometer, exceeds approxi-
mately 0.5 mm).
In cases o uncertainty (e.g. where the corneal astigmatism
is between 2.00 and 3.00 D), a toroidal back optic zone would
be used in pre erence to a spherical back-sur ace curve in the
ollowing situations:
• A spherical lens exhibits poor centration or excessive
movement.
• Excessive lens exure is noted with a spherical lens.
• Fluorescein patterns with a spherical lens reveal excessive
bearing along the atter corneal meridian, regardless o
the BOZR that is tted.
• Signi cant 3 and 9 o’clock staining occurs with a spherical
lens.
• T ere is marked corneal distortion and spectacle blur upon
removal o the spherical lens rom the eye. T is occurs as
a result o poor alignment between the spherical lens and
the toric cornea, with the spherical lens subsequently hav-
ing a moulding e ect on the toric cornea.
• T ere is signi cant residual astigmatism. In this case, a
spherical back sur ace may provide an adequate t; how-
ever, a toric back sur ace is utilized to stabilize the lens and
prevent rotation, owing to the presence o the correction
or the residual astigmatism on the ront sur ace o the
lens.
A great deal depends on actors other than corneal astigmatism.
Lid positions and tension are important. In a case o high with-
the-rule corneal astigmatism – and a low, loose lower lid – a
toroidal back optic zone may be needed to obtain a good physi-
cal t and centration. But a similar eye with a rm, high lower
lid may well be success ully tted using a lens with spherical
back-sur ace curves.

T e majority o cases o corneal astigmatism are ound with
the steeper corneal curve in the vertical meridian (with-the-
rule). I an attempt is made to t such an eye with a spherical
BOZR, the lens o en exhibits harsh bearing along the atter
(horizontal) meridian o the cornea and poor centration, caus-
ing physical discom ort and / or poor vision. Such an example is
illustrated in Fig. 16.1. I the same eye is tted using a lens with
toroidal back optic and peripheral curves, then the physical t
and centration are usually much improved (Fig. 16.2).
T e presence o against-the-rule corneal astigmatism usually
necessitates the use o a toroidal back optic zone earlier than
would be required with an equivalent amount o with-the-rule
corneal astigmatism. T is is due to the tendency or rigid spher-
ical lenses to decentre laterally on corneas with even moderate
amounts (1.50–2.00 D) o against-the-rule astigmatism.
Fig . 16.1 Le t e ye with hig h corne al astig matism. Ke ratome te r re ad ing
8.19 mm along 176, 7.47 mm along 86. Fitting with sp he rical (7.70 mm)
b ack op tic zone rad ius re ve als harsh b e aring along the horizo ntal ( at-
te r) me rid ian and p oor ce ntration.
Fig . 16.2 Same le t e ye as in Fig . 16.1 we aring an alig nme nt f tte d rig -
id le ns using a toroid al curve o b ack op tic zone rad ius 8.15 × 7.50 mm.
16 Rig id To ric Le ns De sig n and Fit t ing 157
De sig n Co nsid e rat io ns
Although rigid lenses may be success ully tted with either
apical clearance or apical contact, it is generally more satis-
actory to t lenses with toroidal back optic zones in or near
alignment. T e physical t, as denoted by the uorescein pat-
tern, will be similar to that seen with a well- tted spherical
lens in alignment to a cornea devoid o clinically signi cant
astigmatism.
A toric lens aligning too closely to the cornea can lead to
poor tear interchange. Consequently, it is advisable to use a
toroidal back optic zone with the steeper radius tted slightly
atter (longer radius) than the corresponding corneal radius so
as to assist the interchange o tears. T e atter radius will gener-
ally be tted ‘on K’ or else slightly steeper than its corresponding
corneal radius.
Consider the type o physical tting that might be derived
rom keratometer readings:
Keratometry reading: 7.90 mm (42.72 D) along 180
7.35 mm (45.91 D) along 90
7.85 8.45 9.25
Prescribed lens : C3 toric : 7.50 : 8.50 : 9.50
7.40 8.00 8.80
T e back optic zone radii should always be chosen such that
there is at least a 0.3 mm meridional di erence in radii (or 1.50
D di erence i the BOZR are speci ed in dioptres). Otherwise,
the toroidal BOZR may not position properly on the toroidal
cornea, leading to lens rotation and possible visual disturbance,
depending on the type o toric lens design. (Note that BOZR
indicates back optic zone radius or a spherical sur ace and back
optic zone radii or a toroidal sur ace.)
T e peripheral radii are usually chosen to re ect the type
o peripheral t pre erred by the practitioner concerned. Each
meridian is considered separately, and the peripheral ttings in
the two principal meridians are selected to provide the same
di erence between back optic and peripheral radii most com-
monly used by the practitioner in tting spherical corneas.
In addition, the peripheral curves will usually have the same
degree o toricity as the BOZR. For example, i a practitioner
usually speci es the secondary curve 0.9 mm atter than the
BOZR or a spherical lens, then or a lens with toroidal BOZR
o 7.90 / 7.40 the secondary curve ordered would be 8.80 / 8.30.
For lenses with a spherical back optic zone and a toroidal
peripheral zone, the peripheral curve region should be as large
as possible to increase the likelihood o alignment with the toric
cornea. T ese lenses are usually tted airly small to minimize
meridional sag di erences and slightly steeper centrally than
the atter corneal meridian to achieve a compromise t. T e
meridional di erence in the peripheral curves should be at least
0.6 mm to help minimize lens rotation (Ruston, 1999).
A typical case might be as ollows:
Keratometry reading: 7.90 mm (42.72 D) along 180
7.30 mm (46.23 D) along 90
BOZR chosen: 7.70 mm
BOZD chosen: 6.50 mm
D chosen: 9.50 mm
Prescribed lens:
8 50 9 20 10 00
C4/ 7 70 : 6 50 : 7 50 : 8 50 : 9 50
7 90 8 60 9 40
158 PART 3 Rig id Co nt act Le nse s

Although this type o lens can be very use ul in certain cases Based on a tear lens re ractive index o 1.336, this change in
where a ully spherical lens is not adequate, the toroidal periph- tear lens power is given by the ormula:
eral zones are, at best, only an attempt at compromise. T ey ( )
usually rotate more than lenses with all toroidal back-sur ace 336 336
−
curves, and the steeper peripheral radii occasionally end up in BOZRf nal BOZRtrial
close proximity to the atter corneal meridian, thus causing
slight corneal abuse. where BOZR nal is the BOZR that has been chosen or the lens
to be ordered and BOZRtrial is the BOZR o the trial lens.
O p t ical Co nsid e rat io ns It can be approximated that, or every 0.05 mm decrease in
BOZR, −0.25 D must be added to the BVP o the contact lens.
T e calculations involved in determining the necessary radii Likewise, +0.25 D must be added to the BVP o the contact lens
and power o these lenses are quite straight orward and the or every 0.05 mm increase in BOZR. T is approximation holds
complexity o this topic is o en exaggerated. It is important, only or relatively small di erences in BOZR and, i in doubt, it
however, that the undamentals o the optics o contact lenses is sa er to use the above ormula.
are understood i some o the complications o toroidal optic Given that the BOZR is being changed rom that used or the
sur aces on corneal lenses are to be appreciated. tting, the BVP that needs to be ordered (BVPCL) is given by:
o help understand and per orm some o the calculations ( )
needed in toric lens work, the reader is re erred to Chapter 13 336 336
BVPCL = BVPtrial + OR − −
and also to Douthwaite (1995). BOZRf nal BOZRtrial

When calculating the BVPs or a rigid toric lens based on tting

REFRACTIO N
with a spherical trial lens, there will be a change to the trial lens
Calculating the back vertex powers (BVPs) or a rigid lens with BOZR in at least one meridian. In this example, the back optic
toroidal back optic zone is undoubtedly a more complex task zone radii to be ordered are both di erent rom the trial lens
than determining the BVP or a spherical lens, and yet the two BOZR and so it will be necessary to allow or the change in tear
processes involve the same basic principles. For spherical lenses, lens power in both meridians.
the power o the contact lens in air plus the power o the tear ( )
336 336
lens in air should add up to the ocular re raction. With toric Along 180, BVPCL = + 1.00 + 1.00 − − = + 2.25 D
lenses, the same rule applies, but here the two separate merid- 8.00 7.95
ians must be considered. ( )
Example 1: Calculating the back vertex power or a rigid lens 336 336
Along 90, BVPCL = + 1.00 + 1.00 − − = − 0.25 D
with a toroidal back optic zone 7.55 7.95
Spectacle re raction (vertex distance ignored):
(When calculating BVP, values are rounded o to the nearest
+ 2.50/ − 3.00 × 180
0.25 D.)
(Note that the e ect o the vertex distance must be taken into Final prescription (Rx) o lens:
account i this distance is great or i the re ractive power in BOZR 8.00 mm along 180 +2.25 D
either meridian exceeds 4.00 D.) BOZR 7.55 mm along 90 −0.25 D
Alternatively, the BVPs o the contact lens can be calculated
Keratometry reading: 8.04 mm (42.00 D) along 180
empirically, by rst using the required BOZR and the keratometry
7.50 mm (45.00 D) along 90
reading o the patient to calculate the tear lens power (BVPtears)
A rigid spherical trial lens with BOZR 7.95 mm and BVP +1.00 D and then using the ormula:
is placed on the cornea. Re raction with this lens in situ gives
+1.00 DS (no residual astigmatism) and 6 / 6 acuity. Note that BVPCL = ocular refraction − BVPtears
the overre raction is usually best per ormed over a spherical trial
contact lens aligned along the attest meridian o the cornea and to calculate the BVPs along both meridians.
only one overre raction is required to calculate both BVPs. T e power o the tear lens is obtained rom the ollowing
Based on the keratometry readings, BOZR o 8.00 mm and ormula:
7.55 mm are chosen to t the horizontal and vertical meridians, ( )
336 336
respectively. BVPtears = −
T e power determination is now per ormed in the same way BOZR K
as with a rigid spherical lens, except that two meridians need to where K is the corneal ront-sur ace radius o curvature (in mil-
be considered instead o one. T e BVP that needs to be ordered limetres) along that respective meridian.
(BVPCL) is calculated by taking into account the BVP o the trial Once again, it can be approximated ( or very small di er-
lens (BVPtrial) and the overre raction (OR) and then using the ences) that there is 0.25 D o tear lens power or every 0.05 mm
ormula: di erence between the BOZR and the corneal ront-sur ace
BVPCL = BVPtrial + OR . radius o curvature.
Along 180,
For a spherical lens, i the BOZR o the trial lens is di erent rom ( )
336 336
the BOZR to be ordered, then, when determining the BVPCL, it BVPtears = + 2.50 − − + 0.25 D
is necessary to take into account the change in tear lens power 8.00 8.04
that will occur as a result o changing the BOZR. BVPCL = + 2.50 − 0.25 = + 2.25 D
 16 Rig id To ric Le ns De sig n and Fit t ing 159

Along 90,
( )
336 336
BVPtears = + 2.50 − − − 0.25 D
7.55 7.50
BVPCL = − 0.50 − ( − 0.25) = − 0.25 D
Although the empirical method is probably simpler, clinical
experience would suggest that more accurate results are usually
obtained when the BVP is calculated based on a re raction over
a trial lens.

RESIDUAL ASTIGMATISM
T e term ‘residual astigmatism’ is o en used loosely and is re-
quently con used with induced astigmatism or corneal astig-
matism. Residual astigmatism has been de ned in various ways
(Goldberg, 1964), including the simplistic de nition o residual
astigmatism as the component o the spectacle (ocular) astig-
matism that is not due to the cornea. In the context o rigid lens
tting, a better de nition would be: residual astigmatism is the
astigmatic component o a lens required to correct ully an eye
wearing a spherical powered rigid contact lens with a spherical
BOZR.
Example 2: Calculating the back vertex power or a rigid lens
with a toroidal back optic zone when there is residual astigma-
tism present.
Spectacle re raction (vertex distance ignored):
+ 2.50/ − 2.00 × 180
Keratometry reading: 8.04 mm (42.00 D) along 180
7.50 mm (45.00 D) along 90
A rigid spherical trial lens with BOZR 7.95 mm and BVP +1.00
D is placed on the cornea. Re raction with this lens in situ gives
+2.00 / −1.00 × 90 and 6 / 6 acuity.
Based on the keratometry readings, BOZR o 8.00 mm and
7.55 mm are chosen to t the horizontal and vertical meridians
respectively.
In this case, residual astigmatism is equal to −1.00 DC × 90. I
the patient is to be given the best possible vision it is necessary
to incorporate the correction or this residual cylinder into the
BVP to be ordered.
T e method or determining the BVPs is the same as used in
the previous example.
Along 180,
( )
336 336
BVPCL = + 1.00 + 1.00 − − = + 2.25 D
8.00 7.95
Along 90,
( )
336 336
BVPCL = + 1.00 + 2.00 − − = + 0.75 D
7.55 7.95
T e values or the overre raction are in bold to emphasize the
act that there is residual astigmatism present in this case.
Final Rx o lens:
BOZR 8.00 mm along 180 +2.25 D
BOZR 7.55 mm along 90 +0.75 D
In examples 1 and 2, the powers speci ed are the BVPs o the
toric lens in the appropriate meridians. T ese are the powers
read by the laboratory when checking the lens on a ocimeter
(vertometer).
It is requently use ul, in considering bitoric lenses, to draw
a representation o meridional powers to ensure that simple
Fig . 16.3 Me rid ional p owe rs re q uire d in Examp le 2. This shows the
p owe rs and d ire ctions as the y will b e me asure d b y the contact le ns
lab oratory.
errors in con using axes and meridians are not made. Such a
power cross is shown in Fig. 16.3.
Sometimes, the axis o the residual astigmatism does not cor-
respond exactly with one o the principal meridians o curvature
o the cornea. I the di erence between the axes o the spectacle
re raction and the principal meridians o the cornea is marginal
(less than 20°), one can assume that the axes o the spectacle
re raction over the lens do correspond with the principal merid-
ians o corneal curvature. By doing this, the need or any com-
plex oblique cylinder calculations is obviated and the resulting
error in the power calculations is usually not signi cant (Lindsay,
1996). I there is a large di erence between the cylinder axis o
the ocular re raction and the axis o the corneal astigmatism,
then an oblique bitoric lens (where the principal meridians o the
toroidal ront and back sur aces are not parallel) will be required.
INDUCED ASTIGMATISM
Induced astigmatism is the astigmatic e ect created in the con-
tact lens / tear lens system by the toroidal back optic zone bound-
ing two sur aces o di erent re ractive index, namely the lens
(re ractive index 1.41–1.49 depending on the material) and the
tears (re ractive index 1.336). As a general rule, rigid lenses with
re ractive indices lower than 1.458 are made rom uorosilicone
acrylates; lenses with re ractive indices in the range 1.458–1.469
are made rom either uorosilicone acrylates or silicone acry-
lates; and lenses with re ractive indices greater than 1.469 are
made rom silicone acrylates ( ranoudis and E ron, 1998).
Consider the lens designed in example 1 with back-sur ace
toric curves o 8.00 mm and 7.55 mm. Assuming a re ractive
index o 1.47 or the lens material, the sur ace powers o these
curves in air are −58.75 / −62.25, giving a back-sur ace cylinder o
−3.50 DC × 180. On the eye, where the back sur ace rests against
the tear layer (n = 1.336), the powers o the back-sur ace inter ace
are now −16.75 / −17.75 respectively and the back-sur ace cylin-
der in tear uid is −1.00 DC × 180. T is 1.00 D back-sur ace cylin-
der (‘induced astigmatism’) must be compensated by generating a
+1.00 D cylinder axis 180 on the ront sur ace (Sarver et al., 1985).
T e ront-sur ace cylinder correction or the induced astig-
matism is automatically incorporated into the lens prescrip-
tion when the practitioner calculates the BVPs or the rigid
toric lens. Once again, consider the lens designed in Example
1. I a re ractive index o 1.47 or the lens material and a lens
centre thickness o 0.25 mm is assumed, the required ront-
sur ace powers (calculated using thick lens ormulae) based
on BOZR o 8.00 and 7.55 mm and BVP o +2.25 and −0.25 D
160 PART 3 Rig id Co nt act Le nse s
would be +60.37 / +61.35, respectively. Speci cation o the
appropriate BOZR and BVP there ore results in the ront
sur ace incorporating the required compensating cylinder o
+1.00 DC × 180.
A quick way to calculate the induced astigmatism is to use
the appropriate radii considered with the change rom the rigid
lens to the tears. T at is:
1000 (1.336 − 1.47)
Power of the RGP lens/tear boundary =
r
= − 134
r ront sur ace can be le spherical.
where r = radius (in millimetres) and the re ractive index o the
rigid lens material is assumed to be equal to 1.47.
By subtracting the values ound o −134 / r or one princi-
pal meridian rom the other, the value or the induced astig-
matism may be obtained directly. With rigid lens materials o
re ractive index not equal to 1.47, the gure o −134 / r no longer
applies: or example, a re ractive index o 1.45 would yield a g-
ure o 114 / r or determining the sur ace power at the lens / tear
boundary.
SPHERICAL PO WER EQ UIVALENT
(‘CO MPENSATED’) BITO RIC LENSES
T ese are lenses that, like spherical lenses, do not correct or any
residual astigmatism (Sarver, 1963). T ey are bitoric because the
ront sur ace contains a cylinder solely or the correction o the
induced astigmatism. T e lens designed in Example 1 would be
characterized as a compensated bitoric lens.
A compensated bitoric can be thought o as a lens designed
to correct all o the re ractive cylinder created because o the
corneal toricity (Lowther, 1990). I the corneal toricity is equal
to the spectacle astigmatism, when a compensated bitoric is
placed on the cornea the cylinder will be ully corrected.
A compensated bitoric lens can rotate on the eye without
visual disturbance because the e ect o the rotation is counter-
acted by an equal change in the cylinder power o the tear lens.
CYLINDRICAL PO WER EQ UIVALENT TO RIC
LENSES
All other types o rigid toric lenses come under this classi ca-
tion, and the uni ying eature o these lenses is that they incor-
porate a correction or residual astigmatism. T is type o lens
can be urther categorized as ollows.
Alig nme nt Bitoric Le nse s
T ese are also known as parallel bitoric lenses. Both the ront
and back sur aces are toroidal. T e ront sur ace incorporates
correction or residual astigmatism as well as or the induced
astigmatism. In addition, the axes o the spectacle re raction
over the lens correspond with the principal meridians o cor-
neal curvature, so the correction or the residual astigmatism
will be along one o the principal meridians o the lens (hence
the name ‘alignment bitoric’). As such, the use o the term
‘alignment bitoric’ here should not be con used with alignment
in regard to lens tting. T e lens speci ed in Example 2 was an
alignment bitoric lens.
Back-surface Toric Le nse s
T ese lenses have a toroidal back sur ace but a spherical ront
sur ace. T e design principle is similar to that or alignment
bitorics. As with alignment bitorics, the ront sur ace incor-
porates correction or residual astigmatism as well as or the
induced astigmatism and the axes o the spectacle re raction
over the lens correspond with the principal meridians o cor-
neal curvature, so the correction or the residual astigmatism is
along one o the principal meridians o the lens.
In the case o a back-sur ace toric lens, however, the correc-
tion or the residual astigmatism is equal and opposite to the
correction or the induced astigmatism. Hence the two required
cylindrical corrections cancel each other out, meaning that the
Very occasionally a case o induced and residual astigmatism
cancelling out one another is encountered in practice, as in the
ollowing example.
Example 3: Spectacle re raction (vertex distance ignored):
+ 3.00/ − 4.00 × 180
Keratometry reading: 8.04 mm (42.00 D) along 180
7.50 mm (45.00 D) along 90
A rigid spherical trial lens with BOZR 7.95 mm and BVP +1.00
D is placed on the cornea. Re raction with this lens in situ gives
+1.50 / −1.00 × 180 and 6 / 6 acuity. Hence there is residual astig-
matism present, namely −1.00 DC × 180.
Based on the keratometry readings, BOZR o 8.00 mm and
7.55 mm are chosen to t the horizontal and vertical meridians,
respectively.
T e induced astigmatism can be determined using the
method described previously o calculating the change in power
o the RGP lens / tear boundary. By subtracting the values ound
o −134 / r or one principal meridian rom the other (assuming
a lens re ractive index o 1.47), the value or the induced astig-
matism is obtained.
− 134 − 134
Induced astigmatism = − = + 1.00 D
8.00 7.55
T e induced astigmatism, expressed in negative cylinder orm,
will always have the same axis as the corneal astigmatism. Hence,
the induced back-sur ace cylinder here is −1.00 DC × 180.
T e correction or the residual astigmatism is −1.00 DC × 180,
so the residual astigmatism and the induced astigmatism should
cancel each other out. T is can be con rmed by calculation o
the BVPs and the ront- and back-sur ace powers o the lens
(assuming a lens centre thickness o 0.25 mm).
Along 180,
( )
336 336
BVPCL = + 1.00 + 1.50 + − = + 2.75 D
7.95 8.00
1000 (1 − 1.47)
Back-surface power of the contact lens =
+ 8.00
= 58.75 D
Front-surface power of the contact lens = + 60.86 D
Along 90,
( )
336 336
BVPCL = + 1.00 + 0.50 + − = − 0.75 D
7.95 7.55
1000 (1 − 1.47)
Back-surface power of the contact lens =
+ 7.55
= − 62.25 D
Front-surface power of the contact lens = + 60.86

T e ront sur ace is spherical (same power along both principal
meridians) so the residual and induced astigmatism have indeed
cancelled each other out. (When calculating sur ace powers, or
clinical purposes a di erence in power o ≤0.12 D between the
principal meridians constitutes a spherical sur ace.)
A back-sur ace toric design is possible only i the correction
or the residual astigmatism is equal and opposite to the correc-
tion or the induced astigmatism. A back-sur ace toric design
is there ore worth considering only i the ocular astigmatism
o the patient is greater than the corneal astigmatism (Meyler
and Ruston, 1995). T e residual astigmatism must also then be
o a magnitude whereby it will be neutralized by the resultant
induced astigmatism. T e likelihood o both o these require-
ments being met is low, so in only a small percentage o cases
will a back-sur ace toric design be appropriate. Indeed, in most
cases the induced astigmatism usually exaggerates the e ect o
the residual astigmatism.
Front-surface Toric Le nse s
Residual astigmatism requently needs to be corrected in cases
where the patient is tted well, physically, with a lens utilizing a
spherical back optic zone. Such a lens there ore requires a toroi-
dal ront sur ace, but lens rotation must be avoided, otherwise
visual disturbance will result. When the corneal astigmatism is
less than 2.00 D, a toric back sur ace will not generally prevent
lens rotation and so other orms o lens stabilization, such as
prism ballast or truncation, are required.
Prism ballast is the most commonly used method o lens sta-
bilization or rigid lenses that have toroidal ront sur aces com-
bined with spherical back optic zones. With prism ballasting,
the lens is prescribed in the normal manner with the addition o
between 1 and 3Δ. When ordering the lens, practitioners assume
that the weight or prism ballast orients the lens in a certain
xed position on the cornea and order the cylinder axis with
respect to this position. o avoid recording the prism base posi-
tion as ‘down along 90’ or ‘down along 100’, its actual location is
recorded as being at 270 or 280, respectively.
Prism ballast may also be used in combination with a toroi-
dal back sur ace, where a patient’s corneal astigmatism is too
small (<2.00 D) to maintain the proper position o a bitoric lens
but large enough (>1.00 D) to cause a ront toric lens to become
unstable (Gonce and Kastl, 1994).
runcations can also be added to ront-sur ace toric lenses
i prism ballasting is insuf cient to stabilize the lens. T e usual
method o designing a truncation or a prism-ballasted lens is
to prescribe the lens in the normal way with the addition o the
ront-sur ace cylinder at the correct angle relative to the esti-
mated or observed position o the prism base. T e relationship
o the lower lid to the edge o the lens is observed and a trunca-
tion is then cut to align with the lower lid (Fig. 16.4).
Prism ballasting can o en cause rigid lenses to sit in eriorly,
causing patients to experience symptoms o discom ort and
are. runcations can also be uncom ortable or the patient
and they are not always success ul in preventing lens rotation.
Consequently, a so toric contact lens is generally pre erred to
a rigid toric contact lens when tting lenses in patients who
have signi cant residual astigmatism but negligible corneal
astigmatism.
O b liq ue Bitoric Le nse s
As with alignment bitoric lenses, oblique bitoric lenses have a
toroidal ront and back sur ace. With oblique bitorics, however,
16 Rig id To ric Le ns De sig n and Fit t ing 161
Fig . 16.4 A p rism-b allaste d rig id toric le ns with sing le truncation. This
o te n p rove s ve ry succe ss ul in p re ve nting unwante d rotation.
the principal meridians o the toroidal back and ront sur aces
are not parallel, owing to a di erence between the axes o the
spectacle re raction and the principal meridians o corneal cur-
vature. T e speci cation and manu acture o these type o lenses
are very dif cult. One solution is to use a tting set o lenses, all
o which have a toroidal back optic zone and a spherical ront
sur ace. A re raction is per ormed over the appropriate trial lens
and then the oblique cylinder obtained rom this re raction is
incorporated onto the ront sur ace o the lens. T ese lenses are
rarely prescribed.
EFFECT O F LENS RO TATIO N
With all cylindrical power equivalent bitoric lenses, some
visual disturbance will occur with rotation as the lenses incor-
porate a correction or residual astigmatism and the axis o
correction or the residual astigmatism remains xed in rela-
tion to the eye.
T is limitation on rotation is important, or when residual
astigmatism is o a low degree rom a clinical standpoint then it
is not worthwhile incorporating its correction with that or the
induced astigmatism. I , however, the residual astigmatism is
clinically signi cant then it is worth incorporating provided that
lens rotation can be kept to a minimum (Figs. 16.5 and 16.6).
With lenses incorporating a toroidal back sur ace, rotation
is generally not a problem owing to the stabilizing e ect o the
toric back sur ace on the toric cornea (provided there is su -
cient corneal toricity).
Co nclusio n
Advances in so toric lens technology have resulted in it being
the predominant and pre erred method o correcting astig-
matism, especially when considering the increased chair time
required to arrive at a success ul rigid toric lens tting. Neverthe-
less, there will be occasions when one o the more sophisticated
rigid toric lenses is required or a given patient. In act there is
an apparent trend or rigid lenses to be used more or specialist
ts, such as sophisticated toric designs, multi ocals and ortho-
keratology (Morgan and E ron, 2008). Blackmore et al. (2006)
surveyed diplomates o the American Academy o Optometry,
162 PART 3 Rig id Co nt act Le nse s
Fig . 16.5 A rig ht le ns with a toroid al b ack op tic zone f tte d in alig n-
me nt. Ke ratome te r re ad ing is 8.13 mm alo ng 160 and 7.62 mm along
70. Le ns b ack op tic zone rad ius 8.10 × 7.70 mm. The 8.10 me rid ian is
marke d with g re ase p e ncil and can b e se e n alig ning we ll with the 160
me rid ian. The re is no sig nif cant rotatio n, thus p e rmitting accurate cor-
re ction o re sid ual astig matism, as we ll as ind uce d astig matism, with a
ront-sur ace cylind e r.
most o whom considered that back-sur ace toric and bitoric
rigid lenses are easy to design and t. Some practitioners, how-
ever, may choose to re er especially challenging cases to a col-
league who takes a special interest in rigid toric lens tting and
who has the necessary repertoire o custom-designed trial lens
sets. Notwithstanding that possibility, the utility o this chapter
Fig . 16.6 Same rig ht e ye as in Fig . 16.5. Le ns b ack op tic zone rad ius
8.05 × 7.75 with 8.05 me rid ian marke d with g re ase p e ncil. This should b e
locate d along the 160 me rid ian b ut, as shown, this le ns ro tate s b ad ly,
thus p e rmitting only the accurate corre ction o ind uce d astig matism
with a ront-sur ace cylind e r.
is that it provides an overview o the optical considerations and
possible lens designs or the various orms o complex astig-
matic correction that can sometimes present in practice.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
REFERENCES
Blackmore, K., Bachand, N., Bennett, E. S., et al.
(2006). Gas permeable toric use and applications:
survey o Section on Cornea and Contact Lens
Diplomates o the American Academy o Optom-
etry. Optometry, 77, 17–22.
Douthwaite, W. A. (1995). Contact Lens Optics and
Lens Design. Ox ord: Butterworth-Heinemann.
Goldberg, J. B. (1964). T e correction o residual
astigmatism with corneal contact lenses. Br. J.
Physiol. Opt., 21, 169–174.
Gonce, M. A., & Kastl, P. R. (1994). Bi-rigid to-
ric contact lens with prism tting in rare cases
o moderate corneal and residual astigmatism.
CLAO J., 20, 176–178.
Lindsay, R. G. (1996). Rigid toric gas-permeable
contact lenses: indications, tting principles and
prescription calculations. Pract. Optom., 7, 218–
224.
Lowther, G. E. (1990). oric RGPs: should they
be used more o en? Int. Contact Lens Clin., 17,
260–261.
Meyler, J., & Ruston, D. (1995). oric RGP contact
lenses made easy. Optician, 209(5504), 30–35.
Morgan, P. B., & E ron, N. (2008). T e evolution o
rigid contact lens prescribing. Cont. Lens Anterior
Eye, 31, 213–214.
Ruston, D. (1999). T e challenge o tting astigmatic
eyes: rigid gas-permeable toric lenses. Cont. Lens
Anterior Eye, 22(Suppl.), S2–S13.
Sarver, M. D. (1963). A toric base corneal contact
lens with spherical power e ect. J. Am. Optom.
Assoc., 34, 1136–1137.
Sarver, M. D., Kame, R. ., & Williams, C. E. (1985).
A bitoric gas permeable hard contact lens with
spherical power e ect. J. Am. Optom. Assoc., 56,
184–189.
ranoudis, I., & E ron, N. (1998). Re ractive index
o rigid contact lens materials. Cont. Lens Anterior
Eye, 21, 15–18.
162.e 1
17
Rig id Le ns Care Syst e ms
PHILIP B MO RGAN
Int ro d uct io n
T is chapter reviews the care systems used with rigid contact
lenses. O course, many o the general principles o contact
lens care, such as the rationale or lens cleaning and disin ec-
tion, regulatory control o the contact lens care industry and
various approaches to comparing the e cacy o di erent solu-
tions, have already been discussed in Chapter 10 and will not be
repeated here.
Disinfe ct io n and We t t ing So lut io ns
raditionally, rigid lens products were preserved with ben-
zalkonium chloride, thiomersal and chlorhexidine. However,
there is some evidence that su cient levels o chlorhexidine or
benzalkonium chloride can bind to the sur ace o a rigid lens,
leading to a toxic reaction at the ocular sur ace a er lens inser-
tion (Rosenthal et al., 1986). More recent products have seen
a move away rom these preservative agents or, as in the case
o the Boston Advance product, a reduction in chlorhexidine
concentration compared with previous care solutions. Also,
polyhexanide (more traditionally part o so lens disin ectant
products) has been introduced as a second preservative in rigid
lens solutions ( able 17.1). For example, Boston Simplus multi-
action solution (Bausch & Lomb) contains polyhexanide as its
disin ectant (Fig. 17.1).
Multipurpose solutions or cleaning and disin ecting rigid
gas-permeable lenses have replaced single-purpose solutions,
but there are ew reports o the e cacy o these multipurpose
solutions, or o the e ects o storage conditions on their disin-
ecting capacities. Boost et al. (2006) showed that multipurpose
solutions or rigid lenses lose activity over the 3 months’ recom-
mended time o use but remain satis actory or use. Disin ecting
capacity reduced more quickly when the solution was stored in
TABLE
17.1 Co nst it ue nt s o f Rig id Le ns Disinfe ct ing So lut io ns
Co mp any Pro d uct
Ab b ott Me d ical O p tics Total Care
Ad vance d Eye care Re se arch Re g ard K RGP
Alcon O p ti-Fre e GP
Bausch & Lomb Boston Ad vance
Bausch & Lomb Boston Simp lus
Me nicon Uniq ue p H
the re rigerator. Rigid lens disin ecting solutions are not able to
kill Acanthamoeba species during manu acturer-recommended
disin ection times (Boost et al., 2012).
In addition to their role in lens disin ection, most rigid lens
storage solutions also act to wet or to condition the lens. T is
role is principally to act as a lubricant, a ording a degree o pro-
tection to the cornea and lid margins when the lens is inserted.
T e cushioning e ect minimizes discom ort at insertion. T e
secondary e ects o success ul lens wetting are that the lens
sur ace is, rst, rendered hydrophilic to aid a stable pre-lens
tear lm and, second, made more biocompatible, which might
reduce protein deposition.
Various agents are incorporated into rigid lens solutions
to aid sur ace conditioning. Polyvinyl alcohol is a positively
charged polymer that is attracted to the negatively charged sur-
ace o lenses containing methacrylic acid to provide a more
wettable lens (Walker, 1997). Another agent used to increase
wettability is the viscosity agent hydroxyethylcellulose. In addi-
tion to preservative and conditioning / wetting agents, rigid lens
care solutions contain bu ering agents to maintain a stable pH,
and chelating agents to increase antimicrobial action and assist
in lens cleaning.
Cle aning So lut io ns
Some rigid lenses are cleaned with a separate solution to the dis-
in ectant and wetting product, whereas others ollow many o
the so lens care systems and are multipurpose products. Sepa-
rate rigid lens-cleaning solutions can be more intensive than
their so lens equivalents because there is less opportunity or
the solution to enter the lens material, with the subsequent pos-
sibility o toxic reaction. For example, Boston Advance Cleaner
(Bausch & Lomb) contains a silica suspension o microscopic
beads, which act like a gentle polish on the lens; this is bene cial
Pre se rvat ive (p p m) Surfact ant / Co nd it io ne r / Visco sit y Ag e nt s
Polyhe xanid e (5) Hyd roxye thyl ce llulose
O xychlorite Pluronic F127
Hyd roxyp rop yl me thylce llulose
Polyq uad (11) Poloxamine
Hyd roxyp rop yl g uar
Polyhe xanid e (5) Polyq uate rnium 10
Chlorhe xid ine (30) Polyvinyl alcohol
De rivatize d p olye thyle ne g lycol
Ce llulose viscosif e r
Polyhe xanid e (5) Poloxamine
Chlorhe xid ine (30) Hyd roxyp rop yl me thylce llulose
Polyq uad (11) Poloxamine
Hyd roxyp rop yl g uar
163
164 PART 3 Rig id Co nt act Le nse s
Fig . 17.1 Care syste ms for rig id le nse s. (Courte sy of Ab b ott, Bausch &
Lomb , and Ad vance d Eye care .)
with deposits such as denatured proteins, which can otherwise
be di cult to remove. T is cleaner also contains an alcohol
base, which assists in removing lipid-type spoilation.
Pro t e in Re mo val So lut io ns
Protein removal is arguably more important with rigid lenses
than with so lenses, in view o the act that most so lenses
prescribed today are replaced more regularly than rigid lenses.
With ew exceptions, protein removal systems that were orig-
inally designed or use with so lenses can also be used with
rigid lenses. T e requency with which patients should be
advised to use protein removal systems, and how such systems
should be applied to the lenses, will vary depending on the lens
material and the strength o the active ingredient in the protein
removal system. Advice on these issues should be obtained rom
the manu acturer.
Individual patient actors will also have an impact on the way
protein removal systems should be applied. Patients who display
a propensity or depositing protein on lenses, and who wear
their lenses more requently and or longer periods o time, may
need to treat their lenses more regularly. ypical requencies o
usage o protein removal systems vary rom weekly to monthly.
Disinfe ct io n o f Trial Le ns Se t s
Proper application o the standard lens care protocols described
in this chapter will be e cacious at killing most bacteria,
viruses, ungi and protozoa, especially those known to cause
in ection in the eye. However, certain in ectious agents have
more recently been identi ed that are apparently resistant to
current so and rigid lens care regimens. O particular concern
is a proteinaceous vector known as a prion – a chameleon-like
in ectious agent that exists in di erent strains that have distinct
biological properties and can alter when the disease or which it
is responsible crosses the species barrier. It has been suggested
by health authorities in the UK that there is a remote theoretical
risk o transmission o variant Creutz eldt–Jacob disease (vCJD)
between humans, via trans er o bodily tissues and f uids such
as tears.
An extension o the above argument leads to the conclu-
sion that vCJD could theoretically be transmitted rom an
in ected individual to another person via a trial contact lens
contaminated with the o ending prion. Although such trans-
mission is theoretically possible, it remains highly improbable
(Armstrong, 2006). In the light o this, the College o Optom-
etrists recommends that single-use trial lenses should be used
whenever possible to limit any chance o disease transmission.
Indeed, excellent success rates in tting rigid lenses empirically
(i.e. the lens is ordered based on measures o re raction and
ocular dimensions) have been demonstrated. However, it is rec-
ognized that in certain cases, particularly where there is disease
or abnormality o the lid, cornea or ocular sur ace, special com-
plex diagnostic contact lenses may be necessary or a success ul
clinical outcome. T ese lenses may need to be reused. An obvi-
ous case is keratoconus, as a practitioner who ts patients with
this condition may have access to a number o trial tting sets,
each representing a di erent design philosophy.
Where empirical tting is impracticable then suitable items
should be decontaminated using a recognized method. Comoy
et al. (2003) ound that Menicon Progent and Menicon MeniLAB
(0.4 and 0.5% sodium hypochlorite respectively) decreased the
in ectivity o prions retained on the sur ace o experimentally
contaminated lenses by a actor o at least 10 million. Current
advice, however, is to use a readily available sodium hypochlo-
rite 1% solution (10 000 ppm available chlorine), such as is sold
or household use, allowing the lens to be sa ely reused. Macali-
ster and Buckley (2002) concluded that sodium hypochlorite
does not appear to distort rigid lenses; however, it may not be
used on so lenses.
Co nclusio n
Multipurpose care systems are becoming the norm or the main-
tenance o rigid contact lenses. Because rigid lenses typically
have a li e span in excess o 6 months, occasional use o protein
removal systems may be required. T e reuse o rigid trial lenses
to determine the best lens t should be minimized because o
the remote theoretical risk o transmission o diseases by agents
such as prions, which are resistant to conventional antimicro-
bial methods. Sodium hypochlorite solution is an e ective rigid
lens disin ecting solution with antiprion activity.
ACKNO WLEDGEMENT
T e author acknowledges the assistance o Kayleigh Walda or photog-
raphy in Figure 17.1.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
REFERENCES
Armstrong, R. A. (2006). Creutz eldt–Jakob disease
and vision. Clin. Exp. Optom., 89, 3–9.
Boost, M., Cho, P., & Lai, S. (2006). E cacy o multi-
purpose solutions or rigid gas permeable lenses.
Ophthal. Physiol. Opt., 26, 468–475.
Boost, M. V., Shi, G. S., Lai, S., et al. (2012). Amoebi-
cidal e ects o contact lens disin ecting solutions.
Optom. Vis. Sci., 89, 44–51.
Comoy, E., Bonnevalle, C., Métais, A., et al.
(2003). Disin ection o gas-permeable contact
lenses against prions. J. Fr. Ophtalmol., 26,
233–239.
Macalister, G. O., & Buckley, R. J. (2002). T e risk o
transmission o variant Creutz eldt–Jakob disease
via contact lenses and ophthalmic devices. Cont.
Lens Anterior Eye, 25, 104–136.
Rosenthal, P., Chou, M. H., Salamone, J. C., et al.
(1986). Quantitative analysis o chlorhexidine
gluconate and benzalkonium chloride adsorp-
tion on silicone / acrylate polymers. CLAO J., 12,
43–50.
Walker, J. (1997). New developments in RGP lens
care. Optician, 213(5583), 16–19.
164.e 1
 PART

4
Le ns Re p lace me nt
Mo d alit ie s

PART O UTLINE
18 Daily Disp osab le Soft Le nse s 167
Nathan E ron
19 Re usab le Soft Le nse s 175
Joe Tanne r and Nathan E ron
20 Planne d Re p lace me nt Rig id Le nse s 187
Craig A Wood s
This pa ge inte ntiona lly le ft bla nk
18
Daily Disp o sab le So ft Le nse s
NATHAN EFRO N
Int ro d uct io n
Daily disposable lenses are one o the two versions o true, single-
use-only, contact lenses – the other being extended-wear lenses.
Daily disposable lenses rst became available in 1994. T e
Premier daily disposable lens was launched in the UK (later this
was sold to Bausch & Lomb) and Johnson & Johnson released the
1-Day Acuvue daily disposable lens into western regions o the
USA at around the same time (Meyler and Ruston, 2006). Since
their release in the mid 1990s, daily disposable lenses rapidly gained
worldwide acceptance. T is trend has continued into the 21st cen-
tury, as indicated in Fig. 18.1, which illustrates the extent o daily
disposable lens prescribing as a percentage o all so lenses tted in
seven nations between 2000 and 2015 (Morgan et al., 2016).
Numerous brands o daily disposable hydrogel lenses have
entered the market over the past two decades, and in 2015, the
our major global contact lens companies produced 11 brands
o spherical, six brands o toric, six brands o multi ocal and
three brands o cosmetic coloured daily disposable lenses, in
both hydrogel and silicone hydrogel materials ( able 18.1) (Kerr
and McParland, 2015).
Usage o daily disposable lenses varies widely among
nations, as shown in Fig. 18.2. In 2015, daily disposable lenses
represented over 50% o all so contact lenses prescribed in
six nations (Australia, Denmark, Italy, Japan, aiwan and the
United Kingdom) (Morgan et al., 2016).
Fig . 18.1 Daily d isp osab le contact le ns f ts as a p rop ortion o all so t le ns f ts b e twe e n 2000 and 2015 in se ve n nations.
he reasons or the discrepancy in the extent o daily dis-
posable lens prescribing between countries may relate to a
number o actors, such as di erences in the retail cost to
lens wearers, pro it margins enjoyed by practitioners, extent
and e ectiveness o distribution and marketing, and the
local in luence o opinion leaders. Cost o product is perhaps
the most signi icant actor. It has been demonstrated that in
two markets – Australia (E ron et al., 2010) and the United
Kingdom (E ron et al., 2012) – the annual cost o wearing
daily disposable lenses on a ull-time basis is greater than
that or reusable lenses, irrespective o lens design (i.e. spher-
ical, toric and multi ocal). Although daily disposable lenses
are more cost-e ective compared with reusable lenses when
worn on a part-time basis, it is likely that the overall pre-
scribing o daily disposable lenses is driven by the perceived
costs incurred or ull-time wear.
E ron et al. (2013) reported that the proportion o daily dis-
posable lens ts (as a unction o all so lens ts) was positively
related to the gross domestic product at purchasing parity per
capita or year 2011 (r 2 = 0.55, F = 46.8, p < 0.0001) (Fig. 18.3).
Inspection o Fig. 18.3 reveals Qatar to be a signi cant outlier;
signi cant outliers such as this have the potential to exagger-
ate estimates o correlation. o test whether this was the case,
E ron et al. (2013) conducted another linear regression analy-
sis excluding Qatar. T is still resulted in a strong correlation
(r2 = 0.43, F = 27.3, p < 0.0001).
167
168 PART 4 Le ns Re p lace me nt Mo d alit ie s

TABLE
18.1 Daily Disp o sab le Co nt act Le nse s
Le ns Brand Manufact ure r Mat e rial Wat e r Co nt e nt (%) BO ZRa (mm) Diame t e r (mm)
SPHERICAL – HYDRO GEL
Focus Dailie s Aq uaCom ort Plus Alcon Ne l lcon A II 2 69 8.7 14.0
Focus Dailie s All Day Com ort Alcon Ne l lcon A II 2 69 8.6 13.8
Biotrue O ne Day Bausch & Lomb Ne so lcon A 78 8.6 14.2
So Le ns Daily Disp osab le Bausch & Lomb Hila lcon B II 2 59 8.6 14.2
BioMe d ics 1 Day Extra Coop e rVision O cu lcon D IV 1 55 8.6 / 8.8 14.2
Procle ar 1 Day Coop e rVision O ma lcon A II 2 60 8.7 14.2
1-Day Acuvue Moist Johnson & Johnson Eta lcon A IV 2 58 8.5, 9.0 14.2
SPHERICAL – SILICO NE HYDRO GEL
Dailie s Total 1 Alcon De le lcon A 30 / 80 b 8.5 14.1
Clariti 1 d ay Coop e rVision Somo lcon A 56 8.6 14.1
MyDay Coop e rVision Ste n lcon A 54 8.4 14.2
1-Day Acuvue TruEye Johnson & Johnson Nara lcon A I 4 46 8.5, 9.0 14.2
TO RIC – HYDRO GEL
Focus Dailie s Aq uaCom ort Plus Toric Alcon Ne l lcon A II 2 69 8.8 14.4
Focus Dailie s All Day Com ort Toric Alcon Ne l lcon A II 2 69 8.6 14.2
Sof e ns Daily Disp osab le Toric or Bausch & Lomb Hila lcon B II 2 59 8.6 14.2
Astig matism
BioMe d ics 1 Day Extra Toric Coop e rVision O cu lcon D IV 1 55 8.7 14.5
1-Day Acuvue Moist or Astig matism Johnson & Johnson Eta lcon A IV 2 58 8.5 14.5
TO RIC – SILICO NE HYDRO GEL
Clariti 1 d ay toric Coop e rVision Somo lcon A 56 8.6 14.3
MULTIFO CAL – HYDRO GEL
Focus Dailie s Aq uaCom ort Plus Alcon Ne l lcon A II 2 69 8.7 14.0
Multi ocal
Focus Dailie s All Day Com ort Pro- Alcon Ne l lcon A II 2 69 8.6 13.8
g re ssive s
Biotrue O ne Day or Pre sb yop ia Bausch & Lomb Ne so lcon A 78 8.6 14.2
Procle ar 1 Day Multi ocal Coop e rVision O ma lcon A II 2 60 8.7 14.2
1-Day Acuvue Moist Multi ocal Johnson & Johnson Eta lcon A IV 2 58 8.4 14.3
MULTIFO CAL – SILICO NE HYDRO GEL
Clariti 1 d ay multi ocal Coop e rVision Somo lcon A 56 8.6 14.1
CO SMETIC – HYDRO GEL
Fre shLook Illuminate c Alcon Ne l lcon A II 2 69 8.6 13.8
Fre shLook O ne -Dayd Alcon Ne l lcon A II 2 69 8.6 13.8
1-Day Acuvue De ne e Johnson & Johnson Eta lcon A IV 2 58 8.5 14.2
a BO ZR = b ack op tical zone rad ius.
b Core wate r conte nt 30%; sur ace wate r co nte nt 80%
c Dark limb al ring p atte rn.
d Availab le in b lue , g re e n, g re y and haze l.
e Limb al ring availab le in ‘natural sp arkle ’ and ‘natural shimme r’.

T e demonstration o a strong relationship between the
extent o daily disposable lens tting and the gross domestic
product at purchasing parity per capita (essentially a measure
o the average wealth o individuals in a nation) supports the
hypothesis that the extent o daily disposable lens prescribing is
driven to a large extent by cost considerations. Indeed, over hal
o the variance in daily disposable prescribing between nations
can be explained by the gross domestic product at purchasing
parity per capita.
Pat t e rns o f We ar
T e in uence o contact lens type on wearing requency was inves-
tigated by E ron and Morgan (2009). All daily-wear lenses were
categorized into three groups: rigid, so daily disposable and ‘so
other’. T e latter group comprises all reusable (non-daily dispos-
able) so lenses. T e proportion o all ts in relation to the number
o days lenses are worn each week is shown in Fig. 18.4 or each
o these three categories. For rigid and ‘so other’ lenses, there is
an increasing proportion o ts being used or a greater number
o days each week; this distribution is more sharply skewed in
respect o rigid lens wearers. T e distribution or daily disposable
lens wearers appears to be bimodal, with peak wearing requencies
at 2 and 7 days per week. So daily disposable lenses are worn, on
average, 3.5 ± 2.0 days per week. I part-time and ull-time wear is
de ned as lenses being worn 1–3 and 4–7 days per week, respec-
tively, 40% o those tted with daily disposable lenses wear lenses
ull-time versus 91% o those using ‘other so ’ lenses.
Dumbleton et al. (2013) surveyed lens-wearing patterns in
Australia, Norway, the United Kingdom and the United States
and reported that, overall, 59% o participants reported wearing
their lenses or 7 days per week. A signi cantly higher propor-
tion o participants reported wearing lenses 7 days per week
in the United States and Norway (64% and 71%, respectively)
than in Australia and the United Kingdom (35% and 41%,
respectively; p < 0.001).
 18 Daily Disp o sab le So ft Le nse s 169

Fig . 18.2 Daily d isp osab le co ntact le ns f ts as a p rop ortion o all le ns f ts in 34 nations in 2015. Country cod e s: AT = Austria; AU = Australia;
BG = Bulg aria; BR = Brazil; CA = Canad a; CH = Switze rland ; CN = China; CZ = Cze ch Re p ub lic; DE = Ge rmany; DK= De nmark; ES = Sp ain; FR = France ;
GR = Gre e ce ; HU = Hung ary; IL= Israe l; IR = Iran; IT = Italy; JP = Jap an; KR = Kore a; LT = Lithuania; MX= Me xico ; MY= Malaysia; NL= Ne the rland s;
NO = Norway; NP = Ne p al; NZ = Ne w Ze aland ; PH = Philip p ine s; PT = Portug al; SE = Swe d e n; SI = Slove nia; SK= Slovakia; TW = Taiwan; UK= Unite d
King d om; US = Unite d State s.

Fig . 18.3 Re lation b e twe e n d aily d isp osab le le ns f ts (as a p rop ortion o all so t le ns f ts) and the g ross d ome stic p rod uct at p urchasing p arity
p e r cap ita or ye ar 2011. Country cod e s: AE = Unite d Arab Emirate s; AU = Australia; BG = Bulg aria; CA = Canad a; CN = China; CZ = Cze ch Re p ub lic;
DE = Ge rmany; DK= De nmark; EG = Eg yp t; ES = Sp ain; FR = France ; GR = Gre e ce ; HK= Hong Kong ; HR = Croatia; HU = Hung ary; IL= Israe l; IN = Ind ia;
IS = Ice land ; IT = Italy; JO = Jord an; JP = Jap an; KR = South Kore a; KW = Kuwait; LT = Lithuania; MY= Malaysia; NL= Ne the rland s; NO = Norway;
NP = Ne p al; NZ = Ne w Ze aland ; PR = Pue rto Rico; PT = Portug al; Q A = Q atar; RO = Romania; RU = Russia; SE = Swe d e n; SI = Slove nia; TW = Taiwan;
UK= Unite d King d om; US = Unite d State s; ZA = South A rica.
170 PART 4 Le ns Re p lace me nt Mo d alit ie s
Fig . 18.4 Prop ortion o rig id , d aily d isp osab le so t, and all othe r so t
le nse s that are worn or b e twe e n 1 and 7 d ays p e r we e k.
T e bimodal distribution o daily disposable lens wearing re-
quency shown in Fig. 18.4 may re ect two distinct approaches
to lens wear. T e peak around 1–3 days per week sel -evidently
represents those using daily disposable lenses on a part-time
basis. Indeed, daily disposable lenses are a logical choice or
part-time wear because o increased convenience and enhanced
sa ety, as discussed below. Full-time wear o daily disposable
lenses is an expensive option compared with ull-time wear o
2-weekly or monthly disposable lenses, and those who wear
daily disposable lenses ull-time (wearing lenses 4–7 days per
week) have presumably determined that the enhanced sa ety
and convenience o this approach are worth the higher cost.
Clinical Pe rfo rmance
I the clinical bene ts o planned replacement are accepted,
then it would seem logical to change lenses as o en as possible.
Soon a er daily disposable lenses entered the market in the mid
1990s, the bene ts o this replacement modality compared with
the reusable and non-planned replacement lenses prescribed
prior to this time were stark. For example, Solomon et al. (1996)
reported that daily disposable lens wearers had ewer symp-
toms, ewer deposits, better vision, ewer tarsal abnormalities,
ewer ocular complications and better overall satis action than
patients using conventional lenses. Jones et al. (1996) ound
that lens com ort, subjective symptoms (i.e. dryness, soreness,
scratchiness) and vision were signi cantly better with daily dis-
posable lenses compared with the previously used lens replace-
ment modality (42% o patients were previously using monthly
or ortnightly replacement). Hamano et al. (1994) observed a
4.9% incidence o complications or daily disposable lens wear-
ers compared with 8.5% or conventional daily-wear so lens
wearers. In a comparison o 2-weekly with daily disposability
lenses, Sindt (2000) noted that, at the very least, patients wear-
ing single-use lenses bene ted rom greater convenience and
com ort.
Contemporary studies show similar bene ts (Cho and Boost,
2013). An extensive evaluation o the ocular response to neo-
phyte patients tted with one brand o silicone hydrogel daily
disposable lenses (Acuvue ruEye, Johnson & Johnson Vision
Care) demonstrated excellent com ort and vision with mini-
mal alterations to ocular physiology (Morgan et al., 2013). Diec
et al. (2012) also noted good subjective and objective responses
to daily disposable lenses, but observed that di erent contact
lens materials and designs elicited di erent ocular and patient
responses.
Ichijima et al. (2016) demonstrated that when patients
switched to daily disposable lenses a er having used 2-weekly
replacement lenses there was a reduction in subjective com-
plaints o dryness, and objectively a signi cant reduction
o super cial punctate keratitis was observed at ollow-up
examinations.
Wol sohn et al. (2015) assessed the in uence o end-o -
day silicone hydrogel daily disposable contact lens t on ocu-
lar com ort, physiology and lens wettability. Among the three
lenses tested, objective lens t changed between 8 and 12 hours
o lens wear. T e authors suggested that the weak correlation in
individual lens t between brands indicates that t is dependent
on more than ocular shape. Consequently, substitution o a di -
erent lens brand with similar parameters will not necessarily
provide a comparable lens t.
Varikooty et al. (2015) compared the clinical per ormance o
three silicone hydrogel daily disposable lenses and ound that
they all per ormed well, with only slight di erences in physi-
ological responses between lenses. T ey ound no di erence
between asymptomatic and symptomatic wearers with regard
to ocular response and contact lens-related parameters, and
concluded that silicone hydrogel daily disposable lenses are an
excellent contact lens modality or the symptomatic patient.
T e obvious advantage o ered by daily lens disposal is a
resh, sterile pair o lenses or wearing each day. I cost was not
a limiting actor, then it could be argued that all daily-wear so
lens patients should be using this modality.
Ad vant ag e s fro m t he Pe rsp e ct ive o f
Pract it io ne rs
Speci c advantages o daily disposable lenses rom the stand-
point o the practitioner include the ollowing:
• Less patient education time is required (virtually no advice
needs to be given about lens care).
• T e absence o a lens storage case rom the regimen is ben-
e cial, given the role that a lens case can play in the devel-
opment o corneal in ltrative events and ocular in ection
(Richdale et al., 2016).
• Less pro essional ‘chair time’ is required because there are
no problems relating to lens care solutions (e.g. toxicity or
sensitivity reactions) (Richdale et al., 2016) and ewer ocu-
lar complications o lens wear compared with that experi-
enced with reusable lenses (Hickson-Curran et al., 2014).
• Less ancillary sta time is required because there is no
need or discussions and sales relating to lens care prod-
ucts.
• T ere are no disputes concerning wearing requency (e.g.
some patients might argue that a lens designed or month-
ly replacement, but only worn once a week, can last or 3
months).
• Daily disposability is more hygienic or intermittent wear-
ers, as long-term storage problems are eliminated, making
daily disposability the replacement modality o choice or
such patients.
• T e regular supply o large numbers o lenses required
or daily lens disposal can be leveraged rom a practice
management standpoint by introducing strategies such as

monthly payment plans (Patel et al., 2015) and subscrib-
er membership systems (Ichijima et al., 2016), which are
considered to be attractive business models and practice
builders (Patel et al., 2015).
Ad vant ag e s fro m t he Pe rsp e ct ive o f
Le ns We are rs
Advantages o daily disposable lenses rom the perspective o
lens wearers include:
• T ere is no need to be concerned with lens care systems,
although it is desirable or daily disposable lens wearers
to have a supply o sterile saline or multipurpose solution
or lens rinsing i there is discom ort during, or soon a er,
lens insertion.
• T ere are no anxieties about lost or damaged lenses.
• Daily disposable lenses are convenient and compact or
travel; there is no need to carry bulky lens care solutions.
• Daily disposable lenses are highly cost-e ective in that lens
wear is directly linked to lens cost (unlike, say, monthly
disposable lenses that may be worn only a ew times dur-
ing the month).
• Daily disposable lenses are excellent or monovision cor-
rection o presbyopia, as it is easy to alternate between
various lens combinations (e.g. two distance lenses versus
monovision, depending on the need; see Chapter 23).
• Daily disposable lenses are easy to discard (‘any time, any
place, without a case’).
• Visual per ormance remains good throughout the day
(Belda-Salmerón et al., 2013).
• Compliance is easier because there are ewer instructions
to remember (Morgan et al., 2011).
Since daily disposable contact lenses eliminate the need or
cleaning and disin ection, they should be strongly considered
as a contact lens treatment option or children. Walline et al.
(2004) demonstrated that 8–11-year-old children are able
to care or daily disposable contact lenses independently and
wear them success ully. Plowright et al. (2105) reported similar
ndings or children aged 13–19. Certainly, E ron et al. (2010)
observed that children aged 6–12 years are tted with the high-
est proportion o daily disposable lenses, and have the highest
rate o ts or part-time wear, compared with in ants, teenagers
and adults (E ron et al., 2011).
Disad vant ag e s
Potential disadvantages o daily disposable lenses include the
ollowing:
• Patients may be non-compliant by way o reusing lenses.
Dumbleton et al. (2010) reported that, o patients who
were given correct instructions, 12% and 13% reused their
daily disposable lenses in the United States and Canada,
respectively. Reuse o lenses poses an important risk or
daily disposable lens users because they are unlikely to
have received proper training in cleaning and disin ection
o lenses and do not use a lens case or disin ecting solu-
tions (Boost et al., 2011).
• Practitioners have been known to sanction patients to
reuse daily disposable lenses. According to Dumbleton
et al. (2010), 4% and 6% o practitioners in the United
States and Canada, respectively, recommended that their
patients reuse daily disposable lenses.
18 Daily Disp o sab le So ft Le nse s 171
• New daily disposable lens wearers who have not previously
worn other lens types – and have thus never been instruct-
ed in lens care – may adopt unwise practices through igno-
rance (e.g. storing a lens overnight in tap water).
• Because o the low unit cost o lenses, patients may think it
is all right to give lenses to riends to try.
Co mfo rt Enhance me nt St rat e g ie s
A number o strategies have been adopted by di erent manu-
acturers to enhance the com ort o daily disposable lenses. For
example, Alcon has modi ed Dailies All Day Com ort lenses
to include additional, non- unctional, polyvinyl alcohol (PVA).
PVA is a success ul tear lm stabilizer and is widely used in
com ort drops. According to Peterson et al. (2006), release o
additional non- unctionalized PVA appears to enhance com-
ortable contact lens wear. Dailies AquaCom ort Plus lenses
contain hypromellose (short or hydroxypropyl methylcellu-
lose, or HPMC), polyethylene glycol (PEG) and dual-molecu-
lar-weight PVA, as com ort-enhancing agents; such strategies
have been shown to be clinically e ective in enhancing com ort
(Fahmy et al., 2010).
Vistakon have incorporated proprietary wetting agents into
their daily disposable lenses. 1-Day Acuvue Moist contains
Lacreon, and Acuvue ruEye contains Hydraclear, although the
detailed chemical ormulations o these agents are not in the
public domain.
T e use o daily disposable lenses has been shown to be an
e ective strategy or managing allergy-su ering contact lens
wearers. Hayes et al. (2003) monitored subjective com ort and
slit-lamp ndings with daily disposable contact lenses in a pop-
ulation o allergy su erers during periods when allergen levels
were elevated. Sixty-seven per cent o subjects agreed that the
daily disposable lenses provided improved com ort when com-
pared with the lenses they wore prior to the study, versus 18%
agreeing that the new pair o habitual lenses provided improved
com ort. T e daily disposable lenses also resulted in a greater
improvement in slit-lamp ndings rom baseline than new
habitual lenses.
Manufact uring Re liab ilit y
E ron et al. (1999) examined 150 −3.00 D lenses o each o
the irst three brands o daily disposable lenses on the mar-
ket, and reported an overall high degree o accuracy and
reproducibility (Fig. 18.5). hey ound that, with one incon-
sequential exception, all measured parameters o all three
lens types examined ell well within clinically acceptable
limits or providing wearers o these lenses with consistent
vision and it.
Each o the currently marketed daily disposable so lenses
is available only in a single diameter. However, diameter is an
important parameter in relation to optimizing lens t. Young
(2008) measured the diameters o 13 designs o daily disposable
lenses at room and eye temperature. He observed that lenses
labelled 14.2 mm ranged in diameter rom 13.5 to 14.1 mm
when measured at eye temperature. T e three lenses showing
the greatest shrinkage when raised to eye temperature were all
Food and Drug Administration group IV lenses. Young (2008)
concluded that comparing labelled diameters is unhelp ul, and
in some cases misleading, or predicting the on-eye per or-
mance o current daily disposable so lenses.
172 PART 4 Le ns Re p lace me nt Mo d alit ie s

Fig . 18.5 Me asure d d i e re nce b e twe e n the manu acture rs’ sp e cif cation and the me an o
the me asure d value s or (A) total d iame te r; (B) b ack op tic zone rad ius; (C) ce ntre thickne ss; (D)
wate r conte nt; and (E) b ack ve rte x p owe r. Error b ars are me an ± stand ard d e viation. The ve rtical
e xte nt o the shad e d are as ind icate the tole rance allowe d und e r ISO 8321-2 (1995). The re is no
ISO tole rance or ce ntre thickne ss or wate r conte nt.

environmental impact o wastage in the use o contact lenses and

Enviro nme nt al Imp act
Concerns that daily disposability will have a greater adverse envi-
ronmental impact compared with other replacement modalities
– with respect to disposal o the lenses and associated packag-
ing – have been dispelled by Morgan et al. (2003). T ese authors
measured the annual wastage involved in the use o unplanned,
monthly and daily replacement systems. Speci cally, the amount
o waste glass, plastic, metal and paper was determined (solu-
tions were ignored because they have a negligible environmental
impact) (Fig. 18.6). O the three replacement systems studied,
unplanned lens replacement was ound to have the highest envi-
ronmental impact and monthly lens replacement had the lowest
environmental impact. It is possible that the levels o wastage
in contact lens manu acture might be more signi cant than
those incurred by consumers. From a wider perspective, the
care systems by consumers pales into insigni cance when con-
sidered against major sources o world environmental pollution
(e.g. road construction, general domestic wastage).
Limit at io ns t o Mo re Ge ne ral
Acce p t ance
Notwithstanding their current popularity, there appear to be
our main reasons why daily disposable lenses are not even
more widely used:
1. Parameter and material limitations – this actor is di-
minishing as volumes increase and more manu acturers
launch daily disposable lenses in wider power ranges,
with toric, multi ocal, cosmetically coloured and silicone
hydrogel lenses available.

Fig . 18.6 Annual wastag e involve d in the use o unp lanne d , monthly
and d aily re p lace me nt syste ms.
2. Practitioner concerns about patient non-compliance –
compliance is always likely to be a problem to some ex-
tent. For example, between 10% and 13% o patients reuse
daily disposable lenses (Qureshi et al., 1998; Dumbleton
et al., 2013). With all contact lens wear, thorough initial
and ongoing patient education to promote compliance is
essential.
3. Practitioner concerns about non-optical-practice lens
supply – the topic o non-optical practice supply is con-
sidered in Chapter 19 as part o a discussion o practice
management issues.
4. Patient concerns about the cost o ull-time wear – daily
disposable lenses are the pre erred choice or part-time
wear, where the cost is lower. As noted above, the dis-
tribution o daily disposable lens wear is bimodal, with
peaks at 2 days and 7 days per week o wear. Clearly many
patients value the convenience over cost in ull-time wear.
Co rne al Infilt rat ive Eve nt s and
Ke rat it is
T e occurrence o corneal in ltrative events (CIEs) is generally
considered the key outcome variable in studies o the sa ety o
contact lens wear. Early reports ollowing the release o daily
disposable lenses onto the market seemed to indicate a higher
risk o developing CIEs with this lens type, compared with reus-
able lenses (Dart et al., 2008). T ose early results are in stark
contrast to contemporary studies that demonstrate a 12.5×
lower risk o developing CIEs with daily disposable lenses ver-
sus reusable lenses (Chalmers et al., 2012).
T ere are a number o possible reasons or the apparently
spurious early results, which ailed to demonstrate increased
sa ety with daily disposable lenses. First, when any new prod-
uct enters the market, and widespread sa ety and ef cacy in
the ‘real world’ is yet to be established, the ‘early adopters’ tend
to be those willing to take risks – a trait that may in turn be
consistent with non-compliant behaviour (e.g. reusing lenses).
Second, early-generation daily disposable lenses were perhaps
perceived by practitioners as a ‘problem-solving’ tool, resulting
in a disproportionate number o patients with pre-existing ocu-
lar problems (e.g. papillary conjunctivitis, contact-lens-associ-
ated dry eye, excessive corneal and conjunctival staining, etc.)
18 Daily Disp o sab le So ft Le nse s 173
Fig . 18.7 Distrib ution and size o corne al inf ltrative e ve nts (b lue
circle s) in p atie nts we aring d aily d isp osab le hyd ro g e l le nse s ve rsus all
othe r orms o d aily hyd rog e l le ns we ar. The two larg e b lack circle s re p -
re se nt corne as (rig ht e ye re p re se ntation).
being tted with these lenses. T us, the early studies examining
sa ety with daily disposable lenses (Dart et al., 2008) may have
re ected lens per ormance in risk-takers and patients with pre-
existing adverse ocular conditions.
Numerous other studies have con rmed a lower rate o CIEs
with daily disposable lenses compared with reusable lenses.
Lazon de la Jara et al. (2013) reported a lower incidence o CIEs
with Seno lcon A contact lenses (Johnson & Johnson Vision
Care, Jacksonville, FL) used on a daily disposable basis, compare
with compliant reuse o the same lenses with either hydrogen
peroxide or multipurpose disin ection solutions. T ese authors
also noted that com ort at insertion was signi cantly worse or
participants who experienced CIEs than or those who did not.
Chalmers et al. (2015) reported annual rates o occurrence
o CIEs o 0.4% and 0% in patients wearing silicone hydrogel
versus hydrogel daily disposable lenses, respectively. T ese rates
were signi cantly lower than annual CIE rates reported with
reusable so lenses (3–4%), indicating improved sa ety out-
comes with daily disposable lenses.
E ron et al. (2005) examined the distribution o CIEs o all
levels o severity in symptomatic contact lens wearers present-
ing to a hospital emergency clinic. Fig. 18.7 shows the distribu-
tion o CIEs in patients wearing daily disposable hydrogel lenses
versus all other orms o daily hydrogel lens wear; CIEs tended
to occur more towards the lens periphery in those wearing reus-
able hydrogel lenses and more towards the lens centre in those
wearing daily disposable hydrogel lenses.
E ron et al. (2005) suggested that the disproportionately
greater number o corneal in ltrates occurring in the periphery
o those using reusable hydrogel lenses is related to the typical
methods adopted by patients or manually cleaning so lenses.
T e two classic techniques used to clean contact lenses with
solutions are: (1) to place the lens on the palm o one hand and
rub the lens in a circular motion with the index nger o the
other hand, and (2) to rub the lens between the index nger
and thumb (Stein et al., 2002). In both cases, there is a tendency
or the cleaning e ect to be concentrated towards the centre o
the lens, which leads to a higher concentration o deposits, such
as denatured proteins, in the lens periphery compared with
the more thoroughly cleaned lens centre (Heiler et al., 1991).
Lens deposits can compromise corneal integrity in a number
o ways, such as: having a direct mechanical e ect, harbouring
environmental antigens and causing an immunological reac-
tion in the adjacent cornea, or harbouring microorganisms and
inducing an in ection in the underlying cornea. Excess deposits
in the lens periphery resulting in these orms o compromise
in the peripheral cornea could account or the distribution o
174 PART 4 Le ns Re p lace me nt Mo d alit ie s
in ltrates observed in patients wearing reusable hydrogel lenses
in this study.
Given the above arguments, it would be expected that daily
disposable lenses – which are discarded a er each use and
never manually cleaned – would be associated with a random
distribution o in ltrates. However, a disproportionately greater
number o in ltrates were observed towards the centre o the
corneas o patients wearing such lenses. E ron et al. (2005) sug-
gested that this may relate to patterns o lens contamination
rom the ngers o patients at the time o lens insertion. T at
is, prior to lens insertion, patients typically ‘ sh’ the lens rom
the blister pack with the ore nger, which is placed on or near
the centre o the lens as it is removed. T us, there is a greater
propensity or contamination o the centre o the lens, and or
such contaminants to be trans erred directly to the centre o the
cornea upon lens insertion, inducing in ltrates in that location.
Rad ord et al. (2009) reported that, compared with planned-
replacement so lenses, daily disposable lenses signi cantly
reduced the risk o toxic / hypersensitivity and metabolic
disorders.
T ere are reports o Acanthamoeba keratitis in patients who
reuse daily disposable contact lenses. Diagnosis can be dif cult
to make, but should still be considered in all patients who wear
contact lenses, including daily disposable lenses (Niyadurupola
and Illingworth, 2006). Full compliance, however, cannot nec-
essarily eliminate the risk o microbial keratitis; cases o Pseudo-
monas keratitis have been reported in ully compliant occasional
users o daily disposable lenses (Munneke et al., 2006; Batta
and Goldstein, 2010). In these cases, lenses were not overworn,
reused or slept in – all risk actors or corneal in ection.
wo studies have determined the incidence o microbial ker-
atitis with daily disposable lenses. Morgan et al. (2005) reported
an incidence o 4.9 and 6.4 cases o severe (microbial) keratitis
per 10 000 wearers per year with daily disposable hydrogel lenses
and ‘other’ hydrogel lenses, respectively. Stapleton et al. (2008)
reported an incidence o 2.0 and 1.9 cases o microbial kerati-
tis per 10 000 wearers per year with daily disposable hydrogel
lenses and ‘other’ hydrogel lenses, respectively. However, in
patients who occasionally slept overnight in daily disposable
hydrogel lenses, the incidence o microbial keratitis increased
to 4.2 cases per 10 000 wearers per year.
T e above reports suggest that, or daily lens wear, daily
disposability does not appreciably reduce the risk o severe
microbial keratitis compared with planned lens replacement
protocols. However, Carnt and Stapleton (2016) suggest that
Acanthamoeba keratitis can be avoided by tting patients with
daily disposable lenses, as this will likely minimize contact with
water, which is a primary risk actor.
Le ns Ap p licat io n t o Assist Ame t ro p e s
in Eye w e ar Se le ct io n
In a practice setting, daily disposable lenses can be o ered to
ametropic non-lens wearers prior to spectacle dispensing so
they can clearly visualize their appearance at a com ortable dis-
tance rom the mirror with di erent styles o spectacle rames.
Atkins et al. (2009) adopted this strategy in a clinical trial and
ound that the opportunity to try contact lenses prior to spec-
tacle dispensing was well received by patients who generally
reported a very positive experience. In particular, contact lenses
assisted in seeing rame detail and suitability or wear. One-
third o subjects proceeded to purchase contact lenses. Atkins
et al. (2009) recommended that practitioners consider o ering
daily disposable contact lenses to all suitable patients who are
proceeding to spectacle dispensing to optimize the dispensing
process and to provide an opportunity to try contact lenses.
Co nclusio n
It is likely that all lenses prescribed in the uture will be ‘single-
use’ products, such as daily disposable or extended-wear lenses.
However, patients who wear daily disposable contact lenses
should be reminded that the bene ts o this modality o contact
lens are possible only i the lenses are worn once and thrown
away, and not worn overnight.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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Hamano, H., Watanabe, K., Hamano, ., et al. (1994).
A study o the complications induced by conven-
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Hayes, V. Y., Schnider, C. M., & Veys, J. (2003). An
evaluation o 1-day disposable contact lens wear
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Heiler, D. J., Gambacorta-Ho man, S., Groemminger,
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174.e 1
19
Re usab le So ft Le nse s
JO E TANNER | NATHAN EFRO N
Int ro d uct io n
In this book, the term ‘reusable lenses’ re ers to lenses that are
removed rom the eye, cleaned and stored in a lens case or a
period o time (typically overnight), and then reapplied to the
eye the ollowing day (or at a later date i lenses are not worn
or a while).
Disposable lenses, which were designed to be reused or
a length o time between 1 week and 1 month, were released
internationally in the late 1980s (Fig. 19.1). Prior to this, the
same reusable lenses were worn or many months or years, until
they were damaged or deemed to be unwearable. T e accep-
tance o disposability by practitioners and patients has been
one o the most signi cant changes in the contact lens market.
In a survey o six nations in 2001 (Australia, Canada, Greece,
Netherlands, Norway and the UK), over 90% o so lenses were
replaced monthly or more requently in ve out o six nations
surveyed (i.e. Australia, Canada, Netherlands, Norway and the
UK, but not Greece) (Morgan et al., 2002).
Fig. 19.2 shows trends in the extent o prescribing reusable
lenses in Australia between 2000 and 2015. It can be seen that the
prescribing o lenses intended to be replaced at periods greater
than 1 month ell rom 17% o all new so lens ts in 2000 to 0%
in 2015. Over the same period, lenses designed or 1- to 2-weekly
replacement has also dropped away to 1%, meaning that virtu-
ally all so lenses prescribed in Australia in 2015 were or either
monthly or daily replacement. Similar trends have been docu-
mented in many international markets (Morgan et al., 2016).
T e Acuvue lens (Johnson & Johnson) was initially packaged
in plastic boxes, but this was soon replaced by cardboard boxes
or reasons o reduced cost and packaging e ciency (to enable
storage o the maximum number o lenses per unit volume). T e
NewVues lens (CIBA Vision) was originally supplied in glass
vials, but this was soon changed to blister packs or the same
Fig . 19.1 The f rst d isp osab le le nse s re le ase d on to the inte rnational
marke t in the late 1980s. Le t: The Acuvue le ns (Johnso n & Johnson Vi-
sion Care ). Ce ntre : Ne wVue s le ns (CIBA Vision). Rig ht: Se e Q ue nce le ns
(Bausch & Lomb ).
reasons. T e orm o packaging initially used or the SeeQuence
lens (Bausch & Lomb) is now adopted by virtually all disposable
lens manu acturers. Products replaced at least monthly have
invariably been designed, packaged and promoted or replace-
ment at speci c intervals. However, this applies less or lenses
replaced 3-monthly, and is almost never the case or lenses
o ered or biannual and annual replacement; such lenses are
usually conventional lenses packaged in vials (Fig. 19.3), and
many o these lenses were developed prior to widespread use o
planned replacement. Lenses designed to be replaced at inter-
vals o more than 1 month are rarely prescribed today.
Planned lens replacement has been shown to be clinically
use ul or extended-wear applications, and since their advent
in 1998 silicone hydrogel so lenses or both extended and
daily wear have been marketed on a planned replacement basis.
Discussion o planned lens replacement in this chapter will be
con ned to lenses intended to be used on a daily-wear basis
(i.e. lenses that are not worn overnight) or at least a week. T e
speci c issue o planned replacement o extended-wear lenses is
dealt with in Chapter 24 and daily disposable lenses are speci -
cally covered in Chapter 18.
Ad vant ag e s o f Planne d Re p lace me nt
Long-term adverse changes in contact lenses when lenses are
not replaced on a planned basis were learned rom bitter experi-
ence in the early days o so lenses, prior to the introduction o
requent replacement lenses in the late 1980s.
So contact lenses have a reactive sur ace and a low modulus
o elasticity, rendering them more susceptible to damage. Fur-
thermore, any damage to the sur ace or edge o the lens cannot
be repaired because a hydrated so lens cannot be repolished.
Although these actors would seem to indicate the desirabil-
ity o regular so lens replacement, the high cost o so lenses
throughout the 1970s and much o the 1980s precluded such, so
strategies were devised to prolong lens li e or as long as possible.
T e norm during this period was to prescribe so lenses in the
same way that rigid lenses were being prescribed – that is, or the
patient to keep using the same pair o lenses until they became
damaged or lost, were too uncom ortable to wear, resulted in a
noticeable deterioration o vision or induced ocular pathology
that was either sel -diagnosed or detected during an eye exami-
nation. Some patients were known to use the same pair o lenses
or up to 7 years. Indeed, it was even possible to take out insur-
ance policies against the risk o lens loss or damage.
All o this changed with the introduction o planned lens
replacement schemes and disposable lenses in the late 1980s.
T is concept rapidly became established and it is now univer-
sally accepted that contact lenses must be replaced regularly.
In act, a recent survey o international prescribing trends con-
ducted by Morgan et al. (2016) revealed that, across 34 countries,
175
176 PART 4 Le ns Re p lace me nt Mo d alit ie s
Fig . 19.2 Pe rce ntag e o so t le ns ne w f ts p re scrib e d accord ing to re p lace me nt re q ue ncy in Australia b e twe e n 2000 and 2015.
Fig . 19.3 Examp le o a non-d isp osab le p lanne d re p lace me nt le ns.
This le ns is re p lace d 3-monthly.
unplanned replacement represented only 1% o all so contact
lens ts, and was 0% in 28 countries.
T e rationale or the planned replacement o so contact
lenses is simple: cleaner lenses should produce ewer adverse
ocular e ects. A signi cant proportion o clinical problems
relating to the wear o so contact lenses can be attributed to
deposition on the lens sur ace with tear-derived substances.
Contact lens deposits result in reduced acuity, com ort and wet-
tability and increased inf ammatory complications such as pap-
illary conjunctivitis and acute red eye (Jones et al., 2000). All
so contact lenses su er gradual spoilation rom the environ-
ment and tear lm components over time. Daily cleaning and
periodic protein removal can slow this rate o deposition but
not prevent its occurrence.
AVO IDANCE O F LO NG-TERM ADVERSE
CHANGES IN CO NTACT LENSES
T ere are currently no indications or non-planned replace-
ment o so lenses. T is raises the question o why a virtually
obsolete, non-indicated practice should even be considered in
Fig . 19.4 Re lation b e twe e n le ns d e p osition (d e te rmine d using the
Rud ko classif cation syste m) on non-re p lace me nt hyd roxye thyl me thac-
rylate (HEMA) le nse s ve rsus le ns ag e (months). (Ad ap te d from Ge llatly,
K. W., Bre nnan, N. A. & Efron, N. (1988). Visual d e cre me nt with d e p osit
accumulation on HEMA contact le nse s. Am. J. O p tom. Physiol. O p t.,
65, 937–941.)
a 21st-century contact lens textbook. Perhaps more than any-
thing else, this section will serve as a reminder o the reason
why it is considered necessary to replace lenses on a regular
basis.
Lens deterioration over time mani ests in a variety o ways
and is attributable to many actors. Lenses become deposited,
irreversibly lose water, su er sur ace damage and can become
contaminated during storage. Each o these actors will be con-
sidered in turn.
Le ns De p osits
T e extent o lens deposition increases over time (Fig. 19.4)
(Gellatly et al., 1988). Numerous actors, many o which are
interactive, are involved in the ormation o deposits on the
ront or back sur ace o contact lenses. T ese actors include lens
wear modality (daily or continuous wear), the bulk chemical
composition o the lens, lens water content, the physicochemi-
cal nature o the lens sur ace (such as ionicity), the chemical

Fig . 19.5 Film o p rote in on a so t le ns worn on a non-re p lace me nt
b asis. (Courte sy of Patrick Caroline , Bausch & Lomb Slid e Lib rary.)
Fig . 19.6 ‘Je lly b ump s’ on a so t le ns worn on a non-re p lace me nt b a-
sis. (Courte sy of Patrick Caroline , Bausch & Lomb Slid e Lib rary.)
composition o lens maintenance solutions, the adequacy o
lens maintenance procedures (a measure o patient compli-
ance), hand contamination, proximity to environmental pollut-
ants and intrinsic properties o the patient’s tears ( ighe et al.,
1991; Maissa et al., 1998). T e most common tear-derived com-
ponents o lens deposits are proteins (Jones et al., 1997), which
cannot be detected under normal conditions. A heavy deposi-
tion o protein can mani est as a general haze on the lens sur ace
(Fig. 19.5) and extensive lipid ormation can appear as a clear
smear or smudge on the lens sur ace.
Visible so lens deposits take months or years to orm,
and are thus encountered only in patients wearing lenses on
a non-planned replacement basis. T e most common orm o
visible deposition that is derived rom the tear lm is known as
‘jelly bumps’ or ‘mulberry deposits’ (Fig. 19.6), which consist
o various layered combinations o mucus, lipid, protein and
sometimes calcium. Barnacle-like calcium carbonate depos-
its (Fig. 19.7), which are also derived rom the tear lm, can
project anteriorly and be a source o discom ort. Iron depos-
its (Fig. 19.8), which contaminate the lens rom exogenous
19 Re usab le So ft Le nse s 177
Fig . 19.7 Calcium d e p osits on a so t le ns worn o n a non-re p lace me nt
b asis. (Courte sy of Bausch & Lomb Slid e Lib rary.)
Fig . 19.8 Iron d e p osits on a so t le ns worn on a non-re p lace me nt b a-
sis. (Courte sy of Patrick Caroline , Bausch & Lomb Slid e Lib rary.)
sources, appear as small red-orange spots or rings and orm
when iron particles become embedded in the lens and oxidize
to orm errous salts. T ese were o en seen in patients who
requently commute on trains or trams, as there is a high prob-
ability o ne iron particles – which are thrown into the air as
the vehicle moves along the steel tracks – coming to rest on
the lens sur ace.
It is clear that proteins and lipids rom the tears can deposit
on so lenses within minutes o insertion (Jones et al., 1997);
however, such deposits are thought to be innocuous over peri-
ods o less than 1 month. Lipid is easily removed with sur actant
cleaning. A small amount o protein deposition may even be
bene cial to the eye, as long as it does not become denatured,
because the protein orms a natural biocompatible lens coating
(Sack et al., 1987; Omali et al., 2015). Although these rapidly
orming deposits cannot be seen and do not generally compro-
mise vision or com ort, they can reduce lens sur ace wettability
(Jones et al., 1996a).
178 PART 4 Le ns Re p lace me nt Mo d alit ie s
Fig . 19.9 Re lation b e twe e n p re -inse rtion wate r conte nt (WC: re d re g re ssion line ) and p ost-re moval wate r conte nt (b lue re g re ssion line ) ve rsus time
or the Acuvue , Fre q ue ncy 38, Ge ntle Touch and Procle ar le nse s. The ag e ing e e ct is ind icate d b y the d e cre ase in p re -inse rtion wate r conte nt ove r
time . (Ad ap te d from Morg an, P. B. & Efron, N. (2000). Hyd rog e l contact le ns ag e ing . CLAO J., 26, 85–90.)
Long-term protein deposition can be problematic because,
in time, it can become denatured and thus no longer ‘recog-
nized’ by the eye, leading to an adverse immunological reaction
(Sack et al., 1987). Lens sur ace protein can also absorb, and
concentrate, preservatives and other active ingredients in con-
tact lens care solutions, which may be released back into the eye
in noxious concentrations, leading to toxic reactions. T e physi-
cal presence o excess deposits can also cause direct mechanical
insult to the anterior eye.
So lenses can also become discoloured over extended time
periods (many months or years). T e cause may be intrinsic or
extrinsic. High levels o melanin can lead to a brown discolor-
ation. Nicotine can become absorbed into the lenses o patients
who smoke or spend time in a smoky environment, leading to
an orange-brown discoloration. Exposure to mercury can lead
to a black / grey discoloration. Extreme lens discoloration can be
cosmetically unsightly to an onlooker.
Irre ve rsib le Wate r Loss
Morgan and E ron (2000) noted a signi cant lens ageing e ect
whereby the pre-insertion lens water content decreased signi -
cantly over a 28-day cycle or our so lens types evaluated (Fig.
19.9). T is ageing process is di erent rom the well-known phe-
nomenon o lens dehydration over the course o a number o
hours throughout a day. Although this irreversible water loss
was monitored or only 28 days, the trend clearly indicated that
water loss would continue well beyond this time rame, albeit at
a progressively slower rate.
It is clear that a combination o physical and / or physi-
ological actors caused a reduction in water content o the
hydrogel lenses examined by Morgan and E ron (2000). It ol-
lows that some change to the lens appears to have caused a
progressive reduction in water uptake by the lens each night
during storage, in what amounts to a ‘lens-ageing’ e ect.
T e most likely explanation or this ageing e ect is that lens
spoilation acts either to displace water rom the lens or to
alter the nature o the lens material in such a way that less
water is absorbed by the lens. Some signi cant intersubject
di erences in lens dehydration were observed; the range o
daily dehydration or the group o six subjects investigated by
Morgan and E ron (2000) was 1.7–5.9% or all lenses or all
days. T ese di erences may relate to intersubject di erences
in ocular physiology.
One o the most important clinical rami cations o this phe-
nomenon is that there is an associated loss o oxygen per or-
mance with dehydration o hydrogel lenses (E ron and Morgan,
1999). T us, the corneas o patients wearing hydrogel lenses on
a non-replacement basis will be more prone to hypoxic compli-
cations over time.
Surface Damag e and Crazing
All so lenses are manu actured with a shel -li e, which primar-
ily indicates how long the lens can be guaranteed to be sterile. In
addition, there is the possibility o natural polymer degradation
over time, whereby clinically relevant changes could be noticed
a er about 5 years rom the time o manu acture.
It is sel -evident that physical trauma can lead to a variety
o lens de ects. I a de ect is obvious – such as a large piece o
the lens breaking o – then the patient will typically notice this
and discard the lens. I such a de ect is not noticed, discom-
ort on insertion will normally alert the wearer to this problem.
However, small de ects may not be noticed, which is potentially
problematic because such de ects can compromise ocular integ-
rity at a subclinical level (E ron and Veys, 1992).
Storag e Contamination
For a variety o reasons, patients may suspend lens wear or
extended periods o time, or reasons such as not wearing lenses
when unwell or when travelling. Also, or a variety o li estyle rea-
sons, some patients wear lenses only very occasionally. T e poten-
tial or contamination o the lens and storage case during such
periods is potentially problematic (Szczotka-Flynn et al., 2010).
In particular, some contact lens storage solutions are ine cacious
at killing ungi, which have a propensity or invading the lens
matrix and destroying lenses in storage (Fig. 19.10) (Wilson and
Ahearn, 1986). Stringent measures need to be en orced or the
preservation o lenses during long-term storage, such as regular
cleaning and disin ection and the use o storage solutions known
to be highly e cacious at killing all orms o microorganisms.
AVO IDANCE O F LO NG-TERM ADVERSE
CHANGES IN THE ANTERIO R EYE
By ensuring that so lenses are replaced at a suitable predeter-
mined interval, one o the most enduring medical management
axioms – that o prevention being better than cure – is brought

Fig . 19.10 Fung al g rowth within the matrix o a no n-re p lace me nt so t
le ns ollowing long -te rm storag e in a solution o low anti ung al e f cacy.
(Courte sy of Nicola Pritchard , Bausch & Lomb Imag e Lib rary.)
to bear. In practice, patients who replace lenses regularly report
ewer symptoms and exhibit ewer physiological changes in
most instances (Marshall et al., 1992; Poggio and Abelson, 1993;
Nilsson and Montan, 1994; Pritchard et al., 1996; Nilsson, 1997;
Porazinski and Donshik, 1999; Chalmers et al., 2012), compared
with patients who do not replace lenses regularly.
Primary indicators o long-term lens degradation include
symptoms o discom ort and reduced vision, and signs associ-
ated with adverse ocular reactions.
Discomfort
As indicated above, numerous actors can lead to lenses becom-
ing less com ortable over time; these include the existence o
microscopic lens de ects, physical trauma and / or immuno-
logical reaction due to lens deposition, and progressive hypoxic
e ects due to lens ageing. In a retrospective study o nearly 2000
2-weekly and non-planned replacement daily-wear patients,
Poggio and Abelson (1993) ound a higher rate o symptoms in
the non-planned replacement group.
Brennan and E ron (1989) surveyed the symptoms expe-
rienced by 104 patients wearing hydroxyethyl methacrylate
(HEMA) lenses that were not being replaced on a planned
basis. T ey ound a clear and statistically signi cant association
between the symptom o dryness and age o the lenses. O those
patients whose lenses were older than 6 months, 31% o en expe-
rienced dryness, whereas only 12% o patients whose lenses were
less than 6 months old experienced this symptom (Fig. 19.11).
Re d uce d Vision
T e loss o vision associated with deposit accumulation on
HEMA contact lenses was assessed by Gellatly et al. (1988) in
51 patients presenting consecutively to a large clinic. Both high-
and low-contrast visual acuity decreased with increased deposi-
tion and with lens age. As a general rule, unacceptable vision
loss and deposit ormation occurred a er 12 months or 4000
hours o lens wear (Fig. 19.12).
19 Re usab le So ft Le nse s 179
Fig . 19.11 Fre q ue ncy o the symp tom o d ryne ss among use rs o non-
re p lace me nt hyd roxye thyl me thacrylate (HEMA) le nse s, cate g orize d b y
le ns ag e . (Ad ap te d from Bre nnan, N. A. & Efron, N. (1989). Symp tom-
atolog y of HEMA contact le ns we ar. O p to m. Vis. Sci. 1989, 66, 834–838.)
Fig . 19.12 Re lation b e twe e n hig h-contrast visual acuity (log MAR)
(op e n circle s and d otte d line ) and low-co ntrast visual acuity (log MAR)
(clo se d circle s and continuous line ) d uring we ar o non-re p lace me nt
hyd roxye thyl me thacrylate (HEMA) le nse s ve rsus le ns ag e (months).
(Ad ap te d from Ge llatly, K. W., Bre nnan, N. A. & Efron, N. (1988). Visual
d e cre me nt with d e p osit accumulation on HEMA contact le nse s. Am. J.
O p tom. Physiol. O p t., 65, 937–941.)
O cular Surface Patholog y
Numerous authors have reported that patients using non-
planned lens replacement systems su er rom a higher inci-
dence o adverse ocular reactions compared with patients using
planned replacement lenses. Although planned replacement
lenses are made o similar materials, and have a similar design,
to lenses supplied on a non-planned replacement basis, the
minimization o lens sur ace deposition on requently replaced
lenses has a signi cant e ect on reducing complication rates
(Nilsson, 1997).
Pritchard et al. (1996) observed that there was signi cantly
more clinically relevant corneal staining and conjunctival injec-
tion, as well as a higher incidence o in ltrates and lens depos-
its, in patients using lenses on a non-planned replacement basis.
Additionally, the overall satis action o patients wearing non-
planned replacement lenses decreased over time. Poggio and
Abelson (1993), in a retrospective study o nearly 2000 2-weekly
and conventional daily-wear patients, ound a signi cantly
lower prevalence o complications in the planned replacement
group or corneal abrasions, oedema and super cial punctate
keratitis. Furthermore, patients wearing planned replacement
lenses had a lower rate o symptoms.
180 PART 4 Le ns Re p lace me nt Mo d alit ie s
Fig . 19.13 Examp le s o re usab le sp he rical silicone hyd rog e l contact le nse s: (A) Air O p tix (Alcon); (B) Ultra (Bausch & Lo mb ); (C) Biof nity (Coop e rVi-
sion); (D) Acuvue O asys (Johnson & Johnson Vision Care ).
Soon a er their introduction onto the market, disposable
lenses were recognized as an e ective management strategy or
speci c complications o lens wear such as contact-lens-asso-
ciated papillary conjunctivitis, sterile in ltrative keratitis and
bulbar hyperaemia (see Chapter 40). Papillary conjunctivitis
especially has been shown to decrease with more- requent lens
replacement – typically 1 month or less (Porazinski and Don-
shik, 1999).
Nilsson and Montan (1994) retrospectively evaluated con-
tact-lens-associated keratitis with stromal involvement and
concluded that patients wearing lenses on a 2-weekly dispos-
able basis had a signi cantly lower incidence o keratitis – about
one-third the rate – than patients wearing daily-wear so lenses
on a non-planned replacement basis. Similarly, Marshall et al.
(1992) ound the complication rate or disposable lens wearers
to be about one-third o that or those who wore lenses on a
non-planned replacement basis.
Although many disposable hydrogel lenses are made rom
ionic lens materials that accumulate tear protein rapidly, the
protein does not denature signi cantly prior to replacement
(Omali et al., 2015). However, a heavy coating o denatured pro-
tein may provide binding opportunities or bacteria. Planned
replacement is a proven strategy or minimizing the potential
adverse e ects relating to these phenomena.
USE O F HIGHER-WATER-CO NTENT HYDRO GEL
MATERIALS
T ere are two strategies or improving the oxygen transmissi-
bility (Dk / t) o contact lenses made rom conventional hydro-
gel materials: reduce the lens thickness pro le and / or increase
the lens water content. An analysis o these options by Brennan
et al. (1991) demonstrated that, particularly at higher powers,
the latter strategy is more e ective at improving corneal oxy-
genation. However, lenses made rom higher-water-content
materials generally have lower elastic moduli and there ore
reduced durability than their lower-water-content counterparts.
High-water-content materials, particularly those with an ionic
sur ace chemistry, also attract tear lm deposits such as jelly
bumps and protein at a aster rate (Jones, 1990).
As a result o the above actors, the li e expectancy o lenses
made rom higher-water-content materials is limited to approx-
imately 6 months on average (Jones et al., 1996b). I a planned
replacement system is used, then the issues o durability and
especially deposit resistance become less signi cant. Planned
lens replacement there ore provides a rationale or the use o
medium- to high-water-content hydrogel materials. However,
in many countries the great majority o planned replacement
lenses tted use silicone hydrogel materials.
USE O F SILICO NE HYDRO GEL MATERIALS
Silicone hydrogel lenses (Fig. 19.13) tend to have lower water
content and may accumulate sur ace deposits o signi cantly
di erent type and quantity to conventional hydrogels (Jones
et al., 2003). Although the amount o protein spoilation on these
materials tends to be lower, the proportion that is denatured
and there ore potentially a cause o contact lens-associated pap-
illary conjunctivitis may be higher. Lipid deposition tends to be
greater with silicone hydrogels (Cheung et al., 2007; Nichols,
2013). Planned replacement is there ore still the appropriate
strategy or these materials that in many international markets
are used signi cantly more than hydrogels or this purpose.
SIMPLE LENS CARE REGIMENS
Although the need to clean and disin ect reusable so lenses
is sel -evident, a power ul argument or prolonging the li e o
lenses with elaborate lens care systems emerged in the early days
o so lenses because o their relatively high cost o production.
 19 Re usab le So ft Le nse s 181

TABLE
19.1 Funct io nal Co nt act Le ns Care fo r Daily-w e ar So ft Le nse s use d fo r Diffe re nt Re p lace me nt Int e rvals
Fre q ue ncy o f Le ns
Re p lace me nt Daily Cle aning Rinsing Disinfe ct ing Pro t e in Re mo val
Daily
We e kly
Two-we e kly
Monthly
Thre e -monthly ?
Six-monthly or more

By the start o the 1980s, so lenses were becoming the pre-
erred option in many countries. o achieve the then lens li e
norm o at least a year, a minimum o three lens care product
types were needed. Daily cleaners were used to remove loose
deposits and microorganisms rom the lens sur ace; disin ect-
ing solutions were used to kill any remaining microorganisms;
and protein removal tablets were used to reduce the build-up
o tear proteins on the lens sur ace. T e ongoing cost o these
products was o en ound to be more than that o the contact
lenses themselves.
Reusable so lenses (excluding daily disposable lenses) still
need high standards o lens care to ensure sa e wear, but the
shorter replacement cycles allow some scope or simpli cation.
It should not be necessary to deproteinize lenses changed at
least monthly. In cases where lens sur ace spoilation is a prob-
lem with monthly replacement, shortening the replacement
interval to 1–2 weeks or even 1 day is likely to be a superior
option – at least in terms o patient convenience and there ore
compliance – compared with adding a protein removal step to
the care regimen.
able 19.1 outlines the typical unctional steps that need to
be carried out in the care o lenses replaced at di erent intervals.
While mechanical daily cleaning, rinsing and disin ection
are still essential in the care o 1- or 2-weekly and monthly
replacement lenses, in most cases these unctions can be e ec-
tively achieved with a single lens care product, namely a multi-
purpose solution (Franklin, 1997) (see Chapter 11).
ypical lens care systems that are used or di erent planned
replacement intervals are listed in able 19.2.
As the replacement interval increases, the need or a separate
protein removal step becomes more likely, although the inclu-
sion o a sequestering agent in multipurpose solutions has been
shown to obviate the need or this (Edwards, 1998).
READY AVAILABILITY O F REPLACEMENT LENSES
Lenses replaced weekly, ortnightly or monthly are normally
supplied in packs o three or six. It ollows that the loss or dam-
age o a lens should not, in most cases, be an inconvenience to
a patient wearing disposable lenses. Practices tting disposable
lenses are also likely to have numerous trial lenses, and even
stocks o the more popular parameters, on the premises, which
enables rapid replacement i lens loss or damage occurs.
ENHANCED CO MPLIANCE WITH AFTERCARE
SCHEDULES
Planned replacement protocols require patients to return at reg-
ular intervals or resh lenses. A ercare visits can be scheduled
to coincide with lens collection, which is a urther bene t o
Typ ical Le ns Care Syst e ms fo r Daily-w e ar
TABLE
19.2 So ft Le nse s use d fo r Diffe re nt Re p lace me nt
Int e rvals
Fre q ue ncy o f Le ns
Re p lace me nt Typ ical Le ns Care Re g ime n
Daily Saline / multip urp ose solution for rinsing
We e kly Multip urp ose solution
Two-we e kly Multip urp ose solution
Monthly Multip urp ose solution
Thre e -monthly Multip urp ose solution (p ossib ly with
p rote in re moval) or hyd rog e n p e roxid e
with se p arate d aily cle ane r (p ossib ly
with p rote in re moval)
Six-monthly or Hyd rog e n p e roxid e with se p arate d aily
more cle ane r and p rote in re moval
prescribing this modality. Morgan et al. (2011) observed reduced
compliance in lens wearers who have not consulted their eye
care practitioner or some time. T e behaviours associated
with the lowest levels o compliance in that study were rubbing
and rinsing, handwashing, correct lens replacement and case
cleaning.
SINGLE-USE TRIAL LENSES
In the case o disposable lenses, new diagnostic or trial lenses
are used with each patient, and disposed o therea er. T is elim-
inates the risk o cross-in ection rom a previous wearer o the
lens. It also has the advantage o eliminating the time-consum-
ing chore o trial lens cleaning, disin ection and storage.
TRIAL LENS FITTING WITH ACCURATE
PRESCRIPTIO N
With the ready availability o a comprehensive stock o trial
lenses (Fig. 19.14), it is nearly always possible to undertake a
lens-wearing trial on a prospective disposable lens patient with
the required lens parameters, especially with respect to lens
power.
T is will, o course, allow or the most realistic subjective
impression o lens wear and allow the practitioner to assess
the t o what is likely to be the nal lens speci cation in many
instances. For certain specialist ttings, such as presbyopia, trial
tting is more meaning ul i the appropriate lens powers or the
re ractive condition o the patient are used.
LENS PARAMETERS EASY TO CHANGE
By the very nature o planned replacement, it is straight or-
ward to modi y the prescription o a patient, particularly with
182 PART 4 Le ns Re p lace me nt Mo d alit ie s
Fig . 19.14 The availab ility o sing le -use d iag nostic le nse s allows or
accurate trialling and e liminate s the risk o cross-in e ction.
respect to changes in re ractive error. From a practice manage-
ment viewpoint, it is advisable to carry out a routine a ercare
appointment be ore dispensing the next supply o lenses or the
patient. Any alteration in lens power can then be made without
the need to exchange unwanted lenses.
Po t e nt ial Disad vant ag e s o f Planne d
Re p lace me nt
T ere are probably no clinical disadvantages in prescribing
planned, as opposed to unplanned, replacement lenses. How-
ever, there are some points to bear in mind that may have nega-
tive implications.
PATIENT NO N-CO MPLIANCE
Soon a er the introduction o disposable lenses into the mar-
ket, Matthews et al. (1992) reported a higher level o complica-
tions with disposable daily-wear lenses than with ‘conventional’
lenses not replaced on a planned basis. T is was attributed to
poor lens hygiene, the use o relatively ine cacious disin ecting
systems such as chlorine, patient non-compliance and lens type.
T e rst disposable lens on the market – Acuvue (Johnson &
Johnson) – was originally promoted as an extended-wear lens,
and many problems could be traced to non-compliance relat-
ing to overnight lens wear. T ese issues have now been largely
solved; Acuvue lenses are used primarily or daily wear, and
chlorine solutions are no longer marketed.
Although it can now be assumed that the use o planned
replacement lenses and simple lens care products (e.g. multi-
purpose solutions) enhances patient compliance (Claydon et al.,
1996), the potential or patient non-compliance is ever present,
and practitioners should be constantly alert to this potential
problem (see Chapter 42).
Nilsson (1997) suggested that, because disposable lenses are
discarded so o en, patients and practitioners can become com-
placent about lens care. Daily cleaning and disin ection remain
a vital part o sa e lens wear or any reusable lens, regardless o
replacement requency. Since the available parameters o dis-
posable lenses, as opposed to prescription or custom lenses, are
limited, practitioners may also be guilty o ‘sloppy tting’ (Nils-
son, 1997). It has also been suggested that disposable lens wear-
ers may seek to solve a problem that would otherwise be in need
o pro essional attention by simply changing the lens (Gasson
and Morris, 1992).
Dumbleton et al., 2011 demonstrated that two-thirds o sili-
cone hydrogel lens wearers did not comply with the minimum
recommended replacement requency o the manu acturer and
wearers o lenses designed or 2-weekly replacement stretched
the replacement interval o their lenses to a greater degree than
did wearers o lenses designed or once-weekly replacement.
T ey also ound that ailing to replace lenses when recom-
mended and ailing to rub and rinse lenses were associated with
a higher rate o patient-reported contact lens problems.
It may be di cult to manage in requent lens wearers via a
planned replacement system simply because the rate o lens
spoilation will be lower and more variable compared with that
in ull-time wearers. Also, compliance with the recommended
replacement schedule may become problematic i the lenses are
discarded at irregular intervals (Saitou et al., 2005). For part-
time wearers, there ore, daily disposable lenses are the pre erred
choice.
Provided lens tting, a ercare and patient education are o
a good standard, there are no compelling reasons or avoiding
planned replacement, as long as the required parameters are
available.
Q UALITY AND REPRO DUCIBILITY ISSUES
E ron and Veys (1992) observed small de ects in early-gen-
eration disposable lenses and suggested that these can cause
complications. With any lens replaced at least monthly, it is not
practical or each lens to be inspected, either prior to insertion
or while in the eye o the patient. For planned replacement to be
success ul it is a requirement that lenses are su ciently consis-
tent in quality such that the patient will not notice any change in
com ort, t or visual acuity rom lens to lens. Certainly, the vari-
ous types o moulding systems used to produce most disposable
lenses are developed on the principle o building quality into
the product, as the traditional manual methods previously used
by manu acturers to examine conventional lenses would not be
cost-e ective with a mass-produced lens.
Wider quality issues are also important when the patient
is using many lenses each year. Consistency o packaging and
labelling are o great signi cance when the patient is supplied
with unopened packages. I patients nd that some blister packs
are empty, dry or contain more than one lens, their con dence
in the product is likely to be reduced.
Notwithstanding the above considerations, the recent litera-
ture is ree o descriptions o complications attributable to poor
disposable lens quality; nevertheless, patients should be advised
to inspect visually all lenses prior to insertion and discard any
lenses exhibiting sur ace or edge de ects, or any that are persis-
tently uncom ortable, cause signi cant eye redness or provide
poor vision.
Practitioners can be reassured that the processes used to
manu acture disposable lenses result in consistent lens param-
eters. Young et al. (1999) evaluated eight reusable lens types
and ound reproducibility to be good or power, base curve and
 19 Re usab le So ft Le nse s 183

centre thickness, and acceptable or total diameter. T e same

researchers ound adequate reproducibility o requent replace-
ment so toric lenses (Young et al., 2001).

De t e rmining t he Ap p ro p riat e Le ns
Re p lace me nt Fre q ue ncy
It is not straight orward to identi y the ideal lens replacement
requency or a given patient. An appropriate replacement
interval can be chosen rom one o the standard replacement
intervals ormulated or various products by contact lens
manu acturers. Such a decision is made a ter consideration
o the desired pattern o wear and contact lens history o the
Fig . 19.15 Planne d re p lace me nt e nab le s p ractice s to p rovid e le nse s
patient. here are essentially three key reasons why a greater and le ns care p rod ucts in a conve nie nt b und le .
requency o lens replacement may be required: excessive
lens deposition, recurrence o ocular complications thought
to be related to lens deposition, and poor lens replacement
compliance (Dumbleton et al., 2011). It is advisable, or both
legal and practical reasons, to use the replacement interval(s)
or a given lens recommended by the manu acturer as a
maximum.

Pract ice Manag e me nt Issue s Re lat ing

t o Planne d So ft Le ns Re p lace me nt
For planned lens replacement, practitioners need to employ
systems or tracking and managing lens stocks, delivering
lenses and solutions to patients, sending recall reminders and
arranging a ercare visits. Specialised approaches to nancial
management are required. In many instances, these approaches
nurture a close working relationship between practitioners and
manu acturers.

LENS DELIVERY SYSTEMS

wo main methods or managing the implementation o
planned lens replacement systems can be adopted: manu ac-
turer-driven systems and practice-driven systems.
Manufacture r-d rive n Syste ms
T e names o new patients are registered with the manu ac-
turer by the practice along with relevant prescription details.
Depending on the lens type, there may also be an option to
select a requency o lens delivery to the practice; or example,
monthly replacement lenses may be supplied to the practice in
3- or 6-month quantities. Once the patient is registered, resh
supplies o lenses will be automatically dispatched to the prac-
tice until countermanded.
Manu acturers have, in some cases, branded their systems
to promote the service provided. T e main bene t to prac-
tices is reduced administration. Simple computer programs
run the systems, and the arrival o a new supply o lenses
or a given patient acts as a trigger or the practice to recall
that particular lens wearer. In many countries, such systems
complement the method by which many patients pay or re-
quent replacement lenses – namely, monthly direct payment
rom their bank account to the account o the practice. In this
way, both payment and regular lens supply are automated
and compliance with the designated replacement schedule is
encouraged.
Some manu acturers have expanded their service to
include direct delivery o lenses and lens care products
Fig . 19.16 A re sup p ly se rvice e nab ling p ractice s to o e r p atie nts con-
ve nie nt re -ord e ring on the ir mob ile d e vice s. (Courte sy of Coo p e rVision.)
(so-called ‘bundling’) to the home address o the patient (Fig.
19.15). he increased convenience a orded by this approach
is promoted as a means o retaining the custom o the patient
or replacement lenses, given the growth o non-practice
sources o supply such as direct mail and the internet (see
below). A urther recent development is the provision by
some manu acturers o replenishment systems designed or
mobile devices. hese may allow branding o the portal by
the practice to maintain continuity o the patient relation-
ship and o er a direct alternative to third-party internet
resellers (Fig. 19.16).
Practice -d rive n Syste ms
I a manu acturer-driven system is not employed, an in-house
system is required to ensure the timely purchase o replace-
ment lenses and recall o patients. With larger patient bases,
the amount o stock involved can be quite large and adequate
storage space is o en an issue. On the other hand, bulk pur-
chasing may allow practices to secure pre erential terms
rom suppliers. A practice operating its own system is also
in complete control o the process and less vulnerable to any
184 PART 4 Le ns Re p lace me nt Mo d alit ie s

TABLE
19.3 Parame t e r Availab ilit y fo r Co mmo nly Availab le Disp o sab le Daily-w e ar Le nse s*
Le ns Typ e Diame t e rs (mm) Base Curve s (mm) Po we rs (D)
O ne - to two-we e kly and 14.0–14.5 8.2–9.3 +15.00 to −20.00
monthly sp he re
O ne - to two-we e kly and 14.0–14.6 8.3–9.2 +10.00 to −11.00DS
monthly toric −0.75 to −5.75DC
Axe s 5 to 180 (5° ste p s)
O ne - to two-we e kly and 14.0–14.5 8.3–8.9 +6.00 to −10.00
monthly b i / multifocal
O ne - to two-we e kly and 14.0–14.5 8.6–8.9 +6.00 to −8.00
monthly tint

*Exclud e s p rivate lab e ls and alte rnative b rand ing o the same le ns, and le nse s p rimarily inte nd e d or e xte nd e d we ar.

Fig . 19.17 Examp le s o re usab le toric silicone hyd rog e l contact le nse s: (A) Air O p tix or Astig matism (Alcon); (B) Pure Vision 2 or Astig matism
(Bausch & Lomb ); (C) Biof nity toric (Coop e rVision); (D) Acuvue O asys or Astig matism (Jo hnson & Johnson Vision Care ).

manu acturer supply problems. In some markets it is possible
to bulk purchase product without taking delivery until sup-
ply or an individual patient is required. T is is re erred to as
owning a ‘virtual stock’ or ‘lens banking’. It saves space, means
there is no need to manage the stock in respect o powers and
allows the prepurchase o lenses not usually stocked, such as
torics and multi ocals.
LENSES AVAILABLE FO R PLANNED
REPLACEMENT
It is possible to t a substantial majority o so lens patients
with lenses replaced at least monthly ( able 19.3). T e principal
lens types – such as spherical (see Fig. 19.13), toric (Fig. 19.17),
multi ocal (Fig. 19.18) and tinted (Fig. 19.19) – are available in
several alternative replacement requencies and increasingly
in silicone hydrogel materials, as illustrated in Figs. 19.13 and
19.17–19.19. In act, none o the major international contact
lens manu acturers has launched a hydrogel planned replace-
ment lens or some years.
Patients or whom the desired lens replacement requency
is unavailable are now mainly restricted to those with extreme
prescriptions. Patients needing a lens diameter that is smaller
than usual, say 13.50 mm, are also less easily tted with the
current range o disposable lenses, most o which are at least
14.00 mm total diameter. However, 3-monthly replacement
potentially allows manu acturers to o er custom or prescrip-
tion lenses, so that even outlying parameter requirements can
be met in many cases.
PRACTICE LO GISTICS
T ere is no doubt that planned replacement can generate con-
siderable extra workload in a practice. T e main issues are stock
levels, patient a ercare and recall and payment.
As an example, a practice with 500 patients using 2-weekly
disposable lenses will handle over 4000 six-packs o lenses
per annum, ignoring new ts, or over 80 lens packs per week
on average. Five hundred patients will also require 500–1000
a ercare appointments, depending on the pre erence o the
 19 Re usab le So ft Le nse s 185

Fig . 19.18 Examp le s o re usab le b i / multi ocal silicone hyd rog e l contact le nse s: (A) Air O p tix Multi o cal (Alcon); (B) Pure Vision 2 or Pre sb yop ia
(Bausch & Lomb ); (C) Biof nity multi o cal (Coop e rVision); (D) Acuvue O asys or Pre sb yop ia (Johnson & Jo hnson Vision Care ).

Fig . 19.19 Examp le o re usab le tinte d silicone hyd rog e l contact le ns.
Air O p tix Colors (Alcon).

practitioner. T is is perhaps as much as 30% o annual available

chair time. I patients collect their supplies quarterly, practice
sta will deal with nearly 40 collections per week.
Assuming the above level o activity, a reasonable stock, or
inventory, o lenses will need to be kept in the practice to ensure
good service to patients, and such stocks can consume a consid-
erable amount o space (Fig. 19.20).
T ere are several approaches to deciding what levels o
stock to maintain. T e simplest involves keeping a ew boxes
o each parameter or ‘stock kept unit’ (commonly re erred to
by manu acturers as the acronym ‘SKU’). As next-day deliv-
ery is o en available, large numbers o lenses do not need to
be stocked, although several spherical disposable lens brands
have parameter ranges o over 100 SKUs. Practices may wish to
Fig . 19.20 Practice s with larg e p atie nt b ase s will ne e d to manag e , and
f nd sp ace or, e xte nsive stocks o p lanne d re p lace me nt le nse s.
weight their stock towards the more commonly occurring pre-
scriptions, such as the range rom −1.00 to −5.00 D. With very
large patient bases, it may be help ul to consult with suppliers,
who can advise on an appropriate in-practice stock holding
based on statistical stock models used to manage their own
inventory.
Practices that are computerized may wish to model their
stock on the actual prescriptions o their patient base. T is
approach can be tied in with the a ercare recall system. Due
allowance needs to be made or unpredictable purchasing
186 PART 4 Le ns Re p lace me nt Mo d alit ie s
Fig . 19.21 Diag nostic le nse s allow or conve nie nt and accurate f tting
asse ssme nt.
patterns, which can arise, or example, ahead o holiday
periods. As well as holding su cient stock or purchase, an
adequate number o trial or diagnostic lenses are needed or
ongoing tting (Fig. 19.21).
CO ST TO THE PATIENT
E ron et al. (2012) constructed a cost-per-wear (CPW) model to
assist practitioners and patients in considering the cost implica-
tions o various lens replacement requencies (daily, 2-weekly
and monthly), tailored to the wearing habits o individual
patients. T e CPW is a simple calculation o the total cost o
lenses (and solutions or non-daily lens replacement) over
a 12-month period divided by an estimate o the number o
days that lenses will be worn over 12 months. For the ull-time
wearer, the di erence in CPW between 2-weekly and monthly
replacement lenses was small. For part-time wearers, daily dis-
posable lenses were usually cheaper than monthly replacement
lenses (E ron et al., 2012).
FINANCIAL MANAGEMENT
he clinical bene its o planned replacement have been
described above. It would be remiss not to mention the com-
mercial bene its that this modality also delivers. Patients
changing their lenses regularly, particularly i wearing dis-
posable lenses, will generate a more predictable practice cash
low.
Contact lenses are o en promoted as ‘practice builders’ since
they usually require more practice visits and a more detailed
appreciation by the patient o the pro essional skills required to
maintain success ul wear. T is encourages greater loyalty than
or spectacle-wearing patients. By reducing complications and
increasing patient satis action, requently replaced lenses ur-
ther enhance the business bene ts o developing a large base o
contact lens wearers.
ALTERNATIVE SUPPLY RO UTES
T e issue o non-optical-practice supply now a ects virtually all
contact lens types, although disposable lenses are particularly
susceptible to third-party distribution given the brand aware-
ness that many o these products have with the public. In the
USA, the Fairness to Contact Lens Consumers Act (2004) is
intended to allow contact lens wearers the reedom to shop
around or their contact lens supplies.
T e critical issue here is that it is in the public interest to have
a system o lens supply that guarantees the ongoing preserva-
tion o the ocular health o lens wearers. A system that provides
no disincentives to patients to continue to purchase lenses or
many years without having their eyes examined poses a sig-
ni cant public health risk. Contact lens wearers who purchase
lenses online have been shown to be at greater risk o microbial
keratitis (Stapleton et al., 2008).
Notwithstanding the role o regulatory authorities in dis-
charging their responsibilities or public health and sa ety, there
are strategies that practitioners can employ to retain control o
lens supply and to link this to patient care. Fee splitting – where
materials are charged at relatively low mark-ups on cost, and
these charges are separated rom pro essional ees – helps dem-
onstrate to patients that most o the cost involved in wearing
contact lenses is attributed to the pro essional time involved.
Home delivery plans, perhaps operated on behal o the practice
by a supplier, enable practitioners to match the perceived conve-
nience o mail order and internet supply companies. Large prac-
tices or group practices may be able to come to an arrangement
with manu acturers so that lenses and solutions supplied by that
manu acturer are ‘rebranded’ prior to delivery. T e rebranding
(or so-called ‘own-labelling’ or ‘private labelling’) acilitates an
association o the products with the practice and thereby serves
to enhance patient loyalty. However, as the lens speci cations
cannot be altered, it is relatively straight orward to determine
the original brand and there ore purchase the original brand
elsewhere i the patient desires.
Co nclusio n
Planned contact lens replacement enhances clinical per or-
mance, increases convenience and promotes practice pro tabil-
ity. Planned so lens replacement will continue to represent a
viable approach to prescribing contact lenses or the oreseeable
uture; however, some countries are now trending strongly in
avour o daily disposables and their eventual dominance over
lenses with longer replacement intervals seems likely in many
developed markets.
ACKNO WLEDGEMENTS
T e author wishes to thank revor Rowley, Bausch & Lomb, CooperVi-
sion, CIBA Vision and Johnson & Johnson Vision Care or providing
photographs, and Phil Morgan or supplying in ormation on the UK
market.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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Jones, L., Mann, A., Evans, K., et al. (2000). An in vivo
comparison o the kinetics o protein and lipid
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Jones, L., Senchyna, M., Glasier, M.-A., et al. (2003).
Lysozyme and lipid deposition on silicone hydro-
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Maissa, C., Franklin, V., Guillon, M., et al. (1998). In-
f uence o contact lens material sur ace character-
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Marshall, E., Begley, C., & Nguyen, C. (1992). Fre-
quency o complications among wearers o dis-
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Matthews, ., Frazer, D., Minassian, E., et al. (1992).
Risks o keratitis and patterns o use with dis-
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Morgan, P. B., & E ron, N. (2000). Hydrogel contact
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Morgan, P. B., E ron, N., oshida, H., et al. (2011).
An international analysis o contact lens com-
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Morgan, P. B., E ron, N., Woods, C. A., et al. (2002).
International contact lens prescribing. CL Spec-
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Morgan, P. B., Woods, C. A., ranoudis, I. G., et al.
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Nichols, J. (2013). Deposition on silicone hydro-
gel contact lenses. Eye Contact Lens, 39, 20–23.
Nilsson, S. (1997). en years o disposable lenses – a
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o lysozyme deposition on so contact lenses. Op-
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Pritchard, N., Fonn, D., & Weed, K. (1996). Ocular
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186.e 1
20
Planne d Re p lace me nt Rig id Le nse s
CRAIG A WO O DS

Int ro d uct io n patients and were able to show that the li e expectancy o rigid
lenses was related to the material’s oxygen permeability (Dk).
T e perceived advantages o rigid lenses, compared with so T e mean li e expectancy o rigid lenses was ound to be 20 ± 17
lenses, include increased corneal oxygenation (E ron and months or low-Dk materials, 16 ± 13 months or mid-Dk mate-
Ang, 1990), longer li e expectancy (Atkinson and Port, 1989), rials, and 9 ± 8 months or high-Dk materials (Fig. 20.5).
reduced risk o microbial keratitis (Dart et al., 2008; Stapleton
et al., 2008), ewer toxic / allergic complications (Hamano et al.,
1988) and superior vision in cases o corneal astigmatism. Many
clinicians believe that rigid lenses should be considered the lens
o rst choice (Dart et al., 1991).
It has been shown that, as so lenses age, their physical and
clinical per ormance deteriorates, resulting in reduced com-
ort (Poggio and Abelson, 1993), reduced vision (Gellatly et al.,
1988) and decreased wettability (Guillon et al., 1992). T is has
resulted in the wide acceptance o planned replacement or so
contact lenses (Jones, 1994).
T e concept o planned replacement or so contact lenses is
well established and the bene ts o regular replacement o so
contact lenses are covered in Chapter 19. T e regular replace-
ment o rigid lenses gives rise to similar bene ts. Rigid lenses
can develop deposits such as the presumed protein haze shown
in Fig. 20.1. T e lens sur ace can become scratched over time
(Fig. 20.2), necessitating lens polishing or replacement. Fine
splits (Fig. 20.3) can occur at the edge o rigid lenses, requiring
lens replacement. Another ageing problem with rigid lenses is
the development o crazing – that is, the appearance o inter-
connecting cracks that can extend deep into the lens (Fig. 20.4).
Fig . 20.1 Pre sume d p rote in haze on a rig id le ns worn on a non-re -
Crazing predisposes the lens to the development o secondary p lace me nt b asis. (Courte sy o f Arthur Back, Bausch & Lomb Photo Li-
deposits, and the lens can become uncom ortable owing to the b rary.)
crazing and / or the existence o deposits (Lembach et al., 1988).
Crazing can also be due to problems occurring during manu-
acture (McLauchlin and Schoessler, 1987) and is not o en
seen today. T e aim o regular lens replacement is to avoid such
adverse occurrences.

Life Exp e ct ancy o f Rig id Co nt act

Le nse s
T e perception might be that rigid lenses have a longer li e than
so contact lenses. Due to their negligible water content and
high modulus o elasticity, rigid materials lend themselves well
to prolonged li e. T e method o manu acturing (lathe cutting)
is relatively labour intensive and costly compared with that o
manu acturing disposable so lenses, which raises questions o
the cost-e ectiveness o regular rigid lens replacement.
T e literature reports a wide range or the li e expectancy or
rigid lenses. Atkinson and Port (1989) concluded that they last
between 2 and 3 years and Yokota et al. (1992) estimated the
li e o rigid lenses to be between 5 and 10 years. Both o these
reports re ect the clinical opinions o the authors with limited Fig . 20.2 Scratche s on the sur ace o a rig id le ns worn on a non-re -
evidence-based data. Jones et al. (1996) analysed data rom 600 p lace me nt b asis.
187
188 PART 4 Le ns Re p lace me nt Mo d alit ie s
Fig . 20.3 Fine sp lit at the e d g e o a rig id le ns worn on a non-re p lace -
me nt b asis. (Courte sy of Lynd on Jone s, Bausch & Lomb Slid e Lib rary.)
Fig . 20.4 Crazing on the sur ace o a rig id le ns worn on a non-re p lace -
me nt b asis.
Fig . 20.5 Me an le ns li e or various contact le ns mate rials. Rang e s or
low-, mid - and hig h-Dk mate rials are shown in b racke ts. HWC = hig h-
wate r-conte nt mate rials.
In the same study, the li e expectancy o high-water-content
so lenses was ound to be 6 ± 5 months. T is compared well
with other published data (Jones, 1990), which also established
an expected li espan or high-water-content so lenses o about
6 months.
All contact lenses should have suf cient oxygen transmis-
sibility (Dk / t) to maintain near-normal corneal metabolism.
A Dk / t o 24 Barrer / cm is required rom a lens worn on a
daily-wear basis, or an average cornea (Holden and Mertz,
1984). High-Dk materials have been shown to result in reduced
hypoxia and hypercapnia (E ron and Ang, 1990), reduced stro-
mal acidosis (Polse et al., 1992), a lower overall complication
rate (Hamano et al., 1988) and reduced binding o Pseudomo-
nas aeruginosa to the corneal sur ace (Imayasu et al., 1994).
T e conclusion rom these studies is that, rom a physiological
standpoint, contact lenses should be made rom high-Dk mate-
rials wherever possible.
T e study by Jones et al. (1996) demonstrated that lenses
manu actured rom higher-Dk materials have a reduced li e
expectancy when compared with lower-Dk materials. T is
is not unexpected, since lenses made rom high-Dk materials
are less mechanically stable (i.e. subject to warpage) and more
prone to sur ace scratching ( ranoudis and E ron, 1996) than
lenses made rom low-Dk materials. able 20.1 indicates that
lenses manu actured rom materials with nominally quoted
uncorrected Dk values o ≥90 Barrer should last approximately
9 months, compared with 20 months or lenses with a Dk o ≤40
Barrer.
All contact lenses demonstrate a deterioration in per or-
mance with age. Although this has been clearly demonstrated
with so lenses (Poggio and Abelson, 1993), studies o rigid
lenses also show a gradual deterioration in wettability (Guil-
lon et al., 1995) and visual per ormance (Jones et al., 1995), and
an increase in sur ace scratching and deposition (Allary et al.,
1989; Guillon et al., 1995; Jones et al., 1995), irrespective o Dk
or material type.
It was common with PMMA materials to ‘prolong’ the
li e o the lens by repolishing the lens sur aces. Some clini-
cians believe that repolishing techniques can also be applied
to prolong the li e o rigid lenses; however, caution should
always be exercised with this procedure as overpolishing can
lead to reduced sur ace wettability and ultimately result in
reduced com ort and visual per ormance (Grohe et al., 1988)
(Fig. 20.6).
Re g ular Re p lace me nt o f Rig id Le nse s
he concept o regular replacement o rigid lenses was irst
considered by Grohe in 1992. He concluded that the major
problem with the introduction o such systems would be
the increased cost to the patient with little obvious bene it
(Grohe, 1992). However, i it is accepted that: (1) higher-Dk
materials should be itted or clinical reasons, (2) such lenses
have a reduced li e expectancy and (3) all lenses show a dete-
rioration in per ormance with age, then the planned replace-
ment o high-Dk rigid lenses would appear to be a logical
modality or practitioners and patients to adopt. he ben-
e its o such a schedule have been demonstrated or lenses
worn on a daily-wear basis (Guillon et al., 1995) (see able
20.1). Allary et al. (1989) reported that sur ace scratching
and deposition on rigid lenses increase with lens age; how-
ever, this study was not controlled or designed to investigate
 20 Planne d Re p lace me nt Rig id Le nse s 189

TABLE Time Sp an fo r t he De ve lo p me nt o f Ad ve rse Chang e s t o Vario us Parame t e rs o f t he Co nt act Le ns and Eye

20.1 d uring Rig id Le ns We ar
Parame t e r Time Sp an Mo d e o f We ar Re fe re nce
Life e xp e ctancy 5–10 ye ars Daily we ar Yokota e t al., 1992
Life e xp e ctancy 2–3 ye ars Daily we ar Atkinson and Port, 1989
Life e xp e ctancy* 20 months Daily we ar Jone s e t al., 1996
Life e xp e ctancy† 16 months Daily we ar Jone s e t al., 1996
Corne al staining 12 months Daily and e xte nd e d we ar Wood s and Efron, 1996a
Conjunctival staining 12 months Exte nd e d we ar Wood s and Efron, 1996b
Limb al hyp e rae mia 12 months Daily we ar Wood s and Efron, 1996a
Mucus coating 12 months Daily and e xte nd e d we ar Wood s and Efron, 1996a
Surface d e p osition 12 months Daily we ar Wood s and Efron, 1996a
Tarsal chang e s 12 months Daily we ar Wood s and Efron, 1996a
Life e xp e ctancy‡ 9 months Daily we ar Jone s e t al., 1996
Surface d rying 9 months Daily we ar Wood s and Efron, 1996a
Surface scratching 9 months Daily and e xte nd e d we ar Wood s and Efron, 1996a
Surface we tting 9 months Daily we ar Wood s and Efron, 1996a
Le ns b ind ing 6 months Exte nd e d we ar Wood s and Efron, 1996b
Surface d e p osition 6 months Daily we ar Guillon e t al., 1995
Surface we tting 6 months Daily we ar Guillon e t al., 1995

*Low-Dk mate rials.

†Mid -Dk mate rials.
‡Hig h-Dk mate rials.

Fig . 20.6 Rig id le ns sur ace d isp laying the e e cts o ove rp olishing .

Fig . 20.7 Rig id contact le nse s f tte d on a p lanne d re p lace me nt and

lens ageing, and their comments were an aside to the actual
purpose o their study.
Grohe (1992) considered the above issues and expressed
concern that rigid contact lens disposability might be intro-
duced or marketing rather than clinical reasons. Hannon
(1990) expressed the view that there were tremendous bene ts
in regularly replacing rigid lenses rom a marketing point o
view, which patients would nd an acceptable concept.
T e concept o planned replacement has not been embraced
rom a marketing perspective, nor have any speci c planned
replacement products been developed or promoted. Despite
this, contact lens prescribing data gathered rom around the
world demonstrates that, between 2006 and 2015, about 40%
o rigid lenses have been prescribed on a planned replace-
ment basis (Fig. 20.7). In 2015 the proportion o rigid lenses
prescribed on a planned replacement schedule was 48% over-
all, although there were signi cant di erences between nations
(Fig. 20.8) (Morgan et al., 2016). E ron et al. (2013) reported
non-p lanne d re p lace me nt b asis acro ss the world b e twe e n 2006 and
2015.
that 7% o rigid lenses were replaced more requently (i.e.
2-weekly or monthly).
Ad vant ag e s o f Re g ular Re p lace me nt
o f Rig id Le nse s
Woods and E ron (1996a, b) investigated the e ects o planned
replacement o rigid lenses on the integrity o the lens and the
anterior ocular structures. In a masked, controlled and random-
ized experiment, these authors compared a group o rigid lens
wearers on a planned replacement basis with a control group who
were not scheduled to replace their rigid lenses over a 12-month
period. T is investigation was per ormed with rigid contact
lenses worn on a daily-wear basis (Woods and E ron, 1996a) and
on an extended-wear basis (Woods and E ron, 1996b).
190 PART 4 Le ns Re p lace me nt Mo d alit ie s

Fig . 20.8 Planne d re p lace me nt rig id le nse s p re scrib e d in 19 countrie s in 2015. Country cod e s: AR = Arg e ntina; AT = Austria; AU = Australia; BG = Bul-
g aria; CH = Switze rland ; CN = China; DE = Ge rmany; ES = Sp ain; FR = France ; IL= Israe l; JP = Jap an; MY= Malaysia; NL= Ne the rland s; NO = Norway;
NZ = Ne w Ze aland ; PH = Philip p ine s; SI = Slove nia; UK= Unite d King d om; US = Unite d State s.

Fig . 20.10 Scratche s on the sur ace o a non-re p lace me nt b asis rig id
Fig . 20.9 Rig id le ns with a non-we tting sur ace . le ns, se e n a te r le ns re moval with the le ns susp e nd e d ag ainst a d ark
b ackg round .

DAILY WEAR
For daily-wear basis, planned replacement was shown to reduce
the grade or:
• corneal staining within 12 months o commencing the study
• the extent o limbal hyperaemia over time
• the extent o tarsal conjunctival changes over time (Woods
and E ron, 1996a).
Regarding the condition o the lenses, planned replacement
reduced:
• sur ace drying within 9 months o commencing the study
(Fig. 20.9)
• sur ace scratching within 9 months o commencing the
study (Fig. 20.10)
• mucus coating within 12 months o commencing the study
• sur ace deposition within 12 months o commencing the
study (Woods and E ron, 1996a).
Conventionally worn daily-wear rigid lenses demonstrated a
signi cant reduction in lens thickness over time (Woods and
E ron, 1999); this is attributed to the rubbing action causing an
erosion o material rom the lens centre.
EXTENDED WEAR
For extended wear, planned replacement signi cantly reduced:
• the grade or corneal staining over time (Woods and E ron,
1996b)
• the grade or conjunctival staining over time (Woods and
E ron, 1996b)
• the measured immunoglobulin E levels in the tear lm
over time (Woods, 1997).
Planned replacement did not prevent a signi cant increase in
tarsal conjunctival changes in the extended-wear group.
Participants not in the planned lens replacement group dis-
played a signi cant increase in myopia and a reduction in high-
contrast acuity.

Fig . 20.11 Pe rce ntag e o sub je cts re p orting le ns b ind ing . DW
RR = d aily-we ar re g ular re p lace me nt; DW N-RR = d aily-we ar non-re g -
ular re p lace me nt; EW RR = e xte nd e d -we ar re g ular re p lace me nt; EW
N-RR = e xte nd e d -we ar non-re g ular re p lace me nt.
Regarding the condition o the lenses, planned replacement
reduced the grade or:
• mucus coating over time
• sur ace scratches over time (Woods and E ron, 1996b).
LENS BINDING
In their studies, Woods and E ron (1996c) observed that lens
binding occurred in both the daily-wear groups and the extended-
wear groups o wearers. T e occurrence o binding was monitored
both subjectively and objectively. Subjective binding assessment
appeared to be a reliable indicator as to the occurrence o this
phenomenon, whereas objective assessment appeared to pro-
vide less reliable results. Regular replacement o lenses worn on
an extended-wear basis signi cantly reduced the level o subjec-
tively reported lens binding compared with that reported or the
unplanned replacement group. A low incidence o lens binding
was shown to occur with daily wear o rigid lenses, irrespective o
whether lenses were regularly replaced or not (Fig. 20.11).
O p t imum Re p lace me nt Sche d ule
With very little published in the literature to demonstrate the
time course o occurrence o adverse events in the eye and
lens during rigid contact lens wear ( able 22.1), it is dif cult
to ormulate a clinical criterion or the ideal rigid lens replace-
ment requency. T is criterion can be determined using clinical
data, or it can be based on a theoretical model. Both o these
approaches are presented below.
CLINICAL DATA
T e data o Guillon et al. (1995) suggest that a measurable
reduction in sur ace wettability and increase in sur ace deposit
ormation occurs with rigid lenses a er 6 months o use. T e
data o Woods and E ron (1996a, b) suggest that those changes
occur a er a longer period o wear – that is, clinically signi -
cant changes do not appear to occur until a er about 9 months.
Furthermore, a recommended requency o replacement should
not exceed the li e expectancy o any orm o rigid lens, which is
9 months. It is reasonable to assume, there ore, that an optimum
20 Planne d Re p lace me nt Rig id Le nse s 191
replacement requency or rigid lenses would be less than 9
months. In conclusion, there ore, a recommendation to replace
rigid lenses every 6 months would seem reasonable, based on the
argument that: (1) lenses should be replaced be ore any adverse
ocular or lens sur ace changes would be expected to occur; and
(2) this is an easy-to-remember calendar-based requency that
would acilitate patient and practitioner compliance.
THEO RETICAL MO DEL
An alternative approach to ormulating a recommended replace-
ment requency or rigid lenses would be to estimate the theoret-
ical ideal replacement schedule using the li espan and optimum
replacement requency o high-water-content so lenses as a
guide. High-water-content so lenses have been shown to have
an average li espan o 6 months (Jones, 1990; Jones et al., 1996).
T e optimum replacement requency or planned replacement
so lenses could be considered to be between 2 weeks and 3
months (Guillon et al., 1992). A simple ratio o li espan to opti-
mum replacement requency could act as a guide to determine
how requently to replace the rigid lenses. Jones et al. (1996)
established that the li espan o rigid lenses made rom high-Dk
materials is on average 9 months, which is 50% greater than that
or high-water-content so lenses (6 months). T e ideal theo-
retical rigid lens replacement requency would there ore be 50%
more than the range o the optimal so lens replacement re-
quencies – that is, between 0.75 and 4.5 months.
Planne d Re p lace me nt Sche me s
Availab le
As is the case with so contact lenses, manu acturers and practi-
tioners had to be prepared to embrace the concept o planned rigid
replacement i this modality was to succeed. Planned replacement
o so lenses required manu acturer-driven schemes to be adopted
by practitioners as an accepted standard o practice. Rigid lenses
generally are produced by a large number o relatively small pre-
scription or specialist laboratories and it would be unreasonable to
expect all o these manu acturers to develop a universal approach to
the question o planned rigid lens replacement. As a consequence,
manu acturer-driven rigid lens replacement schemes are generally
bespoke and provided around their lens warranty arrangements;
planned replacement lenses being provided not covered by the
warranty agreement are thus at a reduced cost.
Co nclusio n
T e planned replacement o rigid contact lenses has been shown
to be clinically bene cial, in terms o maintenance o the integ-
rity o the sur ace o the contact lens and preservation o ocular
health (Woods and E ron, 1996a, b, c). T ese bene ts have been
demonstrated to apply to patients wearing rigid lenses on daily-
and extended-wear regimens. Based on the limited amount
o in ormation available, it is concluded that optimum ocular
physiology will be realized by tting lenses made rom high-Dk
materials that are designed to be replaced every 6 months. Year-
on-year data suggests that practitioners are embracing planned
replacement o rigid lenses as they have done or so lenses.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
This pa ge inte ntiona lly le ft bla nk
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[PhD thesis]. Manchester, UK: University o
Manchester Institute o Science and echnol-
ogy.
Woods, C. A., & E ron, N. (1996a). Regular re-
placement o daily-wear rigid gas-permeable
contact lenses. J. Br. Contact Lens Assoc., 19,
83–89.
Woods, C. A., & E ron, N. (1996b). Regular replace-
ment o extended wear rigid gas permeable con-
tact lenses. CLAO J., 22, 172–178.
Woods, C. A., & E ron, N. (1996c). Regular re-
placement o rigid contact lenses alleviates
binding to the cornea. Int. Contact Lens Clin.,
23, 13–18.
Woods, C. A., & E ron, N. (1999). T e parameter
stability o a high Dk rigid lens material. Cont.
Lens Anterior Eye, 22, 14–18.
Yokota, M., Goshima, ., & Itoh, S. (1992). T e e ect
o polymer structure on durability o high Dk gas-
permeable materials. J. Br. Contact Lens Assoc., 15,
125–129.
192.e 1
 PART

5
Sp e cial Le nse s and Fit t ing
Co nsid e rat io ns
PART O UTLINE
21 Scle ral Le nse s 195
Nathan E ron
22 Tinte d Le nse s 204
Nathan E ron and Suzanne E E ron
23 Pre sb yop ia 214
John Me yle r and David Ruston
24 Exte nd e d We ar 231
Noe l A Bre nnan and M-L Chantal Cole s
25 Sp ort 246
Nathan E ron
26 Ke ratoconus 251
Laura E Downie and Richard G Lind say
27 Hig h Ame trop ia 263
Jose p h T Barr
28 Bab ie s and Child re n 268
Cind y Tromans and He le n Wilson
29 The rap e utic Ap p lications 275
Nathan E ron and Suzanne E E ron
30 Post-re fractive Surg e ry 282
Suzanne E E ron
31 Post-ke ratop lasty 287
Barry A We issman
32 O rthoke ratolog y 296
Paul Gi ord
33 Myop ia Control 306
Pad maja Sankarid urg and Brie n A Hold e n
34 Diab e te s 314
Clare O ’Donne ll
This pa ge inte ntiona lly le ft bla nk
21
Scle ral Le nse s
NATHAN EFRO N

Int ro d uct io n or the unadapted eye because there is no eyelid–lens edge inter-
action, oreign bodies behind lenses are not a problem, and
Up until the end o the 20th century, contact lenses manu ac- there is no localized exposure due to disrupted blinking.
tured rom polymethyl methacrylate or rigid gas permeable Generally, the end point to the tting process is well de ned
materials were abricated as either corneal lenses (7.0–12.0 mm and quickly reached, and an extensive power range is possible
diameter) or the much larger scleral lenses (>18.0 mm in diam- without excessive mobility. Insertion may be easier or less-dex-
eter), with nothing in between. However, it has become appar- trous patients, because the lens is not balanced on one nger
ent over the past decade that there is considerable clinical utility but rather held between the thumb and a nger. Maintenance is
in abricating rigid lenses with diameters alling within these straight orward as dry storage is generally satis actory even with
two extremes; speci cally, corneo-scleral lenses (12.1–15.0 mm gas-permeable materials. Polishing or resur acing is possible.
diameter) and miniscleral lenses (15.1–18.0 mm diameter) are For a balanced view it is also necessary to appreciate the
being used to manage a variety o re ractive and pathological drawbacks. Production is labour intensive compared with most
conditions. T is chapter considers ‘classic’ large-diameter scleral other lens types. T e large size can be intimidating, and there
lenses; there is considerable overlap in the indications, tting, may be a eeling and appearance o excessive bulkiness. Even i
handling, maintenance and a ercare between this lens type and skil ully tted, corneal oxygenation is reduced, and the visual
the recently introduced, smaller corneo-scleral and miniscleral per ormance is not always as good as with a smaller corneal lens
lenses. Corneal lenses are discussed in Part III and the tting o in cases o keratoconus, although Salam et al. (2005) showed
corneo-scleral and miniscleral lenses, in the context o correct- that scleral lenses are not necessarily optically in erior to cor-
ing keratoconus, are considered in Chapter 26. neal lenses. Decentration in the vertical meridian can cause sig-
Scleral contact lenses are generally perceived as being ni cant prismatic e ects, especially i only one eye is wearing a
cumbersome, di cult to t and problematic. However, rigid lens. However, the reason or scleral lens tting is not usually to
gas-permeable (RGP) materials have enabled predictable and enhance the vision compared with corneal lenses, but to provide
straight orward scleral lens tting methods, creating opportu- respite rom other problems.
nities or e ective, non-surgical visual rehabilitation at all levels
o pathology. T e uniquely valuable role o ers respite rom the
problems caused by other lens types, or can be the only option
when a success ul visual outcome is most needed (Picot et al.,
2015). T e aim o this chapter is not to provide an in-depth cov-
erage o clinical techniques, but rather to give a broad overview,
so that the practitioner can be aware o what to expect should a
scleral lens wearer seek advice.
o meet a clinical de nition o a scleral lens, the diameter
must be large enough to have a scleral bearing sur ace with optic
zone clearance extending just beyond the limbus (Fig. 21.1).
Assuming a corneal diameter o 12 mm, a minimum annular
limbal clearance o 1 mm and a minimum annular scleral bear-
ing sur ace o 1 mm, the very smallest possible diameter is 16
mm or an eye o normal dimensions. Lenses o less than 16 mm
have a role to play, but it is con using to put them in the category
o a scleral lens. At the other end o the range, impression lenses
could be greater than 25 mm i necessary, but 23 mm is a more
normal diameter or a ‘ ull-diameter’ scleral lens.

Ad vant ag e s and Disad vant ag e s o f

Scle ral Le nse s
Contrary to popular belie , the large size and bearing sur ace
provide many positive bene ts. Close alignment between the
corneal sur ace and the lens is not necessary; there ore a scleral
contact lens can be success ul with virtually any corneal topog- Fig . 21.1 Scle ral zone alig nme nt with op tic zone cle arance e xte nd ing
raphy (Kok and Visser, 1992). T ey are surprisingly com ortable just b e yond the limb us.
195
196 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns

Ind icat io ns fo r Scle ral Le nse s

o assess the extent o scleral lenses around the world, E ron
et al. (2011) analysed data relating to 105 734 contact lens ts
(137 in ants, 1672 children, 12 117 teenagers and 91 808 adults
[age ≥18 years]). Scleral lenses were tted to a considerably
greater number o in ants (0.7% o all ts), compared with
children (0.1%), teenagers (0.2%) and adults (0.2%); these di -
erences were statistically signi cant (χ2 = 3.0, p = 0.4). An inter-
national survey o 23 000 ts in 34 countries in 2015 revealed
that scleral lenses accounted or approximately 8% o all rigid
lens ts (Morgan et al., 2016).
Visser et al. (2007a) have reported that the primary indica-
tions or scleral lens tting today are keratoconus (50%) ollowed
by post-penetrating keratoplasty (20%), lesser indications being
irregular astigmatism, keratitis sicca, corneal dystrophy, and
multiple diagnoses. T e nding o E ron et al. (2011) o very
low levels o scleral lens tting to minors and adults highlights
the highly specialized but vital role that such lenses have in the
clinical management o rare ocular abnormalities in minors as
well as adults.
Provided there is a sound underlying indication or con-
tact lens management, scleral lenses are indicated when they
can be applied to bene cial e ect (Schein et al., 1990; Visser,
1990; Kok and Visser, 1992; Foss et al., 1994; Pullum et al.,
2005; Pullum and Buckley, 2007; Jacobs, 2008). T e main
indication is optical correction o an irregular corneal sur ace
(Visser et al., 2007a).
An analysis o 888 consecutive patients (1353 eyes) who
were continuing scleral lens wear at their most recent a ercare
appointment was carried out at a dedicated clinic at Moor elds
Eye Hospital, London; the percentages or each indication are
shown in Fig. 21.2. A total o 61.6% (824 eyes) were or kerato-
conus or other primary corneal ectasia (PCE), and 20.5% (274
eyes) were or corneal transplant, most o which were keratoco-
nus indicated. Retention o a precorneal f uid reservoir or vari-
ous ocular sur ace disorders constituted 10.7% (143 eyes), high
myopia or aphakia combined 4.1% (55 eyes) and ptosis props
1.3% (18 eyes).
Ocular sur ace disorders where scleral lenses might be
bene cial include errien’s marginal degeneration (Cotter
and Rosenthal, 1998), Stevens–Johnson syndrome (Fine et al.,
2003), pellucid marginal degeneration (Looi et al., 2002),
ocular cicatricial pemphigoid, persistent corneal epithelial
de ects (Rosenthal et al., 2000) and moderate to severe dry
eye (Alipour et al., 2012). T eir use may reduce the rate o
epithelial de ect recurrence in stem-cell-de cient and neuro-
trophic corneas (Rosenthal and Cotter, 2003). Margolis et al.
(2007) have also reported on their use in advanced atopic
keratoconjunctivitis.
Moderate ametropia rarely warrants scleral lens tting as
rst choice, but should be considered i there are intractable
problems with corneal or hydrogel lenses. T ere is an indication
or recreational or occupational reasons when extra stability is
required, sometimes or water sports, or to cater or dusty envi-
ronments. Many people were issued with scleral lenses be ore
the use o corneal and hydrogel lenses became widespread: they
are mostly elderly, but some have every intention o continuing
lens wear. T ey may not be receptive to re tting with corneal
or hydrogel lenses, nor do they need to be i any sequelae do
not represent a threat to their vision or the duration o their
expected li espan.
Fig . 21.2 Ind ications or contact le ns manag e me nt o p atie nts atte nd -
ing Moor e ld s Eye Hosp ital 2000–2007. A total o 888 p atie nts (1353
e ye s) we re stud ie d .
Fit t ing Princip le s
Initially scleral lenses were made rom glass ( rom 1888 until
the 1940s), then polymethyl methacrylate (PMMA); however,
the introduction o RGP materials brought renewed interest
in the tting o scleral lenses (Ezekiel, 1983; Ruben and Benja-
min, 1985; Pullum 1987; Lyons et al., 1989; Schein et al., 1990).
Scleral lenses can be tted either rom pre ormed sets or by
impression moulding.
NO N-VENTILATED PREFO RMED SCLERAL
LENSES
T e term ‘sealed’ has been widely used to describe a lens with-
out a enestration. However, the same word can also mean
there is no or minimal tear exchange under the scleral zone,
or that the lens retains an air- ree precorneal f uid reservoir.
T ere may be a signi cant tear exchange or even admission
o air bubbles into the precorneal f uid reservoir via uninten-
tional scleral zone channels i a non- enestrated lens is imper-
ectly aligned with the sclera. o clari y or the remainder o
this chapter, ‘non-ventilated’ rather than ‘sealed’ is used to
describe a lens designed with no intentional means o tear
exchange, such as a enestration.
T e increased corneal oxygenation available with RGP mate-
rials avoids the need or enestrations (Pullum et al., 1990, 1991;
Pullum and Stapleton, 1997), thereby reducing the problem o
air bubbles admitted to the precorneal f uid reservoir. T e reser-
voir acts as an e ective cushion, there ore settling on the globe
is reduced and the e ect is more predictable, giving increased
latitude reaching an end point in the tting process. Conse-
quently, many more eyes can be tted with coaxial pre ormed
designs than was ever possible with PMMA (Ramero-Rangel
et al., 2000).
A detailed description o the tting process is beyond the
scope o this chapter, but it is appropriate to outline the prin-
ciples. More in-depth accounts can be ound in two recent texts
(Pullum, 2005, 2007).

Fig . 21.3 Ste e p scle ral zone causing vaulting and incre ase d op tic
zone cle arance with an unchang e d b ack op tic zone rad ius.
Fig . 21.4 Pre ormed rig id g as-pe rme able scle ral in situ illustrating a
steep scleral zone. Fluorescein is seen extending beyond the limbus, al-
though not excessively. However, the p eripheral conjunctival blood ves-
sels beneath the lens are occluded , g iving a blanched app earance. The
pathology is corneal transplant that has been complicated by secondary
glaucoma. A bleb just above the limbus is visible. Although somewhat
ste ep on the scle ra, this was d e emed p re erab le to chang ing to a f atte r t-
ting, which could compress more on the bleb ollowing any settling b ack.
THE SCLERAL ZO NE
T e objective in non-ventilated RGP scleral lens tting is to
achieve corneal clearance extending ar enough into the scleral
zone to avoid compression o the limbus with optimum scleral
alignment over the broadest possible area, as previously shown
in Fig. 21.1. Per ect alignment to the sclera is not crucial, nor
is it possible, as it is not conveniently spherical or symmetrical
21 Scle ral Le nse s 197
Fig . 21.5 Flat scle ral zone with a re d uce d annular scle ral b e aring sur-
ace just outsid e the limb us, b ut no chang e to the ap ical cle arance .
Fig . 21.6 Pre orme d rig id g as-p e rme ab le scle ral in situ illustrating a
f at scle ral zone . Conjunctival ve sse l b lanching is cle arly se e n in the mid -
p e rip he ry. The annular scle ral comp re ssion zone cause s a marke d un-
sig htly cong e stion b e twe e n the b lanche d re g ion and the limb us, which
may le ad to an incre ase d risk o corne al vascularization in a p re d isp ose d
e ye .
about its axis. T ere should be minimal occlusion o the con-
junctival blood vessels, but su cient sealing on the sclera to
prevent introduction o air bubbles into the precorneal f uid
reservoir.
T e back optic zone radius (BOZR), back optic zone diameter
(BOZD) and back scleral radius (BSR) inf uence the optic zone
clearance. I the BSR is too steep, the lens may vault the whole
anterior eye rom its periphery, occluding the peripheral con-
junctival vessels i excessive, as illustrated in Figs. 21.3 and 21.4.
I the BSR is too f at, the scleral zone stands o the globe, and
may occlude the mid-peripheral conjunctival vessels, as seen in
Figs. 21.5 and 21.6.
198 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns

T e back scleral size (BSS) has a less predictable impact. A

larger-diameter lens may impinge on peripheral scleral nodules
(e.g. the medial and lateral recti muscle insertion points). I so,
the lens vaults rom the periphery, giving a similar appearance to
that with a steep BSR. T e optic should be displaced 1–1.5 mm
i the diameter is greater than 20 mm. T is reduces the width o
the nasal scleral zone, improving centration and preventing the
edge impinging on the inner canthus on nasal gaze movements.

O PTIC ZO NE SAGITTAL DEPTH AND O PTIC

ZO NE PRO J ECTIO N
T e optic zone sagittal depth (OZS), and hence the corneal
clearance, is determined by varying the BOZR and BOZD in
combination. Modern designs blend the optic zone–scleral zone
junction so that it is barely perceptible, or include an aspheric
transition zone. T e primary BOZD remains at the junction
between the continuation o the BOZR and the BSR. Alterna-
tively, progressive increments in the projection o the optic zone
(OZP) rom the extrapolation o the BSR, but without re erence
to the BOZR or BOZD, can be used to determine the optimum
apical clearance (Fig. 21.7).
For an indication o the OZP scale, the range or most nor-
mal corneas is 1.0–2.0 mm compared with a rare highly globic
corneal pro le, which may require up to 5.0 mm (Fig. 21.8).
Fig. 21.9 shows a non-ventilated RGP scleral lens in situ with
a glancing contact on the same eye. Even an eye with such a
protrusive corneal pro le is quite o en straight orward when
tting a non-ventilated RGP scleral lens.
Between 0.20 and 0.30 mm is a suitable OZS or OZP incre-
ment or non-ventilated lenses, and 0.25 ± 0.1 mm an optimal
apical clearance. Pachymetry is not necessary as the depth o
the precorneal f uid reservoir is estimated accurately enough in
comparison with the corneal thickness; 0.25 mm is considerably
greater than a typical clearance or a enestrated lens, where any-
thing over 0.1 mm at the apex would admit air bubbles crossing
the visual axis. Fig. 21.10 shows an eye with moderate keratoco-
nus. T e same eye is tted with scleral lenses to illustrate corneal
contact (Fig. 21.11A), the e ect o an OZP increment o 0.25
mm giving glancing contact (Fig. 21.11B), and the e ect o an
OZP increment o a urther 0.25 mm giving corneal clearance
(Fig. 21.11C).
I air bubbles do become trapped in the precorneal f uid res-
ervoir, re tting a lens with reduced apical clearance, i there is
scope, tends to shi the bubbles towards the periphery. Fitting
with a f atter BSR may improve scleral zone sealing by moving
the bearing sur ace closer to the limbus, which is the most sym-
metrical region o the sclera. Reducing the diameter may have
the same e ect. I still unsuccess ul, an eye impression may be
necessary to improve alignment on the sclera.
Fig . 21.7 (A) O p tic zone p roje ction (O ZP). (B) Incre ase d ap ical and
limb al O ZP.
NO N-CO AXIAL SCLERAL LENSES
Toroid al Le nse s
approximation to the scleral topography but may be a closer
I a non-ventilated coaxial RGP lens is impossible to it match to typical scleral contours than a coaxial design, hence
because the sclera is insu iciently symmetrical, toroidal may improve centration and sealing on the sclera. oric
scleral zone designs and impression RGP lenses are avail- scleral lenses have been shown to return rapidly to their
able (see below). he itting objectives are similar to those original position a ter rotation (Visser et al., 2006). Wear-
or non-ventilated coaxial lenses – that is, optimal scleral ing time, com ort, visual quality and overall satis action may
zone alignment and a precorneal luid reservoir extending be improved when back-sur ace toric designs are used, com-
1–2 mm beyond the limbus. A toroidal design remains an pared with spherical ones (Visser et al., 2007b).

Fig . 21.8 Sp e ctacular, b ut rare , ke ratog lob us. This case was also d i-
ag nose d as Te rrie n’s marg inal d e g e ne ration, typ i e d b y circum e re ntial
op aci cation at the limb us, b ut the imp act on the visual unction and
the manag e me nt op tions are the same irre sp e ctive o the name g ive n
to the cond ition.
Fig . 21.9 Pre orme d rig id g as-p e rme ab le scle ral le ns in situ on the
same e ye as shown in Fig . 21.8, illustrating a g lancing ap ical contact
zone b ut limb al cle arance .
Imp re ssion Mould ing
An impression lens has by de nition the best possible align-
ment, but requires development o di erent skills on the part o
both the clinician and the manu acturer (Pullum, 1987; Lyons
et al., 1989; Pullum et al., 1989). Unlike with PMMA, an RGP
scleral lens cannot be produced by heat moulding as the materi-
als are not thermoplastic, but an optimally tting PMMA lens
can be duplicated in an RGP material.
Fe ne strate d Le nse s
A means o ventilation is a prerequisite or a PMMA scleral
lens to acilitate some tear exchange. Most commonly this
21 Scle ral Le nse s 199
Fig . 21.10 Mod e rate ly ad vance d ke ratoconus with a d ownward ly d e -
ce ntre d ap e x.
is done with a enestration; however, slots, truncations and
channels have also been used (Pullum and rodd, 1984).
Compared with tting a non-ventilated lens, enestrated
scleral lens tting represents a major undertaking, but there
are indications or trying – or example, i there are intrac-
table di culties inserting a non-ventilated lens air ree. Some
enestrated PMMA scleral lenses are used by established wear-
ers and some are still being issued or new cases. I there is
a satis actory wearing schedule, and acceptable sequelae, the
best option may be to leave well alone. I unacceptable, an
RGP scleral lens could be o ered, either by re tting a non-
ventilated design or, i necessary, by duplicating the existing
shape. However, the wearer may have had the same lens or
many years, and could have a distinct pre erence or his / her
‘old riend’. In particular, a corneal contact zone with a PMMA
lens that has been well tolerated could be less com ortable i
the original shape is duplicated in an RGP material, probably
because o the increased coe cient o sur ace riction with
RGP materials.
Bubbles trapped in the precorneal f uid reservoir are almost
unavoidable with enestrated lenses, hence the t o the lens is
in part determined by their appearance. I the bubble crosses
the visual axis, the vision is disrupted. A crescent-shaped bubble
extending approximately one-third o the corneal diameter, but
restricted to the limbus, is considered optimal (Fig. 21.12).
I the lens settles back on the globe, which it usually does, the
apical clearance is reduced. I initially there was optimal clear-
ance, just avoiding a bubble, a er a ew minutes there may be
an unacceptable contact zone. I the corneal topography is not
regular, which is the case in the majority o cases needing scleral
lenses, the depth o the precorneal f uid reservoir is not uni-
orm. T e lens there ore ts too close in places as well as there
being bubbles in the precorneal f uid reservoir. An impression at
the starting point helps to reduce these problems as the scleral-
bearing sur ace is maximized, and the optic zone is abricated
according to the individual topography.
200 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
Fig . 21.11 Pre orme d rig id g as-p e rme ab le scle ral le nse s in situ on the
same e ye as shown in Fig . 21.10. (A) The ap ical contact could b e d e -
scrib e d as comp re ssive . (B) Le ns with an ap ical op tic zone p rog re ssion
incre me nt o 0.25 mm to g ive g lancing contact. (C) Le ns with an ap ical
o ptic zone p rog re ssion incre me nt o 0.5 mm to g ive corne al cle arance .
Mo d ificat io n
It is likely that a currently worn enestrated PMMA lens was origi-
nally tted rom an eye impression. T e practitioner should never
attempt to modi y an existing impression lens but rather should
make adjustments to a new shell pressed over a dental stone cast
o the original lens. Alternatively, another eye impression should be
taken to start again rom the beginning. Modi cation o an RGP
scleral lens, other than a power change carried out by a competent
laboratory, should not be attempted as the outcome is ar rom pre-
dictable, and it is impossible to restore a lens to its original condition.
Fig . 21.12 Typ ical shap e and size o b ub b le b e ne ath a e ne strate d
scle ral le ns.
Fig . 21.13 Pre orme d scle ral le ns p arame te rs.
O rd e ring Scle ral Le nse s
For a pre ormed scleral lens o ‘traditional’ style, the practitioner
should speci y the BOZR, the primary BOZD, the BSR, the optic
zone displacement (D) in mm, the BSS, which is independent o
the thickness, and the BVP. A transition curve to blend the optic–
scleral junction is usually required, but the manu acturer should
be le to select the optimum design. Fig. 21.13 illustrates the
parameters o a scleral lens. Wide-angle lenses are probably the
most widely used integrated scleral zone / optic zone lenses and
have been available, unchanged rom their original design, or
over 60 years. T e BOZD is a unction o the BOZR and the BSR,
so speci cation requires just the BOZR, BSR, BSS, D and BVP.
For non-ventilated RGP scleral lenses, it has become more
usual or manu acturers to have their own ordering system,

which should be ollowed to avoid errors. Usually, this entails
stating the optimum lens used rom the diagnostic tting set,
and details o the overre raction, with any departures rom the
trial set parameters described.
A cast o an impression or pre erably a cast rom which a
moulded lens can be made can be sent to a competent labora-
tory. T e BSS can be indicated by drawing a line on the cast. I
the requirement is or a PMMA lens, the manu acturer should
be given ull reedom to produce the back sur ace. T e optic
zone is abricated by grinding diamond-coated spherical stones
on to the back sur ace o the shell, the optimum reached by a
skilled trial-and-error process. A power ormula must be pro-
vided – that is, the result o a re raction over a scleral lens or
a limbal diameter corneal lens o known BOZR and BVP. T e
manu acturer can then make the appropriate power allowance
or the di erence between that BOZR and that o the nal lens.
For a non-ventilated impression RGP lens, a specialist manu-
acturer would need a tted PMMA shell or a cast o the shell in
order to duplicate the lens in an RGP material.
Le ns Hyg ie ne and Maint e nance
STO RAGE
Dry storage is normal or PMMA scleral lenses and is also sat-
is actory or RGP sclerals. Wet storage may enhance sur ace
wetting in some cases, in which case hydrogel lens multi unc-
tional solutions are pre erable to the more viscous rigid lens
soaking solutions.
CLEANING AND CO NDITIO NING
T ere being very little tear exchange with non-ventilated RGP
scleral lenses, viscous solutions to condition the back sur ace
remain in contact with the cornea or long periods and they may
lead to accumulative sensitivity to the preservatives. A non-pre-
served cleaner, rather than a conditioning solution, which is rinsed
o with non-preserved saline prior to insertion, may be pre erable.
SALINE FO R FILLING NO N-VENTILATED RGP
SCLERAL LENSES
Non-preserved saline is necessary or lling non-ventilated RGP
scleral lenses prior to insertion, because the solution is retained
in contact with the cornea or the duration o wear. Some wear-
ers become sensitive to multidose saline, in which case preser-
vative- ree unit dose preparations are necessary. Aerosol saline
tends to be too gassy or this application.
REWETTING
I lenses need re reshing during the day, so lens multipurpose
solutions may be bene cial. T e cleaning action is not as power ul
as dedicated cleaners, but rinsing rom the sur ace prior to reinser-
tion is a quick process compared with the use o a cleaning agent.
Pro b le ms and Co mp licat io ns w it h
Scle ral Le ns We ar
Walker et al. (2016) have reviewed the recent literature in rela-
tion to complications o current generation scleral lenses. T ey
ound reports o in ection with the scleral devices, although
21 Scle ral Le nse s 201
these are o en seen in severely compromised corneas. Hypoxic
and inf ammatory complications are rarely reported in the lit-
erature. T e somewhat complex relationship o a scleral lens
on the eye can create tting and removal challenges. Anoma-
lies such as conjunctival prolapse, epithelial bogging, midday
ogging, and limbal bearing have been reported, and appear
to be unique sequelae to scleral lens wear. Walker et al. (2016)
concluded that, although modern scleral lens technology has
broadened the scope in which practitioners can treat patients
with irregular ocular sur aces, reports o these complications
indicate that there is still a need or urther e orts to enhance
the clinical outcomes o this modality.
DISCO MFO RT
Some degree o discom ort rom any contact lens cannot always
be completely eliminated. With scleral lenses it can be a con-
sequence o apical corneal contact zones, limbal occlusion, an
ill- tting scleral zone or an early symptom o corneal hypoxia.
Ortenberg et al. (2013) have shown that daily wearing time
with scleral lenses can be signi cantly improved by taking brie
breaks rom lens wear every 4 to 5 hours.
BUBBLES
Elimination o air bubbles behind the lens is also not always
possible, especially when the depth o the precorneal reservoir
is not uni orm. T ey may enter via non-aligned scleral zone sec-
tors, but rarely disappear without removing and reinserting the
lens. Lining the inside sur ace o the lens with a non-preserved
viscous eye drop prior to inserting helps to reduce the problem.
Bubbles entering the precorneal f uid reservoir via enestrations
sometimes cause clicking sounds, which can be very annoying.
Instilling a viscous eye drop just at the site o the enestration
may o er a solution or a short period.
ACCUMULATIO N O F MUCUS
Scleral lenses sometimes generate oversecretion o mucus,
which is trapped in the precorneal space. It can be globular or
ne particulate matter. T is is more o a problem with non-
ventilated RGP lenses as there is some f ushing action through
a enestration. Removal and reinsertion with resh saline are
necessary, and lining the back sur ace with a non-preserved
viscosity agent appears to give an improvement in some cases.
Instillation o mucolytic drops such as acetylcysteine be ore
reinsertion may be considered.
CO NJ UNCTIVAL BLANCHING AND HYPERAEMIA
I localized, conjunctival blanching and adjacent hyperaemia
may indicate compressive contact on the scleral zone. T e lim-
bus should be watched care ully or early signs o limbal vessel
engorgement, which may be the precursor o corneal vascular-
ization, but otherwise some hyperaemia is not a threat and may
be impossible to alleviate.
CO NJ UNCTIVAL DISPLACEMENT AND
THINNING
Displacement o the conjunctival f ap over the limbus and
peripheral cornea can occur, in particular with non-ventilated
202 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
RGP scleral lenses, i there is insu cient limbal clearance
(Fig. 21.14). It does not cause a serious problem as reversal
takes place on removal o the lens, but wearers notice it when
looking in a mirror.
Alonso-Caneiro et al. (2016) observed that optimal- tting
miniscleral contact lenses worn or 3 hours resulted in signi -
cant tissue compression in young healthy eyes, with the greatest
thinning observed superiorly, potentially due to the additional
orce o the eyelid, with a partial recovery o compression 3
hours a er lens removal. Most o the morphological changes
occur in the conjunctiva / episclera layers.
INFECTIO N
In ection does not appear to be a common problem with scleral
lenses. Cleaning can be carried out e ectively prior to both
storage and insertion. A dry, clean case is a hygienic environ-
ment and un avourable or bacterial replication. Zimmerman
and Marks (2014) reported the case o neurotrophic keratitis in
which scleral contact lenses improved vision rom 6 / 30 to 6 / 6;
however, due to poor lens care, an incident o microbial keratitis
developed. Fortunately the lesion ully healed and the patient
did not su er additional vision loss.
GIANT PAPILLARY CO NJ UNCTIVITIS
Upper tarsal plate changes are seen sometimes with long-term
scleral contact lens wear, but do not o en appear to cause the
typical discom ort described by so lens wearers. T is is pre-
sumably because there is no tarsal plate–lens edge interaction,
and deposits are easily cleaned rom rigid lens sur aces. T e
issue is clouded as atopy is a common coexisting pathology in
keratoconus.
HYPO XIA
T e corneal response to scleral lens wear has greatly improved
with the introduction o gas-permeable materials (Bleshoy and
Pullum, 1988; Pullum et al., 1990, 1991). Corneal thickness
changes are demonstrably less (Mount ord et al., 1994; Pullum
and Stapleton, 1997). Hypoxia and consequent corneal vascu-
larization have been signi cantly reduced. T is means that, with
the use o modern materials, overnight wear o scleral lenses
Fig . 21.14 Conjunctival d isp lace me nt ove r the limb us is a common
minor p rob le m. It can b e unsig htly, b ut normality is re store d imme d i-
ate ly a te r re moval o the le ns.
can be considered (Rosenthal et al., 2000; appin et al., 2001;
Smith et al., 2004; Vincent et al., 2016a). Compañ et al. (2014)
have demonstrated that scleral lenses must be comprised o at
least 125 Barrer o oxygen permeability and must be less than
200 µm thick to avoid hypoxic e ects under open-eye condi-
tions. Post-lens tear lm layer should be below 150 µm to avoid
clinically signi cant edema.
ALTERATIO N TO CO RNEAL NERVE STRUCTURE
AND FUNCTIO N
Wang et al. (2015) examined changes in corneal nerve structure
and unction in two patient groups wearing long-term f uid-
lled scleral lenses – those with distorted corneas or ocular
sur ace disease. T ey observed that tear production decreased
in patients with distorted corneas (21.2 ± 8.5 to 10.4 ± 4.6 mm;
p < 0.0001) but did not change in patients with ocular sur ace
disease (7.5 ± 5.2 to 8.7 ± 7.2 mm; p = 0.71). Corneal sensation
increased in the distorted cornea group (45.6 ± 9.2 to 55.0 ± 5.6
mm; p < 0.05). T ere was no signi cant change in sensation in
patients with ocular sur ace disease (45.0 ± 8.7 to 49.1 ± 14.8
mm; p = 0.37). Subbasal nerve density, subbasal nerve tortuos-
ity, and stromal nerve thickness remained unchanged in both
the distorted cornea and ocular sur ace disease groups a er
long-term wear (p > 0.05).
NEO VASCULARIZATIO N
Corneal vascularization is the long-term e ect o chronic cor-
neal oedema (Fig. 21.15). Corneal vessels do not necessarily
cause a major visual loss, but have a tendency to leak lipid, and
can cause a dense opacity. Sudden-onset visual loss can occur
even i the vessels are apparently quite ne in calibre. Some
absorption is possible a er a time, but the rate is slower or
older patients. T ere have been some cases when PMMA scleral
lens-induced vascularization has been reversed on re tting with
RGP scleral lenses, leaving only ghost vessels ( an et al., 1995).
Some vessel ingrowth may be an acceptable complication i
the visual indication or scleral lens wear is strong, and espe-
cially i the alternative management options are likely to be
worse. T e main concern is that any hypoxic changes may be
Fig . 21.15 Ne ovascularization a te r 5 ye ars’ rig id g as-p e rme ab le
scle ral le ns we ar. The ind ication or tting was op tical irre g ularitie s con-
se q ue nt to he rp e s simp le x, so it is p ossib le that the ve sse l g rowth was
p artly hyp oxia and p artly d ue to the d ise ase p roce ss.

sight threatening: complacency must be avoided, but overstat-
ing the threat is not productive i there is a signi cant bene t
rom continued wear. It is possible that vascularization is sel -
limiting i compensating or an oxygen de cit. A small amount
o vascularization is not sight threatening i , a er the antici-
pated rate o progress, based on the existing extent o the vessels
and assuming the same rate o progress, the vessels do not cross
the visual axis within the patient’s expected li espan.
It must be recognized, however, that a bed o corneal ves-
sels may increase the risk o later corneal transplant rejection.
T is is especially the case when the apex is eccentric, requiring
a larger donor cornea that is in closer proximity to the limbal
arcades. Care ul monitoring and liaison with the ophthalmolo-
gist who may carry out uture surgery are clearly essential.
CO RNEAL DISTO RTIO N
Vincent et al. (2016b) examined the inf uence o modern mini-
scleral contact lenses – which land entirely on the sclera and
overlying tissues – upon anterior corneal curvature and optics.
T ey observed that, although corneal clearance was maintained
throughout an 8-hour lens wear period, signi cant corneal f at-
tening (up to 0.08 ± 0.04 mm) resulted, primarily in the superior
mid-peripheral cornea. T is caused a slight increase in against-
the-rule corneal astigmatism (mean +0.02 / −0.15 × 94 or an 8
mm corneal diameter). Higher-order aberration terms o hori-
zontal coma, vertical coma and spherical aberration all under-
went signi cant changes (p ≤ 0.01), which typically resulted in a
decrease in RMS error values (mean change in total higher order
RMS −0.035 ± 0.046 µm). T ere was no association between
the magnitude o change in central or mid-peripheral corneal
clearance during lens wear and the observed changes in corneal
curvature (p > 0.05). However, East Asian participants displayed
a signi cantly greater reduction in corneal clearance (p = 0.04)
and greater superior–nasal corneal f attening compared with
Caucasians (p = 0.048). Vincent et al. (2016b) warned that prac-
titioners should be aware that corneal measurements obtained
ollowing miniscleral lens removal may mask underlying cor-
neal steepening.
DEGRADATIO N O F THE LENS SURFACE
RGP materials are subject to spoilation and deposition. Polish-
ing is possible, but this can be carried out only a limited num-
ber o times be ore the optic quality is lost. Resur acing is also
possible provided there is su cient substance. T ere is much
21 Scle ral Le nse s 203
to be said or issuing a new lens be ore attempting to polish or
resur ace one that is currently worn.
Fut ure De ve lo p me nt s
Scleral lenses can reduce higher-order wave ront error asso-
ciated with keratoconus; however, during wear the residual
higher-order aberrations remain elevated, compared with
normal eyes. Custom-designed scleral lenses can achieve this
additional reduction in aberration. Scleral lenses are especially
suited to this approach because o their stability on the eye.
When a lens is not stable or is misaligned – as would be the
case with a conventional rigid lens – aberration correction is
reduced and can lead to an increase in higher-order aberration
and a reduction in visual per ormance.
Marsack et al. (2014) examined the per ormance o state-
o -the-art wave ront-guided scleral contact lenses on a sample
o keratoconic eyes, with emphasis on per ormance quanti-
ed with visual quality metrics. T ey ound that these lenses
are capable o optically compensating or the deleterious e ects
o higher-order aberration concomitant with the disease and
could provide visual image quality equivalent to that seen in
normal eyes. T is research points towards the more widespread
adoption o such technology i it can be deployed or use at a
reasonable cost.
Co nclusio n
oday’s requirement or scleral lenses constitutes the smallest
o all contact lens types, but their applications are o en when
other lens types are unsuccess ul, or when the patient may
ace the alternative o potentially hazardous ocular surgery. It
is vital to preserve clinical tting skills as e ectively as pos-
sible to avoid discredit due to too many unsatis actory results.
A relatively small number o practitioners need to be actively
involved but those who may not wish to undertake the work
personally can still be amiliar with the application o scleral
lenses so that suitable patients are recognized and re erred or
tting.
ACKNO WLEDGEMENT
T e author would like to acknowledge Kenneth W. Pullum as the
author o this chapter in the previous edition.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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203.e 1
22
Tint e d Le nse s
NATHAN EFRO N | SUZANNE E EFRO N

Int ro d uct io n modi y natural iris colours. T is e ect is success ul only with
relatively light-coloured irides.
Eye colour is universally recognized as an important and de n- Opaque tints can substantially or completely block the pas-
ing natural physical characteristic o the body human, and a sage o light. A coloured pattern can be applied over a totally
contact lens is an e ective vehicle or modi ying or enhanc- opaque base to e ect a complete change o eye colour, while at
ing this appearance or those who wish to do so. More impor- the same time, or example, masking out underlying iris dis-
tantly, tints can be applied to contact lenses to help normalize gurations. T us, the primary cosmetic application o opaque
the appearance o dis gured eyes and help improve vision in tints is to change the colour o dark irides or have the prosthetic
diseased eyes. e ect o restoring a normal appearance to a dis gured eye.
ints have been applied to all orms o contact lenses since
their invention over a century ago. In his original treatise in
1888, Fick clearly recognized the potential prosthetic bene ts
Tint e d Le ns De sig ns and Ap p licat io ns
o contact lenses upon which opaque iris patterns and black ranslucent and opaque tints are applied to rigid or so lenses
pupils could be painted (E ron and Pearson, 1988). T e inven- or a variety o reasons, which are outlined below.
tor o the corneal lens, Kevin uohy, attempted to tint lenses,
and Otto Wichterle, the inventor o the so lens, was awarded HANDLING TINTS
two patents describing processes or tinting hydroxyethyl
methacrylate (HEMA) lenses. T is chapter describes the vari- Handling tints – which are also known as ‘lens visibility tints’
ous applications o tinted lenses and current technology used or ‘locator tints’ – are incorporated into so lenses so that these
or lens tinting. lenses can be easily seen in the lens case or on a domestic sur-
ace i accidentally dropped (Fig. 22.1). Such tints are very light
(between 5 and 15% absorption) and do not alter iris colour; how-
Basic O p t io ns ever, they make the lens slightly more visible on the eye by virtue
An important initial consideration in deciding on the most o the handling tint being noticeable where the lens edge impinges
appropriate tinted lens or a given patient is whether to use a
rigid or so lens. A particular lens type may be indicated or
clinical reasons; or example, a rigid lens would be required in
the case o a sighted eye with corneal distortion.
In general, rigid lenses are best suited or prosthetic use. An
advantage o rigid lenses is that it is possible to paint unique
designs and so e ect a realistic iris appearance in terms o a
more precise match o colour and iris eatures. A convincing
cosmetic e ect is di cult to achieve with a conventional rigid
lens o , say 9.5 mm diameter, because it would not completely
cover the cornea and iris, and move on blinking. T ese poten-
tial disadvantages can be obviated by tting slightly tight, large-
diameter lenses, semiscleral lenses or miniscleral lenses. In
certain cases o extensive ocular dis guration, painted scleral
lenses may give the best result. So lenses have the advantage
o o ering ull corneal coverage and stability on the eye, and are
thus particularly suited or cosmetic use.
T e applied tint can be translucent or opaque. T e result-
ing lens may be wholly translucent i translucent tints alone are
applied, semiopaque i opaque tints have been used on portions
o the lens and completely opaque i opaque tints have been
applied across the entire lens sur ace. A translucent tint allows
certain wavelengths o light to pass through, thus e ecting a Fig . 22.1 Le nse s d rop p e d in a b athroom sink. The le ns with the han-
colour change. Light passing through such a tint, and ref ecting d ling tint can b e cle arly se e n at the hal -p ast-9 p o sition with re sp e ct to
the d rain hole , ab out 10 mm rom the e d g e o the d rain-p late . The le ns
back o the iris, will be urther modi ed such that the cosmetic without the hand ling tint is ar le ss visib le ; its rig ht-hand e d g e can just
e ect is a combination o the colour o the translucent tint and b e d e te cte d at the 4 o’clock p osition, ab out 10 mm rom the e d g e o
the iris. ranslucent tints can there ore be said to enhance or the d rain-p late .
204

over the sclera. Handling tints do not a ect vision or colour per-
ception. Some wearers nd lens handling di cult as even with the
pale handling tint the lenses can be hard to see. In those cases a
cosmetic tinted lens may be tted to enable easier handling.
CO SMETIC TINTED LENSES
A cosmetic tinted lens can be de ned as a lens that is designed
to beauti y an otherwise normal appearance. T is can amount
to enhancing eye colour with translucent tints, modi ying eye
colour with a combination o translucent and opaque tints, or
completely changing eye colour with opaque tints. Cosmetic
tinted lenses are considered to be a ashion accessory, and as
such they are o en worn by emmetropes. Indeed, most tinted
lenses are produced or their cosmetic e ect (Fig. 22.2). T e
most requently used tints are aquamarine, blue, green and
amber. As is the case with handling tints, cosmetic tints do not
appreciably a ect vision or colour perception ( an et al., 1987),
although patients may report an initial transient e ect. T e light
transmission through cosmetic tinted lenses is usually in the
range 75–85% (Harris et al., 1999).
A recently introduced concept in cosmetic lenses is the
iris-enhancing ring. T is is aimed at the Asian wearer, whose
average horizontal visible iris diameter is 11.2 mm. T e outer
diameter o the limbal ring o the 1-Day Acuvue De ne lens is
12.5 mm, thus enlarging the appearance o the eyes (Fig. 22.3).
PRO STHETIC TINTED LENSES
A prosthetic tinted lens is designed to normalize an otherwise
abnormal appearance. Providing the patient does not have
unreasonable expectations, the lenses are generally satis actory
in terms o wearing time, com ort and colour (Cole and Vogt,
Fig . 22.2 Stunning cosme tic e e ct cre ate d b y a le ns with a b lue d ot-
matrix tint in the rig ht e ye o a p atie nt with id e ntical irid e s in the rig ht
and le t e ye s (the re is no le ns in the le t e ye ).
Fig . 22.3 Eye without (A) and with (B) a le ns with iris-e nhancing ring . (Courte sy of Johnson & Johnson Vision Care .)
22 Tint e d Le nse s 205
2006). ypical cases or which such lenses are indicated include
a ermath o trauma, ocular disease and congenital abnormali-
ties (Fig. 22.4).
Visible de ormities o the anterior ocular structures – in par-
ticular the cornea, iris and crystalline lens – can be e ectively
masked using dark (Luo et al., 2012) or opaque (Key and Mob-
ley, 1987) tints. Speci c tinting con gurations can be tailored
or di erent circumstances (Fig. 22.5); examples include:
• a painted iris and clear pupil or a sighted eye with a dis g-
ured iris
• a painted iris and opaque pupil or a non-sighted eye
• a clear iris and opaque pupil or a non-sighted eye with a
dense cataract.
THERAPEUTIC TINTED LENSES
A therapeutic tinted lens can be de ned as a lens that is designed
to treat an underlying de ect or disease. Primary therapeutic
applications o tinted contact lenses include reducing excessive
photophobia and glare due to aniridia or other pupil anomalies
(Olali et al., 2008)(see Fig. 22.4), albinism (Omar et al., 2012) or
retinal disease (Severinsky et al., 2015), eliminating monocular
polyopia due to trauma, eliminating binocular diplopia in squint
(in cases where surgical and optical intervention is not viable or
contraindicated) and managing variable nystagmus (Astin, 1998).
Several studies have shown that red tinted contact lenses may
be use ul in relieving the photophobia associated with a number
o cone disorders, including achromatopsia (Zeltzer, 1979; Park
and Sunness, 2004; Schornack et al., 2007). T e dark-tinted
glasses with side-shields and f oppy hats usually used to manage
these conditions are very conspicuous and can cause marked
psychological morbidity in children. Rajak et al. (2006) tted
children with 70% brown contact lenses and observed marked
improvements in their quality o li e. Similar dark-brown tinted
lenses were shown to help patients with Bothnia dystrophy
(Jonsson et al., 2007), a variant o retinitis pigmentosa.
T ere are o en secondary therapeutic bene ts o tinted
lenses designed or prosthetic use. T ese include the ollow-
ing examples: a lens with an opaque pupil masking a cataract
but also eliminating disturbing light in a near-blind eye, a rigid
lens with an opaque iris pattern tted to a distorted cornea in
a sighted eye also having the e ect o improving vision by neu-
tralizing corneal optics and the incorporation o appropriate
lens power to correct vision, and a lens with an opaque iris pat-
tern to mask aniridia in a sighted eye also reducing glare.
Opaque contact lenses have been used or occlusion therapy
in amblyopia (Eustis and Chamberlain, 1996) and prosthetic
206 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
lenses have also been trialled or this purpose. T e degree o
penalization can be varied with di erent iris print patterns and
opaque pupil sizes. Peripheral usion can be preserved with
some lenses (Collins et al., 2008).
PERFO RMANCE-ENHANCING TINTED LENSES
Colour Vision
Monocular prescription o red tinted lenses to enhance colour
vision in colour-de ective patients has long been advocated;
Fig . 22.4 (A) Trauma has re sulte d in p artial anirid ia, g iving rise to an
unsig htly ap p e arance and e xce ss g lare . (B) An op aq ue d ot-matrix p rint
so t le ns o e rs the p rosthe tic ad vantag e o an imp rove d ap p e arance
and the the rap e utic b e ne t o re d ucing e xce ss g lare . (Courte sy of H. J.
Völke r-Die b e n, Bausch & Lomb Imag e Colle ction.)
Fig . 22.5 Thre e b asic le ns tint con g urations or comb ine d p rosthe t-
ic / the rap e utic e e cts. (A) Cle ar p up il and op aq ue iris; (B) op aq ue p up il
and op aq ue iris; (C) op aq ue p up il only.
however, their use is controversial. X-Chrom lenses have a
dark red pupil, the diameter o which may be varied to suit
individual needs. One eye receives a di erent luminance and
chromatic signal rom the other eye and through a process
o retinal rivalry a wider range o colours can apparently be
interpreted.
Swarbrick et al. (2001) showed the ChromaGen lens signi -
cantly reduced Ishihara error rates, particularly or deutan sub-
jects, but had no signi cant e ect on Farnsworth lantern test
per ormance. Similarly, Mutilab et al. (2012) reported similar
ndings or both light-red and dark-red lenses; colour-de ective
patients wearing such lenses gave near-normal results on Ishi-
hara plates but the FM100Hue test did not show any improve-
ment with either tinted lens. T ere are medico-legal implications
in prescribing these lenses to enable patients to pass the colour
vision tests required in occupations with colour-vision-related
restrictions.
Dysle xia
Various tinted lenses have been devised to cure dyslexia and to
alleviate migraine. T ese can also technically be described as
therapeutic applications, although in most cases it appears that
improvements are attributed to a placebo e ect rather than a
true therapeutic e ect.
Sp ort
Sport-tinted contact lenses have become available to athletes in
an attempt to improve per ormance by enhancing contrast. wo
shades are advocated or di erent sports. An amber tint is sug-
gested or ast-moving ball sports such as ootball, rugby, tennis
and baseball. A grey-green tint is suggested or gol , running
and training. T e now-discontinued Amber and Gray-Green
Nike Maxsight lenses had 50% and 36% visible light transmis-
sion, respectively.
Although there may be statistically signi icant di erences
in contrast when sport-tinted contact lenses are worn, there
does not appear to be evidence that the lenses provide any
clinically signi icant di erence when considering contrast
enhancement (Porisch, 2007; Cerviño et al., 2008; Zimmer-
man et al., 2011). However, it has been suggested (Erickson
et al., 2009; Horn et al., 2011) that the Maxsight Amber and
Gray-Green lenses provide better contrast discrimination in
bright sunlight, better contrast discrimination when alter-
nating between bright and shaded target conditions, better
speed o visual recovery in bright sunlight and better over-
all visual per ormance in bright and shaded target condi-
tions compared with clear lenses. hese lenses are no longer
produced.
Schürer et al. (2015) investigated the impact o yellow
and orange Wöhlk ‘Sport Contrast’ tinted contact lenses on
colour discrimination using the Erlangen colour measure-
ment system in a study with 14 and 16 subjects, respectively.
Both lenses caused a shi t o the re erence colour towards
higher-saturated colours. Colour discrimination ability with
the yellow- and orange-coloured lenses was signi icantly
enhanced along the blue-yellow axis, in comparison with
the re erence measurements without a tinted ilter. Along
the red-green axis only the orange lens caused a signi i-
cant reduction o colour discrimination threshold distance
to the re erence colour. hey concluded that yellow- and
orange-tinted contact lenses enhance the ability o colour
discrimination.
 22 Tint e d Le nse s 207

PRO PHYLACTIC TINTS contact lenses, and that the t is satis actory. Regular a er-
care examinations are also recommended. Users should also
he purpose o a prophylactic tint is to prevent injury or be warned that such lenses should never be shared with any-
disease o the eye. he primary prophylactic application o one else because: (1) the contact lenses may not t, or be con-
tinted lenses is protection rom excess ultraviolet (UV) light. traindicated, in another person; and (2) there is a danger o
Lenses with UV protection tints may be bene icial to lens cross-contamination and in ection (Johns and O’Day, 1988;
wearers who are requently exposed to UV radiation, such Steinemann et al., 2003; Connell et al., 2004; Lee et al., 2007;
as those who: Kerr and Ormonde, 2008; McKelvie et al., 2009; Chang et al.,
• pursue an active outdoors li estyle, especially near snow, 2010; Guyomarch et al., 2010; Niyyati et al., 2010; van Zyl and
sand and sea Cook, 2010; Sauer et al., 2011; Singh et al., 2012; Ray and Kim,
• work outdoors (such as pro essional tennis players) 2013; Abdelkader, 2014; Mahittikorn et al., 2016). Certainly,
• use photosensitizing drugs concern has been expressed regarding the unsupervised pur-
• are o en exposed to arti cial UV sources during work or chase o tinted lenses through unauthorized or non-licensed
recreation sellers (Gaiser et al., 2016).
• are aphakic. Opaque lenses with clear pupils may also cause changes in
Some argue that everyone can bene t rom UV tints to pre- corneal topography during wear, which can take up to 150 min-
vent chronic ocular damage. Non-tinted lenses and lenses with utes to recover. Wearers o such lenses need to be made aware o
standard cosmetic tints transmit light down to 230 nm and thus the potential or reduced visual per ormance, both during lens
do not provide acceptable UV protection ( ønnesen et al., 1997; wear and or several hours a erwards (Voetz et al., 2004).
Harris et al., 1999). Lenses with special UV tints were ound by
Harris et al. (1999) to block light lower than about 350 nm rom IDENTIFICATIO N TINTS
entering the eye, thus a ording the desired protective e ect.
Osuagwu and Ogbuehi (2014) reported that the UV-blocking Lens buttons are colour coded with light tints by some manu-
characteristics o ve lenses evaluated per ormed equally well acturers who supply a wide range o products so as to acilitate
across the UV spectrum. Otman et al. (2010) measured the UV correct product identi cation at the lens- abrication stage. ints
transmission spectra o 30 'UV protective' contact lenses at 5 are sometimes used as lens identi cation imprints and toric lens
nm intervals between 290 and 400 nm and concluded that most axis location marks.
lenses did not provide signi cant UV protection in the UVA
range. Rahmani et al. (2014) noted a statistically signi cant di -
erence among our contact lenses tested or the visible, UV-B
and UV-A portions o the spectrum.
T e UV transmittance characteristics o a range o daily
disposable and silicone hydrogel contact lenses were investi-
gated by Moore and Ferreira (2006). T ey noted that even those
contact lenses not incorporating a UV-blocking monomer still
demonstrated some attenuation o the UV spectrum and can
there ore also serve to reduce the amount o UV incident at the
anterior ocular sur ace.
Patients must, however, be warned o the limitations o
UV-tinted contact lenses. For example, solar keratitis can
occur in exposed regions o the cornea in UV-tinted rigid
lens wearers, and the conjunctiva is susceptible to solar dam-
age in both so t and rigid lens wearers. Accordingly, patients
should be advised to wear UV-protecting sunglasses or gog-
gles during prolonged periods o UV exposure, and to pro-
tect exposed regions o skin in extreme conditions. Contact
lenses may be the only orm o UV protection possible in
situations where spectacles cannot be worn, or example or
sports such as sur ing.

THEATRIC TINTED LENSES

Lenses can be designed and tinted – typically with opaque
agents – to create dramatic or theatrical e ects. Such lenses are
also known as ‘costume’ or ‘party’ lenses. E ects such as wol
eyes (Fig. 22.6), national f ags, hearts, stars and smiley aces can
be created, and some companies market a ocal lenses speci -
cally or this purpose.
Although these lenses are viewed as a ashion accessory,
potential users must be advised to have a thorough initial eye
examination to check that their eyes are suitable or wearing
Fig . 22.6 The atric ‘wol -e ye ’ le ns. (A) The cle ar p up il o the le ns e a-
ture d he re is slig htly d e ce ntre d with re sp e ct to the natural p up il. (B)
Vie we d at arm’s le ng th, the ‘wol -e ye ’ le ns is se e n in the rig ht e ye o a
p atie nt with id e ntical irid e s in the rig ht and le t e ye s (the re is no le ns in
the le t e ye ). The ye llow tint contains f uore sce nt d ye s so that the le ns
g lows in the d ark und e r ultravio le t rad iation.
208 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns

Manufact ure colour elements can be applied, and the pupil region can be
kept clear.
Numerous ingenious chemical processes and manu acturing Alcon has developed a unique printing process to produce
techniques have been devised or tinting contact lenses (Meshel cosmetic silicone hydrogel contact lenses – known as Air Optix
and Smith-Kimura, 1996). Concepts have been variously ‘bor- Colors – which are capable o altering or enhancing iris colour.
rowed’ rom industries as diverse as abric dying, map making, A clear layer o polymer is applied to the base curve o a male
leather decorating, paper printing, photography and lithogra- mould in the region where iris coloration is to be located (i.e.
phy. A vast patent literature protects the proprietary interests most o the lens sur ace except or the central 5 mm optic zone).
o many o those who have devised the various processes. T e T e clear layer, which constitutes the back sur ace o the lens,
general principles underlying some o the key techniques or ensures that pigments are not exposed directly to the cornea
producing translucent, opaque and combination tints are out- during wear.
lined below. T ree layers o coloured inks – in the orm o concen-
tric rings o varying diameter that orm di erent potions o
TRANSLUCENT TINTS the iris – are then applied separately over the clear polymer
using a ‘pad-printing’ process. T e three partially overlap-
ranslucent tints can be created using our basic techniques – ping concentric layers are: (a) an outer ring, which de nes
dye dispersion tinting, vat dye tinting, chemical bond tinting and emphasizes the iris, (b) the main body o the iris, which
and printing. contains the primary dyes that trans orm eye colour, and (c)
an inner ring, which brightens the eye and adds a sense o
Dye Disp e rsion Tinting depth (Fig. 22.9).
T is method is used primarily to tint rigid lenses. A dye or pig-
ment is mixed into the polymer matrix by adding the dye to
the monomer mixture prior to polymerization, or by adding the
dye to the polymer and then mixing to disperse the colour. T is
results in an evenly distributed, stable dye. T e disadvantages o
this process are:
• It is not possible to vary the distribution o tint across the
lens (e.g. to create a clear pupil).
• he density o tint is proportional to lens thickness
(Fig. 22.7).
• T is process is unsuitable or so lenses because the dye,
which is non-water-soluble, can leach out rom the poly-
mer during hydration.
Vat Dye Tinting
T is process is suitable or so lens tinting. T e nished con-
tact lens is soaked in a water-soluble dye or a xed amount o
time at a speci ed temperature. T e lens is then exposed to air,
rendering the dye insoluble and trapped within the lens matrix.
Because the dye enters the lens sur ace only to a depth o about
10 µm, the lens will appear to have a uni orm tint across its
entirety, the intensity o which will be independent o opti-
cal power (see Fig. 22.7). T e dye is held in position by strong
absorptive orces, resulting in a stable, permanent tint (Lutzi
Fig . 22.7 E e cts o tint p roce ss on le ns ap p e arance . (A) Dye d isp e r-
et al., 1985). T e dye can be extracted only by the use o power- sion tinting o a p lus-p owe re d le ns can re sult in g re ate r tint d e nsity
ul solvents. T is technique can be used or tinting prosthetic toward s the le ns ce ntre . (B) Vat d ye and che mical b ond tint p roce sse s
silicone hydrogel lenses. re sult in an e ve n tint d istrib ution across the le ns.

Che mical Bond Tinting

In this process, a strong covalent chemical bond is ormed
between the dye chromophore and the polymer. T e technique
involves soaking the lens in a dye solution, in the presence o
a catalyst, or a xed time at a speci ed temperature. T e lens
then needs to be put through a series o extraction processes
to remove any residual unreacted agents. T e result, as with vat
dye tinting, is a stable, uni orm tint (Fig. 22.8).
Printing
Dye can be placed on the lens sur ace in a controlled manner Fig . 22.8 Sub tle cosme tic e e ct cre ate d b y a lig ht aq ua che mical
using a printing process similar to that used or ink printing b ond tint in the rig ht e ye o a p atie nt with id e ntical irid e s in the rig ht
on paper. In this way, realistic iris patterns containing many and le t e ye s (the re is no le ns in the le t e ye ).

T e mould with the resulting ‘triple-stack’ o printed layers is
then exposed to UV light, partially cross-linking the colour, yet
leaving a portion available or urther cross-linking to lotra l-
con B polymer, which is added to orm the ront sur ace o
the lens. T e ink is there ore sealed within the lens and can-
not removed during cleaning cycles. T e lenses are then plasma
treated to enhance sur ace wettability.
Coloration is achieved using various combinations o the
ollowing colour additives: yellow, red and black iron oxides;
phthalocyaninato copper (blue) and green; and titanium diox-
ide. A range o nine di erent colour e ects are available; these
include ve ‘subtle’ colours: pure hazel, blue, green, grey and
brown; and our ‘vibrant’ colours: honey, brilliant blue, gem-
stone green, and sterling grey (Fig. 22.10).
Fig . 22.9 Three partially ove rlapp ing conce ntric laye rs that comb ine to
orm the iris pattern o the Alcon Air Op tix Colors lens. (Courtesy of Alcon.)
Fig . 22.10 The ve ‘sub tle ’ and our ‘vib rant’ colours in the Alcon Air O p tix Colors rang e . (Courte sy of Alcon.)
22 Tint e d Le nse s 209
O PAQ UE TINTS
Opaque tints can be applied using dot-matrix printing, laminate
constructions and opaque backing.
Dot-matrix Printing
T is technique involves applying a matrix pattern o small
opaque dots to the ront sur ace o the lens (Fig. 22.11). T e
dots are created by bonding an opaquing agent, such as titanium
dioxide, and a colouring agent, which may be a pigment or dye,
to the lens sur ace. A binding polymer, such as di-isocyanate,
is used to orm a strong chemical bond between the opaque
tinted agent and the lens sur ace. T e nal cosmetic e ect will
be a combination o dot matrix pattern and ref ections rom the
natural iris between the opaque matrix dots (Fig. 22.12).
Laminate Constructions
An opaque tinted iris pattern can be incorporated within the
lens using a laminate construction. An iris pattern is painted,
using opaque dyes and tints, onto the sur ace o an unhydrated
HEMA button that has been lathed to the curvature o the
intended nished lens. A second pouring o HEMA over the
top o this pattern is e ected. Once set, the laminate button is
lathed to create the nished lens orm, which is then hydrated in
the usual way. T e advantage o this process is that the painted
eatures are encapsulated, and there ore protected, within the
lens. T e disadvantages are that the lens is thicker, thus reducing
oxygen transmissibility, and the tensile properties o the lens are
altered, which can a ect tting characteristics (Fig. 22.13).
A variation o laminate construction is known as ‘sandwich
technology’. T e top and bottom layers o clear HEMA are
copolymerized with a thin middle layer o coloured non-toxic
210 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
Fig . 22.11 Le ns with a matrix o op aq ue b lue d ots (the ap p e arance o
this le ns at arm’s le ng th can b e se e n in Fig . 22.2).
Fig . 22.12 The cosme tic ap p e arance o a d ot-matrix le ns will re sult
rom a comb ination o the colour o the d ots on the le ns sur ace and the
natural colour o the und e rlying iris.
Fig . 22.13 Laminate tinte d le ns construction, whe re b y the op aq ue iris
tint is e sse ntially e ncap sulate d within the ce ntre o the le ns. The lami-
nate is ab se nt rom the p up illary re g ion and le ns p e rip he ry.
pigments, allowing the composite button to be lathed and
then hydrated into an ultrathin lens design. An alternative
approach is to use non-coloured opaquing agents to create an
iris pattern in the centre o the two HEMA buttons, and then
tinting the top HEMA section to create the desired cosmetic
coloration.
O p aq ue Backing
T e matrix o a lens can be tinted with a translucent dye, and an
iris pattern and black pupil are applied to the back sur ace o the
lens using opaque paints. In this way, the entire back sur ace o
the lens is rendered opaque; light ref ects o the opaque layer
and the coloured appearance is created rom the translucent tint
in the lens body (Fig. 22.14).
Surface Characte ristics of Tinte d Te nse s
A number o studies have examined the sur ace character-
istics o opaque tints that appear on the sur ace o tinted
lenses. Hotta et al. (2015) analysed the sur aces and prin-
cipal elements o the colourants o ive commercially avail-
able tinted lenses using scanning electron microscopy with
energy-dispersive X-ray analysis. hey observed that, in
some lenses, colourants were ound on the ront and back
sur aces o lenses, with uneven patterns apparent in dot-
matrix design lenses. Colourants used in all lenses contained
chlorine, iron, and titanium. In the magni ied scanning
electron microscopy images o one lens, chlorine is exuded
and spread. he authors suggested that colourants might be
deposited on the lens sur ace and consist o elements that
have tissue toxicity.
Jung et al. (2016) investigated ten di erent types o tinted so
contact lenses using light microscopy, ocused ion beam mill-
ing and scanning electron microscopy, Fourier-domain opti-
cal coherence tomography and atomic orce microscopy. T ey
noted that when pigment particles were buried below the ront
sur ace there was no signi cant impact on sur ace roughness.
However, all tinted lenses with sur ace pigment had a signi cant
di erence in roughness between ront and back sur aces at the
pigmented area.
Chan et al. (2014) reported higher levels o adherence
o pseudomonas aeruginosa to 13 o 15 di erent brands
o tinted contact lenses tested, compared with adherences
to clear lenses, and Ji et al. (2015) observed an associa-
tion between sur ace roughness and bacterial adhesion on
tinted lenses. hese indings have implications in terms o
the importance o maintenance and disin ection o tinted
lenses, and an increased risk o in ection during wear o such
lenses.
Fig . 22.14 Lig ht re f e cts o an op aq ue b acking and re turns throug h
the tinte d b od y o the le ns, g iving the iris a coloure d ap p e arance .

Fig . 22.15 Four b asic comb inations o cosme tic tint.
Clinical Co nsid e rat io ns
T e distribution o tint and method o manu acture o tinted
lenses have certain clinical rami cations o which the practi-
tioner needs to be aware. T ese considerations are outlined
below.
TINT DISTRIBUTIO N
Selective distribution o a tint across the sur ace o lenses
designed or cosmetic use allows our basic combinations
(Fig. 22.15). he variables are: (1) whether or not to leave
a 1.5 mm band clear o tint around the lens edge; and (2)
whether or not to have a clear pupil. A ull tint covering the
pupil appears more natural, but this creates a small but con-
stant tinting e ect on vision. A clear pupil eliminates the
visual e ect, but introduces problems o obtaining good
alignment and size-matching between the clear pupillary
zone o the lens and the natural pupil o the eye, the lat-
ter varying with ambient lighting (Fig. 22.16). ints that
extend to the edge o the lens are cosmetically unsatis ac-
tory because they are visible against the white sclera at the
limbus.
LENS FITTING
he procedures or itting tinted lenses may di er rom those
employed or itting non-tinted lenses. inted rigid lenses
need to be o a large diameter so as to cover as much o the
cornea as possible and to minimize lens movement. inted
so t lenses are also best itted marginally steeper than non-
tinted lenses so as to reduce lens movement. A ull appre-
ciation o the cosmetic e ect o tinted lenses is gained by
viewing the lenses in the eyes (using a mirror in the case
o the patient) in environments that the patient anticipates
22 Tint e d Le nse s 211
Fig . 22.16 Blue tint with a cle ar p up il. He re in b rig ht lig ht, the natural
p up il is much smalle r than the tint- re e p up illary zone o the le ns, g iving
rise to an imp e r e ct b ut acce p tab le cosme tic e e ct o a he te rochromic
iris with a larg e b lue oute r zo ne ( rom the tinte d le ns) and small haze l
inne r zone ( rom the natural iris).
being in – that is, both inside under arti icial light and out-
side in natural light.
LENS MAINTENANCE
Chlorine-based disin ecting solutions can cause some lens
ading (Brazeau, 1989). All other lens care products appear
to be innocuous in this regard, including hydrogen perox-
ide disin ecting solutions (Jano , 1988) and alcohol-based
daily-cleaning sur actant solutions (Lowther, 1987). Inten-
sive cleaners that employ acids, bases and oxidizing agents
could cause tint ading, and so should not be used on tinted
lenses.
O XYGEN TRANSMISSIBILITY
Although tinting using laminate construction reduces oxygen
transmissibility by increasing lens thickness, the other tint pro-
cesses described above do not appear to a ect lens oxygen per-
ormance (Benjamin and Rasmussen, 1986).
VISUAL EFFECTS
Patients who wear opaque lenses with a clear pupil sometimes
complain o haze or a veiling e ect in their peripheral vision.
T is is due to a slight restriction o the visual eld during the
wear o such lenses. T e phenomenon is more noticeable i the
lens becomes decentred. Spraul et al. (1998) have demonstrated
measurable visual impairment when wearing such lenses, and
advise against wearing them when driving. T eir nding is
supported by Albarrán Diego et al. (2001), who showed tinted
lenses also a ected static perimetry results, but not colour
vision (Farnsworth-Munsell 100-hue colour test) or contrast
sensitivity (Vistech 6000). Others have ound colour-tinted con-
tact lenses are associated with a reduction o contrast sensitivity
unction (Ozkagnici et al., 2003) owing to an increase in ocu-
lar higher-order aberrations (Hiraoka et al., 2009; akabayashi
212 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
et al., 2013; Ortiz and Jiménez, 2014; Watanabe et al., 2014; Jung
et al., 2015).
O CULAR EFFECTS
Spiteri et al. (2012) reported a case o pigmented corneal iron
lines ollowing use o tinted so t contact lenses. A 16-year-old
girl was re erred with suspected contact-lens-related kera-
topathy in both eyes, having recently switched to tinted so t
monthly disposable contact lenses (8.4 / 14.0; RE −3.00 OD,
LE −3.25; Aquamarine So Lens Natural Colours, Bausch and
Lomb, New York, USA). Both corneas exhibited symmetric
super icial corneal pigmented iron lines, which gradually
disappeared ollowing discontinuation o lens wear. he
authors suspected that a poorly itting tinted lens resulted in
localized tear pooling between the lens and cornea and sub-
sequent iron pigment deposition, similar to that seen with
orthokeratology.
Kurna et al. (2012) reported the unusual case o a 38-year-
old woman who presented to a clinic with a pain ul red eye and
epiphora a er having worn hydrogel coloured contact lenses.
On biomicroscopy, a large corneal epithelial de ect and ring
in ltrate were observed. T e patient had been using topical
anaesthetic drops or 10 days. A er cessation o the anaesthetic
drops, the corneal lesions resolved completely in 2 weeks. T e
authors advised that misuse o topical anaesthetics should also
be considered when observing a contact lens user with atypical
keratitis.
Hau and u (2009) reported a case o presumed corneal
argyrosis in a 67-year-old woman who had worn silver-nitrate-
coated occlusive so lenses or 17 years or the management o
intractable diplopia. Slit-lamp examination revealed a di use
blue-grey deposit that was characteristic o corneal argyro-
sis just anterior to Descemet’s membrane. Con ocal micros-
copy showed hyper ref ective granules in Bowman layer, deep
stroma, and Descemet’s membrane. Specular microscopy
showed an abnormal ref ection rom the region o Descemet’s
membrane. Central corneal endothelial cell density was 2560
cells / mm 2.
Hong et al. (2010) reported a case o corneal deposi-
tion o pigments rom cosmetic contact lenses a ter intense
pulsed-light therapy. A 30-year-old emale visited an out-
patient clinic with ocular pain and epiphora in both eyes;
these symptoms developed soon a ter she had undergone
acial intense pulsed-light treatment. he patient was wear-
ing cosmetic contact lenses throughout the procedure. At
presentation, her uncorrected visual acuity was 2 / 20 in both
eyes, and the slit-lamp examination revealed deposition o
the colour pigment o the cosmetic contact lens onto the cor-
neal epithelium. he corneal epithelium was scraped using a
number 15 blade; seven days a ter the procedure, the corneal
epithelium had healed without any complications. his case
highlights the importance o considering the possibility o
ocular complications during intense pulsed-light treatment,
particularly in individuals using contact lenses. he authors
advised that, to prevent ocular damage, intense pulsed-light
procedures should be per ormed only a ter removing contact
lenses and applying eye shields.
T e wearing o tinted lenses containing iron oxide and other
metals are contraindicated during magnetic resonance imaging
as they are a potential hazard (Kuroda et al., 2014). okue et al.
(2013) presented a rare case o incidental discovery o tinted
contact lenses that showed up in images in a patient wearing
such lenses. T e authors advised that radiologists, radiogra-
phers and re erring physicians should be amiliar with the
imaging ndings and potential risk o scanning tinted contact
lenses by magnetic resonance imaging.
SAFETY
Concerns regarding the sa ety o cosmetically tinted contact
lenses have been reported in the literature. o investigate this,
Rah et al. (2013) evaluated the sa ety o cosmetically tinted
contact lenses in a large number o patients across six clinical
trials that varied rom 1 week to 3 months in duration. Lenses
tested included the Naturelle limbal ring daily disposable,
Lacelle limbal ring daily disposable, Lacelle coloured cosmetic
daily disposable, Lacelle limbal ring planned replacement at
2 weeks, and Alamode traditional / annual coloured cosmetic
lens. T e primary sa ety outcome was slit-lamp examination,
including epithelial oedema, epithelial microcysts, corneal
staining, bulbar injection, limbal injection, upper lid tarsal
conjunctival abnormalities, corneal neovascularization, and
corneal in ltrates. High-contrast logMAR visual acuity with
lenses and lens-wearing time, movement and centration were
also presented.
A total o 871 subjects (1742 eyes) and 23 clinical investiga-
tors participated in the six studies, with an average completion
rate o 96.4% across all studies. T e mean age o the patients
was 26.8 ± 8 6.6 years, and 86.7% o participants were emale.
T e total number o slit-lamp examinations across the six stud-
ies was 2456 visits by eye (1228 visits by patient). T ere were
no slit-lamp signs >grade 2 or any nding, with the exception
o corneal staining in one study. In this study, grade 3 corneal
staining was noted in one eye (0.1%) at ollow-up visit 1 and
our (0.6%) o all eligible dispensed eyes at ollow-up visit 2,
with no eyes requiring medical treatment. No adverse events
were reported during any o the trials.
Rah et al. (2013) concluded that cosmetically tinted lenses
are sa e when properly prescribed by an eyecare pro essional
and used in a compliant manner.
REPLACEMENT FREQ UENCY
inted lenses are available in daily disposable and reusable
modalities. Although a hand-painted prosthetic lens cannot
be supplied on a requent replacement basis, where lenses
are itted or a medical reason they are likely to be worn
regularly so should be replaced as requently as possible.
Daily disposable tinted lenses are the most convenient way
o avoiding problems o compliance with intermittent use o
reusable lenses.
CARE O F MULTIPLE PAIRS
Some ashion-conscious patients may possess numerous pairs
o lenses o di erent tint designs. Such patients should be
advised to mark their lens cases to avoid repeated opening, thus
reducing the risk o contaminating stored lenses. Advice should
be given to the patient concerning long-term lens storage, such
as the desirability o periodic lens cleaning even i the lenses
have not been worn.

LENS DEPO SITS
Although disposable tinted lenses are available, some products,
such as theatric lenses, are more expensive and are retained or
long periods o time. Long-term lens maintenance there ore
becomes an important issue. Some tinting processes can alter
the lens sur ace charge. T is could acilitate increased protein
deposition (Lowther, 1987), the consequences o which may be
decreased vision and com ort, sensations o dryness, suscepti-
bility to adverse eye reactions, lens distortion and alterations to
lens tting characteristics.
DISCO MFO RT AND DRYNESS
inting processes can alter lens sur ace chemistry, which in turn
can reduce sur ace wettability and lead to symptoms o dryness
22 Tint e d Le nse s 213
(Daniels and Mariscotti, 1989). Slight irregularities caused by
sur ace tints may render tinted lenses slightly less com ortable
than equivalent non-tinted lenses (Ste en and Barr, 1993). Ocu-
lar lubricants can help alleviate these sensations.
Co nclusio n
T e utility o contact lenses has been extended considerably
as the result o the development o innovative tinting proce-
dures, so that almost any desired e ect can be achieved. inted
lenses there ore constitute an important vehicle or satis ying
the cosmetic, prosthetic, therapeutic and prophylactic needs o
patients.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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23
Pre sb yo p ia
JO HN MEYLER | DAVID RUSTO N
Int ro d uct io n
An area that historically has been perceived as being particu-
larly challenging within contact lens practice is tting presby-
opic patients with contact lenses so as to allow them to ul l the
majority o their visual requirements. However, the availability
o newer optical designs, daily disposability and lens designs in
enhanced hydrogel, silicone hydrogel and high-permeability
rigid lens materials means there is less restriction to the modal-
ity o wear or physiological compromise when attempting to
correct presbyopia with contact lenses and that the visual out-
comes are signi cantly better than previously. T is has resulted
in a higher rate o prescribing by practitioners o contact lenses
or presbyopic patients (Fig. 23.1) (Morgan et al., 2016). Not-
withstanding this increased prescribing, the penetration o con-
tact lenses alls away dramatically in the over-45-year-old age
group – a demographic or which the need or a presbyopic cor-
rection doubles (Fig. 23.2). o obviate this necessitates a keen
interest in meeting the visual and physiological needs o this
very important patient group.
With the presbyopic population growing in size at an ever-
increasing rate along with the pre-presbyopic, practitioners
can expect to see a rise in the number o presbyopic patients
attending or this orm o lens tting. O ering contact lens
correction to this group should now be considered as an inte-
gral, routine part o contact lens practice and represents a
214
very signi cant opportunity or practice growth and increased
patient satis action.
T e options or the correction o presbyopia to both existing
and new contact lens wearers include:
• distance-powered contact lenses and near-reading
spectacles
• bi ocal or multi ocal contact lenses:
• simultaneous image contact lenses
• alternating image contact lenses
• monovision.
T e contact lens options or presbyopic correction are shown in
Fig. 23.3 with some examples o the di erent brands available.
Each option has advantages and disadvantages, which vary
with the lens type, the tting approach used and the degree
o presbyopia present. A systematic approach to lens selection
can be used depending on the stage o presbyopia, as shown in
Box 23.1 (Christie and Beertren, 2007).
Distance-powered contact lenses combined with near-read-
ing spectacles may be the simplest and least expensive option.
However, it does not address the problem or the patient who
does not wish to wear spectacles, and it may even demotivate
an existing lens wearer. Many contact lenses wearers becom-
ing presbyopic want to continue to wear contact lenses as their
primary correction option or their vision correction needs
and not being given this option is a very signi cant reason
or ceasing contact lens wear. It should be remembered that
Fig . 23.1 Multi ocal and monovi-
sion contact le ns ts as a p rop ortion
o all so t le ns ts to p re sb yop e s
(those ove r 45 ye ars o ag e ) in se ve n
nations b e twe e n 2000 and 2015.
 23 Pre sb yo p ia 215

Fig . 23.2 Comp arison o the p e rce ntag e o p atie nts we aring vision corre ction across the ag e rang e ve rsus the p rop ortion we aring contact le nse s.
(Ad ap te d rom VisionTrak Data 2007; includ e s d ata ro m the UK, France , Ge rmany and Italy.)

Fig . 23.3 Contact le ns op tions o r p re sb yo p ia corre ction with some e xamp le s o various b rand s.
216 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
BO X 23.1 FITTING APPRO ACH DEPENDING O N
DEGREE O F PRESBYO PIA
EMERGING PRESBYO PE (UP TO + 1.00 D)
Simultane ous: ull corre ction in b oth e ye s
Monovision: d istance and ull ne ar
MID-PRESBYO PE (+ 1.25 TO + 2.00 D)
Simultane ous: ull corre ction to b oth e ye s
Translating : ull corre ction to b oth e ye s (d o not ove rcorre ct ad d )
Monovision: d istance and ull ne ar
LATE PRESBYO PE (+ 2.25 TO + 3.00 D)
Simultane ous: mod if e d monovision; e nhance d monovision
Translating : ull corre ction to b oth e ye s
Monovision: d istance and p artial ne ar; consid e r top -up sp e c-
tacle s to p rovid e ad d itional p lus
(Ad ap te d from Christie & Be e rtre n, 2007.)
intermittent use o spectacles is o en ar more inconvenient
than constant use.
Pat ie nt Se le ct io n
Patient motivation plays an important role in any orm o contact
lens tting. However, this motivation is o en restricted to those
patients who are aware o the various contact lens options, which
they are then keen to explore urther. Perhaps more important
is in ormed choice based on the advantages and disadvantages
o the various options available, as the majority o patients are
not aware that contact lenses are a possibility or the correc-
tion o presbyopia. T is more ‘proactive’ approach may result
in somewhat lower success rates but, inevitably, a larger contact
lens patient base. Back et al. (1989) have shown that a signi cant
proportion o an unselected presbyopic population can achieve
success with simultaneous image multi ocal contact lenses.
Caution should prevail when considering patients with com-
promised binocular vision, amblyopia, distance acuity o less
than 6 / 12 or exacting critical vision needs or either distance
or near vision. High- and low-contrast visual acuity charts (Fig.
23.4) give more in ormation about acuity. In particular, the di -
erence in low-contrast acuity between spectacles and contact
lenses may give some indication o possible success.
It is more important, however, to have access to trial lenses
to obtain an idea o potential success or any particular type o
multi ocal lens or tting technique based on both patient sub-
jective eedback and objective measurement. As with any con-
tact lens preassessment, care ul attention should be paid to tear
quality and quantity, which are o en reduced in this age group,
as well as eyelid tone and position. Selection o a lens mate-
rial that o ers high wettability and low coe cient o riction
may be especially relevant in the presbyopic age group. When
commencing this orm o lens tting, it may help to start with
selecting patients that are generally accepted as being ‘better’
candidates rather than choosing those who might be considered
as ‘more challenging’ to t success ully. able 23.1 summarizes
the di erent patient types when considering tting simultane-
ous image, alternating image and monovision (Bennett, 2007).
PATIENT EXPECTATIO NS
It is important that patients are given realistic expectations
about the likely level o vision, as with any type o vision
Fig . 23.4 Hig h- and low-contrast visual acuity chart. (Mod i e d rom
Be nne tt, E. S. (2007). Bi ocal and multi ocal contact le nse s. In A. J. Phil-
lip s and L. Sp e e d we ll (e d s) Contact Le nse s (5th e d ., p p . 311–331). O x-
ord : Butte rworth-He ine mann.)
correction or presbyopia. It is necessary to ensure that patients
ully understand the basis o presbyopia and their expectations
should be set out in a positive but in ormative manner. T is
involves discussing the bene ts o combined distance / near cor-
rection without the need or spectacles (less head movement,
no peripheral distortion, more natural image ormation) as well
as likely di erences between the visual per ormance o mono-
vision, simultaneous image or alternating image lenses. When
compared with spectacles or single-vision contact lenses, visual
decrements may be noticed, such as reductions in visual acu-
ity (especially in low luminance) and possibly stereopsis, and
reduced intermediate vision depending on the type o lens t-
ted. It should also be explained to the patient that it is quite nor-
mal or tting to require more than one appointment in order to
try out alternative lens powers and tting approaches, depend-
ing on their assessment o lens per ormance in their everyday
visual environment.
Init ial Me asure me nt s
Measurement o the ocular dominance or sighting pre er-
ence is use ul in establishing which eye to correct or distance
vision during monovision tting, or while making adjust-
ments during simultaneous lens tting. Ocular dominance
can be determined using pre erential looking tests or alter-
natively by the +1.00 D sensory test. T e ormer is carried
out by sitting opposite the patient and asking the patient to
look through a hole in a piece o card at an open eye o the
practitioner. Whichever eye the patient lines up with the open
eye o the practitioner is the dominant one. T e latter test
involves placing the best binocular distance re raction in the
trial rame and, while patients look at the lowest line they can
read, a +1.00 D lens is placed alternatively in ront o each eye.
Patients indicate when the vision is clearest, viewing the dis-
tance chart. I the +1.00 D lens is in ront o the le eye when
the image is reported as clearest, then the right eye is consid-
ered as distance dominant, and vice versa. It has been ound
that unsuccess ul wearers became success ul a er switching
near and distance corrections contrary to the dominance as
measured by traditional methods, but rarely contrary to the
+1.00 D sensory test (Michaud et al., 1995). Nowadays most
manu acturers recommend the +1.00D sensory test to assess
dominance. Historically, pupil size measurements were use-
ul when tting biconcentric designs; however, this procedure
is less relevant with more recent designs. Nevertheless, larger
 23 Pre sb yo p ia 217

TABLE
23.1 Pat ie nt Se le ct io n fo r Pre sb yo p ic Co nt act Le ns Co rre ct io n

Simultane ous
Good cand id ate s Existing so t le ns we are rs who are
(g e tting starte d ) e me rg ing p re sb yop e s
Mod e rate inte rme d iate -vision
re q uire me nts
Sp he rical or ne ar-sp he rical re ractive
e rrors
Willing to acce p t some limite d
comp romise in d istance vision
More challe ng ing Do not d e sire any comp romise in
cand id ate s d istance vision
(e xp e rie nce Emme trop ic or ne ar-e mme trop ic
re q uire d ) d istance re ractive e rror
Would b e ne t rom a toric corre ction
Small p up il size (<3 mm)
Pat ie nt Se le ct io n
Alte rnating
Mod e rate and ad vance d p re sb yop e s
Lowe r lid ab ove , tang e nt to, or no
more than 1 mm b e low the limb us
Myop ic or low hyp e rop ic p owe rs
Normal to larg e p alp e b ral ap e rture s
Normal to tig ht lid te nsion
Hig h hyp e rop e s
Small p alp e b ral ap e rture s
Loose lowe r lid s
Monovision
Sig ni cant astig matic re ractive
e rror
Re ad ing p ositions othe r than
stand ard d ownward g aze
Curre nt contact le ns we are rs
Motivate d and re alistic
e xp e ctations
Low myop e s
Conce ntrate d sp e ci c visual
ne e d s
Hig h re ad ing ad d ition
Hig h visual d e mand s and
e xp e ctations

(Mod i e d rom Be nne tt, E. S. (2007). Bi ocal and multi ocal contact le nse s. In A. J. Phillip s and L. Sp e e d we ll (e d s) Co ntact Le nse s (5th e d .,
p p . 311–331). O x ord : Butte rworth-He ine mann.)

4.0

3.8
Average size
Max/min size
)
2
3.6
m
/
d
c
0
5
3.4
2
/
0
5
(
r
3.2
e
t
e
m
a
i
3.0
d
l
i
p
u
Dim light
p
2.8
a
i
p
o
y
b
2.6
s
e
r
P
2.4 Bright

2.2
10 20 30 40 50 60 70 80
Fig . 23.5 Variation o p up il size at two luminance le ve ls
Age (years) with ag e . (Ad ap te d rom Dumb le ton e t al. (2015).)

pupils can be more challenging when tting alternating image
lenses and very small pupils may be less success ul when t-
ting simultaneous image lenses.
Pup il Size
Pupil size is known to decrease with age, as well as when look-
ing at near objects and, o course, under photopic conditions
(Fig. 23.5). I a centre-near multi ocal contact lens design is
not optimized and has a xed design or all reading additions,
visual per ormance can be reduced as the pupil size diminishes
with age. Most, but not all, current multi ocal designs (Fig. 23.6)
are adapted to ref ect this age change as the reading addition
increases assuming that higher reading adds will be required or
older patients.
A more recent nding is that not only does pupil size vary
with age but also that re ractive error can inf uence pupil size,
with myopes tending to have larger pupil size than hyperopes,
particularly in mesopic light conditions (Cakmak et al., 2010)
(Fig. 23.7). A study by Dumbleton et al. (2015) has recently con-
rmed this nding and discussed the implications or multi o-
cal design.
Although these pupil size di erences may be relatively small,
when considered as an area this can have a signi cant impact
on visual per ormance. Dumbleton’s data indicates that the di -
erence in pupil size area rom a −8.00 D myope to a +6.00 D
hyperope is 24%. I not considered in the lens design, this can
result in di erences in success between myopes and hyperopes.
A more recent lens design (Fig. 23.8) varies the optic pro le
both across the prescription and the reading addition range so
as to optimize optics and visual per ormance.
Bifo cal and Mult ifo cal Co nt act Le nse s
Bi ocal and multi ocal contact lenses can be simultaneous or
alternating image designs. Simultaneous designs generally
218 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
–3.00D Low Add –3.00D Medium Add
Fig . 23.6 Diop tric p owe r map s o thre e d i e re nt re ad ing ad d itions having the same d istance p owe r in a ce ntre -ne ar multi ocal le ns d e sig n. It can
b e se e n that the p owe r d istrib ution alls away more rap id ly as the ad d incre ase s. (Re d ind icate s hig he r p owe rs; b lue ind icate s lowe r p owe rs.)
Fig . 23.7 Variation o p up il size with re ractive e rror in me sop ic cond i-
tions. (From Cakmak, H. B., Caq il, N., Simavli, H. e t al. (2010). Re ractive
e rror may inf ue nce me sop ic p up il size . Curr. Eye . Re s., 35, 130–136.)
require the lens to be relatively stable on the eye and will be asso-
ciated with some orm o visual compromise because objects at
both distance and near are imaged simultaneously on the retina.
Alternating image lenses require signi cant lens movement so
that the distance and near portions o the lens can be positioned
over the pupil by interaction with the lids.
Comparative studies have concluded that multi ocal contact
lenses per orm better, in many di erent orms o visual mea-
surements, than monovision correction (Rajagopalan et al.,
2006; Richdale et al., 2006; Bennett, 2008; Gupta et al., 2009;
Woods et al., 2009. However, Chu et al. (2009) reported that
multi ocal contact lens wearers were signi cantly less satis ed
with aspects o their vision during night-time driving compared
with daytime driving, particularly regarding disturbances rom
glare and haloes.
HISTO RICAL DESIGNS
Early so and rigid simultaneous image lenses were biconcen-
tric in design, consisting o two discrete zones o distance and
near power. A centre-distance design has the central portion o
the optical zone or distance vision, which is surrounded by an
area containing the near power. In centre-near designs, the opti-
cal principle is the same as or the centre-distance lens, although
reversed so that the central portion o the lens ocuses the light
rom close objects and this is surrounded by a distance-powered
area. Visual per ormance with both these designs was signi -
cantly impacted by their dependency on pupil size. Biconcentric
designs in both so and rigid materials are still available but
are now rarely used owing to the availability o more advanced,
–3.00D High Add
easier-to- t designs and single-use disposable lenses. Di rac-
tive bi ocal contact lenses used re raction to correct distance
vision and a combination o re raction and di raction to correct
near vision. Di ractive lenses were largely independent o pupil
size (Young et al., 1990); however, like aspheric designs, they
were dependent on lens centration. Image ormation is achieved
by a di ractive ‘zone plate’ on the back sur ace o the lens, which
is able to split the incident light passing through into two dis-
crete ocal points. Approximately 20% o incident light is lost
to higher orders o di raction, leaving 40% o light to make up
each image (Benjamin and Borish, 1994), which explained the
greater reduction in low-contrast acuities with such lenses when
compared with monovision correction (Harris et al., 1992). Di -
ractive contact lenses are no longer available, but di ractive
optics continues to be used in bi ocal intraocular implants.
Another approach to reduce the dependency o lens unc-
tion on pupil size especially in di erent lighting conditions was
to increase the number o concentric zones, and to power these
zones alternatively or distance and near vision. T is approach
was adopted in a centre-distance multizone design consisting o
ve alternating distance and near-powered zones (Meyler and
Veys, 1999).
T e multiple-ring con guration is designed to provide vision
that is more speci c to the available lighting conditions.
SIMULTANEO US IMAGE DESIGNS
A variety o simultaneous lens designs are available in both rigid
and so materials. T e availability o single-use disposable so
trial lenses and empirically ordered individually based aspheric
rigid lenses has resulted in an increased prescribing o this orm
o lens correction; it has approximately doubled in the last 10
years (Morgan et al., 2016).
In simultaneous image designs, the distance, intermediate
and near correction zones are both positioned in ront o the
pupil in every direction o gaze so that light rom either a distant
or near object passes through all zones. As xation is directed
to either a distant or a near object, one zone produces a ocused
image while the others produce a blurred image that overlaps
the same retinal elements as the ocused one (Benjamin and
Borish, 1994) (Fig. 23.9).
T e placing o simultaneous images on the retina by any
optical system relies on the visual system being able to select the
clearer picture and to ignore the out-o - ocus image, whether
a distant or near object is being viewed. T e phenomenon o
binocular summation improves the end result by improving on

Myope Emmetrope
Pupil
size
Optical
design
Fig . 23.8 Sche matic showing how the p up il size varie s across the re ractive rang e and how one manu acture r has op timize d the op tical d e sig n or
e ach ind ivid ual le ns p arame te r to re f e ct this.
Fig . 23.9 Princip le o simultane ous visio n d e sig n. (A) Ce ntre -d istance
d e sig n. (B) Ce ntre -ne ar d e sig n. D = d istance ; N = ne ar.
the monocular images and generating a binocular image that
o ers improved contrast and acuity. Care needs to be exerted
to remain in the zone o summation versus extending into the
zone o inhibition. Summation is thought to occur when the
amount o optical disparity is less than 1.00 D.
T e spread o light rom the de ocused image reduces the
contrast o the ocused image (Borish, 1988). As a result, the t-
ting o a simultaneous image lens is likely to result in some level
o reduction in image quality in comparison with that resulting
rom a single-vision correction. T e extent o contrast loss will
depend upon the relative amounts o in- ocus to out-o - ocus
light striking the retina. I equal contrast is to be achieved or
both near and ar viewing, the re ractive system should allow
approximate equality o the areas o the two portions o the lens
transmitting to the pupil. Lens per ormance may be a ected by
many actors, which include pupil size, lens design and centra-
tion o optics relative to the pupil. I the optics are decentred
23 Pre sb yo p ia 219
Hyperope
with regard to the visual axis then ‘shadowing’ e ects are pro-
duced by virtue o induced asymmetrical aberration, principally
coma (Charman, 2014). T e theoretical retinal intensity o di -
erent lens designs and the e ect o variations in pupil size can
be investigated by measuring their modular trans er unction
(Young et al., 1990).
Regardless o the di erent optical principles and designs
available, large well-controlled independent studies are required
to determine whether patient acceptance is more success ul
with any one design. Comparing patient acceptance success
rates rom di erent studies is di cult owing to di erences in
success criteria, patient pro le and length o study. A study by
Situ et al. (2003) showed that existing success ul monovision
wearers could be success ully tted with bi ocal contact lenses
and that a er a 6-month period 68% pre erred bi ocal lenses,
compared with a 25% pre erence or monovision.
Asp he ric De sig ns
With aspheric designs the re ractive power gradually changes
rom the geometric centre o the lens to the more peripheral
area o the optic zone. Such lenses are best described as ‘mul-
ti ocal’ or “stretch ocus” owing to the progression o powers,
but can also be considered as a type o concentric design as the
power distributions are concentric around the centre o the lens.
By the nature o their design, lens unction will vary somewhat
with changes in pupil size. T is can lead to variations in dis-
tance- and near-vision image contrast, which can be minimized
i the lens design takes pupil size variation into account.
Power distribution is produced by the use o a continuous
aspheric sur ace o xed, or more typically, variable eccentricity.
Aspheric lens designs can be subdivided according to whether
the power distribution is most plus (least minus) centrally,
resulting in a centre-near design (Fig. 23.10A), or most minus
(least plus) centrally resulting in a centre-distance design (Fig.
23.10B). Although both options are available in so and rigid
materials, centre-near ront-sur ace aspheric designs are much
more prevalent amongst so modern aspheric multi ocals.
Front-surface Aspheric Designs. Front-sur ace so aspheric
designs generate negative spherical aberration, resulting in
decreasing plus power rom the geometric centre o the lens.
T is in essence creates a centre-near design. T e aspheric curve
is calculated to increase the overall spherical aberrations o the
eye and, i necessary, o the lens itsel . T e increase in depth
o ocus can be e ective at correcting the early presbyopic
patient (up to +1.50 D). As presbyopia increases, the ront-
sur ace curve must have a greater degree o asphericity to allow
more plus re ractive power within the overall optical system.
220 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
T is o en involves more complex sur ace geometry o varying
eccentricity to allow stabilized distance and near power zones
within a speci ed area.
Apart rom the visual demands o the presbyopic patient, it
would also be expected that visual per ormance would depend
upon the interaction o the optical characteristics o the par-
ticular lens design with the aberrations o the eyes o the wearer.
Ocular spherical aberration is unique to the individual. Conse-
quently, variations in ocular aberration between patients may
explain in part why lenses o this type meet the needs o some
wearers but sometimes not others (Plakitsi and Charman, 1995).
Eyes with greater positive spherical aberration e ectively
work against negative spherical aberration generated by a cen-
tre-near aspheric design resulting in less multi ocal add e ect.
Although the patient may demonstrate improved intermedi-
ate acuity, they may require a higher reading add than their
spectacle add to improve their near vision e ectively. Di erent
centre-near aspheric so lenses do have di erent distributions
Fig . 23.10 (A) Front sur ace asp he ric ce ntre -ne ar d e sig n. (B) Back sur-
ace asp he ric ce ntre -d istance d e sig n.
Fig . 23.11 Diop tric p owe r map s o two le ad ing ce ntre -ne ar asp he ric simultane ous imag e contact le nse s o similar p re scrip tion. Both le nse s are
− 3.00 D with a low ad d . (Re d ind icate s hig he r p owe rs; b lue ind icate s lowe r p owe rs.)
o optical power on their sur aces (Fig. 23.11) and thus it may
be possible to improve per ormance by changing to a di erent
design.
T e optical per ormance and patient satis action with ront-
sur ace aspheric simultaneous image so lenses has improved
signi cantly in recent years and they orm a very signi cant part
o the recent growth o presbyopic contact lens correction with
multi ocals (see Fig. 23.1).
Back-surface Aspheric Designs. Back-sur ace aspheric
sur aces that generate the reading addition are mostly ound in
rigid lens designs and result in power changes rom the central
distance correction to that required or near vision by inducing
positive spherical aberration. T e greater the eccentricity (or
rate o f attening), the higher is the reading power in relation to
distance power. However, the higher the reading addition, the
more likely it is that distance vision will be a ected adversely,
especially in low-contrast and / or low-light conditions. Back-
sur ace centre-distance aspheric so lenses designs are limited
in the amount o positive spherical aberration they can generate
and are there ore suitable only or early presbyopia o up to
+1.25 D.
However in rigid lenses the back-sur ace geometry may
depart signi cantly rom corneal topography with the ‘higher-
eccentricity’ designs. T is is due to rapidly f attening back-sur-
ace aspheric geometry. Such lenses will need to be tted airly
steep to allow or appropriate lens centration (Edwards, 2000).
Back-sur ace aspheric rigid lens designs can now be based on
corneal topography and ocular prescription to create an indi-
vidual lens design or correcting presbyopia (Woods et al.,
1999). T e aim is to modi y the combined optical system o the
lens, tears and cornea to provide a predictable vari ocal e ect.
Zonal Aspheric and Spherical Designs. T is approach
is designed to allow balanced vision at all distances and
synergistically combines the bene ts o historical multizone
spherical and aspheric so lens designs. T e resulting lens
has a zonal aspheric ront sur ace designed to leverage the
eyes’ natural depth o clear ocus. It is available with a range
o reading additions. T e power pro le and zone distribution
or each o the add powers have been optimized or the normal
 23 Pre sb yo p ia 221

physiological change in pupil size with age as well as illumination
changes (Fig. 23.12).
Another approach with zonal designs is to use modi ed
monovision approach with the rst pair o lenses trialled. T e
lens used or the dominant eye is a centre-distance lens design
whereas the lens or the other eye is centre-near in design. Lens
designs can use aspheric sur aces, spherical sur aces or a com-
bination o both with unique zone sizes to produce two comple-
mentary but inverse geometry lenses (Fig. 23.13). Each lens is a
multi ocal and the intention is that some binocular summation
Fig . 23.12 Zonal asp he ric d e sig n.
Fig . 23.13 Multizone conce ntric mod i e d monovision d e sig n.
will still occur, with the intention o providing acceptable vision
at all distances under binocular conditions. Both centre-near
and centre-distance designs have xed optical zones regardless
o add power (Fig. 23.14). T is could have the e ect o bias-
ing the optical per ormance towards pure monovision in older
wearers. Once again caution is needed to not exceed the level o
disparity to cause inhibition.
Hyb rid and Se miscle ral Le ns De sig ns
Recent introductions in the practitioner’s tting armoury are
hybrid simultaneous image multi ocals and semiscleral rigid
multi ocal lenses. T e hybrids have rigid lens centres with sil-
icone hydrogel so skirts. T e semiscleral lenses and hybrids
typically have diameters similar to so lenses. Optically they
both have similar designs to so multi ocals, but with the added
advantage o correction o corneal astigmatism by virtue o the
tear lm trapped behind the back sur ace o the lens. Fig. 23.15
shows the f uorescein pattern o a well- tted hybrid lens and
Fig. 23.16 a semiscleral rigid lens. Problem-solving vision issues
with these lenses is similar to that o so simultaneous-image
multi ocals.
Le ns Fitting
Initial lens power selection and optimal adjustments will vary
with each individual lens type; however, the distance power o
the multi ocal lens will most o en be based on the vertex dis-
tance-corrected best sphere prescription. T is is best derived by
placing the calculated best vision sphere in a trial rame and add-
ing positive power until the patient begins to notice a decline in
the distance acuity. When vertex corrected, this spherical power
will guide the distance power o the initial contact lens. General
guidance in determining the reading addition is to prescribe the
lowest addition that meets the patient’s visual needs at their near
working distance.
Front-sur ace aspheric lenses, however, may occasionally be
designed so that lens power is based on the total reading power
or a value midway between the distance and near power. Always
re er to the manu acturers’ tting advice, which is speci c or
that particular lens design. T is is particularly important to get

–5 –4 –3 –2 –1 0 1 2 3 4 5

–0.5 Add +1.50 Optical Power (D)

Add +2.00 Optical Power (D)
–1.0 Add +2.50 Optical Power (D)

–1.5

–2.0

–2.5

–3.0

–3.5

–4

Fig . 23.14 Po we r p ro le s o the multizone conce ntric mod i e d monovision d e sig n illustrating how the re d uction in p up il size with ag e is not re -
f e cte d in the d e sig n.
222 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
the best outcome or the patient with the lowest number o lens
designs.
Re ractive end-points are more di cult to determine when
wearing a simultaneous-vision correction in each eye, and
there ore the lens power selected should always be based on
a current re raction. T e re raction should also be care ully
binocularly balanced and the best vision sphere determined
as above.
T e t o a so lens should meet the normal criteria used
or single-vision so lens tting, as outlined in Chapter 8;
however, good lens centration and minimal movement are
especially critical in allowing optimal vision per ormance
with multi ocal lenses. T is is even more important i tting
an aspheric lens design, as decentration may result in induced
higher-order aberrations, principally coma (E ron et al., 2008).
A slit lamp is o little value in determining the centration o a
so multi ocal as it does not show the position o the lens cen-
tre with regard to the pupil. T e technique o choice is to look
at an elevation map on a corneal topographer be ore and a er
Fig . 23.15 Fluore sce in p atte rns o a we ll- tte d hyb rid multi ocal le ns.
(Courte sy Sop hie Taylor We st.)
Fig . 23.16 Fluore sce in p atte rns o a we ll- tte d se miscle ral RGP multi-
ocal le ns. (Courte sy Sop hie Taylor We st.)
lens insertion. T e ideal scenario (Fig. 23.17) shows a well-
centred lens with slight nasal positioning. When decentration
occurs, particularly in a temporal direction, the induced aber-
ration results in reduced acuity (Fig. 23.18). One manu ac-
turer uses a combination o central aspheric and peripheral
spherical curves to improve lens centration. In the absence o
a topographer a simple technique is to get the patient to look
at a spot o light in dim conditions and draw what they see.
A comet’s tail extending rom the light is usually a sign o a
decentred lens.
Back-sur ace aspheric rigid lens designs are usually tted
0.5–0.8 mm steeper than the cornea to give the desired opti-
cal e ect and to obtain the required centration. Although this
may seem excessively steep, the rapidly f attening aspheric back
sur ace should result in a f uorescein pattern that shows a small
central area o apical clearance surrounded by a wide area o
mid-peripheral alignment (Fig. 23.19). Near per ormance
will bene t, with this lens type, rom lens translation during
downward gaze.
Fig . 23.17 Ele vation top og rap hy map o a we ll-ce ntre d ce ntre -ne ar
simultane ous-imag e so t multi ocal le ns. (Courte sy o Dr Trusit Dave .)
Fig . 23.18 Elevation topography map o a temporally decentred centre-
near simultaneous-image so t multi ocal lens. (Courtesy o Dr Trusit Dave.)
 23 Pre sb yo p ia 223

Le ns Ad justme nts
he most common problem that the practitioner has to BO X 23.2 ADJ USTMENT O PTIO NS FO R
IMPRO VING DISTANCE VISIO N DURING
address with simultaneous lens itting is poor visual per- SIMULTANEO US-VISIO N FITTING*
ormance or either distance vision or near vision, or both.
he irst step is to con irm lens itting and end-point over- ADD ADDITIO NAL MINUS TO DISTANCE LENS PO WER
re raction. he most e ective adjustment options may vary Show more minus p owe r in − 0.25 D ste p s to the d ominant e ye
with the lens design being used, and once again it is criti- f rst or to b oth e ye s i ne ce ssary
Ensure sig nif cant imp rove me nt to d istance -vision p e r ormance
cally important to ollow the manu acturer’s guidance. I the (sub je ctive and ob je ctive )
best vision sphere and correction or vertex distance have Ensure ne ar vision re mains unchang e d or acce p tab le
been made correctly, then spherical overre raction may not Co ntinue to ad d ad d itio nal minus p o we r o nly i urthe r im-
be necessary and any change will be made based on the it- p ro ve me nt is co nf rme d while ne ar-visio n p e r o rmance is
ting guide and will involve altering the addition in one eye maintaine d
and / or making a small predetermined change to the spheri- REDUCE READING ADD PO WER
cal power o one lens. I p arame te r rang e allows, re d uce re ad ing ad d p owe r in one or
However, some designs are sensitive to 0.25 D adjustments b oth e ye s
to the distance lens power, which can have a signi cant e ect ALTER BACK-SURFACE FITTING RELATIO NSHIP
on distance or near visual per ormance. Lens power adjust- So me rig id le ns d e sig ns re q uire alte rnative f tting to achie ve a
ments are best investigated by using ±0.25 D twirls / f ippers or chang e in p owe r g rad ie nt ove r the p up il are a and the ne ce s-
trial lenses during binocular vision in ambient illumination or sary d istance vision imp rove me nt
the illumination where problems are being experienced by the EXPLO RE MO DIFIED MO NO VISIO N
wearer. T e use o phoropters should be avoided during over-
Push e xtra minus in d ominant e ye and e xtra p lus p owe r in non-
re raction as the resulting light reduction will increase pupil d ominant e ye
size and alter optical per ormance. Any distance minus-power De cre ase re ad ing ad d b y one ste p in the d ominant e ye
adjustment should be made only i it has been demonstrated Try ce ntre -ne ar d e sig n in one e ye and ce ntre -d istance in the
to make a signi cant impact on distance visual acuity (i.e. hal othe r
to one line o Snellen visual acuity) combined with a subjec- EXPLO RE ENHANCED MO NO VISIO N
tive improvement. Small additional minus-power adjustments Trial sing le -vision d istance le ns in d ominant e ye and ne ar-b ias
can be shown to the dominant eye rst whilst investigating b i ocal in the othe r
distance-vision improvement, or to both eyes at the same
time. T e ormer approach may lessen the risk o reducing *NB always ollow manu acture rs’ tting g uid e initially i p rovid e d .
near-vision per ormance whilst improving distance vision. In
addition, i the parameter range allows, distance vision may be
improved by reducing the reading addition by one step in the
dominant or both eyes (Key et al., 1996). Adjustment options
are summarized in Boxes 23.2 and 23.3. It must be stressed BO X 23.3 ADJ USTMENT O PTIO NS FO R
that these are options and that be ore contemplating making IMPRO VING NEAR VISIO N DURING
changes based on these tables, the manu acturers tting guide SIMULTANEO US-VISIO N FITTING*
should be ollowed.
ADD ADDITIO NAL PLUS TO DISTANCE LENS PO WER
Show more p lus p owe r in + 0.25 D ste p s to the non-d ominant
e ye f rst or b oth e ye s i ne ce ssary
Ensure sig nif cant imp rove me nt to ne ar-vision p e r ormance
(sub je ctive and ob je ctive )
Ensure d istance vision re mains unchang e d or acce p tab le
Ad d ing e xtra le ns p owe r to non-d ominant e ye alone may re -
d uce the risk o re d ucing d istance vision p e r ormance while
imp roving ne ar vision
ALTER BACK-SURFACE FITTING RELATIO NSHIP
Some rig id le ns d e sig ns re q uire alte rnative f tting to achie ve the
chang e in p owe r g rad ie nt ove r the p up il are a and the ne ce s-
sary ne ar-vision imp rove me nt
EXPLO RE MO DIFIED MO NO VISIO N
Push e xtra minus in d ominant e ye and e xtra p lus p owe r in non-
d ominant e ye
Incre ase re ad ing ad d b y one ste p in the non-d ominant e ye
Try ce ntre -ne ar d e sig n in one e ye and ce ntre -d istance in the
othe r
EXPLO RE ENHANCED MO NO VISIO N
Trial sing le -vision ne ar le ns in d ominant e ye and d istance -b ias
b i ocal in the othe r
Fig . 23.19 Fluore sce in p atte rn o hig h-e cce ntricity b ack-sur ace
asp he ric d e sig n showing ce ntral ap ical cle arance and mid p e rip he ral *NB always ollow manu acture rs’ tting g uid e initially i p rovid e d .
alig nme nt. (Courte sy o Bruce Brid g e wate r.)
224 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
TABLE
23.2 Cause s o f Po o r Visio n and Disco mfo rt w it h Simult ane o us Visio n De sig n and So lut io ns
Symp t o m Po ssib le Cause
Poor vision Poor mate rial we ttab ility / te ar lm
q uality
Inaccurate initial re raction
De ce nte re d le ns
Uncorre cte d astig matism
Exacting visual re q uire me nts
Unre alistic e xp e ctations
Patient’s sp he rical ab e rration is hig her
than averag e neg ating some o le ns-
es’ and so reducing de pth o ocus
Poor com ort Mate rial characte ristics
De sig n characte ristics
MGD = me ib omian g land d ys unction; BVS = b e st vision sp he re .
Me e ting Exp e ctations
Although modern simultaneous image so or rigid lenses have
high rates o reported clinical success, no one lens or approach
will satis y all presbyopic patients. Lens adjustments will o en
need to be made to improve the optical per ormance based
patient eedback. T is is obviously more readily undertaken
using so disposable lenses, where the initial adjustment can
be made at the rst visit i the practitioner has a comprehen-
sive tting bank. For rigid lenses, the manu acturer will o en
make a replacement lens at little or no urther cost to enhance
per ormance.
T e common reasons why lenses ail to meet patient needs,
even a er adjustment, and the likely solutions are set out in
able 23.2.
ALTERNATING-IMAGE (TRANSLATING) DESIGNS
T e vast majority o alternating designs are available as rigid
lenses owing to challenges in so lenses translating e ectively.
However, in recent years a number o so alternating-vision
designs have become available, but have not become widely t-
ted. Both so and rigid gas-permeable designs have distance-
and near-powered portions, set out in a similar way to that
observed in a bi ocal spectacle lens. During primary gaze the
distance portion o the contact lens is positioned over the pupil.
When gaze is directed downwards during reading, the near
portion translates upwards to allow near-vision correction (Fig.
23.20A and B).
Segment position and lens translation are the keys to suc-
cess, and the lower lid has an important role in positioning
and stabilizing the lens against the globe. T e position o the
lower lid should be no lower than the in erior limbus, otherwise
translation is less e ective and o en inadequate (Fig. 23.20C).
So lut io n
Switch to b e tte r we tting mate rial (e .g . e nhance d hyd rog e l d aily d isp osab le )
Ad d re ss any re late d p atholog y (e .g . MGD)
Shorte n re p lace me nt inte rval (e .g . g o to d aily d isp osab ility)
Utilize te ar sup p le me nts
Re che ck maximum p lus sp e ctacle BVS that d oe s not re d uce visual acuity
Ensure b ack ve rte x d istance comp e nsation ap p lie d corre ctly
Re che ck sp e ctacle re ad ing ad d ition is corre ct or working d istance
I so t, e ithe r alte r b ase curve or choose a d i e re nt d e sig n o le ns.
I rig id , incre ase d iame te r and / or incre ase are as o alig nme nt. Consid e r
alte ring lid / le ns attachme nt to raise or lowe r the le ns
Consid e r rig id or hyb rid op tions, monovision with toric so t le nse s or toric
multi ocal so t le ns
Consid e r ‘top up ’ sp e ctacle s or sp e ci c activitie s or comb ine multi ocal
sp e ctacle s or the se activitie s and multi ocal contact le nse s or othe r
activitie s
Consid e r alte rnating -vision contact le nse s
Consid e r same op tions as or e xacting visual re q uire me nts b ut b e p re p are d
or p atie nt not to acce p t any o the m
I ce ntration is g ood the n incre asing the ad d should he lp . I not, chang ing
to a d i e re nt d e sig n would b e the b e st ne xt ste p .
For so t le nse s use low coe cie nt o riction mate rial. Avoid hig h-mod ulus
mate rials and e nsure we ttab ility is hig h.
For rig id le nse s consid e r re tting in hyb rid multi ocals.
Ensure le ns volume is low and e d g e is tap e re d .
Ensure vision is op timize d as p oor vision can imp act on sub je ctive com ort.
Upper-lid movement also plays an important role in lens trans-
lation, as the upward movement o the lower lid is restricted
to about 0.8 mm (Borish and Perrigin, 1987). It may be more
challenging to t patients with ambient pupil sizes greater than
3 mm, as the segment has to be positioned lower to avoid the
pupil margin and consequently requires greater translation to
achieve adequate pupil coverage o the near portion.
Ge ne ral Princip le s of Le ns De sig n
T e two distinct portions that make up an alternating lens are
either used (encapsulated) or solid segments with a range o
alternative shapes available (Fig. 23.21).
Lens stability, position and translation can be controlled by
introducing prism on to the lens, truncating the lens, or both. A
more recent alternating so lens design uses prism and dynamic
stabilization to orient the lens correctly and is available as a toric
option. Regardless o lens design, the success o alternating-
vision contact lenses is made possible by adequate lower-lid
tone, which acilitates upward translation o the lens during
downgaze. T is positions the near portion o the lens over the
pupil and allows near vision. T e truncated edge should be n-
ished in such a way as to encourage com ortable e ective trans-
lation and minimize the risk o the lens slipping beneath the
lower lid.
Solid Design. Designs are cut rom a single piece o material
and the segment shape and design can vary (see Fig. 23.21). In
some older designs where the optical centres o the distance
and near portion do not coincide, image jump will occur with
downgaze, and lenses o 3.00 D or greater requently result in
intolerable diplopia or the wearer. For this reason, it is better
to avoid lenses in these powers and use a monocentric design.
In these designs the optical centres o both distance and near
portions o the lens are coincident, which produces a straight-top
 23 Pre sb yo p ia 225

Fig . 23.20 (A) Se g me nt p ositio ne d in p rimary p osition o g aze .

(B) Se g me nt p ositione d ove r p up il in d owng aze d ue to succe ss ul
le ns translation. (C) In anothe r p atie nt, se g me nt p ositione d p oorly
d ue to ailure o the lowe r lid to translate the le ns up ward s.

less translation is required to allow e ective near correction. T e

design is also more orgiving i the lens rotates out o position
compared with straight-top designs, and also has negligible
image jump (Fig. 23.22).

Fused Design. Fused-segment rigid lenses use a used insert

Fig . 23.21 Bi ocal se g me nt shap e s. Fuse d : A = straig ht top ; B = cre s-
ce nt. Solid one -p ie ce : C = straig ht top ; D = re ve rse d cre sce nt; E = cre s-
ce nt; F = triang ular.
segment bi ocal contact lens with the same properties as an
‘executive’ bi ocal spectacle lens. riangular-shaped segments
are also available, which makes the design more independent o
pupil diameter compared with straight-top bi ocals, and o en
o higher re ractive index than the rest o the lens to generate
the add power, while the ront-sur ace curvature remains
continuous. T ere is minimal image jump and blanks are
supplied to laboratories allowing individual lens speci cations
to be made to order, including more complex ront- and back-
sur ace geometries. Care must be taken not to t these lenses
with the segment position too high as this increases the risk o
ref ections being noticed rom the top o the segment (Ruston
and Meyler, 1995). T e used segment is f uorescent, allowing
easy observation using a Burton lamp.
Le ns Fitting
Alternating rigid lenses are generally tted on alignment or with
minimal apical corneal touch. T e truncation should rest on the
lower lid. T e lens should have a vertical diameter at least 2 mm
smaller than the horizontal visible iris diameter; this encour-
ages the required in erior centration and rapid recovery o lens
226 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
Fig . 23.22 (A) Triang le -shap e d se g me nt d e sig n. (B) Triang le -shap e d
se g me nt in p rimary p osition o g aze . (Courte sy o David Ruston.)
position ollowing blink as well as upward movement during
depressed gaze. ranslation over the corneal sur ace is more
likely i there is unimpeded vertical movement, so a steep- tting
approach should be avoided. In general, a lens tted too steeply
will tend to rotate nasally (Fig. 23.23) and shows poor translation,
unlike a f at lens t, which rotates temporally and decentres.
Most alternating bi ocal contact lenses are tted so that the
segment is positioned in line with the in erior pupil margin dur-
ing primary gaze in ambient illumination. Alternatively, some
solid designs are such that the segment should be tted higher
to occupy approximately 20% o the pupil area (Fig. 23.24).
More importantly, the near segment should occupy at least
75% o the pupil diameter during depressed gaze to allow ade-
quate near vision. As a general rule, it is best to err on setting the
segment top slightly high as this can subsequently be lowered
by increasing truncation (Gasson and Morris, 1998). A near-
horizontal segment line position is pre erred; however, a small
Fig . 23.23 Nasal rotation re sulting ro m a ste e p - tting translating im-
ag e le ns. (Courte sy o David Ruston.)
Fig . 23.24 Id e al se g me nt line p ositio n o a straig ht-top solid d e sig n
or d istance vision.
amount o nasal rotation is acceptable because the natural con-
vergence o the eyes at near helps o set this rotation (Edwards,
1999).
Observing segment positions under slit-lamp illumination can
be deceptive owing to the resultant pupil miosis. A better assess-
ment can be made using an ophthalmoscope ocused on the lens
sur ace. I an optimal alignment t shows signi cant rotation
away rom the desired position, the lens can be reordered with
prism o set by the angle through which the lens mislocates to
compensate or the rotation. For example, i the lens persists in
rotating by 15° nasally in the right eye, ordering the prism base
at 285° rather than 270° orients the lens correctly. Increasing the
amount o prism can also be use ul in reducing superior centra-
tion. Discom ort and adequate oxygen delivery (mainly due to
lens thickness) are still challenges or so alternating designs.
MO NO VISIO N
Monovision is the correction o one eye with the required dis-
tance re ractive power and the other eye with the required near
re ractive power. T is approach is based upon the principle that

Fig . 23.25 Log MAR acuity at d istance and ne ar at two contrast le ve ls
or sp e ctacle , monovision and simultane ous-imag e multi ocal corre ction.
Fig . 23.26 Ne ar ste re op sis me asure s or sp e ctacle s, monovision and
ce ntre -ne ar (CN) multi ocal contact le ns (MFCL) we are rs.
the visual system can alternate central suppression between the
two eyes when viewing is alternating between distance and near
targets. T e degree o interocular blur suppression, which varies
between patients, may be linked to the nal success o monovi-
sion. Essentially all orms o so and rigid contact lenses can
be used or monovision corrections, whether spherical or toric.
T e more recent availability o new hydrogel materials with
embedded wetting agents and silicone hydrogel materials, some
o which can reduce lens-related dryness symptoms in this age
group, are also help ul when tting monovision.
With monovision correction, there is only a slight reduction
in per ormance in distance acuity tests compared with spectacle
correction, and no signi cant di erence in acuity results at near
vision (Back et al., 1992). When comparing spectacle, mono-
vision and simultaneous-image centre-near lenses, results or
high-contrast and low-contrast visual acuity at distance were
comparable (Richdale et al., 2006), with some losses or both
monovision and simultaneous vision in low contrast at near
(Fig. 23.25). Distance and near stereopsis is compromised with
monovision (Richdale et al., 2006) (Fig. 23.26), but the degree o
reduction is patient speci c and may or may not result in ailure
with this method o tting.
Contrast loss and di culty in suppressing bright images
against dark backgrounds (e.g. car headlights) while wear-
ing monovision lenses may also contribute to poor tolerance
(Schor et al., 1987). Glare when driving at night is the most
common complaint and this should be discussed with the
potential monovision wearer during the initial tting assess-
ment. Despite such compromises, monovision has historically
23 Pre sb yo p ia 227
had high patient acceptance in early and moderate presbyopia
with success rates varying rom 67 to 86% (Koetting and Castel-
lano, 1984; Back et al., 1989; Collins et al., 1994). Monovision
causes little compromise in near visual acuity per ormance in all
illumination conditions; thus, this type o tting option could
be considered or presbyopic patients with strong near-vision
demands when multi ocal options have ailed. However, when
critical or sustained tasks requiring good binocularity predomi-
nate, it is advisable to avoid monovision or to consider supple-
mentary correction.
Although visual acuity measures may compare avourably
with spectacle correction, this orm o correction has several
limitations. Whereas binocular high-contrast visual acuity is
similar to that in multi ocals, contrast sensitivity unction is
reduced binocularly (Rajagopalan et al., 2006; Richdale et al.,
2006). When wearers have experienced both modes o correc-
tion, most pre er multi ocals to monovision (76 versus 24%)
(Richdale et al., 2006)
It is also important to remember that success with monovi-
sion and clarity o intermediate vision decline as the required
addition and interocular disparity increases (Evans 2007). It is
or this reason that many practitioners now pre er to introduce
multi ocal contact lenses to patients at the onset o presbyopia,
with the belie that they can remain in this mode o correction
longer than with monovision. T e current pre erence or multi-
ocal contact lenses over monovision is evident rom a survey
o multi ocal versus monovision prescribing in 34 countries in
2015 (Fig. 23.27) (Morgan et al., 2016). Although the extent o
prescribing or presbyopia varies between the nations surveys,
it is clear than multi ocal lenses are the pre erred choice. It may
now be considered that monovision should be employed only
when multi ocal contact lenses are not available or have not
adequately satis ed the patient’s visual needs.
Ge ne ral Princip le s of Monovision Fitting
No single predictive test exists to identi y success ul monovision
patients, so systematic trial and error is the best approach. How-
ever, the initial impression o the patient can be an important
indicator o likely success. T e more usual tting approach is
to t the dominant eye with the distance-vision-correcting lens
and the non-dominant eye with the near-vision-correcting lens
(Jain et al., 1996; Maldonado-Codina et al., 1997). It is impor-
tant to correct any astigmatism equal to or greater than 0.75 D
in either or both eyes; uncorrected astigmatism can result in
reduced visual per ormance, asthenopic symptoms and poor
tolerance. Binocular visual acuity similar to that achieved with
the spectacle correction – with no signi cant reduction in ste-
reopsis or contrast sensitivity – is usually a good sign o likely
success.
Some patients require spectacles or de ciencies with mono-
vision to wear ‘over’ their monovision contact lens correction.
For example, there may be a requirement or extra minus cor-
rection over the near-correcting lens / eye and plano over their
distance-correcting lens to give ull binocular vision and opti-
mal distance acuity or night driving, especially when higher
reading additions are required. T e degree o interocular blur
suppression, which varies between individuals, may be linked
to the nal success o monovision.
Partial Monovision
In general, the acceptance and there ore success o monovision
alls as the reading add increases (Schor et al., 1987; Erikson,
228 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns

1988, Evans 2007). With reading adds over +2.50 D at low
levels o illumination or with near-threshold stimuli, visual
per ormance o monovision wearers is reduced (Johannsdottir
and Stelmach, 2001). As the e ective add increases, binocu-
lar stereoacuity has also been shown to decrease (Heath et al.,
1986). As the indicated add exceeds +2.00 D, tolerance can
o en be improved i a reduced reading addition is given. T e
patient may need supplementary glasses or small print, a di -
erent pair o supplementary glasses or driving or a secondary
distance-correcting contact lens. T is orm o monovision is
ideal or social users whose near-vision demands will be lower
than that o ull-time wearers. Partial monovision may also be
a use ul strategy or patients who have greater intermediate-
vision needs.
Enhance d Monovision
Enhanced monovision – which is considered by some to be a
modi ed monovision tting approach – involves tting one
eye with a multi ocal lens and the other with a single-vision
lens. A variety o options exist. T e most requent approach
involves tting the dominant eye with a single-vision distance
lens (spherical or toric) and the non-dominant eye with a mul-
ti ocal lens. T is improves binocular summation provided that
the induced optical disparity remains low and o ers some level
o stereoacuity to the monovision wearer who is experiencing
increasing blur with a higher reading add. Alternatively, the
same approach can be used when tting patients who require
sharper distance vision than bilateral simultaneous image can
o er. T e multi ocal lens in the non-dominant eye may need
more bias or near vision. T is modi cation can be achieved
e ectively by increasing the distance power o the multi ocal
lens by +0.50 D to +0.75 D.
Other enhanced monovision options include:
• a single-vision near lens in the dominant eye to improve
near vision and a distance-bias multi ocal lens in the non-
dominant eye
• a single-vision lens with slightly excess plus power in the
dominant eye and an intermediate-bias multi ocal lens in
the non-dominant eye
A summary o the di erent problem-solving approaches or
monovision tting is shown in Fig. 23.28.
Monovision remains an e ective approach or some pres-
byopic patients and can o er less objective visual compromise
than simultaneous image lenses in high- and low-contrast visual
environments. However, a study by Dutoit et al. (2000) has
shown that adapted monovision wearers rated many aspects o
subjective vision per ormance – such as distance vision in good
and poor lighting, driving at night and depth perception – to
be superior with simultaneous image multi ocal contact lenses.
Near vision in poor lighting was rated higher during monovi-
sion wear. Subjects with no previous experience o presbyopic
contact lens correction pre erred monovision compared with
multi ocal correction (58% versus 42% i excluding spectacle
lens pre erence).
Mod ifie d Monovision
Modi ed monovision involves adjusting the re ractive power
o the lens or selecting alternative lens designs or each eye
to improve distance vision deliberately in one eye, at the
expense o near per ormance in that eye, while improving near
vision in the other. T is can be achieved by increasing minus
power / decreasing plus power on the dominant eye to enhance
distance vision while decreasing minus power / increasing plus
power in the non-dominant eye. A similar bias can be obtained

Fig . 23.27 Multi ocal and monovision contact le ns ts as a p rop ortion o all so t le ns ts to p re sb yop e s (those ove r 45 ye ars o ag e ) in 34 nations
in 2015. Country cod e s: AT = Austria; AU = Australia; BG = Bulg aria; BR = Brazil; CA = Canad a; CH = Switze rland ; CN = China; CZ = Cze ch Re p ub lic;
DE = Ge rmany; DK= De nmark; ES = Sp ain; FR = France ; GR = Gre e ce ; HU = Hung ary; IL= Israe l; IR = Iran; IT = Italy; JP = Jap an; KR = Kore a; LT = Lithu-
ania; MX= Me xico; MY= Malaysia; NL= Ne the rland s; NO = Norway; NP = Ne p al; NZ = Ne w Ze aland ; PH = Philip p ine s; PT = Portug al; SE = Swe d e n;
SI = Slove nia; SK= Slovakia; TW = Taiwan; UK= Unite d King d om; US = Unite d State s.

by using di erent add powers in each – the lower-add power
being tted to the dominant eye to improve distance vision.
Similarly, one eye may be tted with a centre-distance simulta-
neous design and the other with a centre-near design lens. More
recently lens designs are available that use this modi ed-mono-
vision approach automatically when tting presbyopic patients.
As noted previously, the amount o optical disparity needs to be
low to maintain binocular summation.
Co nclusio n
T e key to meeting the visual needs o a presbyopic patient is the
development o an awareness o the di erent tting approaches
and lens designs, and the associated advantages and disadvan-
tages o each ( able 23.3).
It is equally important to gain an appreciation o the per-
sonality, occupation and previous lens-wearing history (i
any) o the patient. Presbyopia correction is o ten perceived
by practitioners as being complicated to it, with limited
Fig . 23.28 Prob le m-solving ap p roache s or monovision tting . (Ad ap te d rom Be nne tt, E. S., Jurkus, J. M. & Schwartz, C. A. (2000). Bi ocal contact
le nse s. In E. S. Be nne tt & V. A. He nry (e d s) Clinical Manual o Contact Le nse s (2nd e d ., p p . 410–449). Philad e lp hia, PA: J. B. Lip p incott Co.)
23 Pre sb yo p ia 229
success rates; however, there are now more lens options than
ever to o er our presbyopic patients, resulting in higher it-
ting success rates than previously. No correction option or
presbyopia (including spectacles) is without some compro-
mise and the lack o a ‘per ect’ contact lens option should
not discourage practitioners rom itting this ever-increasing
patient base. New simultaneous designs with improved opti-
cal per ormance and itting approach are now relatively easy
to prescribe, supported urther by the availability o single-
use diagnostic lenses that allow e ective trials to help elimi-
nate ailures prior to dispensing. Daily disposable multi ocal
lenses are also available or patients, o ering even greater
levels o convenience whether worn every day or part-time.
here are multi ocal lens designs available in enhanced
hydrogel, silicone hydrogel and high-permeability rigid lens
materials, which may enable continuous wear o the lenses
(Lakkis et al., 2006).
I the initial lens powers selected ail to provide adequate
visual per ormance, alternative tting approaches, such as
230 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
TABLE
23.3 Ad vant ag e s and Disad vant ag e s o f Le ns Fit t ing O p t io ns fo r Pre sb yo p ia Co rre ct io n
Ad vant ag e s
SIMULTANEO US IMAGE
Availab le in b oth rig id and so t d e sig ns
Vision in all d ire ctions o g aze
Late st d e sig ns have hig h tting succe ss rate s
Ste re oscop ic vision maintaine d
No rotational stab ility re q uire d
Usually more com ortab le than alte rnating d e sig ns
Availab le as sing le -use so t d isp osab le trial and p re scrip tion le nse s
Easie r to t than alte rnating d e sig ns
ALTERNATING IMAGE
Distance and near acuity can be comp arable with sp e ctacle correction
Minimal re d uction in ste re op sis
Minimal re d uction in contrast
MO NO VISIO N
Simp le tting me thod
Binocular hig h-contrast visual acuity similar to sp e ctacle s
Larg e rang e o le ns d e sig ns / mate rials to choose rom
Le ss e xp e nsive than multi ocal op tions
No ad d itional tting se ts re q uire d
Patie nts q uickly acce p t or re je ct te chniq ue
Can e asily corre ct astig matism
TABLE
23.4 Clinical Pe arls fo r Pre sb yo p ia Fit t ing
Se t re alistic e xp e ctations up ront. Succe ss is what is rig ht or the
p atie nt and re me mb e r the 20 / hap p y rule
De cid e your clinical strate g y with e ach p atie nt and avoid trying d i -
e re nt d e sig ns b ase d on the same op tical p rincip le . Consid e r d i -
e re nt ap p roache s, includ ing mod i e d monovision and e nhance d
monovision
Stud y and ollow the manu acture r’s tting ad vice or any one p ar-
ticular d e sig n o le ns, as the y all d i e r slig htly in d e sig n characte r-
istics and op timal tting
(Ad ap te d rom Christie and Be e rtre n, 2007)
enhanced and modi ed monovision, can be explored. Key t-
ting tips are summarized in able 23.4.
Alternating designs can be added to the lens choice to o er
patients bi ocal correction i more exacting visual per ormance
is required. In addition, monovision remains an alternative
option or some presbyopic patients. No one lens design will
work or all patients, there ore it is recommended that practi-
tioners select and use two to three alternative lens designs so
that a sound clinical approach can be developed and used with
con dence. T ere is no doubt that, with recent improvements in
optical design, material choice and greater availability o daily
Disad vant ag e s
Some visual ad ap tation re q uire d b y p atie nt
Some contrast loss always occurs, e sp e cially in low luminance
More d i cult to e stab lish re ractive e nd -p oint d uring ove rre raction
O p tical p e r ormance can d e p e nd on p up il size (varie s with d e sig n)
Le ns ce ntration more critical
Fitting more comp le x
Pe r ormance g aze d e p e nd e nt
Inte rme d iate corre ction not always an op tion
Lid p osition and tig htne ss critical to succe ss
Com ort can b e lowe r than simultane ous vision d e sig ns
Sig ni cant re d uction in ste re op sis (e sp e cially at ne ar); howe ve r,
p atie nt d e p e nd e nt
Unsuitab le or monocular p atie nts or those with sig ni cant amb lyo-
p ia (6 / 12 or worse )
Loss o contrast se nsitivity
Re d uce d inte rme d iate corre ction as re ad ing ad d incre ase s
Succe ss rate alls as re ad ing ad d incre ase s
He ad lig ht g lare can b e d i cult to tole rate
Re d uce d b inocular summation
Always asse ss vision p e r ormance with b oth e ye s op e n using re al-
world targ e ts, such as the p atie nt’s mob ile p hone . Le t the p atie nt
trial le ns p e r ormance at home and work, and have the p atie nt
re turn a we e k late r or ollow-up asse ssme nt
Avoid p horop te rs or ove rre raction. Trial rame or f ip p e rs are b e st
and look or an imp rove me nt in ove rall vision. Use the Sne lle n
le tte r chart only to re cord visual acuity or le g al p urp ose s and as a
b e nchmark or uture le ns chang e s
Always look or the op timal b alance b e twe e n ne ar and d istance vi-
sion that me e ts the p atie nt’s visual ne e d s
disposable products, the number o patients being tted with
contact lenses or presbyopia will continue to increase, allow-
ing existing wearers to enjoy the bene ts o lens wear and new
wearers to be tted at the onset o presbyopia.
ACKNO WLEDGEMENTS
T e authors would like to acknowledge Eric Papas and Kurt Moody or
their constructive input to the content o this chapter.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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230.e 1
24
Ext e nd e d We ar
NO EL A BRENNAN | M-L CHANTAL CO LES
Int ro d uct io n
Practitioners and researchers have long sought to develop a lens
that can be worn on an extended basis. T e term ‘extended wear’
(EW) has generally been applied to describe wear o contact
lenses or periods in excess o 24 hours between removal, includ-
ing sleep with the lenses on eye and regular, planned removal
o the lenses. T e term ‘continuous wear’ was originally used
to describe prolonged wear o unspeci ed duration, but was
discarded during the early 1980s because prolonged wear was
considered to be an unachievable goal. In the late 1990s, ‘con-
tinuous wear’ was reintroduced as a term to describe intended
lens wear o up to 30 days between removals. o a certain extent,
the terms are used interchangeably, but or the purposes o this
chapter, the term ‘extended wear’ will be used.
T e demand or more convenient orms o optical correction
has increased over the years. Numerous marketing surveys have
revealed the desire o the majority o the contact-lens-wearing
population or EW. Various actors in uence this desire: con-
venience, a sense o vulnerability, particularly in patients with
higher re ractive errors, relie rom tedious maintenance and
handling procedures, and vocational and li estyle issues. T e
widespread interest in re ractive surgery since the 1980s under-
scores the appeal o a longer-term solution to re ractive error.
Marketing surveys agree that the recommendation o the prac-
titioner is critical in determining the choice o correction. T e
industry, practitioners and patients alike have there ore keenly
sought the development o a sa e and e ective EW contact lens.
For a detailed history o EW the reader is re erred to Bren-
nan and Coles (1997). Analysis o the early ventures in EW pro-
vides important clues as to the pit alls with this wearing style.
T e current status o EW and its current ormat can be traced to
the prominent aspects o this history.
Exp e rie nce s w it h Ext e nd e d We ar
T e earliest report o EW appears to be a 1957 description o a
non-compliant patient wearing an oxygen-impermeable poly-
methyl methacrylate (PMMA) contact lens continuously or
3 months. Details o a planned clinical trial were published in
1965, reporting on 50 patients wearing PMMA on a continu-
ous-wear basis over a 7-year period (that is, without planned
removal or replacement). Although such lenses have long since
been condemned as unsuitable or EW, the absence o complica-
tions in these reports is noteworthy, and indicative o the resil-
ience o the eye to sleeping in contact lenses.
CO NVENTIO NAL SO FT EXTENDED WEAR
T e original so lenses, designed or long-term repeated
usage, are now re erred to as ‘conventional’, ‘traditional’ or
‘unplanned-replacement’ hydrogel lenses to distinguish them
rom ‘ requent-replacement’ or ‘disposable’ lenses. So hydro-
philic lenses were introduced around the world in the late 1960s
and early 1970s as a result o the pioneering work o Wichterle.
T ese lenses were very well received by the public, which was
principally due to the com ort a orded. Contact lens sales
promptly soared. But the inconvenience o caring or the lenses
and the need to insert and remove them on a daily basis led to
increased experimentation with extended periods o wear.
Early reports ocused on the use o prolonged periods o wear
or therapeutic use, particularly in aphakia. Perceived advan-
tages included alleviation o the possible risks associated with
removal and handling o lenses rom diseased eyes and relie or
patients with limited dexterity. T e rst material promoted or
use in cosmetic EW was per lcon A (Permalens™ , CooperVi-
sion, Rochester, NY). It was suggested at the time that this could
be worn continuously, day and night, or many months or even
years (E ron et al., 2012).
Numerous studies o so lens EW or cosmetic use soon
appeared with encouraging results. T e remainder o this chap-
ter deals largely with EW lens usage or such a purpose. Fol-
lowing clearance by the US Food and Drug Administration
(FDA) or cosmetic EW in 1981, a large proportion o contact
lens prescriptions, particularly in the USA, were written or this
purpose. An intense and exciting period o research ollowed
during which many o the problems preventing complication-
ree EW were identi ed.
T e reports o early clinical experiences with hydrogel EW
lenses are too numerous to review here, but even a cursory
review shows dramatic variation in quoted success rates. Such
di erences appear to depend upon patient selection, the type
o lenses tted, tting approach (tight or loose), diligence o
ollow-up, and criteria used by investigators in assessing the
severity o adverse reactions and in the categorization o suc-
cess. For example, the study o Lamer (1983) reports a success
rate as high as 81% ollowing 3 years’ EW compared with 48%
reported by Binder (1983). Variation in study design remains a
common problem in modern evaluation o EW success.
Despite the apparently low success rate, the retrospective
study o Binder (1983) provides good insight into the success
o these trials. T is article reviewed over 1000 patients entered
into a number o FDA regulatory studies o EW lenses, with
intended wearing times o 2–4 weeks. As noted above, nearly
hal (48.5%) o patients ‘survived’ EW with only minor problems
or 3.5 years. O the discontinuations, almost a third (31.3%) o
the subjects did so prior to beginning EW, 16.2% were lost to
ollow-up, 14.5% ound lens com ort inadequate, and 12% expe-
rienced ocular complications. T e requency o individual com-
plications was as ollows: injection 3.7% (o the discontinued
group), abrasion 1.6%, conjunctivitis 1.4%, contact-lens-related
papillary conjunctivitis (CLPC) 1.4%, neovascularization 1.1%,
231
232 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
dry eye, epithelial staining and oedema all less than 1%, and
in ections 0.2%.
T e relative success observed in these trailblazing studies was
quite astounding and provided considerable scope or optimism
that relatively minor adjustments to the lens parameters would
provide a sa e, e ective correction. By modern standards though,
these studies used lenses and modalities that were grossly inap-
propriate or EW. T e thick hydrogel lenses had oxygen trans-
missibility (Dk / t) levels that were later deemed to be inadequate.
T e period between lens removal was also up to 6 months in
many o the early studies, and more recent research has arrived
at the conclusion that this interval is too long or uncomplicated
wear. But by ar the greatest hazard with these early EW lenses
was the emerging picture o severe complications due to in ec-
tious keratitis. A study conducted in the USA in 1987 and spon-
sored by the Contact Lens Institute (CLI) demonstrated that
sleeping in contact lenses posed a signi cant risk over and above
that o contact lens wear alone (Poggio et al., 1989). T e adverse
publicity subsequent to publication o this study meant that EW
usage decreased dramatically during the 1990s.
NO N-HYDRO PHILIC MATERIALS
T e high oxygen permeability (Dk) o silicone elastomer led to
interest in using this material or extended contact lens wear.
In the late 1970s, a number o tting trials were undertaken.
Un ortunately, the hydrophobic nature o the lens sur ace
resulted in poor wetting and sur ace deposition (Fig. 24.1). T e
highly elastic nature o the material and resistance o the mate-
rial to water permeation also brought about lens binding. T ese
actors prevented the success o this material except or limited
use in paediatric and aphakic tting.
owards the mid 1980s, rigid gas-permeable materials
became a popular alternative to hydrogels or EW, the principal
attraction being a higher Dk / t without the adverse properties
o silicone elastomer. Other perceived advantages o rigid lenses
over hydrogel lenses include a higher rate o tear exchange
beneath these lenses, less corneal coverage and a more inert lens
sur ace.
A considerable body o literature provided evidence or
success ul EW in patients using these lenses (Maehara and
Fig . 24.1 A silicone e lastome r le ns d isp laying p oor we tting . (Courte sy
of Timothy Grant, Bausch & Lomb Slid e Lib rary.)
Kastl, 1994). Certainly, preclinical evaluations con rmed
that rigid lenses produced ewer oxygen-related physiological
changes, such as corneal oedema, than hydrogels. However,
there remained a range o limitations with rigid lenses or EW.
Complications ound with hydrogels, such as in ectious kera-
titis, in ltrative keratitis and CLPC, were not eliminated. T e
elevated risk o in ectious keratitis caused by sleeping in con-
tact lenses observed with hydrogels was also evident with rigid
lenses (Macrae et al., 1991). As well, rigid lenses induce a greater
degree o initial discom ort than hydrogels and complications
largely unseen with hydrogels, such as 3 and 9 o’clock staining,
corneal distortion and lens binding.
Most practitioners have been unwilling to devote the addi-
tional time required to achieve a suitable t and deal with
patient complaints o discom ort, so rigid lenses are nowadays
rarely tted or traditional cosmetic EW. However, overnight
wear o rigid lenses to achieve temporary reversal o re ractive
errors, known as orthokeratology, maintains a ervent, i spe-
cialized, ollowing and has become a specialty area o contact
lens practice (Chapter 32).
DISPO SABLE SO FT LENSES
Ef ciencies o manu acture allowed Johnson & Johnson Vision
Care (Jacksonville, FL) to bring low-cost disposable lenses made
o eta lcon A material (Acuvue®) to the US market in 1987. T e
original intention was that the lenses be worn continuously or
1 week at a time. At the end o each week, the lenses were to be
discarded and replaced by a new set o lenses. In essence, this
was a simultaneous launch o the concepts o weekly EW and
lens disposability (E ron et al., 2012).
Frequent replacement o lenses o ers a range o potential
advantages or increasing EW success. Practitioners perceived
that the most signi cant problem with conventional hydrogel
lenses was the build-up o sur ace deposits and associated com-
plications, such as CLPC (Orsborn and Zantos, 1989). Frequent
replacement restricts exposure o the eye to accumulated aged
or denatured protein, which seems to act as an antigen in induc-
ing in ammatory reactions such as CLPC and in ltrative kera-
titis. Control o deposit build-up by requent replacement has
the urther advantage o reducing patient symptoms related to
vision and com ort.
While reducing exposure o the eye to lens deposition is the
outstanding advantage o disposable lenses, the regular provi-
sion o resh, clean lenses also showed promise in other areas.
T ere was hope that requent lens replacement would lead to
ewer bacteria being introduced to the eye, thereby reducing the
risk o in ectious keratitis during EW. In regard to lens mainte-
nance, disposability o ers simpli cation o cleaning procedures,
easier lens tting and replacement, and may serve to enhance
patient compliance.
In practice, the bene its with respect to ocular physiol-
ogy, symptomatology and convenience are compelling, and
replacement o lenses every day to every 2 weeks to 1 month
now predominates contact lens prescribing around the world
(Morgan et al., 2016). Clinical studies have certainly con-
irmed that requent replacement reduces the occurrence o
in lammatory events during EW. Both non-in ectious cor-
neal in iltrative events and CLPC show reduced incidence
with more requent replacement. However, these complica-
tions are not entirely eliminated, as will be discussed urther
below.

T e early enthusiasm or prescribing EW with disposable
hydrogel lenses was not maintained. Although the CLI-spon-
sored study was restricted to conventional replacement contact
lenses, damage to the reputation o EW had been done (Pog-
gio et al., 1989; Schein et al., 1989). A number o publications
reported on corneal in ections in association with requent-
replacement lenses. Academics and educators delivered wide-
spread warnings o the potential complications o EW. By and
large, practitioners around the world ell in line and EW pre-
scribing dropped to very low levels globally by the end o the
1990s.
Moreover, despite the apparent bene ts and contrary to the
hopes and expectations o the contact lens industry, requent
contact lens replacement ailed to achieve the desired impact
on the rate o in ectious keratitis. Reports in the early 1990s
suggested that the requency o in ections with disposable
lenses was equal to or even greater than that with conventional
replacement. In a nationwide survey o ophthalmologists in the
Netherlands in 1996, Cheng et al. (1999) demonstrated that
rates o in ection with disposable lenses, in both daily and EW,
were essentially the same as those observed in the CLI study
(Poggio et al., 1989). Despite the signi cant advantages o ered
by disposability, it was evident that the industry had to look
elsewhere or answers to the challenge posed by in ectious kera-
titis with EW.
SILICO NE HYDRO GEL CO NTACT LENSES
With the ailure o requent-replacement hydrogel lenses to
solve the EW in ection problem and persistent physiologi-
cal compromise to the cornea during closed eye wear, the
industry turned its attention to the development o materi-
als with high Dk. In the late 1990s, silicone hydrogel (SiHy)
contact lenses were introduced to the market. he details o
the advances incorporated in these materials are presented
in Chapter 4. In brie , the high Dk and good handling char-
acteristics o silicone are combined with the lexibility and
com ort o hydrophilic materials. Considerable advances
24 Ext e nd e d We ar 233
in technology over previously manu actured lenses were
required to combine these two ostensibly incompatible mate-
rials, not the least o which was new technology to produce
a wettable, deposit-resistant sur ace. he early lenses used
plasma sur ace coatings, but later generations o lenses man-
aged to circumvent the need or this additional manu actur-
ing step.
Clinical research demonstrated that EW o SiHy lenses
produce ewer physiological changes, such as microcysts, cor-
neal striae and endothelial blebs and less limbal and bulbar
conjunctival injection, than did hydrogel lenses (Covey et al.,
2001; Brennan et al., 2002; Inagaki et al., 2003; Rad ord et al.,
2009). T ese bene ts arise rom the lowered resistance o the
materials to oxygen ow. SiHy lenses may also, on occasion,
provide the added bene ts o less corneal staining, less sub-
jective dryness and discom ort, and better handling, owing
to properties such as hydration, modulus, sur ace and design
characteristics.
T ese advantages o SiHy lenses were quickly recognized and
some countries such as Australia, which had previously shunned
EW, enthusiastically adopted these new materials. Other coun-
tries such as the USA and the UK, ollowing ailure o the EW
oray o the 1980s, were more cautious in approach. Nonethe-
less, by 2003 some 10% o all contact lens ts worldwide were
or EW (E ron et al., 2012).
Although the increased corneal oxygenation a orded by
SiHy lenses virtually eliminated physiological or metabolic
corneal disorders during EW, epidemiological studies revealed
that, despite the hopes o the contact lens community, there
was little impact on corneal in ection rates ( Morgan et al.,
2005; Schein et al., 2005; Dart et al., 2008; Stapleton et al.,
2008). As a result, the tting o EW in practice remained at no
more than about 10% globally until 2007 and had declined to
around 8% by 2015 (Morgan et al., 2016) (Fig. 24.2). Nonethe-
less, the vast majority o EW ts are in SiHy materials (Fig.
24.3). T ere remain pockets o devotees to EW, with countries
such as Norway, Lithuania and Sweden continuing new ts
into EW in high numbers.
Fig . 24.2 Exte nt o e xte nd e d we ar so t
co ntact le ns tting as a p e rce ntag e o all
so t le nse s p re scrib e d in se ve n nations b e -
twe e n 2000 and 2015.
234 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns

Fig . 24.3 Exte nd e d we ar so t contact le ns ts as a p rop ortion o all so t le ns ts in 34 nations in 2015. Country cod e s: AT = Austria; AU = Australia;
BG = Bulg aria; BR = Brazil; CA = Canad a; CH = Switze rland ; CN = China; CZ = Cze ch Re p ub lic; DE = Ge rmany; DK= De nmark; ES = Sp ain; FR = France ;
GR = Gre e ce ; HU = Hung ary; IL= Israe l; IR = Iran; IT = Italy; JP = Jap an; KR = Kore a; LT = Lithuania; MX= Me xico ; MY= Malaysia; NL= Ne the rland s;
NO = Norway; NP = Ne p al; NZ = Ne w Ze aland ; PH = Philip p ine s; PT = Portug al; SE = Swe d e n; SI = Slove nia; SK= Slovakia; TW = Taiwan; UK= Unite d
King d om; US = Unite d State s.

SUMMARY daily-wear contact lenses, such as corneal staining, discom ort

As E ron et al. (2012) explain, EW prescribing ‘has ailed to break
through the “glass ceiling” o 15% and is unlikely to become a
mainstream lens-wearing modality until the already low risks o
ocular complications can be reduced to be equivalent’ to those
or daily wear. In particular, a continued EW microbial kerati-
tis rate o around 20 per 10 000 wearers per year is considered
problematic. T e industry is in need o urther breakthroughs,
say or example the commercial release o lenses with antimi-
crobial activity, be ore we are likely to see substantial expansion
o the EW market.
Ad ve rse E e ct s o Ext e nd e d We ar
T e presence o a contact lens on the eye brings with it a num-
ber o potential adverse responses. T is is the case whether the
lens is worn on a daily-wear or EW basis. A detailed discussion
o adverse events with contact lens wear is provided in Chap-
ter 40. Some speci c events are more prevalent during EW and
these are presented below. T e main eature o this discussion is
to analyse the mechanisms o the ocular changes and to review
risk actors and strategies to minimize these e ects. able 24.1
summarizes the major risk actors or complications with
EW and these, as well as methods or mitigating the impact,
are discussed in more detail below. Other issues common to
and the symptom o dryness, remain important in EW, but are
dealt with elsewhere in this book.
INFECTIO US CO RNEAL ULCERATIO N
In ectious corneal ulceration (Fig. 24.4) occurs with higher re-
quency in contact lens wearers than in non-lens-wearers, and
those who sleep in their lenses are at a higher risk than those
who wear their lenses on a strictly daily wear basis (that is, never
sleeping with lenses in). T e in ection can lead to tissue necro-
sis and massive in ammation. Pseudomonas and Serratia spe-
cies are the more commonly isolated bacteria rom in ectious
corneal ulcers in EW patients. T e incidence o in ection by
other microbial species such as ungi and Acanthamoeba may
be higher in contact lens wearers but there is no speci c evi-
dence to suggest a heightened risk with EW. Although viral and
chlamydial keratoconjunctivitis may also occur in contact lens
wearers, there is no elevated risk apparent with the wearing o
contact lenses.
Microbial keratitis can cause severe pain, photophobia and
distress and, in some cases, vision loss. With early hydrogel EW,
such problems were sensationalized by the lay press and numer-
ous cases o legal action were initiated. T e reported success o
the early trials in the light o later reports o a raised incidence
o in ectious keratitis with EW is not surprising given the rarity
 24 Ext e nd e d We ar 235

TABLE Risk Fact o rs o r In e ct io us, In ammat o ry and Physio lo g ical Chang e s Id e nt if e d in Clinical and
24.1 Ep id e mio lo g ical St ud ie s
Risk Fact o r Effe ct * Re me d y
MO DIFIABLE RISK FACTO RS
Sle e p ing in le nse s 1,2,3 Do not sle e p in le nse s
Long p e riod s (>6 nig hts) b e twe e n re moval 1,2 Re d uce d uration o EW
Long p e riod s b e twe e n le ns re p lace me nt 2 Fit d isp osab le le nse s o g re ate r re p lace me nt re q ue ncy
Hot climate s 1,2 Ed ucation and re in orce me nt; consid e r d aily d isp osab le s i on vacation
No / p oor hand washing 1,2 Ed ucation and re in orce me nt o hyg ie ne and care o le nse s
Poor care and mainte nance 1,2 Ed ucation and re in orce me nt o hyg ie ne and care o le nse s
Poor storag e case hyg ie ne 1,2 Fre q ue nt case re p lace me nt, e d ucation and re in orce me nt
Smoking 1,2 Counse l on incre ase d risks
Work e nvironme nt 1,2 Re d uce e xp osure to ocular irritants, use e ye p rote ction, counse l on risks
Top ical ste roid the rap y 1 Susp e nd EW until the rap y comp le te d
Inte rne t p urchase 1,2 Ed ucation on imp ortance o re g ular e xaminations, re g ular re vie w, re in-
orce me nt o hyg ie ne and care o le nse s
Tig htly f tting le nse s 2,3 Fit more mob ile le nse s
Low Dk / t 3 Fit SiHy le nse s
SiHy le ns we ar 2 Fit hyd rog e l le nse s
NO N-MO DIFIABLE RISK FACTO RS
Male g e nd e r 1,2 Use d iscre tion in p re scrib ing ; counse l on incre ase d risks
Ag e (12–25 ye ars) 1,2 Use d iscre tion in p re scrib ing ; counse l on incre ase d risks
Diab e te s 1,3 Use d iscre tion in p re scrib ing ; counse l on incre ase d risks
Early p e riod o EW 1,2 Use d iscre tion in p re scrib ing ; counse l on incre ase d risks

*1 = risk o microb ial ke ratitis; 2 = risk o corne al in ltrative e ve nts (CIEs); 3 = risk o p hysiolog ical d isturb ance .

ound similar estimates or the incidence o microbial keratitis,

con rming that EW entails a higher relative risk than does daily
wear o hydrogel materials, regardless o whether lenses are
worn in disposable or conventional mode, and whether they are
hydrogel or SiHy lenses (Cheng et al., 1999; Morgan et al., 2005;
Schein et al., 2005; Dart et al., 2008; Stapleton et al., 2008). T ese
epidemiological studies and other case reports have highlighted
a number o risk actors or keratitis with extended contact lens
wear (see able 24.1).
T e precise pathogenesis o contact-lens-related microbial
keratitis remains elusive. T e large-scale eld experiments o
requent replacement o lenses and use o SiHy materials tested
whether corneal lens spoliation and hypoxia were important
mechanisms o corneal in ection. Neither advance ‘moved the
needle’ with respect to the apparent rate o EW in ection. Recent
research implicates changes in virulence actors o P. aeruginosa
on prolonged exposure to the ocular environment and decay
in the antimicrobial activity o the post-lens tear uid during
lens wear as important aetiological actors ( am et al., 2010; Wu
et al., 2015).

NO N-INFECTIO US INFLAMMATO RY EVENTS

Fig . 24.4 Microb ial ke ratitis is the most conce rning e ature o e x-
te nd e d contact le ns we ar. This p icture shows a Pse ud omonas in e ction.
(Courte sy of Lynd on Jone s, Bausch & Lomb Slid e Lib rary.)
o in ection. Despite this low incidence, the large number o
people adopting EW led to a disturbingly high requency o
hospital admissions with contact-lens-related in ections. T is
concern came to the attention o authorities, who described it as
a ‘signi cant, preventable, public health problem’.
T e major epidemiological study sponsored by the CLI, as
mentioned above, determined that the incidence o clinically
diagnosed in ectious keratitis or daily-wear and EW hydro-
gel lenses was approximately 4 and 20, respectively, per 10 000
wearers per year (Poggio et al., 1989). Subsequent studies have
While in ectious keratitis is most o en cited as the reason or
ailure o EW in the 1980s, the high incidence o ‘non-in ectious’
corneal in ammatory events probably contributed strongly to
practitioner aversion to this mode o wear. Corneal in am-
mation is characterized by the migration and accumulation
o in ammatory cells into the epithelial and anterior stromal
space. Such events are collectively termed ‘corneal in ltrative
events’ (CIEs). T ese events may or may not be symptomatic.
Although CIEs are not sight threatening, they constitute a suf -
ciently acute response to cause interruption or even termination
o EW. Indeed, the Food and Drug Administration o the USA
has used CIEs as a surrogate measure o the sa ety o contact
lenses in pre-market-approval studies or 30-day continuous
236 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
Fig . 24.5 Both me chanical and hyp e rse nsitivity re sp onse s to le ns d e -
p osits can le ad to contact-le ns-re late d p ap illary conjunctivitis. (Courte sy
of Maki Shiob ara, Bausch & Lomb Imag e Lib rary.)
wear, as the low incidence o in ectious keratitis makes mea-
surement o the rate impractical in trials o new lens materials.
CIEs pose a considerable challenge or clinicians and
researchers alike with respect to diagnosis and classi cation and
these are discussed in more detail below. T e principal concern
is to separate those incidents that are truly in ectious, caused
by virulent organisms, likely to progress and in need o urgent
intensive treatment rom those that are apparently sterile or
caused by less virulent organisms, sel -limiting and in need o
no or minimal treatment.
Although a cornea may not su er rank in ection during a
so-called ‘sterile’ in ammatory keratitis, there remains consid-
erable circumstantial evidence that at least some o these events
are due to the presence o bacteria and their exo- and endotox-
ins at the corneal sur ace. Strategies that minimize the bacterial
load at the corneal sur ace may there ore help reduce the risk
o CIEs.
During EW, the incidence o symptomatic CIEs has been
ound to be between about 2.5–6% per year while inclusion o
asymptomatic events raises this range to 6–26% per year. EW
o contact lenses causes some two to our times increased risk
o CIEs compared with daily wear. T e wide range o values or
rates o CIEs probably arises rom di erences in experimental
designs. Prospective studies with more requent subject visits
certainly show higher rates o asymptomatic CIEs. A series o
studies ollowing the introduction o SiHy lenses with large
sample sizes has shown a consistent doubling o the rate o CIEs
with these lenses compared to hydrogel lenses (Szczotka-Flynn
and Chalmers, 2013). T is nding seems to be consistent across
wearing modalities. We hypothesize that this may relate to the
ability o hydrogel lenses to attract and retain non-denatured
protein to the lens sur ace, which may provide both antibacte-
rial and immunogenic advantages.
Another in ammatory condition, contact lens-related papil-
lary conjunctivitis (CLPC) (Fig. 24.5) was also a principal hin-
drance to success ul EW with early hydrogel lenses. As noted
above, use o requent-replacement contact lenses helped to
lessen the incidence o the condition with hydrogels. However,
the introduction o rst-generation high-modulus SiHy lenses
that were intended to be worn continuously or 30-day periods
saw the re-emergence o CLPC as a signi cant complication o
Fig . 24.6 Fold s ob se rve d in the p oste rior stroma ollowing ove rnig ht
we ar o le nse s o low to me d ium Dk / t. (Courte sy of Ste ve Zantos.)
contact lens wear. T is chronic in ammatory reaction o the
palpebral conjunctiva resembles vernal conjunctivitis but is
directly related to contact lens wear (see Chapter 40 or more
details). Both mechanical and antigenic stimuli are implicated
as causative agents. T us CLPC can be controlled in part by
using lenses with a more requent replacement schedule, a lower
modulus and a lower sur ace coef cient o riction.
ACUTE PHYSIO LO GICAL EFFECTS
When worn during eye closure, hydrogel lenses induce corneal
oedema, which is observable clinically on awakening as striae
and olds (Fig. 24.6). T e e ects persist or some time ollowing
eye opening, and in some cases throughout the day. In some
circumstances, visual disturbance, in the orm o haze and blur,
is noted. Although the acute e ects on corneal oedema resolve
rapidly, wearing a hydrogel contact lens in EW produces a recur-
ring pattern o oedema during the night ollowed by partial res-
olution during the day (Holden et al., 1983). Chronic exposure
to this un avourable environment is considered by some to be
detrimental to long-term corneal health.
T e short-term corneal oedema response has been the gold
standard or assessing the physiological challenge posed by a
contact lens to the eye and it has consequently been a avou-
rite area o investigation or researchers in the contact lens
eld. Understanding actors in uencing this response poten-
tially enables the practitioner to avert long-term adverse physi-
ological e ects. Interpretation o corneal swelling data relies on
comprehension o the expression o measurement, and some
standards against which this can be compared. ypically, cor-
neal oedema is expressed as a percentage swelling rom baseline
corneal thickness, which is usually and perhaps inappropriately
measured as the thickness o the cornea prior to sleep.
Since the cornea that is unadapted to contact lens wear swells
by approximately 4% centrally overnight, this value has been
suggested as a criterion or the sa e maximum level o oedema
 24 Ext e nd e d We ar 237

in response to overnight contact lens wear (Holden et al., 1983).

Fig. 24.7 plots this value against some o the yardsticks or eval-
uating oedema e ects, and Fig. 24.8 gives the average corneal
swelling or a range o di erent lens types.
T ese values are or central corneal swelling, but the cornea
does not swell uni ormly. Figs. 24.9–24.11 plot the topographi-
cal corneal swelling or three di erent lens types. In each cir-
cumstance, the temporal and nasal mid-peripheral cornea swell
more than the central cornea. It is apparent rom Figs. 24.10 and
24.11 that SiHy lenses provide near-normal levels o oxygen to
the cornea during sleep, where hydrogel lenses ail to do this.
Given the ability o SiHy lenses to meet the needs o the cornea
in this regard, other previously suggested criteria or acceptable
levels o overnight oedema should be abandoned.
Not all corneas exhibit the same baseline thickness, and not
all corneas swell by the same amount in either relative or abso-
lute terms. Fig. 24.12 plots the absolute change in corneal thick-
ness measured on two separate occasions versus the baseline
central thickness or 15 subjects wearing thin, medium-water,
hydrogel lenses. T is graph demonstrates intersubject variabil-
ity in both baseline thickness and the extent o swelling. While
variation in swelling between subjects is probably determined
by a complex combination o anatomical and unctional actors
– such as endothelial cell density – one additional prominent
eature seems to be the level o adaptation to contact lens wear.
T e cornea o a subject adapted to daily wear o hydrogel lenses
swells by 2% less than observed in an unadapted wearer, with
adapted extended wearers swelling less by a urther 1% (Cox Fig . 24.9 Thre e -d ime nsional re p re se ntation o ave rag e top og rap hical
co rne al oe d e ma re sp onse to we ar o silicone e lastome r le nse s und e r
et al., 1990). T e relative roles o adaptation versus residual close d -e ye cond itions. To the rig ht is the nasal d ire ction, and the close r
swelling in this e ect are open to some interpretation. None- re g ion is the in e rior corne a.
theless, this observation may in part explain some o the varia-
tion in di erent reports or mean swelling results to the same
stimulus. For example, estimates o the closed-eye swelling

Fig . 24.7 Guid e or asse ssing the imp act o oe d e ma in e xte nd e d we ar.

Fig . 24.10 Thre e -d ime nsional re p re se ntation o ave rag e top og rap hi-
cal corne al oe d e ma re sp onse to we ar o SiHy contact le nse s und e r
Fig . 24.8 Re p re se ntative ove rnig ht corne al swe lling in re sp onse to d i - close d -e ye cond itions. To the rig ht is the nasal d ire ction, and the close r
e re nt le ns typ e s. PMMA = p olyme thacryl me thacrylate . re g ion is the in e rior corne a.
238 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
response in the absence o a contact lens vary between 1.0 and
5.5%, a result that can be traced in part to the adaptation levels
o the subjects. T e criterion or the maximum acceptable level
o overnight corneal swelling should be viewed in the context
o this nding. I the baseline or contact lens corneal-swelling
studies is taken as the corneal thickness upon awakening with-
out overnight lens wear, then apparent variation between indi-
viduals and adaptation levels is substantially reduced.
Fig . 24.11 Thre e -d ime nsional re p re se ntation o ave rag e top og rap hi-
cal corne al oe d e ma re sp onse to we ar o a mid -wate r hyd rog e l le ns un-
d e r close d -e ye cond itions. To the rig ht is the nasal d ire ction, and the
close r re g ion is the in e rior corne a.
Fig . 24.12 O ve rnig ht ce ntral corne al swe lling o 15 sub je cts on two
o ccasions (Se rie s 1 and 2) with we ar o a mid -wate r hyd rog e l le ns. Ind i-
vid ual b ase line thickne ss variab ility is d e monstrate d b y variation along
the x-axis, and ind ivid ual swe lling d i e re nce s are shown b y the variation
along the y-axis.
Di erences in corneal swelling between subjects are o
unknown consequence. One study has suggested that sub-
jects prone to higher amounts o oedema are more likely to
discontinue lens wear and experience adverse ocular ndings
(Solomon, 1996). Another study ound no e ect, in that sub-
jects experiencing in ltrative keratitis show the same degree o
swelling as do subjects without complications (Stapleton et al.,
1998). An opposite argument can be proposed – that the cornea
adapted to EW, which shows the least amount o swelling, has
a reduced metabolic rate and thus has less healing capacity and
lower reserves or de ence against potential threats. T us, the
patient with a cornea that shows a high degree o swelling might
be more prone to contact lens intolerance, but at the same time
may be more resilient to threats against corneal health. Further
research is needed to resolve this question.
THE RO LE O F HYPO XIA
T e principal actor causing corneal swelling during overnight
lens wear is hypoxia (Holden and Mertz, 1984). A decrease
in oxygen concentration within the corneal epithelium leads
to anaerobic metabolism, o which the principal by-product
is lactate. Accumulation o lactate within the stroma creates
an osmotic pressure gradient into the cornea and also has
the e ect o lowering pH. emperature, tear osmolarity and
tear pH may also vary under the closed eye, but such vari-
ances contribute only a small amount o the overall oedema
response.
One way o assessing the oxygen ow through a contact lens
is by measurement o its Dk / t (see Chapter 4). T is laboratory-
derived gure gives an in vitro indication o the likely impact
o a lens on the eye and has become an industry standard. Cer-
tainly, the amount o swelling that occurs in a cornea can be
roughly related to the Dk / t o the lens (Fig. 24.13).
Holden and Mertz (1984) established a Dk / t criterion o
87 Barrer / cm to avoid excess oedema during overnight wear.
T ere were attempts in the interim to install alternate values,
but there seems to be limited scienti c basis to this rewriting
o history. Fig. 24.14 gives a graphical demonstration o the
Fig . 24.13 Variation in ove rnig ht corne al swe lling with we ar o le nse s
o various Dk / t value s or d i e re nt le ve ls o ad ap tation to d aily le ns
we ar (DW) and e xte nd e d le ns we ar (EW).
 24 Ext e nd e d We ar 239

variation in Dk / t or di erent lens materials manu actured at
minimum practical thickness or various powers.
It is clear that hydrogel materials all considerably short o
the Holden–Mertz criterion. Most SiHy and some rigid lenses
meet the desired level. However, the use o Dk / t values as a con-
cept alls short o providing a simple index by which the nega-
tive impact o a lens can be assessed. For example, doubling the
Dk / t does not double the amount o oxygen available.
Consumption values provide a more meaning ul index o the
corneal oxygen supply as these are direct linear estimates o the
volume o oxygen metabolized and o the energy thereby deliv-
ered (Brennan, 2005). Fig. 24.15 plots a mathematically derived
relationship between consumption and the anterior corneal
oxygen tension.
Comparison with Dk / t values and known swelling at these
values enables urther estimates o corneal swelling or various
closed-eye oxygen tensions. T is in ormation is illustrated in
Fig. 24.16. able 24.2 presents data or consumption values or
various lens types under closed-eye conditions. It is evident that
there are decreasing returns in overall consumption or increas-
ing values o Dk / t.
Although corneal oedema is the most-studied short-term
response to closed-eye contact lens wear, two other acute e ects
are worthy o note – limbal hyperaemia and endothelial blebs.
T e extent o both limbal hyperaemia (Papas et al., 1997) and
endothelial blebs (Inagaki et al., 2003; Brennan et al., 2008)
has been associated with oxygenation, and both conditions
are reduced when lenses o high Dk / t are worn. Acute limbal
hyperaemia (Fig. 24.17) may be important as a sign o cor-
neal in ammation and prolonged limbal hyperemia may have
clinical consequences as a precursor to corneal vascularization;
however, the endothelial bleb response seems to be clinically
inconsequential.
CHRO NIC PHYSIO LO GICAL CHANGES
Over the years, researchers have diligently assembled an inven-
tory o structural and unctional changes in the anterior eye as
a result o long-term EW o contact lenses. Many o these nd-
ings might be considered as harmless changes o physiological
interest rather than clinically relevant pathological e ects. T e
ormer category includes phenomena that are characterized by:
• a non-in ammatory nature
• a lack o threat to vision
• an absence o signi cance, unknown signi cance or lim-
ited signi cance when detected at a low level.
Long-term physiological changes have minimal impact on
the rate o patient discontinuation rom EW. It should be noted
that these changes are not necessarily restricted to EW, and
many o them are equally prevalent in daily wear. However, the

Fig . 24.16 Variation in ove rnig ht corne al swe lling ve rsus ante rio r cor-
ne al oxyg e n te nsion.
Fig . 24.14 Variation in Dk / t ve rsus p owe r or various le ns typ e s.

O xyg e n Co nsump t io n Est imat e s o r

TABLE Re p re se nt at ive Le ns Typ e s Assuming
24.2 Minimum Pract ical Thickne ss o r −3.00 D
Le nse s d uring Clo se d -e ye We ar
O xyg e n Co nsump t io n
Le ns Typ e ((nl / cm 3 ) / s)
Low-wate r-conte nt hyd rog e l le ns 21
Me d ium-wate r-conte nt hyd rog e l le ns 30
Hig h-wate r-conte nt hyd rog e l le ns 31
Rig id le ns: Dk* 25 32
Rig id le ns: Dk 50 40
Rig id le ns: Dk 100 43
SiHy: Dk 110 44
SiHy: Dk 140 44
Silicone e lastome r le ns 45
No le ns 45
Fig . 24.15 Variation in corne al oxyg e n consump tion ve rsus ante rior
corne al oxyg e n te nsion. *Barre r.
240 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns

Fig . 24.18 Two microcysts (arrows) can b e ob se rve d at the lowe r p up il

marg in, to the le t o the op tic se ction in which e xte nsive te ar d e b ris is
hig hlig hte d . (Courte sy of Ing e b re t Mojord .)

Fig . 24.17 De monstration o the e e ct o hyp oxia on limb al hyp e rae -

mia. (A) Grad e 2.2 limb al hyp e rae mia is e vid e nt in this p atie nt we aring
a 38% wate r conte nt hyd roxye thyl me thacrylate (HEMA) contact le ns in
one e ye . (B) The same p atie nt is we aring a hig h-Dk / t SiHy contact le ns
in the othe r e ye ; the e xte nt o limb al hyp e rae mia (g rad e 1.0) is much le ss
than that in the e ye we aring the HEMA le ns. (Courte sy of Eric Pap as.)

presence o these changes may be indicative o a compromise

to normal ocular unction. It has been hypothesized that such
compromise may leave the eye more susceptible to other pathol-
ogy or to poor recovery ollowing eye disease, but there is no
evidence base to support such a proposition.
T e ollowing is a non-exhaustive list o changes that have
been observed in humans during EW:
• altered epithelial oxygen consumption
• altered epithelial cell size Fig . 24.19 Contact-le ns-ind uce d corne al staining . (Courte sy of
• altered epithelial cell sloughing rate Michae l Hare .)
• altered epithelial permeability
• increased epithelial ragility components, and also altered ocular microbiota. Even corneal
• epithelial thinning exhaustion – a syndrome characterized by lens intolerance,
• microcystic oedema (Fig. 24.18) endothelial polymegethism and ongoing changes in corneal
• excess corneal staining (Fig. 24.19) re raction and astigmatism – may be considered a severe
• stromal thinning physiological imbalance rather than a pathological state. Fur-
• stromal neovascularization (Fig. 24.20) thermore, animal studies have revealed changes in epithelial
• endothelial polymegethism (Fig. 24.21) mitoses, adhesion, cellular junctional integrity, healing and cel-
• altered corneal shape lular reserves o glycogen.
• re ractive changes Hypoxia during closed-eye lens wear has been de nitively
• reduced corneal sensitivity linked to a great number o these corneal physiological changes.
• limbal injection For example, the link between Dk / t and epithelial microcysts
• eye redness. has been established in clinical trials. Evidence linking corneal
T ere have also been studies that have documented alterations neovascularization and endothelial polymegethism to chronic
to the concentration o a wide range o aspects o tear compo- hypoxia is circumstantial but has widespread acceptance. Ani-
sition, including cell types, protein levels and in ammatory mal studies link hypoxia and low-Dk / t contact lenses with

Fig . 24.20 Hyp oxia d uring contact le ns we ar is imp licate d in causing
vascularization o the p e rip he ral corne a. (Courte sy of Patrick Caroline ,
Bausch & Lomb Slid e Lib rary.)
Fig . 24.21 Sp e cular re f e ction o the e nd othe lium ollowing e xte nd e d
we ar o a hyd rog e l le ns, showing mod e rate p olyme g e thism and g e ne ral
d isrup tion as e vid e nce d b y the b rig ht and d ark p atche s. (Courte sy of
Ste ve Zantos.)
slower epithelial healing ollowing injury, bacterial binding to
the intact cornea and episodes o corneal in ection.
T e main template or managing long-term physiological
problems with contact lens wear was the landmark ‘Gothenburg
study’ by Holden et al. (1985). T ese authors investigated the
e ects o 5 years o unilateral EW in a sample o 27 patients
using the contralateral eyes as a control. T e physiological mark-
ers under study included epithelial oxygen uptake, epithelial
thickness, epithelial microcysts, acute stromal oedema, chronic
stromal thinning, endothelial polymegethism, and limbal and
bulbar conjunctival hyperaemia. T e cornea o the lens-wearing
eye showed a 15% reduction in oxygen ux, a 6% reduction
in epithelial thickness, a 2.3% reduction in stromal thickness
24 Ext e nd e d We ar 241
and a 22% increase in endothelial polymegethism. Epithelial
metabolism recovered 1 month a er ceasing lens wear, but the
stromal and endothelial changes persisted or over 6 months.
Patients with thinner corneas, higher endothelial cell densities
and lower endothelial polymegethism be ore commencing lens
wear showed ewer e ects rom contact lens wear. T e study
demonstrated that adverse physiological responses could be
minimized by tting lenses that were more regularly removed
rom the eye, more requently replaced, more mobile on the
eye and were more permeable to oxygen. o some extent, these
objectives have been met by SiHy lenses. In particular, their
high oxygen transmissibility has largely relegated major corneal
physiological change during contact lens wear to the position o
a historical curiosity.
A phenomenon known as ‘myopic creep’ has been attributed
to chronic hypoxia during EW o hydrogel lenses. T e changes
are observed as di erences in myopic progression rates between
subjects wearing hydrogels compared with those using SiHy
materials. However, the existence o such re ractive changes
should be considered against the ollowing points: young con-
tact-lens-wearing myopes are prone to modest increases in their
re ractive error; the design o the optics in re ractive corrections
can in uence re ractive development; corneal curvature and
re ractive index changes o the cornea during hypoxia are insu -
cient to explain the re ractive shi s; and mechanical orces
with thicker, sti er SiHy lenses have been shown to be responsi-
ble or re ractive e ects (see below). Further research is needed
to clari y the role o corneal physiology in re ractive changes.
MECHANICAL EFFECTS
Rigid materials provide a range o positive e ects when used
or lens manu acture. T ese can include a stable ront sur ace
with accompanying optical bene ts. T e rigidity o the lens and
the di erence in shape between the posterior sur ace o the lens
and the anterior cornea mean that a mismatch o shape occurs.
T is maintains a certain degree o tear pooling under the lens.
With the blink there is a greater exchange o tears, which has the
bene cial e ect o ushing debris and bacteria away rom the
corneal sur ace and enhancing corneal oxygenation.
Notwithstanding the advantages described above, numerous
problems arise with rigid lenses. Discom ort is in uenced by
the sti ness and size o a contact lens, and is the principal rea-
son or discontinuation with rigid lenses. Larger, more exible
lenses, which provide less interaction between the lid and lens
edge, provide greater com ort, at least initially. Lens rigidity and
size also play an important role in complications such as 3 and
9 o’clock corneal staining. Air bubbles beneath the lens can be
trapped against the cornea, producing an e ect known as ‘dim-
ple veiling’. Pressure rom the eyelid during sleep and settling o
the lens can lead to close alignment o the posterior lens pro le
and the cornea, resulting in a depletion o the post-lens tear lm
and ultimately in lens binding, corneal distortion and lens edge
imprint in the cornea.
So lenses contrast with rigid materials in that they drape
across the cornea and thus show a high degree o con ormity to
corneal shape. T is has the e ect o minimizing post-lens tear
lm thickness. T e thinness o the post-lens tear layer, along
with the size o the lens and small amounts o lateral movement
during the blink, limits the extent o tear exchange beneath
so lenses. During sleep, in particular, the lenses may become
immobile, trapping a stagnant tear layer at the corneal sur ace.
242 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns

It may take more than a ew minutes ollowing eye opening or Clinical Ext e nd e d -w e ar Pract ice
lenses to recover mobility, although binding does not occur IS EXTENDED WEAR SAFE?
to the same extent as observed with rigid lenses. Lack o tear
exchange means that sloughed cells, metabolic byproducts, Community and pro essional opinion determined that the rate
trapped incidental tear debris and bacteria may be kept in con- and relative risk o microbial keratitis with EW as quoted above
tact with the corneal sur ace, presenting the opportunity or were unacceptable in 1989. Despite the publication o similar
in ammatory and in ectious conditions. gures with SiHy lenses, EW o SiHy lenses continued to be
Direct pressure rom so lenses may play a role in the or- pursued, albeit on a limited basis. Are there additional consid-
mation o some epithelial de ects, which mani est as uores- erations that might have made a di erence to prescribing rates
cein staining. In particular, superior epithelial arcuate lesions with SiHy lenses?
(SEALs) may be induced by physical interaction o the lens sur- T ere is a reasonable case or arguing that the concern over
ace with the superior region o the cornea (Fig. 24.22). T ere is the rate o in ection with hydrogel lens EW has been overstated
some evidence that these lesions occur more commonly where and that the risk–bene t equation has not been adequately
lid pressure is greater, such as in Asian eyes, thereby increas- addressed (Brennan and Coles, 1997). Improvements in our
ing the physical e ect o the lens. T e mechanical properties o understanding o the risk actors and prognostic symptoms and
SiHy lenses have also directed attention to the issue o trans- signs or in ection quality and access to pharmaceutical thera-
lucent post-lens debris, sometimes re erred to as ‘mucin balls’ pies, treatment protocols and education o both practitioners
(Fig. 24.23). Although present with hydrogel materials, these and patients since the 1980s would appear to have resulted in
phenomena occur requently with SiHy lenses o higher mod- ewer instances o very bad outcomes when microbial in ection
ulus, especially when used in EW. T e bodies appear to orm does occur. However, it is dif cult to provide an evidence base
as a result o shear orces related to lens sti ness and perhaps or this apocryphal observation as comparable data across the
speci c sur ace properties o the lenses. T ese appearances have decades has not been captured. Nonetheless, an in ection rate
not been speci cally associated with an increase in adverse reac-
tions and indeed one study links their presence to a decrease in
the rate o CIEs (Szczotka-Flynn et al., 2011).
T e greater sti ness o SiHy lenses has also led to re rac-
tive changes, a condition termed ‘unwanted orthokeratology’,
especially with higher-modulus rst-generation materials and
in thicker, higher-powered lenses. Studies comparing SiHy
lenses with hydrogel lenses during EW have noted di erences
in re ractive progression between the two material types.
Whereas ‘myopic creep’ with hydrogels has been attributed to
physiological changes arising rom hypoxia as noted above,
corneal attening in the SiHy-lens-wearing group may explain
at least part o the di erence in re ractive changes between the
lens types.
Lens sur ace riction and lens edge rubbing can lead to pal-
pebral conjunctival changes, including lid-wiper epitheliopathy,
hyperaemia and oedema. In association with possible antigenic
e ects o lens deposition, this can also lead to CLPC. More is
presented on this condition below.

Fig . 24.23 Transluce nt sp he roid al p ost-le ns d e b ris, re e rre d to as

Fig . 24.22 Sup e rior arcuate e p ithe lial le sions may occur d uring we ar
o b oth hyd rog e l and SiHy contact le nse s in e xte nd e d we ar. (Courte sy of
Arthur Back, Bausch & Lomb Photo Lib rary.)
‘mucin b alls’, is a commo n slit-lamp nd ing with silicone hyd rog e n le ns
we ar. (A) Mucin b alls ob se rve d b e hind the le ns. (B) A te r le ns re moval,
most o the mucin b alls are washe d away, b ut some re main. Fluore sce in
stains the re maining mucin b alls, and lls e p ithe lial ind e ntatio ns cre ate d
b y the mucin b alls that we re sub se q ue ntly washe d away. (Courte sy of
Russe ll Lowe .)

with SiHy lenses that matches that with hydrogels may be rea-
sonable considering the bene ts that these lenses o er in terms
o improving other aspects o ocular health (e.g. eliminating
pathology relating to hypoxia) and patient convenience.
Studies investigating contact lens-related in ection have used
a clinical case de nition, and commonly ewer than hal o the
cases yield positive cultures. Furthermore, those that yield a
negative culture or were not cultured are known to be associ-
ated with less impact on visual outcome. Fig. 24.24 illustrates
the culture status o ocular in ections quoted in various publica-
tions and the proportion o these that can be attributed to vision
loss with EW o contact lenses.
Vision loss with EW as a result o corneal in ection is argu-
ably the most critical measure o sa ety. Overnight contact lens
use does produce a higher risk o vision loss than daily wear.
Using a criterion o acuity o 6 / 12 or worse, approximately 28
to 40 per 100 000 patients in EW are likely to lose vision per year
(Schein et al., 2005; Stapleton et al., 2008). On a comparable
basis, re ractive surgery is some 10 times more likely to lead to
substantial vision loss over a decade (Fig. 24.25). Community
concern o the danger o EW is dif cult to reconcile with the
public acceptance o procedures such as re ractive surgery.
Another commonly used argument against EW is that the
risk o su ering a microbial keratitis is higher than that with
daily wear. However, daily wear is not a risk- ree venture. T e
relative risk o corneal in ection rom daily wear o contact
lenses is somewhere between 9 and 80 times that o members
o western society without any predisposing actors (Dart et al.,
1991; Qian et al., 2010). Sleeping in contact lenses adds a urther
risk, but only ve times that o daily wear.
History has taught us some important techniques or avoid-
ing detrimental outcomes with EW. One o the important ac-
tors identi ed by early epidemiological studies was the risk
Fig . 24.24 Re lative rate s o d i e re nt culture re sults to susp e cte d cor-
ne al in e ctions. The d ark-b lue se ction d e tails those that are like ly to
cause sub stantial vision loss.
Fig . 24.25 Proje cte d rate o sub stantial vision loss or various re rac-
tive op tions ove r a 10-ye ar p e riod .
24 Ext e nd e d We ar 243
associated with longer periods o uninterrupted wear. Some
experts advocated that decreased handling o lenses, by virtue
o less- requent lens removal, would minimize lens contami-
nation and lead to ewer complications. However, the Contact
Lens Institute study showed that the length o time between lens
removals was related to the risk o microbial keratitis (Schein
et al., 1989), a nding later con rmed by Dart et al. (1991). For
this reason, in the 1990s the United States FDA issued a guide-
line recommending that the wearing time between lens remov-
als during EW be restricted to less than 7 days.
With the expectation that high-Dk materials would lead to
reduced microbial keratitis rates in EW, clearance was given by
the US FDA or some SiHy lenses to be marketed or up to 30
consecutive nights o use. wo studies have been conducted in
the SiHy era that address the issue in part as to whether longer
periods o uninterrupted wear are as sa e as shorter schedules.
Schein et al. (2005) reported on a post-market surveillance
study designed to estimate the incidence o microbial kerati-
tis among wearers o a SiHy contact lens approved or 30-day
continuous wear. T ey concluded that the rate o microbial
keratitis with a wearing schedule o as many as 30 nights was
similar to that previously reported or hydrogel lenses worn
or ewer consecutive nights. However, they did not have a
hydrogel lens control in their study and relied on an historical
control as the basis or comparison. As the authors appropri-
ately explained in detail, reported rates o microbial keratitis
are very sensitive to study methodology and disease de ni-
tions (E ron and Morgan, 2006a) and numerous actors could
in uence the outcomes. T e results should there ore be inter-
preted with considerable caution. In the second study, Staple-
ton et al. (2008) reported that longer periods o uninterrupted
wear o all lens types (≥6 nights) did not present a statistically
signi cantly greater risk or microbial keratitis than shorter
periods. However, the odds ratio was 6.7, with 95% con dence
intervals o 0.54 to 82.3. T ese gures do not provide support
or the proposition o equivalence between longer and shorter
wearing intervals and suggest that the study was not powered
to make this distinction. Adopting the more conservative
approach o restricting uninterrupted wear to 6 nights or less
would appear to be more prudent rom a sa ety perspective.
Patient sa ety is the primary concern when considering
extended contact lens wear. T ere is no such thing as sa e EW, so
minimizing the risks o complications should be the principal
concern o the practitioner. T is is achieved by care ul patient
education, a conservative approach to care, accurate diagnosis
o adverse events and the instigation o timely treatment where
appropriate.
Ap p licat io n o Ext e nd e d We ar in
Pract ice
Incorporating EW into contact lens practice should be a proac-
tive management decision. A number o systems should to be
set in place, involving support sta , documentation and emer-
gency precautions. In particular, the practitioner should pro-
vide the patient with a document disclosing ully the risks o
EW, and in ormed consent should be obtained rom the patient.
Although it is not necessary to purchase additional equipment,
practitioners should obtain grading scales to assess the sever-
ity o ocular complications o extended lens wear. Practitioners
may also wish to adopt a scoring system or assessing the sever-
ity o CIEs (Aasuri et al., 2003).
244 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
T e current standard or EW is to t a highly permeable lens,
most speci cally a SiHy lens or, in certain circumstances, a rigid
lens. Hydrogel materials may be sa ely used or EW, but most
experts consider the induced hypoxia to be excessive when a
broad range o high-Dk materials are available.
A most important component o EW practice is the diagno-
sis and management o adverse events. Below is a discussion on
the signi cant adverse events that may be observed during EW,
and a management plan or dealing with these problems.
MANAGING EXTENDED-WEAR CO MPLICATIO NS
Success in EW practice relies on a number o actors, the most
important o which is diagnosing and managing adverse reac-
tions. Details o the pathogenesis and risk actors are presented
above. T e ollowing sections provide details o symptomatol-
ogy, signs, di erential diagnosis and a management plan. One
o the encouraging eatures o this list is that the number o seri-
ous adverse events likely with EW is small.
MICRO BIAL KERATITIS
In ectious ulcerative keratitis consists o invasion and coloniza-
tion o the corneal epithelial and stromal tissue by a pathogenic
microorganism. T is problem is the only condition associated
with EW that is an acute, serious threat to vision and the long-
term health o the eye.
In the more severe cases, the patient is aware o rapidly
developing irritation, which progresses to severe pain, both
within the eye and around the periorbital region. Photophobia
and re ex lacrimation are present, and aversion to light is o en
strong. On removal o the contact lens, the pain does not sub-
side. T e intensity o the pain leads the patient to seek assis-
tance, possibly at a medical clinic or at an emergency room.
On presentation, the patient will be in obvious distress. Ocular
examination shows the ulcer as an epithelial de ect with under-
lying stromal in ltrate. Small or large regions o the cornea
may be involved, and the surrounding conjunctiva will be red
and in amed. T ere may be obvious mucopurulent discharge.
As the disease progresses, the anterior chamber may become
involved. Aqueous are may be observed, and a hypopyon can
orm in very severe cases.
As discussed previously, in the early stages o the disease pro-
cess, microbial keratitis can be con used with other non-in ectious
CIEs. Because o the potential or an adverse outcome, practitioners
are advised to adopt the conservative approach o considering all
such conditions as in ectious until proven otherwise. In advanced
stages, microbial keratitis is typically characterized by intense pain
and photophobia that do not resolve with lens removal. T e extent
o pain is such that the patient requently presents to the emergency
room with a wet towel covering the eye. Other key eatures evident
with a severe in ection are the presence o epithelial de ect, greater
likelihood o discharge and corneal in ltrates. T e presence o
anterior-chamber reaction or mucopurulent discharge in associa-
tion with these other signs should be treated as pathognomonic o
an in ectious corneal condition.
All eyes with suspected microbial keratitis should be cul-
tured and receive immediate medical treatment. T e patient
may need to be hospitalized. T e condition should be assumed
to be a Gram-negative bacterial in ection, and hourly applica-
tion o antibiosis should be instigated. Nine out o 10 ulcers
diagnosed as in ectious resolve without serious loss o vision,
but the key to this success ul outcome is the speed with which
treatment is instigated.
CO RNEAL INFILTRATIVE EVENTS
T ere has recently been a signi cant shi in thinking in relation
to the clinical evaluation o CIEs (E ron and Morgan, 2006b). In
particular, there has been a shi away rom the approach o clas-
si ying CIEs into various subtypes, such as the so-called con-
tact-lens-associated acute red eye and contact lens peripheral
ulcer (Sweeney et al., 2003). T e new approach is to consider all
CIEs as part o a disease continuum, and to make clinical deci-
sions based upon an overall assessment o the severity o the
condition (E ron and Morgan, 2006b). T e reason or this shi
in approach is that there is so much overlap in the clinical pre-
sentations o the various supposed subtypes o CIEs that clinical
decision making based on such schemes is virtually impossible
(E ron and Morgan, 2006c).
T e simple reality is that, in the early stages o symptomatic
CIE, it is not possible to tell whether the condition is indeed
a non-in ectious CIE or an early-stage microbial keratitis. T e
previous approach o attempting to classi y a CIE as a contact-
lens-associated acute red eye and contact lens peripheral ulcer
was potentially dangerous, because the typical supposed clinical
advice attached to such diagnoses was ‘wait and see’. T ere are a
number o recorded cases in the literature where this ‘wait and
see’ approach was adopted, and the condition developed into a
serious microbial keratitis (Sweeney et al., 2003). T us, a non-
in ectious CIE is a condition that can be labelled as such only
towards the end o the natural history o the disease process.
From a clinical perspective, i a contact lens wearer presents
with ocular discom ort and an in ltrative event is observed in
the cornea, the condition must be considered to be a potential
case o microbial keratitis, and managed accordingly.
PHYSIO LO GICAL STRESS
Corneal physiological stress may potentially be observed by
both acute and chronic signs. T ere is widespread belie that
the individual with chronic oedema is at risk o developing ur-
ther complications and ultimately ailure with EW. Certainly, an
individual wearing a contact lens that provides a higher mean
swelling in the population is more likely to su er rom hypoxic
complications. Oedema assessment is dif cult in practice with-
out the aid o an optical pachymeter, an Orbscan instrument
or an ultrasonic pachymeter, and ew contact lens practices
have ready access to such equipment. An alternative method o
assessing the oedema level is by observing striae and endothelial
olds. Fig. 24.26 plots the likely amount o overnight oedema
present when striae are observed at a given time a er awaken-
ing, based upon projections rom known levels o striae with
oedema, and studies examining the rate o corneal deswelling.
T e likelihood o chronic physiological stress can be pre-
dicted rom the short-term oedema response to lens wear.
However, as mentioned above, it is sometimes dif cult to make
an assessment o the oedema by examination later in the day.
Evaluation o the extent o limbal hyperaemia is another tech-
nique by which the oxygenation can be assessed, although this
response is not speci c to hypoxia.
One suitable method or assessing chronic hypoxia is to
evaluate the epithelial microcyst response. It is important to
note that microcysts are considerably smaller than vacuoles

Fig . 24.26 Like ly ove rnig ht oe d e ma or a sp e ci c numb e r o visib le
striae at a g ive n time a te r e ye op e ning .
and mucin balls, which are commonly con used with micro-
cysts. Observation is best achieved by looking in marginal ret-
roillumination with the ocus at the level o the tear lm such
that small particles within the tears can be observed. During
the blink, the small particles that do not move should be exam-
ined closely or reversed illumination. Once identi ed, the total
number o microcysts in the cornea should be estimated. With
a lens o adequate oxygen transmissibility, there should be no
more than 10 microcysts present.
Another suitable method to assess long-term physiological
compromise is endothelial evaluation. Chronic hypoxic stress
is associated with altered endothelial regularity, and regular
examination o the endothelium allows a practitioner to grade
success ully di erent levels o anomaly (which must be related
to patient age). Grade 2 endothelial irregularity in a patient
under 30 years o age may be a precursor to urther adverse
corneal changes. Signs indicating the presence o chronic physi-
ological stress should be managed by re tting with a SiHy lens.
VASCULARIZATIO N
Aside rom microbial keratitis, corneal vascularization is the
only pathological condition that may cause vision loss with con-
tact lens wear. Vision is impacted only when the leading edge o
the vascular bundle encroaches on the pupil. However, it rarely
leads to vision loss as its development is slow and regular exam-
ination allows diagnosis and remediation. Vascularization is
putatively caused by hypoxia and there ore is more common in
hydrogel lens EW and with thick hydrogel lens use in daily wear.
SiHy lenses virtually eliminate the development o vasculariza-
tion. Where some vascularization has occurred with hydrogel
lens wear, switching to SiHy lenses will see emptying o the ves-
sels present in the corneal tissue and over a period o time there
may even be retraction o such vessels.
24 Ext e nd e d We ar 245
PAPILLARY CO NJ UNCTIVITIS
T is common contact lens complication involves invasion o
the palpebral conjunctiva by in ammatory cells, including mast
cells, eosinophils and basophils. It can occur with any type o
lens wear, but will be more common in EW o hydrogel lenses
and more common in rst generation SiHy lenses.
T e patient reports gradual onset o itchy eyes, awareness o
excessive lens movement, lens deposition, lacrimation and pos-
sibly a stringy discharge. T ese signs will also be evident to the
practitioner. On lid eversion, the most pronounced e ect will
be enlarged conjunctival papillae across the tarsal conjunctival
plate.
Changing lens type, more- requent lens replacement and
a reduced interval between lens removals are use ul ways to
address CLPC. Early treatment o the condition with a mast cell
stabilizer may enable the patient to continue with EW. I treat-
ment is unsuccess ul, reversion to daily wear may be necessary.
Use o daily disposable lenses is another use ul alternative. T e
condition will resolve over a period o weeks without any con-
sequence to vision.
SUPERIO R EPITHELIAL ARCUATE LESIO NS
Superior epithelial arcuate lesions (SEALs) present as regions
o corneal epithelial abrasion that, as the name suggests, are
located in the superior region o the cornea under the top lid.
T e stain is regularly punctate, but may coalesce and take on an
arcuate shape, parallel to the limbus. T e borders o the region
o staining may be slightly raised. Occasionally there may be a
di use in ltrate underlying the lesion. T e condition may be
more prevalent in Asian eyes.
Patients may be unaware o the problem and sometimes
present with the condition at a routine ollow-up examination.
Others may report discom ort consisting o lens awareness
and oreign-body sensation. T e condition is sel -limiting and
will subside ollowing lens removal. It is inadvisable to allow a
patient with SEALs to continue with EW using the o ending
lens type. Re tting with a lens o di erent geometry or lower
modulus will o en solve the problem. Discontinuing EW
is recommended i a change o lens type ails to resolve the
in ammation.
Co nclusio n
Although extended contact lens wear remains attractive to the
population, ongoing concerns about microbial keratitis mean
this modality should be approached with due restraint. Prac-
titioners contemplating an EW practice should care ully plan
their management o lens wearers with this risk in mind. Sil-
icone-containing hydrogel contact lenses should pre erentially
be used or EW because o their high Dk / t and associated ben-
e ts or corneal health.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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245.e 1
25
Sp o rt
NATHAN EFRO N
Int ro d uct io n
A signi cant proportion o the population participates in sport
or physical recreational activities (Australian Bureau o Sta-
tistics, 2016) ( able 25.1). Sport and recreation are o en cited
as the reason or seeking contact lenses. Daily disposable and
reusable lenses are available in hydrogel and silicone hydrogel
materials, in a wide range o parameters that will correct almost
all potential wearers.
With modern contact lens technology, there is no reason
why an ametropic sportsperson cannot compete with a nor-
mally sighted opponent on an equal basis rom the standpoint
o visual unction. T is chapter presents an overview o actors
that should be considered when prescribing contact lenses or
those participating in various sports. Although the emphasis is
on competitive sports, the principles outlined are applicable to
all orms o sport and recreational activity.
De cid ing o n t he Be st Fo rm o f
Co rre ct io n
T e primary vision correction options are: so contact lenses,
rigid contact lenses, orthokeratology, re ractive surgery
or spectacles. Rigid lenses can be made in corneal, corneo-
scleral, miniscleral or scleral designs. Scleral lenses are usu-
ally prescribed only in very demanding circumstances; they
will there ore not be considered in detail in this section (see
Chapter 21).
REFRACTIVE SURGERY
Re ractive surgery represents the most radical alternative. T e
bene ts are that no correction needs to be worn or sport, and
problems o lens loss, lens movement and lens maintenance
are obviated. Although it might seem to be a per ect solution,
laser correction is not without potential drawbacks. Corneal
haze and regression can lead to less than per ect visual acu-
ity, especially during the rst ew months ollowing surgery.
T ere is also potential or ap damage in patients who have
had laser in situ keratomileusis (LASIK). etz et al. (2007)
reported on a case where the le eye o a 39-year-old man was
struck by the nger o a riend while the two were practising
karate, resulting in loss o the ap, which occurred 3 years
and 5 months a er LASIK. Booth and Koch (2003) noted
that a 38-year-old man sustained a dislocated ap a er being
struck in the le eye with a ootball more than 30 months a er
unevent ul LASIK. T ese cases illustrate the need or LASIK
patients to wear protective eyewear when participating in
contact sports.
A comparison o the key eatures o the primary options or
vision correction or sport is presented in able 25.2.
246
Do Co nt act Le nse s Enhance Sp o rt ing
Pe rfo rmance ?
Some clinicians have o ered the anecdotal opinion that, com-
pared with spectacles, contact lenses enhance the visual skills
o the ametropic sportsperson; however, properly controlled
clinical trials do not support these claims. Schnider et al.
(1993) applied a battery o tests (including measurement o
high- and low-contrast visual acuity, assessment o lens t and
subjective assessment o visual per ormance) to ametropic
athletes wearing their spectacle correction versus low-water-
content so contact lenses. T e authors ound that, although
contact lenses did not o er a measurable advantage over spec-
tacles in terms o visual per ormance under these testing con-
ditions, the psychological advantages were signi cant, and in
this way contact lenses may enhance overall sports-oriented
visual per ormance.
T ere have been suggestions that specially tinted contact
lenses can enhance sporting per ormance. For example, Erick-
son et al. (2009) have demonstrated that the now-discontinued
Maxsight Amber lenses (50% visible light transmission) and
grey-green lenses (36% visible light transmission) provide bet-
ter contrast discrimination in bright sunlight, better contrast
discrimination when alternating between bright and shaded
target conditions, better speed o visual recovery in bright sun-
light and better overall visual per ormance in bright and shaded
target conditions compared with clear lenses. However, the
extent to which these visual per ormance attributes translate to
enhanced sport per ormance is less clear (Porisch, 2007). T e
prescription o per ormance-enhancing tinted contact lenses
or sport is discussed urther in Chapter 22.
Enviro nme nt al and Physical
Co nst raint s
T e choice o contact lens or use in a given sport must be
made with re erence to the length o time that it takes to play
the sport, the environment in which it is played and the gen-
eral physical demands o the sport. T e majority o sports are
completed within 2 hours, which equates to a total period o
lens wear o 4 hours, allowing or pre- and post-match activity
during which lens insertion and removal would be impractical
and / or undesirable. Even when these actors are understood,
the lens o rst choice may not be obvious. T e most appropriate
lens is sometimes determined only by trial and error.
ENVIRO NMENTAL CO NDITIO NS
Contact lens wear is o en associated with signs and symptoms
o ocular dryness. T ese drying e ects can be exacerbated by
certain environmental actors, such as low humidity, wind and
 25 Sp o rt 247

TABLE Part icip at io n b y Male s and Fe male s in t he ‘To p Te n’ Sp o rt and Physical Re cre at io n Act ivit ie s in Aust ralia
25.1 (2009–2010)*
Male s Fe male s
Sp ort / Re cre ation Particip atio n Rate (%) Sp ort / Re cre ation Particip atio n Rate (%)
Walking or e xe rcise 15.6 Walking or e xe rcise 30.0
Ae rob ics / f tne ss / g ym 11.2 Ae rob ics / f tne ss / g ym 16.7
Cycling / BMXing 8.2 Swimming / d iving 8.4
Jog g ing / running 7.5 Jog g ing / running 5.6
Gol 7.5 Cycling / BMXing 4.9
Swimming / d iving 6.4 Ne tb all 4.6
Te nnis 4.4 Te nnis 3.6
Socce r (outd oor) 3.7 Yog a 3.1
Cricke t (outd oor) 2.8 Dancing 2.5
Australian rule s ootb all 2.6 Bush walking 2.3

*Pe rce ntag e of the p op ulation ove r 15 ye ars of ag e p articip ating at le ast once d uring the p ast 12 months.

TABLE
25.2 Co mp ariso n o f Diffe re nt Fo rms o f Visio n Co rre ct io n fo r Sp o rt
Charact e rist ic So ft Le nse s Rig id Le nse s O rt ho ke rat o lo g y Sp e ct acle s Re fract ive Surg e ry
Fie ld o vie w Full Full Full Re stricte d Full
Stab ility o vision (p ost-b link) Exce lle nt Good Exce lle nt Exce lle nt Exce lle nt
Glare None In low lig ht None None Some p ost-surg e ry
Glare p rote ction tint p ossib le Cosme tic only No No Ye s N/A
Ultraviole t p rote ction p ossib le Ye s Ye s No Ye s N/A
Initial com ort Good Poor Fair Good Fair
Long -te rm com ort Good Good Exce lle nt Good Exce lle nt
Ad ap tation re q uire d Ve ry little Ye s Ye s Some time s N/A
Suitab ility or inte rmitte nt use Ye s Not usually No Ye s No
Disp osab ility viab le Ye s No N/A No N/A
Risk o loss Low Mod e rate N/A Low N/A
Risk o d islod g e me nt d uring we ar Low Mod e rate Nil Hig h N/A
Risk o d amag e d uring we ar Low Low Nil Hig h Mod e rate (LASIK
ap mislocation)
Risk o d amag e with hand ling Hig h Low Low Low N/A
Ease o care Simp le (nil or d aily Simp le Simp le Simp le N/A
d isp osab le )
Initial cost Low Mod e rate Hig h Mod e rate Hig h
O ng oing costs Hig h Mod e rate Mod e rate Nil Nil
Cost to corre ct astig matism Hig h Low O nly limite d cor- Low Hig h
re ction p ossib le
Bi ocal corre ction p ossib le Comp romise Ve ry d i f cult No Ye s Monovision
Use in rain Good Good Exce lle nt Poor Exce lle nt
Susce p tib ility to og up No No No Ye s No
Susce p tib ility to d irt up No No No Ye s No
Risk o comp lication Low Ne g lig ib le Low None Mod e rate

LASIK= lase r in situ ke ratomile usis; N / A = not ap p licab le .

visual tasks. Wearing silicone hydrogel contact lenses may pro-
vide greater relie o subjective ocular discom ort in adverse
environmental conditions than that a orded by both the habit-
ual lenses o contact lens wearers or no contact lens wear (Young
et al., 2007; Ousler et al., 2008).
Sports are played in almost every environment. Climatic
conditions play a role in disease severity and causative organism
in contact-lens-related microbial keratitis and there ore have
implications or practitioners involved in contact lens care o
wearers who may be engaging in sporting activities in the trop-
ics (Stapleton et al., 2007). T e ollowing environmental condi-
tions are considered as they will directly a ect the choice o lens
or the sportsperson.
Cold
Many sports take place in cold environments, typically in close
proximity to ice and snow. Because the intrinsic temperature o
the eye and tear lm is around 34°C (E ron et al., 1989), con-
tact lenses cannot reeze up in the eye. In an extensive survey o
105 contact lens wearers who were requently engaged in cold-
weather sports, Socks (1983) ound no evidence o eye injury or
disease. ‘Eye redness’ was the most common complaint o rigid
lens wearers; so lens wearers most requently complained o
slightly reduced vision. Large-diameter, medium-water-content
hydrogel, or silicone hydrogel so lenses may provide the best
results in cold conditions.
Altitud e
T e ability o oxygen to reach the cornea through a contact lens,
which is a key prerequisite to sustain good ocular health during
lens wear, is a unction o the oxygen transmissibility o the con-
tact lens and the partial pressure o oxygen in the atmosphere.
T is argument is particularly relevant to sports that are played
at altitude. T e partial pressure o oxygen in the atmosphere
248 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
decreases with altitude, which e ectively means that the tol-
erance o the eye to a lens o given oxygen per ormance will
decrease with increasing altitude. In addition, temperature alls
about 10°C per 1500 metres increase in altitude to a minimum
o −50°C; the e ects o extreme cold on the cornea were dealt
with in the previous section. T ere appears to be a signi cant
connection between the level o available oxygen during contact
lens wear and improved patient symptoms o com ort, includ-
ing dryness (Dillehay, 2007). In view o the rari ed oxygen
atmosphere at high altitude, and the length o time lenses may
be worn, high-oxygen-per ormance silicone hydrogel lenses are
indicated.
Bauer (2015) surveyed the experience o 158 contact lens
wearers while trekking at high altitude in Nepal. T e majority o
the participants (78%) reported no problems with their lenses
(daily disposables, so lenses, extended-wear lenses, hard / rigid
lenses) during their stay, although dry air, dust, wind, cold tem-
peratures and dif cult hygiene maintenance were challenging.
Freezing lenses and reezing solutions were additional chal-
lenges. Almost 60% o participants had not sought any pretravel
health advice, and 22% o trekkers experienced a variety o
problems. Bauer (2015) concluded that remote and wilderness
areas provide a challenge or appropriate contact lens wear and
care. Based on the ndings o his survey, Bauer (2015) made the
ollowing recommendations:
• Lodges should provide better access to clean water, mir-
rors and lighting.
• T e decision between the potential risk o in ection due
to touching lenses (daily disposables, so / hard lenses)
and the potential risk o corneal erosion (extended-wear
lenses) needs to be made in pretravel consultations.
• ravel health pro essionals and travel agencies should
remind contact-lens-wearing trekkers to assess care ully
their wear and care routine so as to accommodate poten-
tially challenging conditions.
Dirt and Dust
Rigid contact lenses are prone to trap debris beneath the lens
and are clearly contraindicated in dirty and dusty environ-
ments. Also, dirty and dusty sporting environments are typi-
cally associated with intense physical activity and a greater risk
o dislodging the lens, which are urther actors contraindicat-
ing the use o rigid lenses. Large-diameter so lenses are the
lens o rst choice in such environments. Lens water content
and oxygen transmissibility are less critical actors. Orthokera-
tology has a distinct advantage in such environments, in that
the lenses are not present in the eyes to trap dirt or dust, or to
become dislodged.
Aq uatic Environme nts
Aquatic sports are de ned here as those that take place immedi-
ately above or in water, but generally not deeper than 2 metres.
Edmunds (1992) has suggested that sportspersons engaged
in aquatic activities be advised o the ollowing strategies or
avoiding lens loss and preserving eye health:
• Close eyes on impact with water.
• Do not open eyes ully when under water; instead, squint
and maintain a head position in the direction o gaze.
• Upon sur acing, gently wipe water rom closed lids be ore
opening eyes.
• Irrigate eyes with resh saline upon leaving the water.
• Remove and disin ect lenses shortly therea er.
Contact lens wear is known to increase the risk o in ection
slightly, and the use o lenses in aquatic environments must be
considered as an additional risk actor. Choo et al. (2005) ound
that wearing a hydrophilic lens while swimming in a chlori-
nated pool allows accumulation o microbial organisms on or
in the lens, in both hydrogel and silicone hydrogel materials.
Wu et al. (2011) reported that the wearing o goggles over con-
tact lenses reduced the number o bacterial colonies ound on
the lens sur ace. However, in ections are rare, and the risk o
lens-related eye disease can be reduced to almost zero i lenses
are removed, cleaned and disin ected in the prescribed manner
soon a er leaving the water. Ideally daily disposable lenses can
be worn and then discarded.
Larger lenses provide the greatest on-eye stability, which is
o particular bene t when engaged in dynamic water sports
(Banks and Edwards, 1987). Goggles worn over contact lenses,
in the same way as worn by a non-lens wearer, will ensure good
vision, help preserve ocular health and help reduce lens loss.
Komori et al. (2013) reported that, over the previous 20
years, Japanese water polo players were increasingly using con-
tact lenses or this sport, presumably as a result o the increas-
ing availability and a ordability o disposable lenses. In 2011,
86% o Japanese water polo players wore contact lenses during
games, and 96% wore so lenses.
A survey o coaches involved in a number o di erent sports
ound that swimming was the sport associated with the lowest
level o recommendation or contact lenses, although this trend
was reversed with appropriate education (Zeri et al., 2011).
Sub aq uatic Environme nts
Various authors advocate the use o both rigid lenses (Holland,
1993) and so lenses (Bennett, 1985) or scuba diving. All seem
to agree that the use o contact lenses with a standard acemask
is pre erred to the use o prescription acemasks. As a result o
the increased physical pressure experienced during deep dives,
inert atmospheric gases, in particular nitrogen, dissolve in body
tissues. As the diver returns to the sur ace slowly, these gases
are released and become trapped as minute bubbles beneath the
lens (Holland, 1993). T is problem is especially acute with rigid
lenses because o the extremely low permeability o rigid lens
materials to nitrogen; the nitrogen gas cannot escape by per-
meating through the lens (Fig 25.1). T is phenomenon can be
alleviated by tting lenses o very high gas permeability, such as
silicone hydrogel lenses, and encouraging the diver to concen-
trate on blinking. Brown and Siegel (1997) concluded there are
no compelling reasons to change lens types in patients who are
already ully adapted lens wearers. Nevertheless, silicone hydro-
gel lenses are the modality o choice.
Ultraviole t Lig ht
Sporting activities conducted on water, sand or snow will result
in the sportsperson being exposed to excessive ultraviolet (UV)
radiation, which can cause skin sunburn and solar keratitis in
the short term, and cataracts ( aylor et al., 1988) and pterygia
(Hill and Maske, 1989) in the long term. T us, contact lenses
with UV protection tints are indicated (Cullen et al., 1989). It
must be recognized, however, that such lenses will not prevent
excessive and potentially damaging UV light rom reaching
those parts o the external eye that are not covered by the lens,
such as exposed parts o the cornea (in rigid lens wearers) and
the bulbar conjunctiva. T e use o goggles with UV-absorbing
tints, to be worn over UV-absorbing contact lenses, constitutes

Fig . 25.1 Nitrog e n g as (N 2) forms in the corne a d uring d e comp re ssion
b ut cannot ve nt throug h the le ns owing to the re lative ly low nitrog e n
p e rme ab ility of rig id le nse s.
an extra precaution or periods when the mask is removed. Ski-
ers should be reminded also to apply UV protection creams to
the remaining exposed skin on the ace and neck. In sur ng,
where use o goggles may not be appropriate, a UV-absorbing
contact lens will at least a ord some protection.
PHYSICAL CO NDITIO NS
Special consideration needs to be given to ametropic sportsper-
sons to acilitate their ull participation in sports characterized
by extreme body movement, body contact, air ow and gravi-
tational orces. Eye, head or even general body protection is
o en mandatory or the sportsperson subjected to such physi-
cal extremes.
Extre me Bod y Move me nts
Stability o a contact lens in the eye is essential or the sportsper-
son participating in activities that involve extreme body move-
ments. Spectacles and sunglasses may be unsuitable or even
banned in many o these sports. Rigid lenses are contraindi-
cated in view o the high risk o dislodgement during the sports
action. Large-diameter so lenses provide the greatest stability
when excessive eye, head and body movements are involved.
T e lens should centre well and display minimal movement.
Slightly thicker lenses resist olding up in the eye.
Bod y Contact
T e same considerations as above apply here, along with the
additional actor o physical contact. T ose participating in ull-
body contact sports can be subjected to excessive body shock
and jarring, and there is also the possibility o direct physical
insult to the ace and eyes. T e obvious extreme example is box-
ing; most authorities governing this sport (such as the British
Boxing Board o Control) ban the use o contact lenses. T e
governing bodies o many body contact sports encourage the
wearing o eye and ace protection via the use o helmets and
masks. In sports where this is optional, the contact-lens-wearing
25 Sp o rt 249
sportsperson is advised to wear such protection to preclude
accidental dislodgement o the lens through direct physical
contact to the eyes by an opponent. In such situations, large-
diameter so lenses o er greatest stability, and rigid lenses are
contraindicated. Daily disposable lenses are pre erred as it is
possible to have many spare replacement lenses available in the
event o lens loss.
Airflow
Signi cant air ow over the eyes typically occurs in the course
o speed sports, such as luge or motor cycle racing. T e most
extreme conditions o air ow over the eyes are experienced by
parachutists during ree- all, which can last up to 60 seconds.
Air ow over the eyes can reach up to 290 km / h. Although
contact lenses a ord some mechanical protection or the eyes
during ree- all, they will not provide complete relie rom the
rapid and constant air ow or rom ying debris and particles
in the air (Gauvreau, 1976). It is pre erable or ametropic para-
chutists to wear contact lenses beneath protective goggles. o
avoid lens dehydration resulting rom rapid air ow over the
eyes, sportspersons should be advised about good blinking
behaviour and should be tted with large-diameter, silicone
hydrogel content lenses. High-water-content hydrogel lenses
are contraindicated.
Gravitational Force s
Aerobatic pilots can be subjected to gravitational orces
(G- orces) o between +6 G and −3 G. Participants in luge, bob-
sleigh, motor car and motor cycle racing are generally subjected
to lower G- orces – typically less than +2 G. Brennan and Girvin
(1985) tted volunteer pilots with 50% and 75% water con-
tent so lenses and subjected them to downward (z) G- orces.
Lenses displaced 1.50 mm downwards in response to +4 Gz and
1.75 mm downwards in response to +6 Gz; tightly tted lenses
remained centred regardless o G- orces.
Dennis et al. (1989) observed that positive orces o up to +9
Gz caused rigid lenses to decentre downwards with a maximum
decentration o 2–3 mm, without adversely a ecting vision. In
view o this evidence, a sportsperson who is likely to be sub-
jected to signi cant G- orces may nd that a large tight- tting
so lens provides maximum stability with minimum inter er-
ence to visual per ormance. It is estimated that 10% o sports
involve the body being subjected to intermittent orces greater
than +1 G.
Ge ne ral Co nsid e rat io ns
T e ollowing points are o particular relevance to the prescrip-
tion and a ercare management o those involved in sport:
• For young sportspersons participating in outdoor sports,
prescribe minimum plus power (remember that an exact
correction based on a 6-metre test distance will result in
0.17 D excess plus power, which could be problematic in
time-critical acuity-dependent activities).
• Silicone hydrogel lenses worn on an extended-wear basis
are indicated or sportspersons who participate in endur-
ance events such as rally car driving, ocean racing and
mountaineering, which are typically spread over weeks
and months.
• In view o the known post-blink visual degradation o
about 100 ms with so lenses (Ridder and omlinson,
1991), spectacles are pre erred to contact lenses when
250 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
critical static visual acuity is the undamental requisite or
optimum per ormance, especially in time-limited events
(such as archery and shooting).
• T e choice o correction or combination sports may in-
volve considerable compromise i there is no pause be-
tween component events (e.g. triathlon, Nordic biathlon
and Nordic combined). Conversely, various orms o cor-
rection may be used when events are spread out over many
days (e.g. decathlon and modern pentathlon).
• Practitioners should be amiliar with details o the particu-
lar sport or sports in which the lens wearer is participat-
ing so that the visual demands involved can be appreciated
and appropriate advice o ered.
• Most sports have seasonal cycles: mid-seasonal contact lens
tting or alteration should be avoided as this could provide
an unnecessary distraction. For routine care, the best time is
immediately ollowing the conclusion o the season.
• Athletes o en come into contact with grip resin, grease, tape
dressings and ointments that are toxic to the eye and highly
irritative, as well as dirt, soil or general contaminants; thus,
hygiene and general compliance must be emphasized.
• T e coach o a contact lens wearer should have ull knowl-
edge o the type o lenses being worn, insertion and re-
moval techniques, the limitations o the particular lens
type, the care system used, and any special constraints on
lens wear, and should maintain a supply kit o lenses and
solutions.
• Since contact lenses will not shield the eye rom potential
trauma, the usual protective eyewear or headgear used in
a given sport should also be used by contact-lens-wearing
sportspersons.
• E ective glare relie can be provided by sunglasses (to be
worn in addition to the contact lenses) and sunshades
or visors. In exceptional cases where the wearing o sun-
glasses is not possible – such as water sports – very dark
tinted lenses (70% absorption) can provide some relie
(Edmunds, 1992).
• In general, presbyopic sportspersons are less o en engaged
in sports that are physically demanding, such as rugby or
ootball, and may be involved in sports such as gol that
require attention to near tasks like recording and reading
strategy notes (Carlson, 1990). Monovision or multi ocal
contact lenses are generally contraindicated, and a spec-
tacle overcorrection or near tasks is o en the best option.
• Ametropic re erees are subject to the same environmental
extremes and visual demands as the competitors they are
adjudicating. T ree main actors will govern the choice o
vision correction or the ametropic re eree:
1. age – in particular, whether or not the re eree is pres-
byopic
2. orientation – a spectacle correction may be more suit-
ed to a static of cial (e.g. gymnastics) and a contact
lens correction to a dynamic of cial (e.g. wrestling)
3. eld o vision – a static re eree o a sport that is played
out over a wide eld o view relative to the viewing po-
sition (e.g. tennis) may pre er contact lenses.
Co nclusio n
A comparison o the various characteristics and attributes o
so t and rigid contact lenses as well as other orms o vision
correction (orthokeratology, spectacles and re ractive sur-
gery) or the sportsperson is presented in able 25.2. Both
so t and rigid contact lenses are capable o a ording optimal
visual unction or sport. Relatively tight, large-diameter,
silicone hydrogel lenses will provide the greatest in-eye sta-
bility, which appears to be an important prerequisite or the
majority o sports. For certain speci ic activities where visual
acuity is critical, such as shooting, archery and darts, spec-
tacles may be the best option. Success ul contact lens cor-
rection or sporting activities requires patience, perseverance
and understanding. he reward or inding the right solution
is the knowledge that the sportsperson is not hampered by
ametropia and is capable o per orming to his or her maxi-
mum visual capabilities.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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250.e 1
26
Ke rat o co nus
LAURA E DO WNIE | RICHARD G LINDSAY
Int ro d uct io n
Keratoconus is classically considered a bilateral, asymmetric,
non-in ammatory corneal disease that is characterized by pro-
gressive thinning and steepening o the central cornea (Rabi-
nowitz, 1998). T ese pathological changes lead to a relative
reduction in vision secondary to the development o irregular
astigmatism and / or corneal scarring (Krachmer et al., 1984).
Keratoconus is the most highly prevalent primary corneal ecta-
sia, a ecting an estimated 54 per 100 000 people (Kennedy et al.,
1986). Although the aetiology o keratoconus remains uncer-
tain, it is recognized to be a multi actorial condition, involving
genetic, biochemical and / or environmental actors (Davidson
et al., 2014).
Contact lens practitioners play a vital role in providing
appropriate optical appliances to delay, or even preclude, the
need or keratoplasty in people with keratoconus. T e rst
application o contact lenses or keratoconus was described
by the German-born physician and physiologist, Adol Fick,
in 1888 (E ron and Pearson, 1988). In more recent times,
advances in contact lens designs and materials have expanded
the tting options or patients with corneal ectasia. T ese
developments are underpinned by the need or contact lenses
not only to deliver the desired improvement to vision, but also
to provide appropriate levels o com ort and to maintain cor-
neal physiology.
his chapter provides a comprehensive overview o the
range o contemporary contact lens modalities, includ-
ing so t, rigid (i.e. corneal, corneo-scleral, miniscleral and
scleral lenses), hybrid and piggyback designs, that are avail-
able or the optical management o keratoconus. he appli-
cation o anterior-segment imaging technologies, including
corneal topography and optical coherence tomography
(OC ), to assist with contact lens itting is also considered.
Furthermore, the importance o monitoring or disease pro-
gression in people with keratoconus, particularly children, is
discussed.
Ke rat o co nus Clinical Asse ssme nt
Robust baseline clinical data are essential both or monitoring
disease progression and or guiding contact lens management
in people with keratoconus. While several keratoconus classi -
cation systems have been proposed, based upon various criteria
that include corneal morphology, clinical signs, topographical
parameters and / or corneal structural changes (Amsler, 1938;
Perry et al., 1980; Maeda et al., 1994; Rabinowitz and Rasheed,
1999; McMahon et al., 2006; Mahmoud et al., 2008; Sandali
et al., 2013), there remains a lack o a universally accepted
keratoconus severity staging scale or either research or clinical
purposes.
ANTERIO R SEGMENT IMAGING TECHNO LO GIES
Contemporary imaging technologies have signi cantly
enhanced the capacity to image the cornea in clinical prac-
tice (see Chapter 41). Compared with traditional keratometry,
Placido-disc-based corneal topography acilitates relatively ear-
lier diagnosis and enhanced disease monitoring o keratoconus
(Maguire and Lowry, 1991; Wilson and Klyce, 1994). A range
o quantitative topographic indices exist to identi y anomalies
o corneal curvature that indicate or corneal ectasia (Wilson
and Klyce, 1994; Mahmoud et al., 2008; Downie, 2011; Sandali
et al., 2013).
More recently, imaging systems that do not rely upon
the quality o the sur ace image, such as optical coherence
tomography (OC ), have emerged and have clinical appli-
cation both or assessing in vivo corneal microstructural
changes and guiding contact lens itting. An OC -based
keratoconus classi ication system, that was reported to also
provide a grading o severity, has been described (Sandali
et al., 2013). Further clinical studies, over ollow-up periods
that are su icient to evaluate the natural history o classi i-
cation using this OC system, are still required to validate
this method o disease categorization. Anterior segment
OC has been used to quanti y post-lens tear ilm clearance
patterns in rigid corneal lens relationships (i.e. three-point-
touch, apical clearance and apical bearing) (Elbendary and
Abou Samra, 2013). he application o OC or itting mini-
scleral lenses is discussed in the ‘miniscleral lens’ section o
this chapter.
KERATO CO NUS CO NE MO RPHO LO GY
Based upon morphological criteria, three major subtypes o
keratoconus are recognized (Fig. 26.1) (Perry et al., 1980;
McMahon et al., 2006). Although the prevalence o these sub-
types can vary in di erent demographics, centred (nipple)
cones are considered to account or about hal o morpholo-
gies; this subtype is characterized by a cone diameter o 5 mm
or less that is round and positioned centrally or slightly in e-
rior to the geometric centre o the cornea. Oval (sagging) cones
are larger in diameter and demonstrate either in ero-nasal or
in ero-temporal displacement o the corneal apex. As rigid
contact lenses tend to align over the corneal apex, achieving
adequate lens centration and pupil coverage or oval cones can
pose a relative challenge (Perry et al., 1980; Romero-Jimenez
et al., 2010; Downie, 2011). Commonly regarded as the least
common cone morphology is the globus cone, in which the
conical area involves at least 75% o the cornea. From a con-
tact-lens- tting perspective, these cases are arguably the most
complex and typically warrant designs with larger diameters
to achieve a desired tting.
251
252 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns

Fig . 26.1 Corne al axial p owe r top og rap hy map s, with normalize d p owe r scale s (in d iop tre s), showing the thre e majo r cone morp holog ie s in ke ra-
toconus. (A) A nip p le cone consisting o localize d ste e p e ning at the corne al ap e x. (B) A sag g ing cone with corne al ste e p e ning p ositione d in e rior to
the corne al g e ome tric ce ntre . (C) A g lob us cone showing a larg e are a o corne al ste e p e ning .

contact lenses when an appropriate level o unctional spectacle

BO X 26.1 NO N-SURGICAL REFRACTIVE acuity can be achieved. Retinoscopic ndings can assist the prac-
MANAGEMENT O PTIO NS FO R titioner with determining an appropriate starting point or sub-
KERATO CO NUS
jective re raction. Re raction should be undertaken judiciously,
• Sp e ctacle s as people with keratoconus may have dif culty with subjective
• Contact le nse s determinations o re ractive end-points; this is probably due to
• Soft
• Rig id the multi ocal nature o the cornea (Camp et al., 1990) and is an
• Corne al e ect that is heightened with advanced disease. In undertaking
• Corne o-scle ral subjective re raction, relatively large re ractive steps (e.g. ±1.00
• Miniscle ral to ±3.00 D) may need to be presented to the patient to enable
• Scle ral
• Hyb rid
subjective di erences to be discernable. Whenever practicable,
• Pig g yb ack and particularly at baseline, best corrected spectacle acuity
should be recorded to serve as a re erence point or longitudi-
nally evaluating signi cant changes to visual unction.
ANTERIO R O CULAR HEALTH T e use o a spectacle correction or the optical management
o keratoconus o en has some notable limitations, however.
An additional important element o the clinical assessment o Subjective re raction can be poorly repeatable (Raasch et al.,
people with keratoconus, particularly in the context o contact 2001) or, particularly as in cases o more advanced keratoconus,
lens tting, is the diagnosis and management o comorbid ocu- simply not easible to per orm. Progressive disease can lead to
lar conditions. Associations between keratoconus and atopic rapid changes to the re raction, with re ractive shi s possible
disease, including eczema, asthma and rhinoconjunctivitis, are over periods o weeks, which can render a relatively recent
well known (Rahi et al., 1977; Harrison et al., 1989; Kaya et al., spectacle correction suboptimal. Consideration with regard to
2007; Downie, 2014a). Allergic and / or dry eye disease can be the likelihood o patient tolerance to high degrees o re ractive
major impediments to success ul contact lens wear and there- astigmatism, particularly in the context o anisometropic re rac-
ore require timely and appropriate ophthalmic care prior to the tions, is also required. Given these actors and the potential or
commencement o contact lens wear (Zhou et al., 2003). enhanced irregular astigmatism correction with many contact
lens modalities, contact lenses remain the predominant optical
Re fract ive Manag e me nt o f corrective modality or keratoconus.
Ke rat o co nus
SO FT LENSES
T e management o keratoconus will vary depending upon
the severity o the disease. Re ractive management options are So contact lenses, typically in disposable orm, are a use ul
largely non-surgical, with contact lens correction o en being visual correction option or orme ruste and / or earlier orms
essential to achieving the best unctional outcomes. Box 26.1 o keratoconus (Grif ths et al., 1998). So lenses may also
provides a summary o the major orms o visual correction that provide a suitable orm o contact lens correction or people
are currently available in clinical practice or the non-surgical with keratoconus who have implanted intrastromal corneal
management o keratoconus; each o these modalities is elabo- ring segments (ICRS) (Fernandez-Velazquez and Fernan-
rated upon in this chapter. dez-Fidalgo, 2015; Romero-Jimenez et al., 2015). Similar to
spectacle correction, a major shortcoming o this modality is
SPECTACLE CO RRECTIO N the inability to mask irregular corneal astigmatism (Grif ths
et al., 1998; Jinabhai et al., 2012). One small study involving
Spectacle correction may provide adequate visual correction in 13 individuals with di erent stages o keratoconus showed
earlier stages o keratoconus and / or be o value as an adjunct to that spherical hydrogel so lenses provide poorer high- and

low-contrast visual acuities than does rigid corneal lens cor-
rection (Grif ths et al., 1998). Similar ndings were reported
in another clinical investigation, whereby rigid corneal lenses
were ound to provide relatively enhanced low-contrast acu-
ity and a reduction in higher-order aberrations compared
with toric hydrogel so contact lenses (Jinabhai et al., 2012).
In this study, visual per ormance with so toric lenses was
reported to be comparable to that measured with a spectacle
correction (Jinabhai et al., 2012). Re ereed studies comparing
the visual ef cacy o so contact lenses made rom silicone
hydrogel materials with rigid lens designs or keratoconus are
currently lacking. It has been suggested that the modulus o
elasticity o silicone hydrogel lenses, being greater than that o
hydrogel materials, may enable these lenses to have relatively
improved con ormational integrity in situ, and thereby pro-
vide enhanced / or more stable visual acuity. Studies to clari y
whether such an advantage exists are still needed.
Major advantages o so contact lenses over traditional
rigid lens correction are the enhanced on-eye com ort pro le
and the relative ease o tting (Koliopoulous and ragakis,
1981). Compared with spectacles, there are also potential ben-
e ts o adopting contact lenses in relation to improved quality
o li e in young adults (Pesudovs et al., 2006). Consideration o
on-eye com ort is pertinent in the context o any prior history
o rigid lens intolerance and / or when rigid lenses are deemed
impractical. Factors that may in uence the practicality o rigid
lens correction include ocular (e.g. monocular correction),
occupational (e.g. dusty working environment) and recre-
ational (e.g. participation in dynamic sporting activities) con-
siderations. From the clinician’s perspective, a so lens tting
procedure or a person with keratoconus essentially mirrors
the process that is routinely applied to eyes without irregular
astigmatism (see Chapter 8). Depending upon the extent o
corneal irregularity, the so lens parameters may need to be
care ully selected to ensure adequate on-eye lens movement.
T e so lens material should also be selected so as to mini-
mize the likelihood o corneal hypoxic complications, such
as corneal neovascularization, which may complicate a uture
keratoplasty procedure.
In recent years, the ability to lathe quadrant-speci c curve
designs in so lens materials has supported the development
keratoconus-speci c so contact lenses (e.g. KeraSo IC,
Bausch & Lomb; So K, So ex; NovaKone, Alden Optical). At
present there is a relative paucity o published data regarding
the clinical ef cacy o these designs. One case series, involv-
ing two people, reported on the use o the So K lens design
or optical correction o mild keratoconus (Gonzalez-Meijome
et al., 2006). A retrospective analysis comparing visual acuity
outcomes in keratoconus eyes with mild to moderate ectasia
that had been tted with either the silicone hydrogel KeraSo
IC lens (n = 94) or the Menicon Rose-K2 rigid lens (n = 94),
reported no signi cant di erence between lens types (Fernan-
dez-Velazquez, 2012). A case series describing the success ul
tting o KeraSo IC lenses to eyes implanted with ICRS has
also been recently published (Fernandez-Velazquez and Fer-
nandez-Fidalgo, 2015).
Computer-based simulations suggest that customized cor-
rection o lower- and higher-order ocular aberrations, not-
withstanding contact lens movement in situ, should bene t
visual unction in keratoconus (Guirao et al., 2001; de Bra-
bander et al., 2003). In recent years, a number o custom
aberration-controlled so contact lens designs have been
26 Ke rat o co nus 253
TABLE
26.1 Rig id Co nt act Le ns No me nclat ure
Le ns Classificat io n Diame t e r (mm)
Corne al 7.0–12.0
Corne o-scle ral 12.1–15.0
Miniscle ral 15.1–18.0
Scle ral >18.0
(Re p rod uce d from Downie & Lind say, 2015.)
developed and have undergone varying degrees o investiga-
tion (Marsack et al., 2007a; Sabesan et al., 2007; Marsack et al.,
2008; Jinabhai et al., 2014). Although signi cant reductions to
overall ocular aberrations have been demonstrated, the suc-
cess o these so lens modalities varies between individuals
with keratoconus (Jinabhai et al., 2014). Such variability may
be attributable to a range o actors, including keratoconus
severity, cone morphology and the magnitude and consistency
o any lens translation in situ. At present, urther research is
needed to determine the clinical applicability o customized,
aberration-controlled so contact lenses or mainstream kera-
toconus management.
RIGID LENSES
Rigid contact lenses, both prior to and since the availability o
gas-permeable materials, have been the primary orm o visual
correction or keratoconus (Rabinowitz, 1998; Zadnik et al.,
1998; Weed et al., 2007). In maintaining their on-eye con or-
mation, rigid lenses create a lacrimal lens between the irregular
anterior corneal sur ace and posterior lens sur ace that neutral-
izes much o the corneal astigmatic error, but will not necessar-
ily normalize higher order aberrations (Marsack et al., 2007b;
Negishi et al., 2007).
Rigid lens classi cation is typically based upon di erences
in lens total diameter ( D), as summarized in able 26.1,
although speci c terminology can vary. It should also be noted
that this classi cation is dependent on the size o the cornea.
For example, i a patient has microcornea with a corneal diam-
eter o 9.0 mm, then in this case a rigid lens with a total diam-
eter o 10.0 mm could arguably be considered a corneo-scleral
lens in situ.
Corneal lenses have been the most common orm o rigid
lens utilized or keratoconus or the past ew decades (Mor-
gan et al., 2016). Over this time, the use o scleral lenses has
become less requent. However, recently contact lens practice
has witnessed the re-emergence o other larger-diameter rigid
lens modalities, in the orm o corneo-scleral and miniscleral
lenses. T e prescription o these alternative rigid lens orms or
the contact lens management o keratoconus has increased sig-
ni cantly in recent years owing to the associated advantages o
larger-diameter contact lenses, which include enhanced on-eye
com ort and stability (van der Worp, 2010a).
Corne al Le nse s
A diverse range o commercial corneal lens designs exist or ker-
atoconus, including spherical multicurve and aspheric designs.
Corneal lenses can also be custom designed by the practitio-
ner, on a case-by-case basis. Most studies that have evaluated
rigid lens correction with corneal lenses in keratoconus have
involved retrospective analyses in speci c clinical populations.
254 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns

T ese studies (Betts et al., 2002; Lim and Vogt, 2002; Zadnik
et al., 2005; Szczotka-Flynn and Patel, 2008; Yanai et al., 2013)
provide insight into the range o corneal lens designs that have
been utilized in practice or the optical correction o keratoco-
nus. However, objective comparisons between lens designs are
not possible in the absence o a suitable control group and / or
clearly de ned criteria regarding the de nition o a ‘success-
ul’ lens tting. T ere is currently a lack o high-quality, con-
trolled prospective clinical evidence to in orm clinical decisions
regarding the relative merit o di erent proprietary keratoconus
lens designs.
Fitting Philosophies. As discussed in Chapter 15, traditionally
the clinical evaluation o rigid lens tting is acilitated by the
application o sodium uorescein to the eye and the subsequent
observance o the uorescence pattern beneath the contact
lens. A Wratten 12 barrier lter, or similar, placed in ront
o the slit-lamp biomicroscope objective, can signi cantly
enhance sodium uorescein pattern assessment. Using sodium
uorescein patterns, three major philosophies or tting
corneal lenses to eyes with keratoconus are recognized (Korb
et al., 1982; Leung, 1999): apical bearing, apical clearance and
three-point touch.
Apical Bearing. In an ‘apical-bearing’ tting relationship,
the primary support o the rigid lens is directly on the corneal
apex. T is results in a sodium uorescein pattern that has a
central darkened region, which corresponds to the back optic
zone diameter (BOZD) o the lens (Fig. 26.2A). Historically, it
was incorrectly hypothesized that this tting philosophy could
retard keratoconus progression by imparting physical resistance
to progressive corneal de ormation. It is now recognized that
any apparent attening e ect on the corneal apex is transient
and not o value or attenuating progressive corneal ectasia
(Woodward, 1997).
Clinically, a primary concern with this mode o tting is the
potential or axial corneal scarring, subsequent to long-term
abrasive contact between the rigid lens and the cornea. It is
important to note that central corneal scarring may occur in the
absence (Krachmer et al., 1984) (Fig. 26.2B) or presence (Korb
et al., 1982) (Fig. 26.2C) o contact lens wear in keratoconus. It
is, however, possible that contact lens wear is an exacerbating
actor that hastens the pathology (Zadnik et al., 2005). Harsh
apical lens bearing can result in signi cant corneal epithelial
disruption, which is clinically identi able by a ‘whorl’-type
staining pattern (Fig. 26.2D). T is apical epithelial breakdown
may progress to corneal scarring in the scenario that an exces-
sively at- tting rigid lens is worn or a prolonged period o
time (Korb et al., 1982).
Apical Clearance. An ‘apical clearance’ rigid lens tting
eatures complete clearance o the corneal apex, with lens
support (landing) on the paracentral cornea (Fig. 26.2E) (Voss
and Liberatore, 1962). T is approach is achieved by tting the
back optic zone radius (BOZR) o the lens relatively steeper
than the apical corneal curvature. T e rationale behind this
tting philosophy is that it should minimize direct corneal
epithelial trauma and the subsequent long-term risk o corneal
scarring (Korb et al., 1982; Leung, 1999). T ere is however,
still the potential or transient corneal-moulding e ects,
peripheral corneal disruption and lens binding (Zadnik et al.,
2005).

Fig . 26.2 Rig id contact le ns tting in ke ratoconus. (A) An ‘ap ical b e aring ’ rig id le ns tting with sig ni cant b e aring on the corne al ap e x. (B) Ap ical
corne al scarring in a ke ratoconus p atie nt who has ne ve r worn contact le nse s. (C) De nse ap ical corne al scarring in a p atie nt we aring a re lative ly f at t-
ting rig id le ns. (D) ‘Whorl’-typ e corne al staining and e p ithe lial d amag e , sub se q ue nt to harsh ap ical b e aring with a rig id le ns. (E) An ‘ap ical cle arance ’
rig id le ns tting with visib le cle arance (vaulting ) o the corne al ap e x. (F) A ‘thre e -p oint touch’ rig id le ns tting with an ap p are nt sub tle d arke ning o
the f uore sce in p ro le ove r the corne al ap e x. (From Downie and Lind say (2015) and use d with p e rmission from Clinical and Exp e rime ntal O p tome try.)

T e Collaborative Longitudinal Evaluation o Keratoco-
nus (CLEK) study developed a standardized approach to api-
cal clearance corneal lens tting, whereby the end-point o
the process was the attest BOZR that showed de nite apical
clearance using sodium uorescein assessment. Based upon
the results o this study, the conclusion was made, despite
absence o a control group, that tting rigid corneal lenses
with apical clearance was pre erred or keratoconus ( Zadnik
et al., 2005). Although the CLEK study reported superior
visual acuity with relatively steep- tting corneal lenses (Zad-
nik et al., 2005), the association between better visual out-
comes and apical clearance tting remains unclear (Voss and
Liberatore, 1962). Whether apical clearance rigid lens t-
ting a ects keratoconus progression is also uncertain. It has
been postulated that apical clearance ttings may actually
increase the risk o progression in early keratoconus, espe-
cially given that with corneal moulding there is a tendency or
the corneal curvature to shi towards the contact lens BOZR
(McMonnies, 2004).
T ree-point ouch. For a ‘three-point-touch’ corneal lens
tting, the aim is to have ‘apparent touch’ at the corneal apex
(evident as a subtle reduction in the brightness o the sodium
uorescein), with the majority o the lens-bearing pressure
residing on the peripheral cornea (Fig. 26.2F). T e term
‘apparent touch’ intends to re ect the lack o true physical
interaction between the lens and the corneal apex; the relative
darkening o the sodium uorescein pro le in this zone is
the consequence o a tear lens thickness below 20 µm, being
the approximate threshold or uorescence. T is method o
tting rigid corneal lenses to keratoconus eyes has previously
been shown to be popular amongst contact lens practitioners
(Mandell, 1997; Zadnik et al., 1998). T e key actor with
this approach is to ensure that the contact lens does not
bear heavily on the corneal apex so as to cause an epithelial
abrasion (Mandell, 1997). In practice, a three-point-touch
tting pattern that tends towards apical clearance is probably
optimal, as it allows both or keratoconus progression and / or
or potential non-compliance with respect to clinical ollow-
up (Leung, 1999).
Lens Designs
Spherical Lens Designs. Many rigid lens designs have been
developed or keratoconus. Most o these designs aim to provide
a steeper than typical BOZR, to accommodate the conical nature
o the central cornea, and then incorporate a series o peripheral
curves with progressively atter radii to clear the relatively
normal peripheral cornea (Caroline and Andre, 1998). Due to
the relatively steeper BOZR, there needs to be relatively more
attening o the peripheral curves to achieve an acceptable
degree, about 0.08–0.1 mm, o edge clearance (Woodward,
1997). T at a greater degree o attening is warranted in the lens
periphery is re ected by the relatively high corneal eccentricity
values, consistent with a relatively prolate corneal shape, being a
clinical eature o keratoconus.
T e multicurve lens, consisting o multiple spherical radii
that are blended together to orm the desired attening con-
tour, is a common rigid lens design or keratoconus (Lee and
Kim, 2004). Multicurve lenses have the advantage o readily
changeable parameters, including BOZR, D, BOZD, back
peripheral curve radii (BPR) and back peripheral curve widths
(Lee and Kim, 2004). Flexibility to customize these parameters
26 Ke rat o co nus 255
is important, as the contact lens practitioner will o en need
to modi y, and typically more than once, some or all o these
parameters be ore determining the optimal contact lens pre-
scription. It is there ore essential or the practitioner to have
access to an appropriate keratoconus rigid lens tting set or this
purpose (Zadnik et al., 2005).
Consider the ollowing three typical corneal rigid lens speci-
cations or keratoconus:
Lens 1 C4 / 6.80 : 6.40 / 7.60 : 7.20 / 8.40 : 8.00 / 10.20 : 8.80 −7.00 AEL 0.23
Lens 2 C4 / 6.20 : 6.00 / 7.10 : 6.80 / 8.20 : 7.60 / 10.40 : 8.40 −11.00 AEL 0.31
Lens 3 C4 / 5.60 : 5.60 / 6.60 : 6.40 / 8.10 : 7.20 / 10.60 : 8.00 −15.00 AEL 0.38
O the three lenses, lens 1 shows parameters or the relatively
earliest stage o keratoconus. Lenses 2 and 3 incorporate param-
eters or increasingly more severe disease, respectively. Note
that, with increasing keratoconus severity, greater axial edge li
(AEL) o the contact lens is required to achieve an acceptable
degree o edge clearance; this is the consequence o the steeper
BOZR.
T ese three rigid lens speci cations also demonstrate some
other important tting principles with respect to corneal lenses
and keratoconus. First, the D generally decreases as the kera-
toconus progresses. Second, the more advanced the keratoco-
nus, the smaller will be the BOZD; this is primarily to acilitate
adequate tear exchange around the apex o the cone, which in
turn will assist with preventing tear pooling and accumula-
tion o tear debris under the optic zone o the lens. Finally, the
required back vertex power (BVP) o the lens will be more nega-
tive (i.e. higher minus) as the keratoconus progresses owing to
the e ect o the tear lens becoming more positive when tting
a steeper BOZR.
T ere are a couple o important points to note in relation
to rigid lens BVPs. First, the higher minus power that is usu-
ally associated with a keratoconic contact lens prescription
does not imply that the patient is highly myopic, although
this mistake is o en made in clinical practice. Indeed, or the
three lenses previously speci ed, the BVPs o −7.00, −11.00
and −15.00 would actually be more typical o patients with
keratoconus who are also relatively emmetropic based on the
corresponding BOZRs o 6.80 mm, 6.20 mm and 5.60 mm,
respectively. A person with keratoconus can also have associ-
ated myopia or hyperopia; in this case, the BVP in the contact
lens prescription would be di erent rom what is normally
predicted according to the BOZR.
Second, with regard to taking into account the change in
tear lens power that will occur as a result o changing the
BOZR, it was noted in Chapter 16 that, as an approximation,
or every 0.05 mm decrease (steepening) in BOZR, −0.25 D
must be added to the BVP o the contact lens. Similarly,
+0.25 D should be added to the BVP o the contact lens or
every 0.05 mm increase ( lattening) in BOZR. However, this
approximation does not hold or BOZR steeper than 7.00
mm, even or small changes in BOZR. For keratoconus, it
is there ore more accurate to use the tear lens ormulae out-
lined in Chapter 16 to calculate the required BVP ollowing
BOZR modi ication.
For example, let us consider the compensatory change
to BVP that is required when a rigid lens BOZR is steep-
ened by a relatively small amount, rom 6.70 mm to 6.60
mm. According to the approximation, we would add −0.50
256 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
Fig . 26.3 Rig id contact le nse s with sp he rical and toroid al p e rip he ral curve s. (A) A sod ium f uore sce in p hotog rap h o a rig id contact le ns with a
sp he rical p e rip he ry, on an e ye with ke ratoconus; the le ns e d g e cle arance is g re ate r along the ve rtical me rid ian than the horizontal me rid ian d ue to
the p e rip he ral with-the -rule astig matism. (B) A sod ium f uore sce in p hotog rap h o a rig id contact le ns with toroid al p e rip he ral curve s on the same e ye ,
showing symme tric e d g e cle arance around the circum e re nce o the le ns.
D to the BVP o the rigid contact lens. However, using tear
lens ormulae, we see that we actually need to add (336 /
6.70 − 336 / 6.60) ≈ −0.75 D to the BVP. he magnitude
o this error increases with increasingly steep BOZR. For
example, using the approximation or a change in BOZR
rom 5.90 mm to 5.80 mm gives a suggested increase in BVP
o −0.50 D; however, actual calculation shows that the BVP
should be adjusted by −1.00 D.
Aspheric Lens Designs. Considerable improvements in
manu acturing and technology, such as precision aspheric
lathing, mean that rigid aspheric lenses also have application
or the contact lens management o keratoconus (Caroline and
Andre, 1998). Aspheric rigid corneal lenses are typically tted
nominally steeper than multicurve lenses in relation to the
corneal curvature; however, their sagittal height is usually less
than a multicurve lens owing to the relationship between the
nominal BOZR and the lens eccentricity (Lee and Kim, 2004).
D is an important tting actor in aspheric designs as it has to
be manipulated, as a result o the base curve–eccentricity value
relationship, to maintain the desired degree o edge clearance
(Bennett, 1986); smaller lens diameters will give greater edge
clearance, whereas larger lens diameters will provide relatively
less edge clearance.
oroidal Lens Designs. Due to the highly irregular and
asymmetric astigmatism that is characteristic o keratoconus,
rigid corneal lenses with toroidal BOZR should be tted
sparingly (Woodward, 1997). A rigid lens with toroidal BOZR
will generally locate poorly on a keratoconic cornea, with
excessive on-eye rotation. Notably, the peripheral corneal
curvature in keratoconus is o en relatively asymmetric and can
have signi cant regular astigmatism; this is most commonly
with-the-rule astigmatism. In such cases, the edge clearance
will be more generous along the vertical meridian compared
with the horizontal meridian (Fig. 26.3A); the quality o the
peripheral tting relationship can be enhanced with the use o
toroidal peripheral curves (Fig. 26.3B).
Let us assume that the rigid lens shown in Fig. 26.3A incor-
porates the ollowing parameters:
C4/6.70 : 6.40/7.40 : 7.20/8.30 : 8.00/10.10 : 8.80 − 7.50
T en, using the notation shown in Chapter 16 or speci cation
o a rigid lens with a spheroidal optic zone and a toroidal back
optic zone, the lens shown in Fig. 26.3B might have the ollow-
ing speci cation:
7 10 8 00 9 80
C4/6 70 : 6 40 : 7 20 : 8 00 : 8 80 − 7 50
7 80 8 70 10 50
In this case, the relatively atter peripheral curves (7.80 mm,
8.70 mm and 10.50 mm) will align along the ( atter) horizontal
corneal meridian and the relatively steeper peripheral curves
(7.10 mm, 8.00 mm and 9.80 mm) will align along the (steeper)
vertical corneal meridian.
I a patient with keratoconus also has signi cant residual
astigmatism, de ned as the non-corneal component o the ocu-
lar astigmatism (Lindsay et al., 2013), a ront-sur ace toric rigid
lens (incorporating a spherical BOZR and a toroidal ront sur-
ace, and is discussed in Chapter 16) can be considered. As a
ront-sur ace toric rigid lens design would also require a prism
ballast or apposite lens stabilization, which may compromise
the tting in more advanced cases o keratoconus, spectacles
(worn over the contact lens correction and incorporating the
residual cylinder) are o en the pre erred mode o correction.
T e development o quadrant-speci c designs has been
another important innovation that has extended the range o
available contact lens options or keratoconus. Quadrant-spe-
ci c designs enable a di erent edge li to be incorporated into
each lens quadrant. T is lens design is use ul or keratoconus as
there is typically signi cant asymmetry in the peripheral corneal
contour (van der Worp, 2010b). T e most requent application
o quadrant-speci c designs in keratoconus is or in eriorly dis-
placed sagging cones; the in erior lens quadrant can be designed
to incorporate relatively reduced edge li , in order to minimize
in erior lens stand-o and interaction with the in erior eyelid.
Placido-disc corneal topography, which was discussed in the
context o keratoconus diagnosis earlier in this chapter, can also
be o clinical value or rigid lens tting. Corneal topography-
derived radii o curvature data can assist the practitioner when
selecting an initial BOZR or rigid lens trial tting. In a study o
35 eyes with keratoconus, the nal rigid lens BOZR was ound
to correlate with the steep axial curvature value obtained rom
Placido-based videokeratography (Szczotka and T omas, 1998).
An alternative approach is to begin a diagnostic tting with an
initial BOZR that is midway between the steep and at keratom-
etry values (Edrington et al., 1999). angential corneal maps
 26 Ke rat o co nus 257

Fig . 26.4 Virtual (simulate d ) rig id contact le ns tting . (A) Corne al axial p owe r map , d e rive d rom Placid o-d isc-b ase d vid e o ke ratog rap hy, with nor-
malize d scale (in d iop tre s). Simulate d sod ium f uore sce in p atte rn, showing the p re d icte d te ar lm cle arance or the chose n rig id le ns d e sig n along
b oth the (B) ve rtical and (C) horizontal me rid ians (re d arrows). (D) A sod ium f uore sce in p hotog rap h o the actual rig id le ns in situ shows a strong
re se mb lance to the simulate d tting p atte rn. (From Downie and Lind say (2015) and use d with p e rmission from Clinical and Exp e rime ntal O p tome try.)

can be used to quanti y the size and location o the cone, which
assist with selecting an appropriate BOZD and D (Sorbara and
Dalton, 2010). Similar application o topographic-derived data
has been reported to be o predictive value or tting hybrid
lenses in keratoconus (Downie, 2013).
Virtual contact-lens- tting so ware, available within many
videokeratoscopic systems, can be used or modelling the
e ect(s) o altering lens parameters on the on-eye tting char-
acteristics o a range o di erent lenses (Fig. 26.4). A 1-year
prospective study that compared the use o a computerized
videokeratography system with standard diagnostic procedures
or tting rigid corneal lenses to patients with corneal ectasia
showed relatively enhanced success and ef ciency with the sim-
ulation system (Nosch et al., 2007). Sindt et al. (2011) assessed
the degree o similarity between theoretical sodium uorescein
patterns derived rom the Medmont E300 corneal topographer
(Precision echnology, Canada) contact lens simulator with
actual tting patterns observed at the slit-lamp biomicroscope
or 31 rigid lens ttings or keratoconus. Accurate prediction o
the sodium uorescein pattern was reported in 74% o cases;
the degree o concordance was ound to be dependent upon the
quality o the captured Placido-disc imagery.
Corne o-scle ral Le nse s
In corneo-scleral designs, lens bearing is shared between the sclera
and the cornea (Bennett, 1986). As or other larger-diameter rigid
contact lenses, the major potential advantages o these designs com-
pared with corneal lenses are enhanced com ort, a larger BOZD to
acilitate more consistent visual per ormance and improved on-eye
stability (Downie, 2014b). Corneo-scleral designs can be particu-
larly use ul or tting in eriorly displaced sagging cones and, simi-
larly, eyes with pellucid marginal degeneration (Fig. 26.5) where
the corneal apex is markedly in erior due to the presence o corneal
thinning in close proximity to the limbus (Lindsay, 1993).
In contrast to miniscleral designs, corneo-scleral lenses
exhibit on-eye movement and provide a moderate amount o
tear exchange (i.e. they are not a ‘sealed’ t). Consequently,
enestrations are not required or corneo-scleral lenses and, in
many respects, the tting approach is similar to that o a cor-
neal rigid lens. Corneo-scleral lenses can also incorporate the
Fig . 26.5 A corne o -scle ral contact le ns on an e ye with p e llucid mar-
g inal d e g e ne ration. Sod ium f uore sce in p hotog rap h o a 14.60 mm Rose
K2 XL corne o-scle ral contact le ns in situ. (Courte sy of Paul Rose .)
complement o design eatures (i.e. multicurve, aspheric, toric
and quadrant speci c) that were described in the previous sec-
tion on corneal lenses.
Oxygen transmissibility (Dk / t) through a corneo-scleral
lens is also generally higher than that through a miniscleral
lens owing to the thinner tear layer associated with the ormer
(usually less than 50 µm compared with in excess o 200 µm).
As or corneal rigid lenses, corneo-scleral lenses must be tted
to ensure that there is adequate peripheral lens clearance. Fur-
thermore, limbal compression by the lens must be avoided with
larger-diameter rigid lenses, as it can be a major stimulus or
angiogenesis (E ron, 1987).
Miniscle ral Le nse s
Similar to corneo-scleral lenses, miniscleral lenses have the
advantages o enhanced on-eye com ort and stability; these ac-
tors have most likely contributed to the rapid increase in the
popularity o these designs in recent years. When tted appro-
priately, miniscleral lenses should vault both the cornea and lim-
bus, with an evenly distributed weight on the sclera (Watanabe,
2013). Generally, miniscleral lenses are tted to achieve a semi-
sealed state, with partial tear exchange (van der Worp, 2010a).
T e lens must not rest on the limbus and the scleral t should
258 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns

not be so tight that the lens shi s rom a semi-sealed to a sealed

state, as this can prevent tear exchange and lead to both short-
term (Bruce and Nguyen, 2013) and long-term (DeNaeyer,
2012) complications. T ese lenses need to be lled with an
appropriate ophthalmic solution, usually unit-dose or non-
preserved saline, prior to their application in order to prevent
air bubble ormation beneath the lens (Gromacki, 2013). T is is
similar to the technique advocated and success ully adopted by
Pullum or scleral lenses (Pullum, 1997) (see Chapter 21).
Upon initial application to the eye, a miniscleral lens should
vault (clear) the corneal apex by approximately 300 µm (Caro-
line and Andre, 2011). T e lens should rest onto the bulbar con- Fig . 26.6 A miniscle ral contact le ns on an e ye with ke ratoconus. An e n
junctiva and enon’s capsule, both being relatively so ocular face sod ium f uore sce in p hotog rap h o a 16.50 mm miniscle ral contact
tissues. As a result, the extent o corneal clearance (also termed le ns in situ showing comp le te vaulting o the le ns ove r the corne al ap e x
‘corneal vault’) will reduce as the miniscleral lens settles and and limb us. (Courte sy of John Mountford .)
compresses these tissues. T is lens settling e ect can induce a
decrease in corneal vault o between 70 and 180 µm (Caroline
and Andre, 2012; Kau man et al., 2014) and there ore needs to
be accounted or during lens tting. Once settled onto the eye,
the lens should have a central clearance o approximately 200
µm, with 50–100 µm o limbal clearance (van der Worp, 2010a;
Caroline and Andre, 2011).
Although sodium uorescein is o en not used to t mini-
scleral lenses by experienced contact lens practitioners, the
sodium uorescein tting pattern or a miniscleral lens on
an eye with keratoconus should demonstrate an even glow o
uorescein over the entire corneal sur ace and extending onto
the sclera (Fig. 26.6). T ere must be no apical touch and lim-
bal clearance is essential. Using white light and high magni -
cation on the slit-lamp biomicroscope, the amount o corneal
clearance can be determined by comparing the contact lens
thickness, usually about 0.30 mm, with the tear layer thickness.
When sodium uorescein has been incorporated into the post-
lens tear uid, the tear layer will appear bright green (Fig. 26.7).
For example, i the central tear layer thickness is approximately
the same as the thickness o the miniscleral lens, then central Fig . 26.7 Photog rap h showing the cle arance o a miniscle ral contact
corneal clearance is estimated to be about 300 µm (0.30 mm). le ns on an e ye with ke ratoconus in cross-se ction. This p hotog rap h o an
Alternatively, anterior-segment optical coherence tomogra- op tical se ction shows how the ap ical cle arance o a miniscle ral contact
le ns on an e ye with ke ratoconus can b e d e te rmine d b y comp aring the
phy (OC ), which acilitates a highly precise, cross-sectional thickne ss o the contact le ns (b lack) with the thickne ss o the te ar laye r
assessment o the interaction between the anterior corneal sur- (b rig ht-g re e n co lour d ue to the instillation o sod ium f uore sce in). (Cour-
ace and contact lens in situ, can be used to quanti y central te sy of John Mo untford .)
and peripheral corneal clearances or miniscleral lens designs.
Such an approach is particularly use ul in keratoconus, where scan o the same lens and same eye as in Fig. 26.8C; however,
asymmetric clearance across the diameter o the lens is relatively the central corneal clearance is now signi cantly reduced owing
common owing to the irregularity o the corneal pro le. Later to marked progression o the keratoconus over an 18-month
in this section there will be discussion regarding the maximal period. Fig. 26.8E shows a poorly tting miniscleral lens with
central clearance that should be adopted to minimize hypoxia- pronounced apical bearing; this picture highlights a poten-
related corneal swelling with miniscleral lenses. OC enables tial drawback o these larger-diameter rigid lens designs. T is
such quanti cations to be per ormed relatively easily and reliably patient was originally prescribed an optimally tted miniscleral
in a clinical setting. Anterior segment OC can also be utilized lens that showed suf cient corneal apical clearance. T e resul-
to analyse the shape o the scleral curvature, which may be o tant harsh apical bearing is the consequence o signi cant pro-
assistance or determining the design o the scleral portion o the gression o the keratoconus. However, this patient was unaware
lens (Choi et al., 2014; Kau man et al., 2014). o any change to the eye (perhaps somewhat surprisingly) as the
T e utility o OC or evaluating the tting o miniscleral lens still elt com ortable and was delivering an acceptable level
lenses is demonstrated by the OC scans shown in Fig. 26.8. o visual acuity.
Fig. 26.8A shows the application o a miniscleral lens to vault a Miniscleral lenses can be speci ed either by the radii o cur-
troublesome central corneal nebule on an eye with moderately vature o the central base curve and peripheral curves, or by the
advanced keratoconus. Fig. 26.8B highlights the ability to t a lens sagittal depth. T e ormer allows the practitioner to speci y
miniscleral lens to an eye with marked corneal ectasia, which the radius or any particular curve and acilitates easier power
is associated with extreme central corneal thinning. Fig. 26.8C calculations as the base curve is adjusted; the latter is use ul as
represents a close to optimal miniscleral lens tting, with about the sagittal depth can be easily linked to the required corneal
250 µm o central corneal clearance. Fig. 26.8D shows an OC vault (Watanabe, 2013). Whereas the central corneal sur ace
 26 Ke rat o co nus 259

Fig . 26.8 Ante rior se g me nt op tical cohe re nce tomog rap hy (O CT) or contact le ns tting in ke ratoconus: 8.0 mm scans o miniscle ral le ns o n (A) an e ye
with mod e rate ly ad vance d ke ratoconus and a p romine nt corne al ne b ule ; (B) an e ye with hig hly ad vance d ke ratoconus and p ronounce d corne al e ctasia;
(C) an e ye with mod e rate ke ratoconus showing ab out 250 µm o ce ntral corne al cle arance ; (D) the same e ye as in p art (C) (and the same miniscle ral
le ns) a te r an 18-month time p e riod ; (E) an e ye with re lative ly ad vance d ke ratoconus and a p oorly tting miniscle ral le ns, with ap ical corne al b e aring .

over a 10 mm chord is curved, and appropriately described
in terms o radii o curvature, beyond this central region the
peripheral cornea, limbus and sclera generally orm a straight
line and are there ore more accurately described as a tangent
angle (van der Worp, 2010a; Kojima et al., 2012). As a conse-
quence, many miniscleral lens designs utilize adjustable tangent
angles to provide limbal vault and tangential scleral landing.
Other miniscleral designs have traditional radii o curvature
that can be manipulated to optimize the tting (Watanabe,
2013).
Miniscleral lenses are available in ront-sur ace toric orms,
to correct residual astigmatism, and can incorporate toric
peripheral curves i the sclera has signi cant toricity. As mini-
scleral lenses vault the cornea, a toric central (base) curve is
typically not required (Bierwerth and Edrington, 2012). Mini-
scleral lenses can also be manu actured with quadrant-speci c
peripheral designs (Watanabe, 2013), to assist with minimiz-
ing on-eye torsional e ects that can arise rom the sclera being
increasingly more non-rotationally symmetric with increasing
distance rom the limbus (van der Worp, 2010a). A peripheral
notch can also be incorporated to aid with avoiding lens interac-
tion with conjunctival obstacles, such as pingueculae and post-
trabeculectomy ltering blebs (DeNaeyer, 2014).
Accurately determining the BVP o a miniscleral lens
requires care. With corneal rigid lenses, the post-lens tear layer
is suf ciently thin that the approximation o thin lens optics
can be applied when calculating the tear lens power. T in
lens theory does not apply or miniscleral lenses owing to the
markedly thicker tear reservoir that is created by vaulting the
cornea (Chan and Jackson, 2014). I thin lens theory is inap-
propriately applied to miniscleral lens BVP calculations, the
power o a positive tear lens will generally be underestimated
and the power o a negative tear lens will be overestimated
(Chan and Jackson, 2014). It is also important to ensure that
the miniscleral lens has ully settled onto the eye be ore per-
orming an overre raction, as the overre raction will vary i
the e ective sagittal depth o the lens is changing during the
period o on-eye lens settling.
Concern has been raised in relation to whether the oxygen
transmissibility (Dk / t) through a miniscleral lens reaches the
level necessary to avoid hypoxic corneal stress during daily wear
(Michaud et al., 2012). T e oxygen transmissibility through a
miniscleral lens alone, when manu actured rom a highly oxy-
gen permeable material (see Chapter 11) such as Boston XO
(Dk = 100 Barrer) would intuitively seem adequate (Weissman,
2006). However, it has been shown that in most cases the com-
bination o the miniscleral lens and the thick underlying tear
reservoir does not provide suf cient oxygen to avoid corneal
hypoxia (Michaud et al., 2012), based on the Holden–Mertz
criterion or the central cornea (Holden and Mertz, 1984) and
the Harvitt and Bonanno standard or the limbal area (Har-
vitt and Bonanno, 1999). Chronic corneal hypoxia may lead to
problems such as corneal neovascularization and / or a loss o
corneal transparency (see Chapter 40). Furthermore, reduced
oxygen supply at the corneal periphery can lead to serious
complications, including limbal stem cell de ciency (Dua and
Azuara-Blanco, 2000). Findings rom a recent study indicate
that miniscleral lenses may subtly in uence corneal shape and
power but do not induce clinically signi cant corneal oedema
during short-term wear (Vincent et al., 2014). Other researchers
recommend that miniscleral lens clearance should not exceed
200 µm i hypoxia-induced corneal swelling is to be avoided
(Michaud et al., 2012). As previously discussed, limbal com-
pression is a major stimulus or angiogenesis and so inadequate
lens clearance at the periphery o the cornea and limbus is also
not acceptable.
260 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
Scle ral Le nse s
As discussed in Chapter 21, scleral lenses can be tted either
rom pre ormed sets or by impression moulding. radition-
ally, impression scleral lenses have be made only in polymethyl
methacrylate (PMMA), as gas-permeable materials are not ther-
moplastic, although it is sometimes possible or an optimally
tting PMMA lens to be duplicated in a gas-permeable mate-
rial. In the 1980s, gas-permeable pre ormed scleral lenses were
introduced. Although the use o these lenses in clinical practice
has remained relatively in requent, scleral lens pioneers, such as
Ezekiel (1983) and Pullum (1997), have demonstrated the rela-
tive value o this modality or keratoconus patients. In addition
to the obvious advantage o using a gas-permeable lens mate-
rial, pre ormed lenses also have a number o advantages over
impression scleral lenses, including an ability to speci y lens
parameters accurately and or ttings to be undertaken with
diagnostic lenses having known speci cations.
T e criteria or a well- tting scleral lens are similar to those
outlined or a miniscleral lens. A scleral lens should clear the
corneal apex a er lens settling (Caroline and Andre, 2012) and
not rest on the limbus; the scleral tting should not be so tight
as to cause conjunctival vessel blanching. As or minisclerals,
scleral lenses can be produced in ront-sur ace toric orms to
correct residual astigmatism and / or with peripheral toricity
i the sclera is highly toric (Bierwerth and Edrington, 2012).
Quadrant-speci c peripheral designs are also available (Wata-
nabe, 2013). Although still currently limited to the research
domain and not yet directly applicable to managing patients
in clinical practice, customized aberration-controlled scleral
lenses (Sabesan et al., 2013; Marsack et al., 2014) show promise
as a potential uture vision-correction plat orm or keratoconus.
A range o actors will need to be overcome or the custom cor-
rection o highly aberrated eyes to achieve clinical translation.
Such actors include the complexity o tting (and the need or
highly repeatable centration), the current cost o the devices (to
patient and practitioner) and longer-duration studies to assess
real-world e ects on visual per ormance.
Scleral lenses can be manu actured with or without enes-
trations. Fenestrations were used with impression scleral lenses
to promote the exchange o reshly oxygenated tears; however,
with pre ormed gas permeable scleral lenses enestrations are
not critical or oxygen delivery (van der Worp, 2010a) and there
is conjecture as to the degree to which enestrations aid oxy-
gen ow to the cornea. T e tting philosophies o enestrated
and non- enestrated scleral lenses are di erent, with the clear-
ance in enestrated lenses (about 100 µm) being less than that o
non- enestrated lenses (approximately 200 µm) (van der Worp,
2010a). (Please re er to Chapter 21 or a more detailed discus-
sion on the tting principles o scleral lenses.)
With regard to the oxygen transmissibility through scleral
lenses, the same principles apply as previously discussed or
miniscleral lenses, especially with non- enestrated lenses; again,
use o a highly oxygen-permeable material is critical, and atten-
tion must be paid to the maximum central lens thickness and
the clearance under the lens so as to avoid corneal hypoxia
(Michaud et al., 2012).
Pig g yb ack Le ns Syste ms
Piggyback systems consist o a so contact lens, usually a dispos-
able silicone hydrogel lens, worn beneath a rigid lens, generally
a corneal or corneo-scleral lens (Lindsay et al., 2013). Changing
to a piggyback system when rigid lenses have been previously
worn alone may require a minor modi cation to the rigid lens
parameters; this is usually an increase ( attening) o the BOZR
so as to achieve an optimal tting (Larson and Edrington, 2010).
Practitioners need to be aware that the e ective power or a
so contact lens worn under a rigid lens in a piggyback system
will be only approximately 20% o the speci ed power (Woo and
Weissman, 2011). For example, i a piggyback system is created
by placing a so lens with a BVP o −0.50 D under a rigid lens,
then the contribution o the so lens to the overall power o the
piggyback system will be negligible. In other words, i a patient
is corrected appropriately with just their rigid lens, then chang-
ing them to a piggyback system by incorporation o a so lens
with BVP o −0.50 D will not necessitate a change to the BVP o
their existing rigid lens. It has been suggested that using a so
lens with a relatively high positive power (i.e. greater than +4.00
D) in a piggyback system will help to improve the centration o
a rigid lens on a keratoconic cornea with a markedly in erior
sagging cone (Larson and Edrington, 2010). In such cases, the
relative contribution o the so lens BVP to the so –rigid lens
system should be considered. Other authors recommend the
use o negative-powered so lenses in piggyback tting, which
can reduce the rigid lens BVP without signi cantly impacting
visual acuity (Romero-Jimenez et al., 2015).
Piggyback contact lens systems are usually adopted when t-
ting with a rigid lens alone may lead to corneal insult, owing to
underlying ocular sur ace disease, or or a highly irregular cor-
nea. T e so contact lens is considered to assist with protecting
the corneal sur ace rom rigid lens bearing, thereby minimizing
this potential complication o rigid lens wear and also enhanc-
ing lens com ort (Szczotka and Lindsay, 2003). wo clinical
examples where the use o a piggyback contact lens system may
be indicated include nebular-like scarring at the corneal apex
and chronic 3 and 9 o’clock corneal staining.
For patients with signi cant residual astigmatism, piggyback
lens systems can have the additional advantage o incorporating
the residual astigmatism correction into a so toric contact lens.
T is option enables the rigid lens to remain spherical and elimi-
nates the need to incorporate rigid lens stabilization eatures,
which may make the lens less com ortable (Lindsay et al., 2013).
Concern has been expressed over whether the oxygen trans-
missibility through a piggyback contact lens system can reach
the level required to avoid hypoxic stress to the cornea during
daily wear (Holden and Mertz, 1984). Weissman and Ye (2006)
have calculated that in open-eye conditions, the oxygen supply
to the cornea is suf cient when both rigid and so lenses have
been manu actured rom materials that have an oxygen perme-
ability (Dk) greater than 60 Barrer.
HYBRID LENSES
Hybrid contact lenses, which were rst introduced into clinical
practice over 30 years ago, consist o a rigid central zone and
a so peripheral ‘skirt’ (Fig. 26.9A). A major attraction o this
modality is the potential to combine the pre erred tting prop-
erties o rigid and so contact lenses (i.e. the visual per ormance
o a rigid lens with a com ort and stability pro le similar to that
o a so lens) (Downie, 2014a).
Historically, the main hybrid lens option or keratoconus
was the So tPerm (CIBA Vision) lens. Although this design
represented a major improvement on its predecessors, it-
ting success or keratoconus was limited by several actors,
including a restricted range o parameters, limited durability

Fig . 26.9 Hyb rid contact le ns tting in ke ratoconus. (A) The con g uration o a Syne rg Eye s hyb rid contact le ns, with a rig id le ns ce ntre b e ing b ond e d
to a so t skirt. Sod ium f uore sce in p hotog rap hs o (B) Syne rg Eye s KC, (C) Syne rg Eye s Cle arKone and (D) Syne rg Eye s UltraHe alth hyb rid le nse s in situ.
(From Downie and Lind say (2015) and use d with p e rmission from Clinical and Exp e rime ntal O p tome try.)
o the rigid–so t junction and suboptimal oxygen transmis-
sibility. In a published retrospective case series o So tPerm
contact lens wearers, peripheral corneal neovascularization
was reported in approximately one in our long-term So t-
Perm lens wearers (Ozkurt et al., 2007). oday, SynergEyes
(Carlsbad, CA, USA) are the leading manu acturer o hybrid
contact lens designs. For keratoconus, SynergEyes hybrid
lenses all into two major categories, namely a base-curve-
based design (KC) and vault-driven designs (ClearKone and
UltraHealth).
A distinct tting rationale applies to each o the Synerg-
Eyes lens designs. T e KC design involves the speci cation o
a rigid BOZR (in millimetres) and so skirt curvature (e ec-
tively being the BPR). A well- tted KC lens should demonstrate
ull apical clearance, with so landing o the lens at the junc-
tion zone (Fig. 26.9B). For this design, steeper skirt curvatures
promote an increase in the over-lens sagittal depth; this has the
e ect o imparting a relatively gentler landing at the junction
zone compared with atter skirt curves.
T e ClearKone lens eatures a reverse geometry design and
requires the determination o rigid lens vault, in µm, and skirt
curvature. As with the KC lens, the aim is to avoid apical bear-
ing. At the rigid–so junction, an optimal ClearKone tting
involves a graded thinning o sodium uorescein; the so skirt
should then land on the cornea, distal to the junction zone (Fig.
26.9C) (Downie, 2013).
T e UltraHealth design requires the speci cation o similar
parameters to the ClearKone (i.e. vault and skirt curvature).
T e tting principles do, however, vary owing to the silicone
hydrogel, rather than hydrogel, skirt and a distinct junction-
zone design. UltraHealth lens ttings typically require relatively
atter skirt curvatures than do KC and ClearKone lenses, so as
to minimize peripheral lens seal-o (personal communication,
26 Ke rat o co nus 261
SynergEyes Inc.). An optimally tted UltraHealth lens is shown
in Fig. 26.9D.
Similar to rigid lenses, hybrid lens designs are tradition-
ally tted using diagnostic sets, although corneal-topography-
derived data have been shown to be o value or predicting
ClearKone lens parameters (Downie, 2013). High-molecular-
weight sodium uorescein should be used when tting hybrid
lenses incorporating a hydrogel so skirt. Hybrid lenses are
applied to the eye using the same method as or scleral lenses
(see Chapter 21). In brie , this would typically involve lling the
hybrid lens with a unit-dose or non-preserved saline solution,
and then gently elevating the lens to approach the sur ace o
the eye whilst the patient’s ace is oriented parallel to the oor.
Care should be taken to minimize the loss o saline rom within
the hybrid lens during this process. T e presence o an air
pocket (bubble) under the rigid portion o the lens represents
a lens application error, rather than being indicative o exces-
sive lens vault. In these circumstances, the hybrid lens should be
removed, re lled with solution and reapplied to the eye in order
to accurately assess the quality o the tting. It has been sug-
gested that the thickness o the tear reservoir beneath the rigid
portion o a hybrid lens should be less than 100 µm in order to
deliver acceptable oxygen tensions at the corneal sur ace (Lee
et al., 2015). Anterior segment OC can be used to quanti y
accurately the amount o corneal clearance o a hybrid contact
lens in situ; as the patient blinks, dynamic changes in clearance
may also be observed.
At present, there is relatively limited literature relating to the
clinical per ormance o hybrid contact lenses in patients with
keratoconus. A chart review o 44 patients (61 eyes) with corneal
ectasia who were tted with SynergEyes KC lenses at the Cornea
Service at Wills Eye Institute (USA) reported that close to 90%
o patients were success ully tted with this design (Abdalla
262 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
et al., 2010). Unsuccess ul ttings were, perhaps surprisingly,
primarily due to inadequate lens com ort (Abdalla et al., 2010).
Visual acuity outcomes with SynergEyes ClearKone and cor-
neal rigid lenses have been reported to be similar in people with
keratoconus; in this comparative case series, overall satis action
and vision-related quality o li e was relatively higher with the
hybrid lens modality (Hashemi et al., 2014).
Mo nit o ring Ke rat o co nus Pro g re ssio n
Patients with keratoconus require care ul monitoring or disease
progression. T e quanti cation o longitudinal changes to cor-
neal curvature is necessary both or contact lens tting ( or the
modi cation o lens parameters i required) and or potentially
enabling timely re erral or ophthalmologic assessment with
regard to corneal collagen cross-linking (CXL). CXL, which
induces photo-oxidative cross-linking o the corneal stroma,
demonstrates signi cant promise or arresting the clinical pro-
gression o keratoconus (Hersh et al., 2011; O'Brart et al., 2011;
Wittig-Silva et al., 2014). T e procedure is undertaken with the
intention o enhancing corneal biomechanical stability so as to
attenuate disease progression (Spoerl et al., 1998). T e need or
spectacle and / or contact lens correction typically persists a er
CXL.
T e relative risk o progressive keratoconus and acute cor-
neal hydrops is strongly associated with a patient’s age at diag-
nosis (Downie, 2014a). Keratoconus is one o the most common
indications or childhood keratoplasty. T e condition accounts
or approximately one in ve corneal gra s per ormed in chil-
dren (Cowden, 1990; Patel et al., 2005). Diagnosis o kerato-
conus in a young patient is there ore essential or enabling an
opportunity or CXL to be administered within the therapeutic
window. Primary eyecare providers have an important role in
screening or childhood corneal ectasia, particularly when risk
actors may be present (e.g. amily history o keratoconus, atopy,
history o eye rubbing), to enable early diagnosis and appropri-
ate management. T ere is a growing body o evidence that sup-
ports the sa ety and ef cacy, in relation to corneal stabilization,
o paediatric CXL (Caporossi et al., 2012; Chatzis and Ha ezi,
2012; Soeters et al., 2014).
T e long-term visual management o a child with keratoco-
nus is also o major importance. T e likelihood o more rapid
progression in younger patients poses a higher risk o vision
impairment, which can negatively impact upon learning and
social interaction (Kankariya et al., 2013). Overall, the approach
or contact lens correction in children with keratoconus is simi-
lar to that in adults, the primary goal being to improve visual
acuity using a lens modality that is com ortable, practical and
physiologically acceptable. Scleral lenses have been used to pro-
vide e ective visual and ocular sur ace rehabilitation to children
with corneal ectasia and comorbid ocular sur ace disease (Rathi
et al., 2012).
It should be emphasized to patients in particular that, with
appropriate care to acilitate unctional vision, most people with
keratoconus will not need to undergo a corneal transplant. At
present, approximately one in ten people with keratoconus may
eventually require a corneal gra (Cassidy et al., 2013); however,
with the availability o CXL we would expect this incidence to
decrease signi cantly over time. T e key indications or oph-
thalmologic re erral or an opinion with regard to suitability
or keratoplasty include highly advanced corneal thinning or
protrusion that precludes contact lens tting by an experienced
clinician, contact lens intolerance to well- tted lenses, the pres-
ence o sight-impairing corneal scarring, and / or when there is
a substantial risk o corneal per oration, albeit this is relatively
unlikely in keratoconus.
Co nclusio n
Keratoconus is a clinically challenging, but extremely reward-
ing, area o contact lens practice. Given the variations in clinical
phenotype that exist, there remains a need or practitioners to
adopt an individualized, and o en creative, approach to kera-
toconus management. Contemporary contact lens practice is
ortunately supported by a diverse repertoire o lens modali-
ties and materials, enabling most people with keratoconus to
achieve success ul, long-term visual outcomes. T e availability
o newer imaging technologies, such as anterior-segment OC ,
are also rede ning many o the methods currently used to assess
corneal integrity and the corneal–lens relationship in vivo. Con-
tinued advances in lens technology are predicted to provide the
oundation or urther improvements in the contact lens care
that can be provided to people with keratoconus.
ACKNO WLEDGEMENTS
T e authors thank Clinical and Experimental Optometry or providing
permission to reproduce some o the content and gures rom a previ-
ous manuscript o the authors (Downie, L. E. & Lindsay, R. G. (2015).
Contact lens management o keratoconus. Clin. Exp. Optom., 98, 299–
311). T e authors would also like to thank Paul Rose, John Mount ord
and Bruce Herbert or their help ul comments and advice.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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Zhou, A. J., Kitamura, K., & Weissman, B. A. (2003).
Contact lens care in keratoconus. Cont. Lens An-
terior Eye, 26, 171–174.
27
Hig h Ame t ro p ia
JO SEPH T BARR
Int ro d uct io n
Care or the highly ametropic patient is one o the most chal-
lenging and yet one o the most rewarding aspects o contact
lens practice. T e most common indications or this care are
high myopia, high corneal toricity and thus high astigmatism,
and adult and paediatric aphakia. T is is especially true in cases
o unilateral high ametropia, resulting in high anisometropia
and possibly aniseikonia. T ese cases are challenging owing
to the high lens centre thickness o plus lenses and high edge
thickness or minus lenses, the need or lenticularization, and
centre-o -mass di culties, as well as the act that these eyes
o en have pathological changes. T ese pathological changes
include degenerative myopia, cataract surgery and increased
risk o retinal detachment.
Highly hyperopic and aphakic patients bene t rom
decreased need or head turning, better peripheral vision,
and elimination o blind areas in their eld o view with spec-
tacles (‘jack-in-the-box’), but they have less magni cation in
contact lens wear as compared with spectacles. T ese patients
also have a larger image size with spectacles but pre er contact
lenses because o the eld-o -vision bene ts. Highly myopic
patients bene t rom the increased magni cation (less mini -
cation) compared with spectacles (see Chapter 3). T ese high
myopes have signi cantly improved visual acuity as a result.
T e highly astigmatic patient bene ts rom contact lenses as
compared with spectacles, primarily as a result o the elimina-
tion o aniseikonia.
All o these patients bene t rom improved cosmesis com-
pared with thick, unsightly spectacle lenses. T is actor, coupled
with a visual per ormance overall that is superior to that with
spectacles, generally means that the highly ametropic patient
will be strongly motivated to persevere during the initial adap-
tation phase o lens wear (Astin, 1999).
Le ns Mat e rials fo r Hig h Ame t ro p ia
Just like the thick spectacles high ametropes seek to avoid, their
contact lenses are also likely to be relatively thick. T is produces
challenges or lens design and oxygen transmission to the cor-
nea. High ametropia usually requires the use o custom-made
lenses to produce the power and base curves necessary. T e
practitioner may choose rom any o the ollowing material
types:
• high-water-content so lenses (may be used with close
monitoring)
• silicone elastomer lenses (o en wet poorly, can be hard to
remove)
• silicone hydrogel lenses (high transmissibility)
• rigid lenses (give the best tear ow).
ELASTO MER
T e use o silicone elastomer lenses has not become widespread;
however, they do have a place in tting aphakic and other high-
plus patients. Silicone lenses are typically 11.3–12.5 mm in
diameter and are tted with a base curve near to or only slightly
atter than K.
SILICO NE HYDRO GEL
Silicone hydrogel lenses have been available or many years or
ametropia between +8.00 and −20.00 D. T e vast majority o
lens wearers are potentially able to bene t rom the increased
oxygen that they provide.
Developing a silicone hydrogel material or the specialty
contact lens industry has not been a straight orward proposi-
tion. First-generation lens materials were all developed or cast
moulding and many required sur ace treatment. T ere were
various obstacles to overcome be ore a silicone hydrogel mate-
rial was produced in a button orm that could be processed into
a contact lens ( apper, 2006):
• T e lathing o silicone hydrogel materials is made di cult
by the inclusion o a silicone component, as such mate-
rials are relatively so . T e lathe turning o these so er
materials to produce lenses with acceptable optical quality
requires the highest-per orming machine plat orms cur-
rently available.
• Commercial constraints: companies have invested heavily
in developing these materials and considerable knowledge
has been derived rom these activities, with any signi cant
breakthroughs being care ully protected by the en orce-
ment o patents.
• Raw material costs are high.
T ere are currently our silicone hydrogel lenses that can
be made in custom designs. T eir properties are shown in
able 27.1. All the lenses are manu actured by lathing and are
recommended or daily wear only. Although the transmissibil-
ity o these materials is not as high as that o other available sili-
cone hydrogels, they still allow the criteria o Holden and Mertz
(1984) or daily wear to be ul lled in a wider range o designs
than can currently be achieved with conventional hydrogels
(Young and apper, 2008).
T ese lenses should there ore provide relie rom the hypoxia
that has been inherent with low-Dk so lenses and allow bet-
ter com ort and planned replacement o lenses compared with
rigid materials. Silicone hydrogel high-plus lenses are tted like
so contact lenses.
Kwok et al. (2012) have noted that correcting the oveal re rac-
tive error in high myopia with standard spherical so contact
lenses can result in signi cant absolute myopic de ocus in the
263
264 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
TABLE
27.1 Silico ne Hyd ro g e ls fo r Lat he Cut t ing and Cust o m Fit t ing
Brand Name Manufact ure r Mat e rial Name
De f nitive Contamac Filcon V3
Filcon V4
Filcon V5
LSH Lag ad o Me nicon LSH Lag ad o
All d ata are manufacture r re p orte d .
For a summary of ap hakic and sp e cialty d e sig n custo m hyd rog e l contact le nse s, se e www.clsp e ctrum.com/class.
peripheral retina. I peripheral re raction does indeed in uence
myopia progression (see Chapter 33), then the induced periph-
eral myopic de ocus that occurs in contact lens correction o
high myopia may be bene cial in reducing myopia progression.
Princip le s o f Hig h-p o w e r Le ns De sig n
T e main aim when designing high-powered lenses is to reduce
the mid-peripheral thickness o minus lenses, or the centre
thickness o plus lenses, and at the same time to ensure that the
optic zone is o su cient diameter and is centred on the pupil.
T ese principles apply equally to so and rigid lenses. It will also
be necessary to correct or back vertex distance in both the at
and steep meridians to determine the lens power (Appendix C).
HIGH-PLUS
High-plus rigid lenses, unless they are o very small diameter
(8.5 mm or less) and o steep t, must be made in regular (paral-
lel) carrier orm or minus (edge thicker than junction) carrier
orm; lenticular lenses are thinner, have less mass and centre
better than non-lenticular designs (Fig. 27.1). ypically these
lenses are 9.0–10.5 mm in diameter. Regular carrier designs
are better or lens positioning between the eyelids. Minus car-
rier lenses are better or lid attachment tting (Fig. 27.2). T e
smaller the ront optic zone diameter, the thinner is the lens. T e
ront optic zone diameter may be equal to, larger than or smaller
than the back optic zone diameter. ypically the ront optic zone
diameter is 7.0–8.0 mm in diameter, and the back optic zone is
designed as needed or tting. Junction thickness or lenticular
rigid plus lenses should be thin enough to minimize lens thick-
ness, but thick enough to allow adequate lens strength (about
0.15 mm). Regular carrier un nished edge thickness is typically
0.10–0.12 mm and minus carrier un nished edge thickness is
typically approximately 0.2 mm. Lenticular ( ront peripheral)
radii range rom approximately 0.2 mm atter than the poste-
rior secondary curve (regular carrier) to 3.0 mm atter than the
posterior secondary curve (minus carrier) (Polse, 1988).
Even with a lenticulated ront sur ace, the centre o gravity o
a rigid lens is relatively anterior and may cause the lens to drop
excessively. T is can sometimes be solved by tting a corneo-
scleral or mini-scleral design. Not only is centration improved,
but also there is less movement and handling may be easier.
APHAKIA
Fortunately, adult aphakia is now rare owing to the high success
rate o intraocular lenses. However, in some cases such as aniridia,
chronic uveitis and glaucoma, contact lenses may be indicated.
O xyg e n Pe rme ab ilit y Mat e rial Mo d ulus
Wat e r Co nt e nt (%) (Barre rs) (MPa)
50 50 0.60
65 62 0.75
74 60 0.35
49 49 0.80
Fig . 27.1 Le nticular le ns d e sig ns. (Top ) re g ular (p aralle l) carrie r. (Bot-
tom) minus carrie r.
I extended wear is desired to minimize requent lens han-
dling, lenses o maximum oxygen transmissibility are recom-
mended. T ese patients may, with proper monitoring, wear
their lenses or a month at a time, i the bene ts outweigh the
risks. High-water-content so contact lenses may be pre erred
or com ort over rigid ones, particularly in monocular aphakia,
and should be selected to maximize oxygen transmissibility or
extended wear. Low-water-content lenses are not used, because
the risk o hypoxic problems is high (interestingly, the aphakic
eye may swell less than an unoperated eye; Holden et al., 1982).
Handling typically will be di cult in bilateral aphakic patients
owing to poor uncorrected vision and reduced manual dexter-
ity in the elderly. Some aphakes may pre er to handle so lenses
because o their large size, and some may pre er rigid lenses
because o their stif ness.
Residual astigmatism and reading additions or near work
can be corrected in spectacles to be worn over the contact lenses.
Patients with conjunctival ltering blebs should be moni-
tored closely and contact lenses should not impinge on these
blebs excessively. Pre erably, topical ocular medication is
instilled be ore and a er lens wear, and only under close super-
vision during contact lens wear.
Lambert et al. (2014) compared the visual outcomes o
patients optically corrected with contact lenses with those o
intraocular lenses ollowing unilateral cataract surgery during
early in ancy. T ey ound no signi cant dif erence between the
median visual acuity o operated eyes in children who under-
went primary intraocular lens implantation and those le apha-
kic. However, there were signi cantly more adverse events and
additional intraoperative procedures in the intraocular lens
group. Lambert et al. (2014) recommend that, when operating
on an in ant younger than 7 months o age with a unilateral cata-
ract, the eye should be le aphakic and corrected with a contact
lens. Primary intraocular lens implantation should be reserved
or those in ants where, in the opinion o the surgeon, the cost
 27 Hig h Ame t ro p ia 265

Fig . 27.2 Fluore sce in p atte rns for hig h-p lus rig id le nse s. (A) 7.5 mm
d iame te r, +13.00 D le ns, p ositioning te mp orally. (B) 9.5 mm d iame te r,
+12.00 D le ns, p ositio ning te mp orally. (C) 9.5 mm d iame te r, + 15.00 D le ns,
with p osition g ove rne d b y up p e r lid .

and handling o a contact lens would be so burdensome as to
result in signi cant periods o uncorrected aphakia. T e correc-
tion o paediatric aphakia is dealt with in detail in Chapter 28.
HIGH-MINUS
A rigid contact lens o −10.00 D would have an un nished
edge thickness o approximately 0.32–0.35 mm i the diam-
eter is 8.8–9.6 mm. Because un nished edge thickness or best
com ort and lens stability should be approximately 0.10 mm,
lenticularization o high-minus lenses is very important. T is
can be per ormed by CN bevelling, grinding the excess edge
thickness by hand in a diamond-impregnated cone-shaped
tool, and then polishing this area. Pre erably, the labora-
tory will use a computer numerical-controlled lathe to cut a
steeper anterior lenticular radius to obtain the proper edge
thickness.
ypical ront optic zone diameters range rom 7.2 mm
(8.8 mm lens diameter) to 7.8 mm (9.6 mm lens diameter)
and are about 0.2 mm larger than the back optic zone. T e
lenticular radius may be cut atter or a smaller ront optic
zone or steeper or a larger ront optic zone. T e latter design
will result in higher mid-peripheral thickness. T e higher
the power – with the same ront optic zone – the thicker will
be this mid-peripheral area (Fig. 27.3). T is may complicate
the t and cause discom ort i the lens does not attach to the
upper eyelid. Greater mid-peripheral thickness may also cause
a high-riding lens to ride even higher. Mid-peripheral thick-
ness can be reduced with proper polishing or advanced multi-
curve computer-controlled anterior-sur ace lathing (Fig. 27.4)
(Moore and Mandell, 1989).
HIGH ASTIGMATISM
High astigmatism is typically caused by high corneal toricity.
Custom so toric contact lenses are available in high powers.
O course, the higher the cylinder power in the lens, the more
a given degree o unwanted lens rotation will cause blur. I
rigid lenses are not desirable, or example in dusty environ-
ments, so toric lenses may be pre erred. Oblique astigmatism
is di cult to manage with so toric contact lenses. T e higher
the corneal toricity, the better is the orientation stability with
266 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
Fig . 27.3 Low-minus-p o we r le ns (le ft) with same front op tic zone d iam-
e te r as the hig h-minus-p owe r le ns (rig ht). Junction thickne ss (horizontal
straig ht line ) is g re ate r for the hig h-minus-p owe r le ns.
Fig . 27.4 O p timize d hig h-minus-p owe r le ns d e sig n.
rigid bitoric lenses. Against-the-rule toric corneas are di -
cult to t with spherical rigid lenses owing to poor lateral
lens centration, unlike with-the-rule corneas where the upper
eyelid can help position the lens properly. Bitoric rigid lenses
may be tted with toric base curves that are slightly less toric
than the corneal toricity. T e spherical power ef ect bitoric
lens (where the base curve toricity in dioptres equals power
dif erence in dioptres) may rotate somewhat of -axis without
causing residual astigmatism. Highly toric rigid lens designs –
up to 11.00 D o base curve toricity and cylinder power – are
possible.
Another option occasionally used or irregular astigmatism,
such as keratoconus, is a very thick so contact lens. Such a
lens will minimize the irregular astigmatism and correct most
o the spherical component o the re ractive error; the residual
re ractive error is corrected with spectacles. T e drawback o
this approach is such lenses will generally have very low oxygen
transmissibility.
Fit t ing Challe ng e s
Blinking can result in excessive movement o high-plus rigid
contact lenses, although more stability and less decentration can
be achieved i lenticular designs are used. So lenses will gener-
ally be more stable in the eye.
Both high-plus and high-minus rigid lenses may tend to
drop on the cornea to a low-riding position. T is will result in
peripheral corneal staining, as well as discom ort and possibly
poor vision. Both lens types have high mass compared with low-
power lenses, with the high-minus lens actually having more
mass than a plus lens o equivalent power and diameter, owing
to the increased thickness around the lens periphery. T is is
complicated by the centre-o -mass dif erences. T e minus lens
has a centre o mass urther behind the lens posterior sur ace
(Carney et al., 1987), which causes better centration orces or
the minus lens and poorer tting (dropping) o the plus lens.
Lenticularization o both designs will assist in tting and a
minus carrier design on a plus lens can help the upper lid to
hold the lens up, much like a high-minus lens that is held in
place by the upper eyelid.
Lens-positioning problems may be solved with ‘piggy-
back’ itting. Most commonly used in keratoconus, this sys-
tem employs a so t spherical lens (typically a disposable lens
in low-minus power) with a rigid lens itting over it. A spe-
cial so t lens with a cut-out central portion (depression in
the ront sur ace) is available. A rigid lens that is 0.5 mm
smaller than the cut-out portion o the so t lens is itted over
this so t lens. Scleral lenses, manu actured rom high-oxy-
gen-permeability rigid materials, are always an option or the
high ametrope. he lens may be designed to incorporate a
negative power tear layer to assist with the myopic correction
(see Chapter 21).
O course, or high ametropia, contact lens power may only
partially compensate or the ametropia and the residual re rac-
tive error may be corrected with spectacles – especially residual
astigmatism and presbyopic correction.
Lo w Visio n
One unique and rarely used contact lens application is the Gali-
lean telescope system. For example a −30.00 D contact lens can
be used in conjunction with a +20.00 D spectacle lens at a 17
mm vertex distance to obtain 1.5× magni cation. With a 40 mm
spectacle eye size, eld o view is limited to 68° with this system
(Mandell, 1988).
Co nclusio n
Best care or highly ametropic patients demands that the prac-
titioner understand:

• the unique examination necessities, especially or paediat-
ric patients
• the lens design options, especially with lenticular orms
• the lens material options
• the interaction between lens design and tting o high-
powered lenses
• the magni cation properties o high-power lenses
27 Hig h Ame t ro p ia 267
• the contact lens treatment options.
By working in collaboration with a custom lens laboratory,
practitioners should be able to nd an appropriate contact lens
solution or most cases o high ametropia.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
REFERENCES
Astin, C. L. K. (1999). Contact lens tting in high
degree myopia. Cont. Lens Anterior Eye, 22, S14–
S19.
Carney, L. G., Barr, J. ., & Hill, R. M. (1987). T e
most important point in contact lens design. Opti-
cian, 94(5126), 40–42.
Holden, B. A., & Mertz, G. W. (1984). Critical oxy-
gen levels to avoid corneal edema or daily and
extended wear contact lenses. Invest. Ophthalmol.
Vis. Sci., 25, 1161–1167.
Holden, B. A., Polse, K. A., & Mertz, G. (1982). E -
ects o cataract surgery on corneal unction. In-
vest. Ophthalmol. Vis. Sci., 22, 343–350.
Kwok, E., Patel, B., Backhouse, S., et al. (2012). Pe-
ripheral re raction in high myopia with spherical
so contact lenses. Optom. Vis. Sci., 89, 263–270.
Lambert, S. R., Lynn, M. J., Hartmann, E. E., et al.
(2014). Comparison o contact lens and intra-
ocular lens correction o monocular aphakia
during in ancy: a randomized clinical trial o
HO V optotype acuity at age 4.5 years and clini-
cal ndings at age 5 years. JAMA Ophthalmol.,
132, 676–682.
Mandell, R. B. (1988). Low vision. In R. B. Mandell
(Ed.), Contact Lens Practice (4th ed., Ch. 28, pp.
770–784). Spring eld: T omas Publishing.
Moore, C. F., & Mandell, R. B. (1989). T e design
o high minus contact lenses. CL Spectrum, 11,
43–47.
Polse, K. A. (1988). Aphakia. In R. B. Mandell (Ed.),
Contact Lens Practice (4th ed., Ch. 27, pp. 732–
769). Spring eld: T omas Publishing.
apper, . (2006). Lathe cut silicone hydrogels. Glob-
al Contact, 46, 28–29.
Young, R., & apper, . (2008). A new silicone hy-
drogel or custom lens manu acturing. Global
Contact, 49, 30–33.
267.e 1
28
Bab ie s and Child re n
CINDY TRO MANS | HELEN WILSO N

Int ro d uct io n congenital cataract can have associated disorders such as

T e contact lens practitioner is a key member o a multidisci- persistent hypoplastic primary vitreous and microphthal-
plinary team involving paediatric ophthalmologists, optom- mos, which require steeper-radii lenses and powers in excess
etrists and orthoptists concerned with ocular health and visual o +50.00 D.
development o the child. Fitting in ants and children with con- Average ttings o a high-water-content hydrogel lens based
tact lenses is a challenging yet rewarding area o clinical contact upon age, corneal radius and diameter are shown in able 28.1.
lens practice. Contact lenses play an important role in the cor-
rection o complex re ractive errors in in ants and young chil-
dren (Davies, 1998). T ey can also be used in the management
o binocular vision anomalies, or therapeutic and prosthetic
purposes, and or elective wear in older children and teenagers.

Ind icat io ns
APHAKIA
One o the most common indicators or contact lens tting in
in ants is aphakia resulting rom the surgical removal o the
crystalline lens because o congenital cataract. T e incidence o
congenital cataract (Fig. 28.1) is reported as being 2.1 per 10 000
live births and 7.7 per 10 000 at 4 years o age ( aylor, 1998); o
these cases, around 40% and 50%, respectively have unilateral
cataracts. Aphakia can also result rom lens subluxation, as seen
in Mar an’s syndrome, or ectopia lentis. rauma to the eye may Fig . 28.1 Cong e nital cataract. (Courte sy of I. C. Lloyd .)
result in the immediate loss o the crystalline lens or subsequent
development o traumatic cataract, which may require surgical
intervention.
Re ractive management o bilateral aphakia can be achieved
with spectacles (Fig. 28.2). However, the drawbacks o apha-
kic spectacles include the weight o the lenses and di culty in
achieving a good rame t in babies and young in ants. In addi-
tion, the maximum power o lenses is restricted, even in lenticu-
lated orm, to around +26.00 D.
Fig. 28.3 shows a 3-week-old bilateral aphake wearing high-
water-content hydrogel contact lenses o around +35.00 D
power.
In cases o unilateral cataract, contact lens correction is
essential or managing the resultant anisometropia.
Surgery or congenital cataract is usually per ormed
within the irst 6 weeks o li e to limit deprivation ambly-
opia, so it is vital to be aware o the rapid changes in the
ocular dimensions that occur within the irst ew months o
li e. he average radius o curvature in a newborn is around
6.90 mm and this will latten rapidly in the irst 6 months o
li e (Inagaki, 1986). Axial length will increase rapidly rom
around 17.00 mm in neonates to 21.00 mm within the irst
6 months o li e and then more slowly during later in ancy
and childhood (Larsen, 1971). hese changes cause a ‘myo-
pic shi t’, with the aphakic correction decreasing rom +35.00 Fig . 28.2 An 8-month-old b ilate ral ap hake we aring he r sp e ctacle cor-
to +20.00 D in the irst ew years o li e. However, eyes with re ctio n.
268

As in ants in the early stages o visual development require
a ocal length o around 30–50 cm in order to see a ace, the
power o the selected contact lens is usually 2–3 D greater than
the ocular re raction. T is overcorrection should be reduced at
18 months to 2 years when the toddler becomes more mobile
and aware o distant objects. A reading correction or bi ocals
can be prescribed rom around 3–4 years o age when the child
starts preschool education.
PSEUDO PHAKIA
T e use o intraocular lenses (IOLs) in the management o con-
genital cataract has now become more common as microsur-
gical techniques and IOL technology has improved. o obtain
a satis actory long-term re ractive result, allowances must be
made or growth o the eye, so pseudophakic eyes are deliber-
ately le hypermetropic to allow or axial elongation with the
corresponding myopic shi . T e desired re ractive result or
in ants undergoing surgery under the age o 10 weeks should
be 8–9 dioptres (D) o hypermetropia, reducing to 4 D at 12
months o age and 2 D by 24 months. T e nal re ractive status,
ollowing cessation o axial elongation, is aimed at emmetropia
or low myopia (Lloyd et al., 2007). T e recent In ant Aphakia
reatment Study (IA S) undercorrected the IOL power by 8 D
or those in ants operated between 4 and 6 weeks, and by 6 D or
in ants aged 7 or more weeks but less than 7 months (Lambert
et al., 2010). T e residual re ractive error can then be corrected
with a contact lens in the early months, with a 2 D overcor-
rection, gradually reducing lens power until the eye reaches an
emmetropic state and contact lenses are no longer required or
spectacles can be prescribed.
Fig . 28.3 A 3-we e k-old b ilate ral ap hake we aring hig h-p owe re d so t
le nse s o around + 35.00 D.
TABLE
28.1 Est imat e d Hyd ro g e l Le ns Sp e cif cat io ns Base d o n Ag e o r an Ap hakic Eye o No rmal Size *
Ag e (mo nt hs) BO ZR (mm)
1 7.00
2 7.20
3 7.50
6 7.80
12 8.10
*The se le nse s would orm the b asis o a p ae d iatric ap hakic d iag nostic tting se t.
BO ZR = b ack zone op tic rad ius; TD = total d iame te r.
28 Bab ie s and Child re n 269
HIGH MYO PIA
High myopia in in ants and young children is not uncommon
and correction with spectacles is the accepted practice. How-
ever, in high myopia, spectacles have the disadvantage o reduc-
ing the retinal image size, inducing peripheral distortion and
reducing the e ective visual eld (especially with lenticulated
lenses). Contact lens correction is warranted where spectacle
correction is problematic or normal visual development is
threatened. High myopia (>10 D) may be present rom birth
and is related to a number o ocular and systemic disorders
(Jensen, 1997). High myopia is also associated with cranio acial
anomalies, which can make the wearing o spectacles di cult
(Fig. 28.4).
T e myopic eye is larger than normal and tends to have a
f atter than average corneal radius and larger corneal diameter.
Adult-sized lenses can o en be used in young in ants and chil-
dren. Myopia can also result rom buphthalmos where the cor-
neal diameter is much larger than normal (>12.5 mm) and so
requires a f atter and larger lens.
Contact lenses in unilateral high myopia have been shown to
be more satis actory than spectacle lenses in the management o
amblyopia in regard to cosmesis, com ort and treatment com-
pliance (Mets and Price, 1981).
O CULAR MO TILITY DISO RDERS
Contact lenses can be use ul in the management o ocular motil-
ity disorders (Evans, 2006). Some uses include:
Fig . 28.4 An in ant with a hig h myop ia in association with a cranio a-
cial anomaly.
TD (mm) Po we r (D)
12.00 + 35.00
12.50 + 32.00
13.00 + 30.00
13.50 + 25.00
13.50 + 20.00
270 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
Fig . 28.5 An ap hakic e ye , ollowing trauma and a ull-thickne ss cor-
ne al lace ration, tte d with a hyd rog e l toric contact le ns.
• aniseikonia induced by anisometropia exceeding 6 D
• accommodative esotropia (older children)
• nystagmus
• occlusion.
IRREGULAR ASTIGMATISM
Irregular astigmatism derived rom primary corneal ectasia is
extremely rare in childhood. Most causes o corneal irregularity
are secondary in nature – or example, ollowing corneal in ec-
tion or laceration (Fig. 28.5). Neutralization o irregular astig-
matism is important during the visual development period so
as to prevent deprivational amblyopia. T e optimum orm o
contact lens correction in this situation is a rigid gas-perme-
able lens, although sometimes, i the irregularity is less severe,
a toric so lens may su ce. Rigid gas-permeable lenses have
been shown to o er a use ul re ractive treatment alternative in
children with traumatized eyes (Pradhan et al., 2014)
TINTED AND PRO STHETIC LENSES
T e aim o this type o contact lens in paediatric use is to
enhance visual per ormance by reducing the e ect o photopho-
bia or improving the cosmesis o the child by camouf aging an
ocular de ect. T e most common reasons or tting these lenses
in childhood are:
• albinism
• aniridia
• achromatopsia
• iris de ects, e.g. coloboma
• nanophthalmos or microphthalmos
• corneal anomalies, e.g. sclerocornea or Peter’s anomaly.
he itting o these lenses is described in more detail in
Chapter 22.
THERAPEUTIC LENSES
Silicone hydrogel lenses have been shown to be sa e and e ca-
cious or continuous-wear therapeutic use in children (Beno-
riene and Vogt, 2006). T erapeutic contact lens use in the
paediatric population is similar to its use in adults – mainly or
the relie o pain, promotion o corneal healing and protection
o the cornea. An example o their use is reported by Maycock
et al. (2008), where two cases o upper-eyelid entropion second-
ary to neonatal conjunctivitis resolved spontaneously ollowing
the insertion o bandage contact lenses. Previously early surgi-
cal intervention was advocated to correct the eyelid abnormal-
ity and prevent any permanent corneal scarring and visual loss.
T e tting o therapeutic lenses is described in more detail in
Chapter 29.
Ele ct ive Co nt act Le ns We ar in
Child re n
Contact lenses can be considered as an additional option to
ull-time spectacle wear or or use while participating in sport-
ing activities or both myopic and hypermetropic children and
teenagers. A study by Jones-Jordan et al. (2010) ound that both
rigid gas-permeable and so contact lenses could be consid-
ered, although gas-permeable lenses took longer to adapt to and
resulted in slightly less com ortable wearing times. Daily dis-
posable contact lenses are particularly use ul whilst participat-
ing in sporting activities, especially i wear is intermittent.
E ron et al. (2011) conducted an international survey to
determine the types o contact lenses prescribed or in ants
(aged 0 to 5 years), children (6 to 12 years), and teenagers (13
to 17 years). Up to 1000 survey orms were sent to contact lens
tters in each o 38 countries between January and March every
year or 5 consecutive years (2005–2009). Practitioners were
asked to record data relating to the rst 10 contact lens ts or
re ts per ormed a er receiving the survey orm.
Data were received relating to 105 734 ts (137 in ants, 1672
children, 12 117 teenagers, and 91 808 adults [age ≥18 years]);
the proportion o minors (<18 years old) tted varied consid-
erably between nations, ranging rom 25% in Iceland to 1% in
China (Fig. 28.6). Compared with other age groups, in ants
tend to be prescribed a higher proportion o rigid, so toric,
and extended-wear lenses, predominantly as re ts or ull-time
wear, and ewer daily disposable lenses. Children are tted with
the highest proportion o daily disposable lenses and have the
highest rate o ts or part-time wear. eenagers have a simi-
lar lens- tting pro le to that or adults, the main distinguishing
characteristic being a higher proportion o new ts. Orthokera-
tology ts represented 28% o all contact lenses prescribed to
minors. E ron et al. (2011) concluded that patterns o contact
lens prescribing to in ants and children are distinctly di erent
to those o teenagers and adults in a number o respects.
Contact lenses have also been proven to improve the quality
o li e o younger children (aged 8–12 years) and teenagers (aged
13–17 years). Studies (Walline et al., 2007a; Rah et al., 2010)
have reported that contact lens wear signi cantly improved how
both children and teenagers elt about their physical appearance
and their ability to participate in activities. T ey concluded that
children should be o ered contact lenses as an option as o en
as teenagers are.
O cular Re sp o nse t o Le ns We ar
Walline et al. (2007b) assessed the ocular response to contact
lens wear in 8–12-year-old children and 13–17-year-old teenag-
ers. Subjects returned or biomicroscopy examination at 1 week,
1 month and 3 months a er lens dispensing. T e presence o
conjunctival staining increased rom 7% o the subjects at base-
line to 20% o the subjects at 3 months, but the changes were
similar between children and teens. No other biomicroscopy
 28 Bab ie s and Child re n 271

Fig . 28.6 Prop ortion all contact le nse s tte d to in ants, child re n, and te e nag e rs in 38 countrie s b e twe e n 2005 and 2009. Error b ars re p re se nt ± 95%
con d e nce limits. AE = Unite d Arab Emirate s; AU = Australia; BE = Be lg ium; BG = Bulg aria; CA = Canad a; CN = China; CO = Colomb ia; CZ = Cze ch
Re p ub lic; DE = Ge rmany; DK= De nmark; EG = Eg yp t; ES = Sp ain; GR = Gre e ce ; HK= Hong Kong ; HR = Croatia; HU = Hung ary; IL= Israe l; IS = Ice -
land ; IT = Italy; JO = Jord an; JP = Jap an; KW = Kuwait; LT = Lithuania; MY= Malaysia; NL= Ne the rland s; NO = Norway; NZ = Ne w Ze aland ; PT = Por-
tug al; Q A = Q atar; RO = Romania; RU = Russia; SE = Swe d e n; SG = Sing ap ore ; SI = Slove nia; TW = Taiwan; UK= Unite d King d om; US = Unite d State s;
ZA = South A rica.

signs increased signi cantly over the 3-month period. T ese

ndings suggest that contact lenses are a sa e option or young
children and can be routinely o ered as a vision correction
option, even or those as young as 8 years old.

Examinat io n Te chniq ue s
ANTERIO R SEGMENT EXAMINATIO N
As with the adult patient, examination o the anterior segment is
an important aspect o contact lens tting and a ercare. A very
simple method to determine the presence o corneal staining or
ulceration is to use an ultraviolet lamp with f uorescein to deter-
mine the location and extent o the lesion. In babies, a major slit
lamp can be used with the ‘f ying baby’ technique (Fig. 28.7) and
in in ants and young children a hand-held slit lamp (Fig. 28.8) Fig . 28.7 The ‘f ying b ab y’ te chniq ue o child sup p ort d uring op hthal-
can be used to examine the anterior segment in more detail. mic e xamination.
Older children, rom 3 or 4 years o age, can usually sit at a slit
lamp, kneeling on a chair and grasping the headrest support bars. lenses or a paediatric trial rame in an older child. T e use o a
cycloplegic drug is recommended in those children with nor-
mal accommodative unction. It is use ul sometimes to dilate
KERATO METRY
the pupil in aphakes or pseudophakes, where there is a small or
A hand-held automated keratometer can be used to determine displaced pupil, or where signi cant media opacity is apparent
the corneal radius o curvature in young in ants and children (e.g. posterior capsular thickening).
too young to sit at a conventional keratometer (Fig. 28.9).
BIO METRY
REFRACTIO N
Prior to cataract surgery, the axial length o the eye can be mea-
Determination o the re ractive error or a contact lens over- sured with ultrasound and the corneal radius o curvature by
re raction is per ormed with retinoscopy using hand-held keratometry. T ese measurements can be used to determine
272 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
Fig . 28.8 Examination o the e ye o a child , with a hand -he ld slit lamp .
Fig . 28.9 Use o a hand -he ld autoke ratome te r on a b ab y.
the power o the contact lens required postoperatively by using
an IOL calculation ormula, such as Holladay, which can deter-
mine the ocular power at the corneal plane a er surgery. T is is
particularly use ul as it allows more or less correct speci cations
to be ordered, which alleviates the need or many lenses to be
used at the initial tting and allows or ewer lenses to be kept
in stock.
Le ns Se le ct io n
HYDRO GEL LENSES
Hydrogel lenses are the most requently used lens types in pae-
diatric contact lens tting. High-water-content lenses are usu-
ally selected as they can be worn or continuous or daily wear.
Daily wear should be considered where possible so as to reduce
the risk o in ection, as oxygen transmission can be reduced
through high-powered lenses such as those used to correct
aphakia (Amaya et al., 1990). However, as babies and young
children sleep during the daytime, the lenses can remain in the
eye during these periods.
Fig . 28.10 A silicone rub b e r le ns tte d to the le t ap hakic e ye o an in-
ant with microcorne a; a so t le ns had aile d owing to le ns d e hyd ration.
Lenses are usually tted according to age or based on kera-
tometry readings and corneal diameter.
T e advantages o so lenses are as ollows:
• T ey are custom made in a range o radii, overall size,
power and water content
• T ey are initially com ortable or the child
• Parents tend to be less apprehensive about inserting a hy-
drogel lens into the eye o a baby or young child.
T e disadvantages o so lenses are as ollows:
• T ey do not correct signi cant corneal astigmatism
• Insertion can be di cult, especially or minus lenses,
where there is considerable lid squeezing or a very small
palpebral aperture
• Hydrogel lenses are prone to dehydration – babies have
relatively dry eyes owing to their low blink rate
• T ere may be requent lens loss as a result o eye rubbing
and dehydration.
SILICO NE RUBBER LENSES
Silicone rubber lenses are o en used in the correction o re rac-
tive errors in babies and young children, and are particularly
use ul where there is requent lens loss or a dry ocular sur ace
(Fig. 28.10). T e lens t can be checked using f uorescein and
ultraviolet light. A period o settling, or example 30 minutes, is
required (Visser, 1997).
Silicone rubber lenses have the ollowing advantages:
• Very high oxygen permeability
• Not susceptible to dehydration on the eye
• Less susceptible to damage
• Not easily rubbed out
• Easier to insert than hydrogel lens owing to increased ri-
gidity.
Silicone rubber lenses have the ollowing disadvantages:
• Range o parameters and availability are limited
• Need to be tted precisely and require more chair time ow-
ing to longer settling periods
• Negative pressure e ects can cause adhesion to the cornea
i the lens is too tight
• Sur ace coating degenerates, so lenses have a relatively
short li e span
• More expensive than hydrogel and rigid lenses.

Fig . 28.11 Pae d iatric contact le ns inse rtion te chniq ue . (A) Hold the le ns and up p e r lid p rior to le ns inse rtion. (B) The le ns is inse rte d into the e ye
with the ore ng e r. (C) Positioning o ng e rs on the up p e r and lowe r lid s p rior to re moval. (D) The le ns is re move d b y ap p lying g e ntle p re ssure and
sq ue e zing the lid s tog e the r.
However, these lenses are becoming increasing di cult to
obtain as silicone hydrogel materials have developed.
SILICO NE HYDRO GEL LENSES
Silicone hydrogel lenses are now readily available in the range o
base curves, diameters and powers that are required or tting
complex re ractive error in young eyes; they are now o en the
lens o rst choice and are particularly use ul as they have simi-
lar properties to silicone rubber lenses. T e use o custom-made
silicone hydrogel lenses is discussed urther in Chapter 27.
RIGID LENSES
T e development o automated hand-held keratometry and
rigid lens design has led to the increased use o rigid lenses or
paediatric use. T ey have been success ully used or the man-
agement o aphakia in in ants and can be tted without the need
or general anaesthesia (Amos et al., 1992) and or correcting
high myopia and irregular astigmatism ollowing corneal scar-
ring and trauma (Shaughnessy et al., 2001).
Rigid lenses have the ollowing advantages:
• T ey are available in a large range o materials and param-
eters.
28 Bab ie s and Child re n 273
• T ey correct corneal astigmatism.
• T ey are durable.
• Rigidity can help ease insertion and removal.
T ey have the ollowing disadvantages:
• T ey are not usually suitable or continuous wear.
• Parents / carers can be more apprehensive about inserting
rigid lenses.
• T ere is a risk o abrasion i insertion is di cult.
• Initial discom ort may be a problem in older children.
Rigid lenses are now available in hyperoxygen-permeable
materials, designs and powers suitable or the treatment o pae-
diatric aphakia and seem to provide adequate corneal oxygen-
ation so that they can be used on a 1-week extended-wear basis
(Saltarelli, 2008).
Hand ling o Le nse s
A modi ed technique or insertion and removal is required in
the young eye and this technique is shown in Fig. 28.11.
Some general points to consider when handling contact
lenses in babies and young children are as ollows:
• Lenses are easier to insert and remove with the child
lying down on a rm, f at sur ace, e.g. an examination
couch.
274 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
• Babies can be swaddled in a blanket to make handling
easier.
• It is ar easier to learn how to handle lenses on a young
in ant than on a more active baby or toddler. It is there ore
important to encourage parents and carers to undertake
lens handling rom the outset o lens tting.
• Parents / carers should be advised to keep to regular times
or handling, so that it becomes accepted as part o daily
routine.
• I handling is di cult in young in ants, lenses can always
be inserted or removed during sleep.
• Handling o en becomes more di cult rom 18 months
onward. Bilateral aphakes can start to use spectacles at this
point and anisometropes can use a spectacle correction
when occluded.
• Cooperation may be extremely limited in children aged
between 2 and 5 years when tting lenses or the rst time.
Spectacles may have to su ce in this age i the bene ts o
contact lenses are outweighed by the distress caused to the
child by handling.
Co mmo n A t e rcare Pro b le ms
In addition to lens tting and handling problems, some other
common problems include:
• Red or sticky eye – this can be due to numerous causes,
including tight- tting lens, in ection, inf ammation or al-
lergic reaction. Parents / carers should be instructed to re-
move the lens immediately and to seek urgent advice rom
a contact lens practitioner or ophthalmologist.
• Neovascularization – especially where thick hydrogel lens-
es have been used or continuous wear. Consider re tting
with rigid or silicone hydrogel lenses.
• Papillary conjunctivitis – eye rubbing is o en a sign o
ocular irritation due to an allergy to care solutions or pro-
tein deposition on lenses. Management is similar to that in
adult patients (see Chapter 40).
• Glaucoma – long-term monitoring o eyes a er congenital
cataract surgery is essential as up to two-thirds will develop
glaucoma or become glaucoma suspects by 10 years a er
surgery (Lambert et al., 2013). Intraocular pressure can be
measured on babies and young children with a hand-held
non-contact tonometer (e.g. Pulsair) or rebound technol-
ogy tonometer (e.g. iCare) and this is advised at each visit.
• Other coexisting ophthalmic disease – regular undoscopy
should be per ormed to exclude the presence o , or ex-
ample, retinal detachment, which is associated with high
myopia and Mar an’s syndrome.
ACKNO WLEDGEMENT
T e author would like to thank the Department o Ophthalmic Imag-
ing at Manchester Royal Eye Hospital or the production o the illustra-
tions used in this chapter.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
REFERENCES
Amaya, L. G., Speedwell, L., & aylor, D. (1990).
Contact lenses or in ant aphakia. Br. J. Ophthal-
mol., 74, 150–154.
Amos, C., Lambert, S., & Ward, M. (1992). Rigid gas
permeable correction o aphakia ollowing con-
genital cataract removal during in ancy. J. Pediatr.
Ophthalmol. Strabismus, 26, 290–295.
Benoriene, J., & Vogt, U. (2006). T erapeutic use o
silicone hydrogel lenses in children. Eye Contact
Lens, 32, 104–108.
Davies, L. (1998). Complex re ractive errors in pedi-
atric patients: cause, management, and criteria or
success. Optom. Vis. Sci., 75, 493–499.
E ron, N., Morgan, P. B., Woods, C. A., et al. (2011).
Survey o contact lens prescribing to in ants, chil-
dren and teenagers. Optom. Vis. Sci., 88, 461–468.
Evans, B. J. (2006). Orthoptic indications or contact
lens wear. Cont. Lens Anterior Eye, 29, 175–181.
Inagaki, Y. (1986). T e rapid change in corneal cur-
vature in the neonatal period and in ancy. Arch.
Ophthalmol., 104, 1026–1027.
Jensen, H. (1997). Re raction and re ractive errors.
In D. aylor (Ed.), Paediatric Ophthalmology (pp.
62–69). Ox ord: Blackwell Science.
Jones-Jordan, L. A., Walline, J. J., Mutti, D. O., et al.
(2010). Gas permeable and so contact lens wear
in children. Optom. Vis. Sci., 87, 414–420.
Lambert, S. R., Buckley, E. G., Drews-Botsch, C.,
et al. (2010). T e in ant aphakia treatment study:
design and clinical measures at enrollment. Arch.
Ophthalmol., 128, 21–27.
Lambert, S. R., Purohit, A., Superak, H. M., et al.
(2013). Long-term risk o glaucoma a er con-
genital cataract surgery. Am. J. Ophthalmol., 156,
355–361.
Larsen, J. S. (1971). T e sagittal growth o the eye:
IV: ultrasonic measurement o the axial length o
the eye rom birth to puberty. Acta Ophthalmol.,
49, 873–886.
Lloyd, I. C., Ashworth, J., Biswas, S., et al. (2007).
Advances in the management o congenital and
in antile cataract. Eye, 21, 1301–1309.
Maycock, N. J., Sahu, D. N., Mota, P. M., et al. (2008).
Conservative management o upper eyelid en-
tropion. J. Pediatr. Ophthalmol. Strabismus, 45,
377–378.
Mets, M., & Price, R. L. (1981). Contact lenses in the
management o myopic anisometropic amblyo-
pia. Am. J. Ophthalmol., 91, 484–489.
Pradhan, Z. S., Mittal, R., & Jacob, P. (2014). Rigid
gas permeable contact lenses or visual rehabilita-
tion o traumatized eyes in children. Cornea, 33,
486–489.
Rah, M. J., Walline, J. J., Jones-Jordan, L. A., et al.
(2010). Vision speci c quality o li e o pediatric
contact lens wearers. Optom. Vis. Sci., 87, 560–
566.
Saltarelli, D. P. (2008). Hyper oxygen-permeable
rigid contact lenses as an alternative or the treat-
ment o pediatric aphakia. Eye Contact Lens, 34,
84–93.
Shaughnessy, M. P., Ellis, F. J., Je ery, A. R., et al.
(2001). Rigid gas-permeable contact lenses are
a sa e and e ective means o treating re ractive
anomalies in the paediatric population. CLAO J.,
27, 195–201.
aylor, D. (1998). T e Doyne Lecture. Congenital
cataract: the history, the nature and the practice.
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Lens Anterior Eye, 20, S19–S25.
Walline, J. J., Gaume, A., Jones, L. A., et al. (2007a).
Bene ts o contact lens wear or children and
teens. Eye Contact Lens, 33, 317–321.
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274.e 1
29
The rap e ut ic Ap p licat io ns
NATHAN EFRO N | SUZANNE E EFRO N
Int ro d uct io n
T e concept o protective eye b n ge origin te in the rst
century a d, when Celsus reporte ly pplie honey-so ke
linen to the site o pterygium remov l to prevent symbleph -
ron evelopment (Weiner, 1994). T e ther peutic use o cont ct
lenses goes b ck to the 1880s when Eugene K lt (1861–1941) t-
te c se o ker toconus. Since then, ll types o cont ct lenses
h ve been use s ther peutic i s. T e term ‘ther peutic con-
t ct lens’ h s become synonymous, or m ny, with so pl no
‘b n ge’ lens, however, the ther peutic use o cont ct lenses is
much wi er th n th t.
Ind icat io ns
A cont ct lens m y be tte ther peutic lly or the relie o p in
or iscom ort, to ssist the he ling o injure or ise se ocul r
tissue or to improve vision in the c se o unusu l or istorte
corne l sh pes. Sometimes ther peutic lens simult neously
resses more th n one clinic l problem; it m y in ition be
use to correct re r ctive error n h s the potenti l to eliver
ophth lmic rugs to the ocul r sur ce.
UNUSUAL O R DISTO RTED CO RNEAL SHAPE
Congenit l or evelopment l bnorm lities o corne l topogr -
phy, such s prim ry corne l ect si (e.g. ker toconus n ker -
toglobus) n corne pl n (Fig. 29.1), typic lly result in visu l
loss th t is usu lly correcte with rigi orms o cont ct lenses
– either corne l or scler l. Some success in correcting c ses o
corne l ect si h s been reporte with custom- esigne so
lenses, such s the Ker So IC lens (L gin , 2015).
T ese con itions re r re but the p tient is usu lly highly
motiv te to we r such lenses. Surgic l tre tment o severe
Fig . 29.1 Unusual corne al shap e s. (Imag e s from le ft to rig ht courte sy of Hilmar Bussake r, J. Mille r, Ig nacio Burg os and W. Vre ug d e nhil, re sp e ctive ly;
all Bausch & Lomb Slid e Lib rary.)
ker toconus n ker toglobus m y be technic lly i cult
n , in the c se o corne l tr nspl nt tion, espite proce ur l
v nces such s eep nterior l mell r ker topl sty (DALK),
there is still risk o llogr rejection, which c n compromise
the n l outcome o the oper tion. Other newer proce ures,
such s the impl nt tion o intr strom l corne l rings, h ve
been given FDA pprov l. However, cont ct lens m n gement,
i success ul, is ne rly lw ys to be pre erre . Optim l visu l
correction c n gener lly be provi e n the lenses c n be
ch nge in esign n power s the un erlying con ition n
other ocul r ctors evolve.
RELIEF O F PAIN
Corne l epitheli l p in c n be severe n is bling. A sim-
ple corne l br sion usu lly he ls quickly n nee s no help
rom the clinici n, but persistent or recurrent epitheli l
ilure m y bene t rom the tting o so b n ge lens o
either hy rogel or silicone hy rogel m teri l, which cts s
mech nic l b rrier between the injure corne l sur ce n
the li . B n ge lenses re routinely use or p in relie ol-
lowing re r ctive surgery proce ures where the epithelium is
remove (see Ch pter 30).
RECURRENT ERO SIO N SYNDRO ME
Minor tr um to the corne m y pre ispose to this con ition.
Very o en, corne l epitheli l b sement membr ne ystro-
phy (such s Cog n’s microcystic ystrophy or m p- ot- n-
gerprint ystrophy) is oun to be present; this is bil ter l
con ition, so both eyes shoul lw ys be c re ully ex mine .
T e eye with the erosion o en becomes cutely p in ul when
the eyes re opene uring the night or when w king, or t
th t time te r pro uction is minim l n riction m xim l,
275
276 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns

so th t the li m rgin pulls on the unst ble p tch o epithe-

lium, sometimes c using epitheli l isruption. A cont ct lens
interpose between corne n li c n re uce the riction
(Willi ms n Buckley, 1985; Liu n Buckley, 1996). T ree
months o exten e -we r b n ge lens use m y be su cient
to voi the recurrence o corne l erosions in the m jority
o c ses (Fr un el er n C bez s, 2011). Anterior strom l
puncture is low-cost ltern tive; however, it c rries the risk
o corne l per or tion.

CO RNEAL DYSTRO PHIES INVO LVING THE

EPITHELIUM
Epitheli l b sement membr ne ystrophy is by r the most
common epitheli l ystrophy, but other ystrophies th t c n
involve the corne l epithelium lso c use p in or iscom ort
th t c n be relieve with so lenses. T ey inclu e Reis–Bücklers’
ystrophy, Meesm n’s ystrophy, l ttice ystrophy n Fuchs’
ystrophy; in the l st o these the iling corne l en othelium
c nnot prevent strom l oe em n bullous ch nge in the epi-
thelium (An rew n Woo w r , 1989). T ygeson’s super ci l
punct te ker top thy is not recognize s ystrophy but is
ppropri tely consi ere here; this con ition c n sometimes be
m n ge success ully with hy rogel lenses (Forstot n Bin er,
1979), lthough we k topic l steroi is more usu l orm o
m n gement.

FILAMENTARY KERATITIS
A ‘wet’ orm o l ment ry ker titis sometimes occurs without
te r volume e ciency in herpes simplex ker titis, recurrent ero-
sion, ystoni n T eo ore’s superior limbic ker toconjuncti-
vitis. T is con ition o en respon s well to the use o hy rogel
lenses (Bloom el et al., 1973). T e more usu l ‘ ry’ orm o
l ment ry ker top thy occurs in te r e ciency, lthough
cont ct lenses h ve little p rt to pl y in the m n gement o this
orm o the ise se. Scler l lenses h ve, however, been use suc-
cess ully in ‘ ry’ l ment ry ker titis.
CO RNEAL DEGENERATIO NS INVO LVING THE
EPITHELIUM
Con itions such s S lzm nn’s no ul r egener tion, ros ce
ker top thy n topic ker toconjunctivitis – with or without
ect si – c n sometimes be so uncom ort ble th t ther peu-
tic cont ct lens is in ic te . In such c ses, lens will prob bly
lso improve visu l potenti l. Concurrent conjunctiv l ise se
n te r bnorm lity m y well bene t rom the use o scler l
lens.
CO RNEAL DEGENERATIO NS INVO LVING THE
ENDO THELIUM
Corne l tr um or surgery th t h s eplete en otheli l unc-
tion l reserves c n le to epitheli l bullous ker top thy, the
iscom ort o which is o en men ble to m n gement with
hy rogel or silicone hy rogel lenses. In some c ses, corne l
tr nspl nt will subsequently provi e cure. Formerly this me nt
ull-thickness proce ure but recently metho o repl cing
the en othelium, Descemet’s stripping en otheli l ker topl sty
(DSEK) h s been escribe n is g ining ccept nce. A combi-
n tion o photother peutic ker tectomy n ther peutic cont ct
Fig . 29.2 A 21-ye ar-old woman su e re d a sod ium hyd roxid e che mi-
cal b urn to the rig ht e ye . (A) A te r surg e ry (te no np lasty) a 12 mm d i-
ame te r p olyme thyl me thacrylate (PMMA) le ns was g lue d to the corne a
or 1 ye ar (p icture d he re ), a te r which a p e r orating ke ratop lasty was
p e r orme d . (B) A hig h-wate r-conte nt so t b and ag e le ns was worn or
6 months to cove r a p e rsiste nt e p ithe lial d e e ct. The corne a re maine d
cle ar and re -e p ithe lialize d . (Courte sy of W. Vre ug d e nhil, Bausch & Lomb
Imag e Lib rary.)
lens we r or limite perio h s been propose in c ses o bul-
lous ker top thy not suit ble or corne l tr nspl nt tion (Lin
et al., 2001).
CHEMICAL INJ URIES
Much h s been written bout the use o cont ct lenses in the m n-
gement o chemic l injuries, especi lly lk li burns (Fig. 29.2).
However, rese rch into the role o the limb l stem cell origin
o the corne l epithelium h s shown th t cont ct lens cover ge
o the chronic epitheli l e ect c nnot prevent the coloniz tion
o the corne by conjunctiv lly erive epitheli l cells. T ere
re, however, some situ tions in which cont ct lens c n ssist
he ling, supporte by topic l me ic tions, lthough very close
supervision is require .
CICATRICIAL CO NJ UNCTIVITIS
It is cle r th t no type o cont ct lens c n prevent conjunctiv l
shrink ge. However, scler l lens or ring c n be use to support
the ornices uring the he ling process ollowing mucous mem-
br ne tr nspl nt tion. More usu lly, cont ct lenses re tte to
protect the corne rom the hostile environment cre te by the
ise se (see below).

Fig . 29.3 Se ve re Ste ve ns–Johnson d ise ase . The e ye is tte d with a
se ale d g as-p e rme ab le scle ral le ns g iving ull corne al f uid cove rag e to
maintain long -te rm hyd ration. The re is e xte nsive corne al ne o vascular-
ization, which is not contact le ns-ind uce d b ut rathe r p art o the d ise ase
p roce ss that was p re se nt b e ore e mb arking on scle ral le ns tting . (Cour-
te sy of Ke n Pullum.)
TEAR DEFICIENCY
e r e ciency is usu lly m n ge with the use o te r supple-
ment rops n lubric ting ointments, n sometimes the l cri-
m l punct or c n liculi re eliber tely blocke . Cont ct lenses
re less o en use . At one time it w s thought th t high-w ter-
content hy rogel lens coul help to rehy r te ry eye, but this
is not possible s the l ck o te rs c uses such lens to ry n
ll out o the eye. Silicone hy rogel (low-w ter-content) lenses
re gener lly more success ul in n bnorm lly ry ocul r envi-
ronment. T e lens o choice is o en scler l lens, which covers
the entire expose sur ce o the eye, m int ins precorne l
ui reservoir n limits the ev por tion o te rs rom the ocu-
l r sur ce.
PRO TECTIO N FRO M LIDS AND ENVIRO NMENT
I the li s re e cient (e.g. congenit lly or ollowing tr um or
surgery) or immobile (e.g. ollowing seventh-nerve p lsy), the
eye is expose n ry. T e corne l epithelium becomes ero e
n un ergoes yspl si , n bloo vessels will inv e the pre-
viously cle r strom , unless protection c n be given. Possibili-
ties inclu e tempor ry or perm nent t rsorrh phy, tempor ry
p r lysis o the lev tor p lpebr e superioris muscle using botu-
linum toxin n the use o ther peutic cont ct lenses.
T e li s themselves m y constitute the ch llenge. T ey m y
be inturne (entropic), so th t the l shes touch the globe (trichi-
sis), or the t rs l conjunctiv – especi lly the re j cent to
the li m rgin – m y be ker tinize . Both situ tions re oun
in chronic cic trizing ise se, such s Stevens–Johnson ise se
(Fig. 29.3) n cic trici l pemphigoi , n ollowing chemic l
injury.
Ker tiniz tion without entropion is e ture o topic ker -
toconjunctivitis. Most so lenses will not survive in this type
o environment, r pi ly becoming ecentre n o en lling
out o the eye. T ere is c se or rigi lenses, especi lly lenses
o l rge (limb l) i meter, but the rst choice will o en be
scler l lens.
When the corne is insensitive, s occurs in trigemin l n es-
thesi – such s ollowing surgery or coustic neurom (Fig.
29.4) n in herpes zoster involving the ophth lmic ivision
29 The rap e ut ic Ap p licat io ns 277
Fig . 29.4 Se ve re e xp osure ke ratitis conse q ue nt to loss o lid closure
unction ollowing an acoustic ne uroma. (A) Vie we d in white lig ht without
the le ns, a se ve re e xp osure ke ratitis and ne ovascularization are e vid e nt.
(B) A se ale d g as-p e rme ab le scle ral le ns was p re scrib e d or ove rnig ht
we ar. The p re corne al f uid re se rvoir e xte nd s just b e yond the limb us on
the te mp oral sid e , and slig htly urthe r on the nasal sid e , p rovid ing an
e nvironme nt to e nhance he aling and maintain co rne al hyd ration. The
co sme tic ap p e arance is imp rove d b y re p lace me nt o the hig hly irre g ular
co rne a with a smoo th le ns ront sur ace and re g ular lig ht re f e x. The le ns
itse l is b are ly visib le : the e d g e can just b e se e n at the inne r canthus.
(Courte sy of Ke n Pullum.)
– the con ition o neurotrophic ker titis is commonly seen n
gre t c re must be t ken when tting cont ct lenses. Congeni-
t l corne l n esthesi n neurotrophic ker titis re extremely
r re but very problem tic con itions, which m y be m n ge
by requent topic l lubric tion n b n ge or scler l cont ct
lenses (M ntelli et al., 2015) T e nger in ll c ses o n esthe-
si is th t the re uce sens tion will il to lert the p tient to
complic tions such s ret ine oreign bo y, epitheli l erosion
n in ection.
P tients with neurop r lytic ker top thy – th t is, corne l
ise se secon ry to exposure (e.g. in severe proptosis or ectro-
pion, or resulting rom ci l nerve p lsy) – re initi lly best
m n ge with li t ping, t rsorrh phy or botulinum toxin-
in uce ptosis. T ere is sometimes role or ther peutic con-
t ct lenses.
MAINTENANCE O F A PRECO RNEAL TEAR
RESERVO IR
Where the eye c nnot support coherent te r ilm – or
ex mple, when mucus bnorm lity or epitheli l yspl si
278 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
Fig . 29.5 A le aking d rainag e b le b tte d with a larg e -d iame te r hyd ro-
g e l le ns in an atte mp t to orm a se al. Eve n at 20 mm d iame te r, the le ns
was not larg e e noug h to cove r the b le b ully, b ut was just unctional as
the p e r oration o the b le b was in p roximity to the limb us. (Courte sy of
Danie l Ehrlich.)
Fig . 29.6 Corne al me lting a te r p e r orating trauma with loss o suture s
and wound le akag e . The corne a was se ale d with histoacryl tissue g lue
and tte d with a larg e -d iame te r (20.5 mm) hig h-wate r-conte nt (76.5%)
so t b and ag e le ns. The g lue sp ontane ously d islod g e d a te r 10 d ays and
the b and ag e le ns was re move d . (Courte sy of Jan Kok, Bausch & Lomb
Imag e Lib rary.)
ren ers the norm lly hy rophilic ocul r sur ce hy ropho-
bic – precorne l te r reservoir c n be cre te with the i
o scler l lens with ull corne l n limb l cle r nce. A
se le lens m y be nee e in or er to ret in the reservoir, in
which c se g s-perme ble m teri l is use n the lens is
ille with norm l s line be ore being pl ce on the eye (see
Ch pter 21).
FO LLO WING TRAUMA O R SURGERY
Persistent or recurrent epitheli l e ects m y he l more r p-
i ly ollowing the pplic tion o so (hy rogel or silicone
hy rogel) b n ge lens. A sm ll queous le k ollowing sur-
gery (Fig. 29.5) or tr um (Fig. 29.6) c n o en be se le
with such lens; i the nterior ch mber is sh llow or bsent
then slightly t lens will be nee e , n this will h ve to
be ch nge or steeper lens s the ch mber re orms n the
corne steepens.
Shoh m et al. (2000) h ve success ully use custom-m e
17.5 mm i meter 78% w ter content b n ge lens to rrest
le k ge rom tr beculectomy ltr tion blebs. Corne l tr ns-
pl nt problems such s loosening sutures or slipp ge o the
onor isc re usu lly best e lt with by urther surgery, or
ex mple suture remov l n / or resuturing. In such situ tions,
cont ct lenses re unlikely to h ve more th n tempor ry role
(e.g. the relie o iscom ort while rr ngements re m e or
surgic l intervention).
FO LLO WING SPO NTANEO US PERFO RATIO N
M n gement o corne l per or tion rom cute hy rops m y be
ttempte with b n ge cont ct lens pl cement. A t nterior
ch mber m y re orm within 24 hours (Yeh n Smith, 2008).
Forooghi n et al. (2006) reporte on their success with b n-
ge lens ollowing per or tion in p tient with pelluci m r-
gin l egener tion.
Le ns Typ e s
It shoul be rec lle th t ll types o cont ct lens h ve ther -
peutic uses.
SO FT HYDRO GEL AND SILICO NE HYDRO GEL
LENSES
When consi ering the tting o b n ge lens, it is necess ry to
e ne or pre ict its prob ble p ttern o use. T e relev nt con-
si er tions re:
• whether exten e we r is necess ry
• whether the p tient (or, iling the p tient, rel tive or
rien ) c n be t ught to h n le, or t le st to remove, the lens
• the likely ur tion o ther peutic lens m n gement
• whether the p tient lives within pr ctic l tr velling is-
t nce o the clinic or hospit l
• whether the necess ry topic l me ic tions re v il ble
unpreserve
• whether the risks o hypoxi , mech nic l tr um n in-
ection re outweighe by the perceive bene ts o ther -
peutic lens we r.
In the p st, clinics m y h ve kept sets o b n ge lenses –
custom-m e rom high-w ter-content m teri ls – in v rious
r ii n i meters. T ese were superse e by commerci lly
v il ble requent-repl cement hy rogel lenses (Rubinstein,
1995; Bouch r n rimble, 1996; Srur n D tt s, 1997),
which in turn, h ve l rgely been repl ce by lenses in silicone
hy rogel m teri ls.
Silicone hy rogel lenses h ve n import nt ther peutic role
bec use o their very high g s perme bility, which minimizes
the in uce hypoxic n hyperc pnic stress (Lim et al., 2001).
T eir rel tively low w ter content is n v nt ge where hy r -
tion o the lens by the te r lm is problem tic, s occurs in que-
ous te r e ciency. Comp rison stu ies h ve been c rrie out
between hy rogel n silicone hy rogel lenses in some ther -
peutic pplic tions. For ex mple, silicone hy rogel lenses h ve
been shown to be s e n ef ective ltern tive to convention l
cont ct lenses or the tre tment o bullous ker top thy (Lim
n Vogt, 2006).
Silicone hy rogel lenses re wi ely use ollowing photore-
r ctive ker tectomy (PRK) n l ser- ssiste subepitheli l ker-
tomileusis (LASEK) (Ch pter 30). In one stu y, the corne l

Fig . 29.7 A larg e (20.5 mm d iame te r) so t b and ag e le ns tte d to re -
lie ve p ain in a 27-ye ar-old man with Mar an’s synd rome ollowing e th-
yle ne d iamine te traace tic acid (EDTA) tre atme nt. A te r nume rous e ye
op e rations (cataract e xtraction, ab latio re tinae , vitre ous oil p roce d ure s),
a p ain ul b and ke ratop athy orme d , and a trop hic ulce r was p re se nt.
(Courte sy of W. Vre ug d e nhil, Bausch & Lomb Imag e Lib rary.)
Fig . 29.8 A larg e limb al d iame te r rig id le ns has b e e n tte d to p ro te ct
a ne urotrop hic corne al le sion in the e arly stag e s o the he aling p roce ss.
(Courte sy of Ke n Pullum.)
epitheli l st tus w s st tistic lly better in the eyes with silicone
hy rogel b n ge cont ct lens 5 ys er surgery comp re
with when hy rogel lens w s worn (Gil-C zorl et al., 2008 ).
Stu ies ev lu ting the rel tive per orm nce o if erent silicone
hy rogel lenses h ve shown little if erence between them,
except in terms o com ort (Gil-C zorl et al., 2008b; Mukher-
jee et al., 2015).
When tting ny so lens, it is import nt or the lens to over-
l p ll re s requiring cover, n to im or little movement on
blinking. T ere must be no compression o the limb l vessels
(Fig. 29.7).
RIGID LENSES
Rigi lenses re requently use or combin tion o optic l
n ther peutic in ic tions. T ough they re usu lly sm ller in
i meter th n the corne , they m y provi e enough cover to
29 The rap e ut ic Ap p licat io ns 279
Fig . 29.9 Rig id le ns tte d to a b up hthalmic e ye . (Courte sy of W.
Vre ug d e nhil, Bausch & Lomb Imag e Lib rary.)
protect the corne rom bnorm l l shes, ker tinize li m r-
gins n other hostile ctors. Sometimes lenses o l rger i m-
eters re use (Fig. 29.8).
Fig. 29.9 shows rigi lens th t h s been tte to highly
myopic (−10.00 D) buphth lmic eye o 29-ye r-ol m le;
r in ge tube c n be seen entering the nterior ch mber rom
the right o the im ge.
In ect tic con itions, such s ker toconus, ker toglobus n
pelluci m rgin l egener tion (together constituting prim ry
corne l ect si ), the corne m y become highly stigm tic,
necessit ting the tting o rigi bitoric lens. Such c se is
emonstr te in Fig. 29.10. A eep crescent-sh pe corne l
sc r exten s rom the 4 o’clock to the 8 o’clock position. T e
sc r is present t the level o Descemet’s membr ne n eep
strom , in the upper region o the zone o corne l thinning
(Fig. 29.10A). T e vertic lly ov l im ge o the per ectly circu-
l r Pl ci o rings (Fig. 29.10B) in ic tes g inst-the-rule stig-
m tism, n the closeness o the in erior rings in ic tes very
steep corne l pro le ue to ect tic bulging o the zone o cor-
ne l thinning. T e bitoric rigi lens (Fig. 29.10C) f or s goo
vision. T e uorescein p ttern is typic l o such con itions (Fig.
29.10D); the in erior ect tic corne l protrusion c n be seen to
be r g inst the lens.
SCLERAL LENSES
Scler l lenses h ve host o ther peutic roles ( n et al., 1995;
Romero-R ngel et al., 2000; Pullum n Buckley, 2007). T eir
v nt ges inclu e the ollowing:
• T ere nee be no corne l cont ct wh tsoever.
• Any eye sh pe c n be tte .
• Complete protection o the corne n bulb r conjunctiv
is provi e .
• Se le ts re possible, using g s-perme ble m teri ls,
which simpli es the tting process n minimizes ‘settling
b ck’.
• Using g s-perme ble m teri ls, overnight we r is possible.
At one time the itting, n especi lly the ventil tion, o scler l
lenses require much pr ctic l experience. With the vent
o g s-perme ble scler l lenses, however, se le its h ve
become the norm n less skill is require . So m ny me i-
c l n ther peutic in ic tions h ve emonstr te th t it c n
280 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
Fig . 29.10 Bitoric rig id le ns tting in p e llucid marg inal d e g e ne ration. (A) Corne a vie we d in op tic se ction. (B) Placid o imag e o corne a. (C) Bitoric
rig id le ns. (D) Fluore sce in p atte rn ind icate s b e aring o the in e rior e ctatic corne al zone ag ainst the le ns (se e te xt). (Courte sy of C. van Mil, Bausch &
Lomb Imag e Lib rary.)
now be reg r e s essenti l or speci list cont ct lens clinics to
be ble to t scler l lenses (see Ch pter 21).
Co ncurre nt Me d icat io n
Unpreserve unit- ose eye rops re in ic te or concurrent
use with so lenses. Preserve eye rops re r rely use in this
situ tion, bec use o concerns th t preserv tives such s ben-
z lkonium chlori e c n ccumul te in the lens n be toxic
to the corne l epithelium. T is ef ect is usu lly o no clinic l
import nce when ispos ble lenses re use or short perio s.
All topic l rugs m y be use with rigi lenses – both corne l
n scler l. It is not known whether rugs chieve suit ble con-
centr tions in the ocul r tissues when se le scler l lenses re
being worn. Ointment prep r tions n oily rops shoul not
be use concurrently with cont ct lenses.
Drug De live ry
Using cont ct lenses or ophth lmic rug elivery is concept
th t is becoming incre singly popul r, owing to their unique
v nt ges like exten e we r n more th n 50% bio v il-
bility. o chieve controlle n sust ine rug elivery rom
so cont ct lenses, rese rchers re working on v rious systems
such s polymeric n nop rticles, microemulsion, micelle, lipo-
somes, n the use o vit min E. Numerous techniques re
being employe to ef ect rug elivery, such s simple lens
so king, novel m teri ls, molecul r imprinting, entr pment
o rug-l en colloi l n nop rticles, if usion b rriers, rug
pl te / lm, ion lig n polymeric systems, sur ce mo i c tion,
l yering n supercritic l ui technology (M ulvi et al., 2016).
Although sust ine rug elivery c n be chieve using so
lenses, critic l properties such s w ter content, tensile strength,
ion perme bility, tr nsp rency n oxygen perme bility m y
be ltere , which h s the potenti l to versely imp ct con-
t ct lens per orm nce. M ny issues re still unresolve – such
s rug st bility uring processing / bric tion ( rug integrity
test), zero-or er rele se kinetics (prevention o burst rele se),
rug rele se uring monomer extr ction step er bric tion
(to remove unre cte monomers), protein herence, rug
rele se uring stor ge in p ck ging solution, n limite shel
li e (M ulvi et al., 2016).

Such techniques h ve been use in the elivery o nti-gl u-
com rugs, ntibiotics, ntivir l gents, epi erm l growth c-
tor n bronectin (LeBourl is et al., 1998). D ily ispos ble
lenses of er the v nt ge o pplying new rug elivery ose
e ch y, or s esire (B jgrowicz et al., 2015).
Co mp licat io ns
T e verse ef ects o cont ct lenses use ther peutic lly re
simil r to those with lenses use gener lly (see Ch pter 40),
lthough the ise se or injure eye m y be especi lly t risk.
Complic tions o p rticul r concern in ther peutic cont ct
lens prescribing inclu e hypoxi with or without neov scu-
l riz tion, sterile corne l in ltr tes n suppur tive ker titis.
S ini et al. (2013) reporte th t even prophyl ctic ntibiotic
use i not elimin te the risk or microbi l ker titis with sili-
cone hy rogel b n ge lens use in p tients with chronic ocul r
sur ce ise se.
C re ul ollow-up is vit l er the tting o lens or ther -
peutic in ic tion, n there is s yet no re son to v ry the con-
vention o ex mining the eye on the y er tting n not
more th n 1 week er th t. I unpl nne -repl cement lenses
29 The rap e ut ic Ap p licat io ns 281
re use , spoil tion m y be observe to occur more quickly
th n with he lthy eyes. Any ch nge in the com ort or vision o
the p tient m y be o gre t signi c nce n instruction shoul
be given to the p tient to remove the lens in such circumst nces,
n to return to the clinic s n emergency i not r pi ly relieve
o the new symptoms.
Co nclusio n
One im o this ch pter w s to ispel the mis pprehension th t
the term ‘ther peutic cont ct lens’ is synonymous with so
pl no ‘b n ge’ lens. All types o cont ct lenses h ve poten-
ti lly import nt ther peutic role to pl y in the relie o p in or
iscom ort n in cilit ting the he ling o injure or ise se
ocul r tissue.
ACKNO WLEDGEMENTS
T e uthors woul like to cknowle ge Roger J. Buckley s the uthor
o this ch pter in the previous e ition.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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281.e 1
30
Po st -re fract ive Surg e ry
SUZANNE E EFRO N
Int ro d uct io n
Fi y years o evolution in re ractive surgery procedures has
le in its wake a large group o patients with suboptimal visual
results. oday, these patients are aced with three corrective
options – glasses, contact lenses or urther re ractive surgery.
For some o these individuals, where there is induced aniso-
metropia, restoration o binocular vision may be achieved with
contact lenses. Where there is induced irregular astigmatism,
contact lenses, and in particular rigid lenses, may provide the
only option or visual rehabilitation (Alió et al., 2002). Rigid
lenses are able to correct the residual re ractive error and reduce
the elevated total higher-order aberrations to more normal lev-
els (Gemoules and Morris, 2007).
Typ e s o f Re fract ive Surg e ry
he number o di erent re ractive surgical procedures con-
tinues to grow. Previous and current procedures are listed
in able 30.1. Each o these procedures modi ies the corneal
sur ace in a unique way, necessitating a rethinking o tradi-
tional lens designs and itting techniques or optimal con-
tact lens per ormance. Laser-assisted in situ keratomileusis
(LASIK) continues to be the dominant procedure or preop-
erative re ractions rom −8.00 to +3.00 D (Du ey and Leam-
ing, 2005).
Co nt act Le ns Fit t ing Fo llo w ing
Pho t o re fract ive Pro ce d ure s
T ere are three main indications or tting contact lenses ol-
lowing photore ractive procedures:
• bandage lenses in the immediate postoperative period
ollowing photore ractive keratotomy (PRK) and laser-
assisted sub-epithelial keratomileusis (LASEK), where the
epithelium is removed during the procedure
• or ametropia ollowing under- or overcorrection
TABLE
30.1 Typ e s o f Re fract ive Surg e ry
Incisio nal Lase r
Rad ial ke ratotomy (RK) Photore fractive ke rate ctomy (PRK)
Astig matic ke ratotomy (AK) Lase r-assiste d in situ ke ratomile usis (LASIK)
Limb al-re laxing incisions (LRI) Lase r-assiste d sub -e p ithe lial ke ratomile usis (LASEK)
Corne al-re laxing incisions (CRI) Lase r the rmoke ratop lasty (LTK)
Small-incision le nticule e xtraction (SMILE)
Femtosecond laser-assisted in situ keratomileusis (Femto-LASIK)
Fe mtose cond lase r le nticule e xtraction (FLEx)
282
• to correct irregular corneal astigmatism, which may have
been pre-existing, induced during surgery, or due to post-
surgical ectasia.
TISSUE ABLATIO N AND CO RNEAL
TO PO GRAPHY
PRK, LASIK and LASEK are all tissue subtraction procedures
and the amount o corneal tissue removed will play an impor-
tant role in the post-surgical management o the patient.
issue removal is determined by the Munnerlyn ormula:
Depth of ablation = [(optic zone diameter)2 × (refractive error)]/3
Example o myopia correction:
Ablation diameter (optical zone diameter) = 6.0 mm
Optical zone squared (6.0 × 6.0) = 36
Multiplied by the desired correction (−6.00) = 216
Divided by 3 = 72
T us, depth o the ablation = 72 µm.
Irregular astigmatism is a relatively rare nding a er either
PRK or LASIK. However, it may be induced by the creation o
a suboptimal lamellar ap – too thin, irregular, bisected, but-
tonholed or a ree ap, or be due to postoperative ectasia. Flap
striae are an other important and o en underrecognized cause
(Polack and Polack, 2003). Irregular astigmatism can also arise
rom a decentred ablation. Patients are o en le with varying
degrees o uncorrected myopia due to the eccentric position o
the treatment zone away rom the visual axis. Viewing through
the edge o the ablation requently results in a loss o best cor-
rected visual acuity (BCVA), monocular diplopia and ghosting
o distance images, especially under scotopic conditions. T e
severity o symptoms o en correlates with the size o the pupil.
A decentred ablation with a large 6–7 mm pupil will produce
more serious visual complaints than does a similarly displaced
ablation over a small 3–4 mm pupil. So contact lenses rarely
provide adequate optical correction in this small subset o
O t he r
Ke ratop hakia
Ke ratomile usis
Ep ike ratop lasty
The rmoke ratop lasty
Cond uctive ke ratop lasty (CK)
Automate d lame llar ke ratop lasty
Intrastromal corne al ring se g me nts (ICRS)

patients. Optimal visual per ormance usually requires the use
o a rigid lens design.
Re ractive surgery techniques are moving orward with the
introduction o emtosecond lasers. T ese create LASIK aps
with better accuracy, uni ormity and predictability than do
mechanical microkeratomes (Chen and Manche, 2016). T e
higher- requency emtosecond plat orms elicit less in amma-
tion, also producing better visual outcomes. Small-incision len-
ticule extraction (SMILE) is another procedure made possible
by emtosecond lasers and it achieves similar sa ety, e cacy and
predictability to LASIK with greater preservation o corneal
nerves and biomechanical strength (Zhang et al., 2016). It is to
be hoped that the need or post-re ractive surgery contact lens
tting may be reduced in uture.
CO RNEAL SENSITIVITY AND DRY-EYE
SYMPTO MS
Practitioners need to be aware o the level o corneal sensitiv-
ity ollowing laser re ractive surgery i contact lenses are to be
tted. T e recovery o corneal sensitivity ollowing PRK and
LASIK was measured by Pérez-Santonja et al. (1999). Follow-
ing PRK, a decrease in central corneal sensitivity was noted at
1 week, but sensitivity had nearly recovered at 1 month a er
surgery. Following LASIK, there was a deep decrease in cen-
tral corneal sensitivity at both 1 week and 1 month a er sur-
gery. Corneal sensitivity values were ound to be similar a er 6
months – a nding in agreement with that o Benitez-del-Cas-
tillo et al. (2001). Darwish et al. (2007) examined subbasal nerve
regeneration a er LASEK using con ocal microscopy and ound
corneal sensitivity had returned to normal levels a er 3 months;
however, subbasal nerves that were injured by LASEK had not
returned to preoperative levels by 6 months a er surgery.
Patients requently experience dry-eye symptoms a er
LASIK; however, the mechanisms that lead to these changes
are not well understood. ear lm dys unction has obvious
implications i contact lenses are required a er surgery. Yu et al.
(2000) ollowed post-LASIK patients or 1 month and observed
increased dry-eye symptoms, and reduced Schirmer test results,
basal tear secretion and tear break-up time during this period.
Benitez-del-Castillo et al. (2001) reported that tear secretion
was reduced or a period o 9 months ollowing LASIK surgery.
A er LASEK, Darwish et al. (2007) ound tear break-up time
had decreased signi cantly and had not returned to the preop-
erative level by 6 months a er surgery.
SO FT LENSES
With myopic ablations, the mid-peripheral cornea (beyond
the central 6.0–7.0 mm) remains unchanged. T ere ore, the
major concern in tting so or rigid contact lenses is the rela-
tive dif erence between the atter central cornea and the steeper
(normal) mid-peripheral cornea. T is dif erence creates ew
problems or patients who had low to moderate myopia prior
to surgery. In such cases, the small amount o tissue ablated
does not noticeably af ect the contact lens t or the on-eye lens
dynamics. Most o the currently available daily disposable or
requent-replacement so lenses are viable options or the post-
laser correction. However, a er surgery a complex relationship
exists between visual acuity, de ocus (re ractive error), dif rac-
tion and optical aberrations. T e loss o postoperative central
corneal asphericity can result in a orm o spherical aberration
30 Po st -re fract ive Surg e ry 283
(Hong and T ibos, 2000). For patients with large pupils this can
be symptomatic. Improved optical correction can be achieved
with so lens designs that incorporate aberration-correcting
anterior aspheric optics.
Band ag e Le nse s
Bandage lenses are used in the immediate postoperative period
to relieve pain and to assist in re-epithelization ollowing PRK
and LASEK. T ese procedures involve removal o the corneal
epithelium. T e corneal sur ace needs between 2 and 4 days to
regenerate, so lenses are typically worn continuously or 3–5
days ollowing surgery. Managing the wound-healing response
is critical or a success ul outcome to ensure re-epithelization
occurs quickly, thereby reducing stromal haze ( omás-Juan
et al., 2015). T is is best achieved with lenses o high Dk / t, or
increased corneal oxygenation.
Many studies have been carried out to assess the relative
bene ts o dif erent silicone hydrogel lens materials and designs
when used as bandage lenses (Gil-Cazorla et al., 2008; aylor
et al., 2014; Mukherjee et al., 2015). All ound no major clini-
cal dif erence between the lenses, although patients reported
greater com ort with seno lcon A lenses. Mukherjee et al.
(2015) concluded that actors other than oxygen permeability
af ect pain and epithelial healing.
RIGID LENS DESIGNS
With both PRK and LASIK, rigid lens tting is best delayed
until approximately 8–12 weeks a er surgery. At this point, the
re raction and topography have stabilized. At 3 months post-
surgery, the integrity o the ap inter ace is usually su cient to
withstand the minor trauma associated with lens insertion and
removal, as well as the normal on-eye movement that occurs
with blinking.
Many patients who have undergone PRK or LASIK can be
success ully tted with traditional spherical or aspheric rigid
lenses. However, Lim et al. (1999) suggest that patients tted
with rigid lenses can display mild to moderate lens instability
and decentration a er PRK. As with so lens tting, the extent
o tissue removal will in uence the ease o tting. For example, a
patient with a preoperative re ractive error o −4.00 D might end
up postoperatively −1.00 D undercorrected. T e 3.00 D myopic
reduction was produced by an ablation o approximately 36 µm
o tissue (less than the thickness o the human epithelium). T e
minimal dif erence between the central and mid-peripheral cor-
nea creates ew tting and / or optical problems or a traditional
rigid lens design. T ese individuals are o en best tted with a
BOZR designed to align the mid-peripheral corneal topography
4.0 mm rom the centre o the cornea (Fig. 30.1).
In contrast, the corneal shape ollowing hyperopic laser cor-
rection is steeper, with a positive value or eccentricity o en
exceeding 0.5–0.7 (Gruenauer-Kloevekorn et al., 2006). It may
be necessary to consider a lens design usually reserved or
keratoconus.
Re ve rse -g e ome try Rig id Le ns De sig ns
When considering a patient with a higher preoperative re ractive
error, or example −10.00 D, who might end up postoperatively
−1.00 D, the −9.00 D myopic reduction requires the removal o
approximately 110 µm o corneal tissue. In this case, the dif erence
between the central and mid-peripheral cornea is such that a tradi-
tional rigid lens (designed to align with the mid-peripheral cornea)
284 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
Fig . 30.1 Simulate d uore sce in p atte rn o a p ost-lase r-assiste d in situ
ke ratomile usis (LASIK) e ye with a − 3.00 D corre ction.
Fig . 30.2 Simulate d uore sce in p atte rn o a p ost-lase r-assiste d in situ
ke ratomile usis (LASIK) e ye with a − 9.00 D corre ction.
may exhibit excessive apical clearance (Fig. 30.2). T e subsequent
large volume o tears centrally can result in unstable optics and
trapped bubbles can orm beneath the centre o the lens.
In such situations, patients may be best managed with reverse-
geometry lens designs (Lim et al., 2000; Martin and Rodriguez,
2005) (Fig. 30.3). A standard rigid design mimics the prolate
shape o the normal, unoperated cornea, which is steeper in the
centre than the periphery. T e reverse-geometry design more
closely parallels the post-re ractive surgery topography (o a
previously myopic eye) by incorporating a at central radius o
curvature with a steeper mid-peripheral design (see Fig. 30.3).
T is creates a plateau con guration on the posterior lens sur ace,
which dramatically decreases the volume o tear uid present
beneath the central portion o the lens (Szczotka, 1998).
SCLERAL LENSES
Scleral or miniscleral lenses are well suited to therapeutic cor-
rection o eyes ollowing re ractive surgery, even in patients who
have previously been intolerant to other contact lenses (Par-
minder and Jacobs, 2015). T ey are indicated or:
• re ractive instability – any diurnal uctuations in re rac-
tion are minimized as they act at a cornea–saline inter ace
not at a cornea–air inter ace
Fig . 30.3 Re ve rse -g e ome try le ns d e sig n.
• irregular astigmatism and keratectasia – the uid reser-
voir behind the lens acts to neutralize optical irregularities
rom the corneal sur ace
• dry eye and postoperative pain syndromes – the uid res-
ervoir appears to ameliorate pain caused by trauma to the
corneal nerves during surgery (Levitt et al., 2015).
T e t o the scleral lens is independent o corneal contour
and issues o poor centration and lens instability are minimized
(see Chapters 21 and 26).
Co nt act Le ns Fit t ing Fo llo w ing Rad ial
Ke rat o t o my
Radial keratotomy (RK) has largely been phased out in avour
o more sophisticated and predictable laser surgical procedures.
However, an understanding o the di culties in tting the post-
RK cornea is still required or the contact lens management
o these patients as it poses ar greater challenges than those
encountered a er photore ractive keratectomy.
Contact lens tting dif ers between laser and incisional pro-
cedures. A er RK:
• T ere are greater changes in the mid-peripheral cornea.
• Fewer so contact lens designs can be used owing to the
presence o perilimbal incisions.
• T e cornea may have elevated mid-peripheral pivot points
secondary to incisional wound healing. T ese areas are the
major cause o rigid lens decentration.
• T ere is more diurnal uctuation in visual acuity because
o the instability o the peripheral cornea. T is is especially
important i so contact lenses are used.
Astin (1991) warns that the cornea is malleable and prone to
warpage during a period o up to 3 months ollowing RK and
advises that one should not carry out lens tting during this
period unless it is medically necessary. A hyperopic shi in
re raction can continue or 10 years a er surgery (Waring et al.,
1994; Charpentier et al., 1998).
CO RNEAL TO PO GRAPHY
When radial incisions are placed into the mid-peripheral cor-
nea, the wounds gape open under the orce o the intraocular
pressure and stresses orm within the corneal tissues (Fig. 30.4).
T e gaping incisions are rst lled with an epithelial plug, which
is eventually replaced by a permanent wedge o broplastic scar
tissue (Fig. 30.5). T is results in an overall increase in corneal
sur ace area, although the corneal diameter remains unchanged.
T ere is a common misconception that the mid-peripheral
cornea steepens ollowing RK. However, as the anterior cornea
displaces to accommodate the gaping incisions, virtually the
entire cornea rom limbus to limbus attens. T e attening ef ect
is simply greater in the central cornea than in the periphery,
resulting in the alse impression o mid-peripheral steepening.

Fig . 30.4 Wound g ap e cre ate d b y symme trically p lace d rad ial inci-
sions.
Fig . 30.5 We d g e -shap e d f b rop lastic scar in a he ale d rad ial incision
(cat e ye ).
T e degree o wound gape and the resultant amount o cor-
neal attening are dictated by a number o surgical and biologi-
cal actors, including the ollowing:
• the number, depth and length o the incisions
• intraocular pressure orces
• stresses and biochemical properties within the corneal
tissue
• patient age at the time o surgery
• individual wound-healing responses.
SO FT LENSES
In principle, the tting o a so contact lens to a cornea that has
undergone RK is very similar to tting a normal cornea. T e
BOZR will usually need to be approximately 0.5 mm greater than
the attest keratometry reading. However, in most cases a BOZR
o greater than 9 mm will be required to achieve satis actory align-
ment with the post-RK cornea, there ore the so lens will need
to be custom made. Disposable lenses will be a possibility only
30 Po st -re fract ive Surg e ry 285
Fig . 30.6 Incisional ne ovascularization se cond ary to the we aring o a
low-wate r-co nte nt so t contact le ns.
when the amount o central attening (and subsequent negative
asphericity) is o a relatively low degree (Lindsay, 2002). It must
be remembered that even toric so lenses will not neutralize the
irregular corneal astigmatism that o en occurs as a result o RK.
Incisional neovascularization is a common complication
associated with the use o so contact lenses ollowing RK (Fig.
30.6). Its incidence can be minimized through the use o high-
oxygen-permeability silicone hydrogel lenses used on a daily-
wear basis.
RIGID LENSES
Following RK, the cornea may exhibit signi cant corneal at-
tening with only minimal mid-peripheral attening (approxi-
mately 0.1–0.2 mm atter than its preoperative curvature).
T ere ore, in the tting o a rigid lens, a back optic zone radius
(BOZR) should be selected to align with the ‘more normal’ mid-
peripheral cornea, approximately 4.0 mm rom the centre along
the horizontal meridian.
T e radius o the postoperative mid-peripheral cornea can
be determined through corneal mapping. Alternatively, a diag-
nostic lens can be selected with a BOZR that is 0.1–0.2 mm
atter than the preoperative at K-reading and the t can be
evaluated. T e appropriate BOZR should result in a uorescein
pattern that displays apical clearance over the atter central cor-
nea and a zone o mid-peripheral bearing at the 3 and 9 o’clock
locations (Fig. 30.7). T e lens should display unobstructed
movement along the vertical meridian.
Lens decentration is a common problem ollowing RK. It is
o en the result o uneven wound healing, which creates geo-
graphic sur ace elevations on which the lens pivots (Fig. 30.8).
Lens decentration is best resolved by increasing the overall
lens diameter to 10.5 mm or larger, or by moving to a scleral
lens design. Final lens power is best determined by per orm-
ing a sphero-cylinder re raction over a well-centred diagnostic
lens.
SCLERAL LENSES
Parminder and Jacobs (2015) reviewed the use o scleral lenses
or re ractive surgery complications and noted that a dispropor-
tionate raction o reports in the literature related to patients
who had previously undergone radial keratotomy. T is is in part
286 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
Fig . 30.7 Fluore sce in p atte rn p ost-rad ial ke ratotomy. The corne a has
a ce ntral at K o 8.76 mm and a mid -p e rip he ral curvature (4 mm te m-
p oral) o 7.94 mm. The le ns has a b ack op tic zone rad ius o 7.94 mm.
due to the greater challenges aced in tting the post-RK cor-
nea. Fortunately, contemporary approaches to scleral lens tting
with no corneal contact and minimal on-eye movement enable
many ormer RK patients to be rehabilitated.
Co nt act Le ns Fit t ing Fo llo w ing
Int rast ro mal Co rne al Ring Se g me nt s
Intrastromal corneal ring segments have been used as a re rac-
tive surgery method or the treatment o myopia and kerato-
conus. T e aim is to alter corneal topography to be atter and
more regular, respectively. However, the changes in corneal
anatomy created by the intrastromal rings may make contact
lens tting more challenging. Corneal irregularity may be exac-
erbated owing to drastic variations in corneal elevation over the
intrastromal ring and directly adjacent to the ring. T is irregu-
larity in elevation leads to di culty in centring a lens on the eye
and problems with bubbles orming under the contact lens over
areas o corneal depression (Hladun and Harris, 2004). When
success ully tted, contact lenses over intrastromal corneal
rings can improve vision signi cantly. T is may be easible with
so toric lenses or, i that proves unsuccess ul, with a piggyback
system (Carballo-Alvarez et al., 2014).
Fig . 30.8 Pivot p oint cre ate d b y une ve n wound ap p osition, se e n he re
at the top rig ht corne r o the tissue se ction (cat e ye ).
Co nclusio n
Over time, new re ractive surgery techniques have emerged and
older techniques are abandoned or modi ed through modern
technology. However, the altered topographies le in the wake
o less-than-success ul procedures remain. T ere ore, contact
lenses will continue to play an important role in the lives o indi-
viduals whose corneas have been permanently compromised by
re ractive surgery. Whether contact lenses are used in lieu o or
in conjunction with urther re ractive surgery, the outcome can
be a positive experience or the patient. With ongoing re ne-
ments in lens materials and designs, contact lens technology
will continue to meet the challenges posed by uture re ractive
surgery procedures.
ACKNO WLEDGEMENTS
T e author would like to acknowledge Patrick J. Caroline as the author
o this chapter in the previous edition.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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286.e 1
31
Po st -ke rat o p last y
BARRY A WEISSMAN
Int ro d uct io n
Corneal transplantation (keratoplasty or KP) is a surgical proce-
dure by which diseased corneal tissue is removed and replaced
by donor material (a corneal gra ) (Fig. 31.1).
Corneal transplantation resulting in relatively clear gra s was
rst reported in the ophthalmic literature with Reisinger’s rabbit
experiments (1824). Such homogra s (or allogra s) are trans-
plants within the same species (i.e. rom one rabbit to another
or rom one human to another) and are the most common orm
o KP. Von Hippel (1888) made several unsuccess ul attempts to
gra a glass prosthesis, but his work orms the basis o modern
KP. Von Hippel and others also used animal corneas as donors
or humans: these are heterogra s – transplants rom one spe-
cies to another – and are commonly rejected. Zirm (1906) is
credited with the rst human corneal transplant (treating a leu-
koma due to a quicklime burn) to retain a moderate degree o
transparency. T e introduction o McCarey–Kau man (MK)
medium (McCarey and Kau man, 1974; McCarey et al., 1976)
enabled donor human cornea to be stored or 3–4 days. Further
advances based on tissue culture techniques extended the pres-
ervation o donor tissue or up to 30–40 days (Doughman et al.,
1976; Sperling, 1979, Doughman, 1980; Sperling et al., 1981).
Autogra s, wherein one eye provides the donor cornea or the
other, although rare or obvious reasons (the author has seen
two human corneal autogra s in his career; Fig. 31.2), have lim-
ited, i any, risk o rejection. Arti cial corneal gra s, such as the
Dohlman ‘Kpro M’, are an area o active research and develop-
ment (Dohlman et al., 2002, Gri th and Harkin, 2014) and have
had some recent success (Srikumaran et al., 2014) (Fig. 31.3).
Fig . 31.1 A p e ne trating ke ratop lasty with inte rrup te d suture s.
Corneal gra s are per ormed or the ollowing reasons:
• optical – to restore visual unction by removing scarred
or irregular tissues (e.g. in keratoconus, post trauma and
in ection, corneal dystrophy)
• therapeutic – to treat disease (e.g. to treat an in ection by
debulking)
• tectonic – to restore, or preclude the loss o , globe integrity
• cosmetic – to improve appearance (e.g. eliminate an un-
sightly scar in a non-seeing eye).
T e indications outlined above are not necessarily mutually
exclusive.
Approximately 60 000 to 70 000 KP procedures were per-
ormed annually in the USA over the past two decades (Eye
Bank Association o America, 2013) with another 2000+ per
year over the last decade in the UK (Keenan et al., 2012) and
another 1000 in Australia (Coster et al., 2014). With the intro-
duction o enhanced lamellar keratoplasty (LK) techniques, this
number appears to be increasing in all three areas.
Ind icat io ns
T e diagnostic indications or corneal gra s include:
• corneal oedema that is severe enough to a ect visual
unction, and pain ul bullous keratopathy, usually a conse-
quence o Fuchs’ endothelial dystrophy or aphakic / pseu-
dophakic endothelial ailure
• keratoconus and other orms o corneal ectasia such as pel-
lucid marginal degeneration and errien’s degeneration.
T e criteria or per orming KP may be when the condition
Fig . 31.2 Corne al autog ra t. This p atie nt had cong e nital syp hilis and
whe n the corne a o he r g ood e ye aile d , it was g ra te d with a d onor b ut-
ton take n rom he r contralate ral, se ve re ly amb lyop ic e ye (to e nhance he r
chance s o avoid ing re je ction) and that d onor re p lace d with a trad itional
allog ra t.
287
288 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
Fig . 31.3 Dohlman ke ratop rosthe sis; note the b and ag e so t le ns in
p lace (b y the b ub b le s se e n in the 3 / 9 zone s).
is severe enough to limit vision with contact lens correc-
tion to 6 / 12 or worse, or when contact lens wear can no
longer be tolerated or physical or physiological reasons.
Approximately 20% o keratoconic patients will eventually
come to bene t rom corneal transplantation (Lass et al.,
1990)
• corneal scars and interstitial keratitis, secondary to trauma
and / or in ection (e.g. herpetic keratitis)
• visually debilitating orms o corneal dystrophy, such as
the trans orming growth actor beta 1 ( GFβ1) dystro-
phies (e.g. granular I or II, lattice, or Reis–Bücklers) and
macular corneal dystrophy
• congenital opacities, such as Peters’ anomaly or buphthal-
mos secondary to congenital glaucoma
• previous gra rejection or ailure.
Typ e s o f Co rne al Graft
Full-thickness penetrating keratoplasty (PKP), rst using
mechanically paired blades to produce square gra s but evolv-
ing to circular gra s produced with trephines, has been the
standard o care in corneal transplantation or more than 50
years. Patch gra s have long been used to seal corneal leaks, but
visual results are not vital. Lamellar procedures (LK), in which
only isolated ‘sick’ layers o the cornea are replaced, however,
have evolved rapidly over the past decade.
Development o the IntraLase emtosecond laser allows
corneal surgeons to create complex, shaped PKP incisions
(e.g. ‘top hat’, ‘mushroom’, ‘zigzag’) that are identical in both
host and gra t tissue. Called IntraLase-enabled keratoplasty
or IEK (or emtosecond-assisted corneal transplant, ‘FAC ’),
this procedure creates PKPs with customized ‘interlocking’-
edge designs that it is hoped will minimize induced astig-
matism and enhance wound strength. Fewer sutures may
be required, healing should be aster, and decreased regu-
lar and irregular astigmatism will hope ully enhance vision
and reduce the need or contact lens correction. he risk
or displacement o the gra t may also be reduced. A study
o 116 keratoconus patients ound that the 56 patients
treated with IEK had signi icantly better vision improve-
ment than did those receiving traditional trephine PKP: 3
months postoperatively, signi icantly more IEK patients were
reported to have better best spectacle-corrected visual acu-
ity (BSCVA) (p = 0.001) and visual recovery 20 / 40 or bet-
ter (p < 0.001) and lower topographic astigmatism (p = 0.001)
(Gaster et al., 2012). An earlier large study had reported a
lower (30%) improvement in 2800 patients treated with tra-
ditional trephine PKP (Vail et al., 1997).
Epikeratoplasty – a short-lived surgical procedure was this
early LK variant wherein a precut (to a speci c optical power)
donor cornea was applied to the anterior sur ace o the intact
host stroma (the epithelium but not the stroma was removed) in
an e ort to address aphakia, keratoconus or high myopia. It was
ound to result in poor vision (secondary to inter ace problems)
and has been abandoned.
Super cial corneal diseases have long been alternatively
treated with anterior lamellar keratoplasty (ALK) wherein,
ollowing initial partial-thickness trephination, a blunt blade
was used mechanically to separate a deep plane in the tissue
to allow replacement o only the diseased super cial cornea.
ALK retains the host endothelium to thereby reduce both
immunological rejection and physiological ailure. ALK opti-
cal results were poor, however, and were usually reserved or
either the corneal periphery or as tectonic procedures later
ollowed by PKP to allow optical rehabilitation. Deep anterior
lamellar keratoplasty (DALK) is a newer LK that utilizes air,
water or a microkeratome to separate the deep stromal bres
rom Descemet’s membrane (Archila, 1985; Price, 1989; Sugita
and Kondo, 1997; Busin et al., 2005). It is thought that deepen-
ing the position o the inter ace between the replacement and
host cornea improves the potential visual results; DALK has
gained some popularity owing to its theoretical advantages, in
treatment o keratoconus in particular, although its practical
superiority to PKP remains in question (Coster et al., 2014;
Keane et al., 2014).
Several endothelial lamellar keratoplasty (ELK) procedures
to replace only damaged posterior corneal tissues (as in Fuchs’
dystrophy) have evolved – rom deep lamellar endothelial
keratoplasty (DLEK) ( erry and Ousley, 2003; Watson et al.,
2004) to Descemet’s stripping endothelial keratoplasty (DSEK)
(Melles, 1998; Price and Price, 2006), or an automated ver-
sion using a microkeratome called Descemet’s stripping auto-
mated endothelial keratoplasty (DSAEK) (Gorovoy, 2006),
and urther to Descemet’s membrane endothelial keratoplasty
(DMEK) (Price and Price, 2013), wherein only the endothelial
layer is replaced (Fig. 31.4), leaving the host anterior corneal
sur ace hope ully smooth and intact so that these patients may
not require contact lens correction. Price and Price (2013) ur-
ther state that DMEK in particular mitigates the two principal
liabilities o KP: immunological gra reactions (Anshu et al.,
2012) and secondary glaucoma rom prolonged topical corti-
costeroid use.
DLEK, DSEK, DSAEK, and DMEK, each more technically
demanding than its predecessor, theoretically also o er rapid
healing, more acceptable re ractive outcomes and better reten-
tion o corneal strength, compared with PKP – but surgery
is technically very demanding and donor adherence may be
challenging.
With increasing optical success o DSEK, DMEK, and DALK,
PKP has lost its position as the sole dominant KP technique
over the past decade, but at the time o writing the discussion
about which procedure may prove optimal or many patients
continues (Coster et al., 2014).
 31 Po st -ke rat o p last y 289

Fig . 31.4 A corne a p ost-De sce me t’s strip p ing e nd othe lial ke rato-
p lasty ( or tre atme nt o the comb ination o iris nae vus or Cog an–Re e se
synd rome ; Chand le r’s synd rome ; and e sse ntial iris atrop hy, calle d ICE
synd rome ). Note incre ase d corne al thickne ss e xte nd ing into the ante -
rior chamb e r se e n in the op tical se ction sup e riorly.
Fig . 31.5 Irre g ular sur ace astig matism in a g ra t, as ind icate d b y the
d istorte d re e x o a p e r e ctly circular ash g un. (Courte sy o De smond
Fonn, Bausch & Lomb Slid e Lib rary.)

BO X 31.1 LEXICO N O F VARIO US KERATO PLASTY

PRO CEDURES
ALK ante rior lame llar ke ratop lasty
DALK d e e p ante rior lame llar ke ratop lasty
DLEK d e e p lame llar e nd othe lial ke ratop lasty
DMEK De sce me t me mb rane e nd othe lial ke ratop lasty
DSAEK De scemet strip p ing automated e nd othelial ke ratop lasty
EK e nd othe lial ke ratop lasty
KPro corne al p rosthe sis
LK lame llar ke ratop lasty
PKP, PK p e ne trating ke ratop lasty
PLK p oste rio r lame llar ke ratop lasty
SALK sup e rf cial ante rior lame llar ke ratop lasty

No modern discussion o KP, however, would be complete

without a discussion o arti cial corneas. T ough viable arti-
cial cornea materials and surgical procedures have long been
sought so as to address insu cient human transplant mate-
rial, immunology and religious concerns, only recently has this
become a practical reality (Dohlman et al., 2002, Srikumaran,
2014); several competitive designs may shortly be available
(Gri th and Harkin, 2014). Box 31.1 presents the lexicon o
various keratoplasty procedures.
Irre g ular Co rne al To p o g rap hy
Fo llo w ing KP
T e main optical challenge ollowing traditional PKP (perhaps
lessened but not eliminated with the advent o FAC and other
orms o ALK) has been irregular sur ace astigmatism (Fig.
31.5). Optical rehabilitation o these distorted corneas remains
a principal unction o specialty contact lens practice, and PKP
remains, despite the growth in the LKs, a common patient pre-
sentation. Hence we will discuss care o this disease in depth.
It should also be noted that according to van Dijk et al. (2013):
‘a er success ul DMEK, 23 o 262 eyes (9%) showed subnor-
mal spectacle [corrected vision] and / or monocular diplopia
due to corneal scarring, sur ace irregularities, or undetectable
Fig . 31.6 Proud g ra t totally e le vate d ab ove the host corne al sur ace
in a ke ratoconic e ye . (Courte sy o Rob e rt Te rry, Bausch & Lomb Slid e
Lib rary.)
optical imper ections that could be managed by contact lens t-
ting. Prolonged preoperative corneal edema or more than 12
months may be a risk actor or di use irregular astigmatism
a er DMEK ... ’.
Waring et al. (1992) documented the prevalence o the
various orms o corneal topography ollowing trephine PKP
as: ‘prolate’ (30%), ‘oblate’ (30%), ‘mixed’ (20%), ‘asymmetric’
(10%) and ‘steep to f at’ (10%). Phillips (1997) discussed these
corneal topographic outcomes in more clinically descriptive
terminology as: ‘nipple’ or steep; ‘proud’, whereby the gra is
totally or partially elevated above the host corneal sur ace
(Fig. 31.6); ‘sunken’, whereby the gra is depressed below the
290 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns

Fig . 31.8 A p e ne trating ke ratop lasty with a sing le running suture .

(Courte sy o Rob e rt Te rry, Bausch & Lomb Slid e Lib rary.)

Fig . 31.7 Gra t p rof le s. (Ad ap te d rom Phillip s, A. J. (1997) Postke ra-
top lasty contact le ns f tting . In M. J. Harris (e d .) Contact Le nse s or Pre -
and Post-Surg e ry (p p . 97–132). St Louis: Mosb y.)

host sur ace; and ‘tilted’ or ‘eccentric’. T ese outcomes are illus-
trated in Fig. 31.7.
Hoppenreijs et al. (1993) suggested that causes o these topo-
graphic outcomes include:
• suboptimal cutting o the donor, the host, or both
• eccentric placement o the gra
• elevation o the gra edge during healing, with poor
wound approximation
• loosening o sutures
• localized abnormal healing
• initial corneal irregularity (e.g. keratoconus).
A second common optical problem ollowing corneal gra s is
anisometropia.

Sut ure Te chniq ue s fo r PKP

Contact lens clinicians should have a general appreciation o
suture techniques used or KP because patients commonly pres-
ent or tting or a ercare visits with some or all sutures still in
place. Sutures may be o the ollowing orms:
• running (or continuous) – a continuous suture orms
a zigzag pattern across the host–gra t inter ace, which
extends around the ull circum erence o the gra t
(Fig. 31.8)
• double running – two continuous sutures orm a zigzag
pattern across the host–gra inter ace, which extends
twice around the ull circum erence o the gra
• interrupted – a number o single sutures, commonly 12 or
16, which are equally spaced around the gra circum er-
ence (see Fig. 31.1)
• combination – both running and interrupted sutures are
used.
T ese various orms o suturing are illustrated in Fig. 31.9.
Most surgeons use either double running or one running
and several interrupted sutures as the technique o choice.
Square gra s (common many years ago) are rarely i ever cur-
rently per ormed, but may be occasionally seen and ollowed.
In a prospective study, astigmatism was ound to be the least
Fig . 31.9 Gra ts and suture s.
ollowing double running sutures compared with interrupted or
single running sutures 18 months a er PKP (Kim et al., 2008).
At some point – commonly some 3–6 months a er surgery –
either one running suture, or the interrupted sutures, is / are
removed, o en selectively in an e ort to moderate astigmatism.
One running suture, or several interrupted sutures, is / are com-
monly le in place inde nitely, only to be removed i problems
or breaks develop. Interrupted sutures alone are avoured when
PKP must be attempted in the ace o active anterior-segment
inf ammation or corneal neovascularization to permit later
individual removal when appropriate. Adjunctive surgery,
relaxing incisions, additional sutures, or even wedge resection
procedures have been used with variable success to address
postoperative astigmatism (Budak et al., 1998).

Ind icat io ns and Co nt raind icat io ns
fo r Co nt act Le ns We ar Po st -co rne al
Graft s
T e indications or contact lens use ollowing corneal gra s are
primarily postoperative irregular or high astigmatism, and sec-
ondarily anisometropia (e.g. as will occur in aphakia). Between
20% and 60% o trephine-cut post-PKP patients bene t opti-
cally rom contact lens wear (Ruben and Colbrook, 1979; Lass
et al., 1990; Smiddy et al., 1992; Silbiger et al., 1996; Wietharn
and Driebe, 2004). Bandage hydrogel contact lenses are also
sometimes used as drug delivery devices or to treat non-healing
epithelial de ects in the immediate postoperative period and or
wound dehiscence at any time (Mannis and Zadnik, 1988) (Fig.
31.10). Bandage so lenses are also used both or protection
(e.g. dehydration) and or optical ‘smoothing’ over the Dohl-
man KPro arti cial cornea (Dohlman et al., 2002).
Contact lens contraindications are as ollows:
• a good (or even just adequate) visual result with spectacle
correction alone
• anticipated poor compliance with contact lens care.
T e clinician should also be concerned about several other
relative contraindications (most o which increase both risks o
in ection and those o rejection), including:
• decreased corneal sensitivity – expected during the rst
year postoperatively (Ruben and Colbrook, 1979; Darwish
et al., 2007)
• dry eyes – tear break-up time was ound to be signi cantly
shorter 3 and 12 months a er keratoplasty (Darwish et al.,
2007)
• blepharitis
• dacryocystitis.
Patients with collateral systemic diseases, such as acne rosa-
cea and rheumatoid arthritis, which can both lead to dry eyes
and increased risk o corneal ulcer / melts and neovasculariza-
tion, need to be monitored care ully. Patients with diabetes or
other immune system depressions, which can increase the risk
o corneal in ection, should also be approached with extra cau-
tion, and monitored requently.
Ge ne ral Co nce rns
Care ul consideration needs to be given to the time period
that should be allowed to elapse ollowing surgery be ore
contact lenses are tted, i so indicated. Previous authors
suggested ‘a year post-surgery, when all sutures have been
removed’ (Soper et al., 1964); however, this advice is not
appropriate today because some sutures are now not removed
unless they break or otherwise become problematic. T e cur-
rent approach, there ore, is that contact lenses can be tted
whenever the gra is considered to have healed su ciently
to tolerate lens wear (Wilson et al., 1992). Contact lens appli-
cation there ore may begin as early as 3–6 months postsur-
gery, and o en with one or more sutures remaining. When
sutures do come out during the postoperative course, a er
patients are already using contact lenses, the clinician should
re- evaluate the patient be ore lens wear is resumed. A new
tting is occasionally indicated to address changes in cor-
neal topography, optics, or both (more so with the removal
o running sutures than with individual interrupted sutures,
although surprises can occur) (Mathers et al., 1991; Mader
et al., 1993; Langenbucher et al., 2005).
31 Po st -ke rat o p last y 291
Fig . 31.10 A b and ag e hyd ro g e l le ns use d 1 d ay a te r surg e ry to cove r
a g ra t that has b e e n se cure d with inte rrup te d suture s.
opical steroid treatment is known to potentiate sec-
ondary glaucoma, cataract and corneal in ection, but many
post-corneal-gra t patients will continue to use topical ste-
roids consistently or intermittently or the rest o their lives
to suppress rejection. Hence, the clinician and patient must
tolerate such risks and the patient should be reasonably
monitored by both the corneal surgeon and the contact lens
practitioner.
It is now accepted that extended wear o contact lenses may
enhance the prevalence and severity o all the physiological
complications o lens wear. T ese may be even more serious in
the post-KP patient than in the cosmetic contact lens patient, as
many such complications potentiate gra rejection. T e clini-
cian must consider whether to advise extended or daily wear
or each patient, accepting that some patients will be elderly or
in other ways in rm and there ore unable to care or contact
lenses. Under certain conditions, there ore, extended wear and
its attendant risks may also need to be accepted by both clini-
cian and patient.
Le ns-fit t ing Te chniq ue s
Rigid lenses remain the overwhelming device o choice or the
majority o post-KP patients because they e ciently and e ec-
tively optically mask most regular and irregular astigmatism.
Soper et al. (1964) suggested that rigid lenses (then re erring
to non-oxygen-permeable polymethyl methacrylate) should
be tted so as to ride within the PKP, meaning that the overall
diameter (OAD) o the lens would probably be less than 7.5–
8.0 mm. T e subsequent introduction o rigid gas-permeable
materials encouraged the use o lenses with larger OADs
(9.0 mm to as much as 11.0 mm) that override the entire gra
without causing hypoxic di culties (Woodward, 1997). As
rigid contact lenses tend to ‘ride’ towards and over the highest
corneal point, larger-OAD lenses allow enhanced stability and
centration – which is still o en di cult to achieve, especially
on sunken or tilted PKPs. Excessively f at cornea topographies
post-PKP, o en associated with donor / hosts o equal diame-
ter, may be especially di cult to t with rigid lenses (Lagnado
et al., 2004). Ozbek and Cohen (2006) reported good results
with the use o very-large-OAD (11.2 mm) rigid lenses on a
series o 27 irregular corneas (primary indication f at central
and steep in erior corneal topography), including 6 post-PKP.
292 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
Fig . 31.11 Examp le s o uore sce in p atte rns ob se rve d on f tting rig id
le nse s to corne as with imp e r e ct g ra ts. (A) Plate au f t on p roud g ra t. (B)
Tilte d sunke n g ra t with small nip p le ; note that the contact le ns p artially
re sts on g ra t–host inte r ace with running suture .
T ey selected the initial base curve equal to the topographi-
cally determined central f at value and then modi ed their
lenses as appropriate with the clinical goal o minimal lens
decentration.
T e back optic zone radius o a rigid lens should be
selected, with initial assistance o keratometry or corneal
topography measurements, so as to achieve some orm o
irregular corneal sur ace alignment, with neither excessive
touch nor pooling o tears. Examples o f uorescein patterns
obtained with rigid lenses tted to imper ect corneal gra s
are shown in Fig. 31.11.
oric and bitoric rigid designs are occasionally help ul in t-
ting PKP corneas exhibiting relatively regular astigmatism, and
occasionally tilted and eccentric gra s. Weissman and Chun
(1987) ound that 7 o a series o 23 eyes tted with bitoric
design rigid lenses or irregular astigmatism were post-PKP
and the majority o these (6 o 7 or 85%) were elt to be clini-
cally ‘success ul’. Phan et al. (2014) similarly ound that bitoric
RGP corneal lenses were e ective at managing higher values o
irregular corneal astigmatism.
Consideration needs to be given to edge design in tting
rigid lenses to gra corneas. Some corneal sur aces can be t-
ted with standard edge parameters. Many abnormal corneal
shapes require f atter than standard, or steeper than standard,
Fig . 31.12 A hyb rid le ns (in this case a Syne rg Eye s TM) is shown on a
p e ne trating ke ratop lasty e ye . Note arcuate are as o touch at the g ra t–
host inte r ace at b oth 12 and 6 o’clock as we ll as ce ntral corne al cle ar-
ance o the te ar f lm, or ‘p ooling ’, shown with hig h-mole cular-we ig ht
Fluore so t, d e sirab le in this kind o hyb rid contact le ns.
or even reverse-geometry edge designs (Lin et al., 2003) to
achieve mechanically acceptable corneal sur ace alignment, tear
exchange and appropriate lens positioning.
Both Genvert et al. (1985) and Mannis et al. (1986) suggest
that the overall success rate o rigid contact lens wear post-PKP
approaches 80%.
Hydrogel contact lenses, both standard and in custom
parameters, may be occasionally help ul, especially or the ol-
lowing situations:
• high re ractive errors with lesser degrees o astigmatism
• rigid lens intolerance
• acceptance o a less than optimal visual result
• protection o KPro [the keratoprosthesis produced by
Claes Dohlman (Dohlman et al., 2002)].
(Hydrogel lenses here include both non-silicone and silicone
hydrogels, the latter o ering enhanced corneal oxygen supply,
which theoretically should be advantageous to a cornea ollow-
ing a corneal gra rom a physiological perspective.)
Hybrid lens designs can be bene cial in post-PKP tting;
these include the ollowing:
• ‘piggyback’ – where a top rigid lens is tted upon a bottom
hydrogel lens (Baldone, 1973); silicone hydrogels are o -
ten employed now as the bottom hydrogel lens to enhance
oxygen supply (Weissman and Ye, 2006) and thereby de-
crease the stimulus to neovascularization
• SynergEyes M (replacing both Saturn II and So perm) – a
lens with a rigid centre and hydrophilic periphery (‘skirt’)
(Fig. 31.12)
• scleral GP rigid lenses (Daniel, 1976; Schein et al., 1990;
Pecego et al., 2012; see Chapter 21). (Fig. 31.13).
T e above hybrid designs o en allow optimal vision, simi-
lar to rigid lenses, but such lenses are expensive, complex in
mechanical tting, o en lead to occlusive lens problems, and
may induce hypoxia or binding, which in turn can increase the
prevalence and severity o many complications, particularly
neovascularization (Fig. 31.14). Scleral GP lenses are tted
by the same technique as or non-gra eyes (see Fig. 31.13);
the clinician should use a material o high oxygen permeabil-
ity and must initially achieve some corneal clearance, both

Fig . 31.13 Scle ral GP contact le ns with g ood me chanical f t on an e ye
with a PKP or ke ratoconus. Note conjunctiva is cle ar and ne ithe r inje ct-
e d nor b lanche d . (Photo cre d it: He id i Mille r, O D, CL Re sid e nt Southe rn
Cali ornia Colle g e o O p tome try at the Marshall B Ke tchum Unive rsity,
Fulle rton CA.)
Fig . 31.14 Vascularize d g ra t f tte d with hig h-oxyg e n-transmissib ility
rig id le ns. (Courte sy o De smond Fonn, Bausch & Lomb Slid e Lib rary.)
apically and over the limbus, and the haptic should neither
compress nor vault the scleral conjunctiva excessively except
in isolated areas.
Co nt inuing Care and Co mp licat io ns
Intraoperative and immediate postsurgery complications are
not part o contact lens management and there ore are beyond
the scope o this chapter. It is important to mention, however,
that non-healing epithelial de ects in the immediate postop-
erative period are sometimes managed with bandage hydrogel
lenses used or extended wear, but only or overall time periods
o a ew days to a ew weeks (see Fig. 31.10).
T e clinician who ollows post-KP patients wearing contact
lenses must be constantly vigilant or non-lens-related compli-
cations as well as pathology directly related to lens wear. Any
complication can increase the risk o gra rejection and / or
ailure. Increased intraocular pressure, leading to glaucomatous
damage to the corneal endothelium as well as the optic nerve
31 Po st -ke rat o p last y 293
– whether surgically induced or as a steroid response – is a good
example (Foulks, 1987). Similarly, phakic PKP patients, espe-
cially those who are older, o en su er cataract within 5 years o
surgery (Martin et al., 1994).
Usual complications encountered in the care o post-PKP
patients include:
• microbial in ection – sometimes associated with contact
lens wear (in particular extended wear), corneal exposure,
steroid use or loose / exposed sutures ( seng and Ling,
1995)
• corneal neovascularization – related to sutures, previous
eye disease (e.g. blepharitis), large gra s, inf ammation
or contact lens wear (especially low-oxygen-transmissible
and / or tight lenses and / or used on extended wear), prob-
ably potentiated by hypoxia or mechanical issues (Lemp,
1980; Dana et al., 1995; Adesina et al., 2013) (see Fig. 31.14)
• loose / exposed sutures – which can lead to localized ab-
scesses and / or neovascularization, possibly induced by
trauma during lens insertion / removals
• wound dehiscence – which can occur even years a er suc-
cess ul KP, and may occur spontaneously, ollowing suture
removal or even accidentally rom trauma (e.g. associated
with the use o mechanical contact lens removal devices
[Ingraham et al., 1998])
• epithelial staining, abrasions or de ects – which may or
may not be related to contact lens wear
• papillary conjunctivitis – a common contact lens compli-
cation, but also associated with exposed sutures and cor-
neal scars
• retinal detachment – Aiello et al. (1993) ound an almost
2% risk o detachment 2 years post-PKP in a cohort o
40 000 medical insurance recipients in the USA between
1984 and 1987
• uncontrolled glaucoma – typically surgically induced or a
response to the use o steroids.
Graft Re je ct io n and Failure
T e clinician ollowing post-corneal-gra patients or contact
lens care must always be speci cally alert or gra rejection
and / or ailure as well as other problems in both asymptomatic
as well as symptomatic individuals. Symptoms o gra immu-
nological rejection include any ocular inf ammation, ‘red eyes’,
pain and photophobia, but while early rejection may be symp-
tom ree (Kamp et al., 1995), an alert clinician may note one or
more o the clinical signs discussed below.
Gra t rejection can be epithelial, stromal or endothelial
(Alldredge and Krachmer, 1981; Adesina et al., 2013).
EPITHELIAL REJ ECTIO N
Epithelial rejection appears as an elevated, undulating line that
stains with f uorescein (Fig. 31.15). T e line represents a zone o
donor epithelial destruction by leukocytes, and, i le untreated,
will march across the sur ace o the gra over several days or
weeks. Although dramatic in appearance, epithelial rejection is
not usually a major problem; the end result is the replacement o
the donor epithelium by that o the host. Nevertheless, epithelial
rejection should be managed with aggressive steroid treatment
to decrease ocular inf ammation, which may precipitate a sec-
ondary ull-thickness rejection.
294 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
Fig . 31.15 Ve rtical e p ithe lial re je ction line in a g ra t corne a staine d
with uore sce in. (Courte sy o J. McCormick (Bausch & Lomb Slid e
Lib rary.)
STRO MAL REJ ECTIO N
Stromal rejection is seen as patchy subepithelial in ltrates, sim-
ilar to those seen in epidemic keratoconjunctivitis (Krachmer
and Alldredge, 1978), and / or ull-thickness corneal swelling
and haze, usually associated with circumlimbal hyperaemia.
ENDO THELIAL REJ ECTIO N
A Khodadoust line and / or keratic precipitates are signs o
endothelial rejection and will undoubtedly lead to an opaque
cornea unless treated aggressively.
Anterior-chamber inf ammation, indicated by the appear-
ance o f are and cells, is another clinical sign o gra rejection.
T e risk o rejection is believed to increase with the ollowing:
• any corneal neovascularization, but particularly deep stro-
mal neovascularization, especially through the gra –host
inter ace
• any ocular inf ammation
• glaucoma
• certain diseases, such as active herpetic keratitis
• each subsequent corneal gra (when the patient under-
goes multiple operations).
While Smiddy et al. (1992) suggested that rigid wear by itsel
does not increase the risk o rejection, Gomes et al. (1996)
observed many complications in a series o 18 post-PKP patients
tted with rigid lenses. Problems observed over a 3-year period
ollowing surgery included corneal staining (8 cases), neovascu-
larization (6 cases), gra rejection episodes (5 cases), papillary
conjunctivitis (3 cases) and suture-related in ltrates (2 cases).
GRAFT FAILURE
Gra ailure (as distinct rom immunological gra rejection),
believed to represent the result o primary or secondary (e.g.
glaucoma) endothelial decompensation, must also be consid-
ered. Failure can occur early or late, and may be the diagno-
sis when gra stromal oedema is seen without inf ammation.
Suspected gra ailure should initially be treated with anti-
inf ammatory drugs (e.g. steroids) in case the diagnosis is really
rejection, which may enable the KP to be saved.
T ompson et al. (2003) report an overall PKP survival rate
o about 88% at 5 and 80% at 10 years postoperatively in a very
large series (3992 consecutive eyes), with the highest risk o ail-
ure or rejection (about 4%) within the rst 2 years but continu-
ing at about 2% per year up through the 10-year point. PKPs
or keratoconus had the best survival rates, but endothelial ail-
ure was common or corneas gra ed or pseudophakic bullous
keratopathy and regra s also had lower survival rates.
O t he r Manag e me nt Issue s
Several studies suggested that PKP topography changes with
rigid wear, with the gra becoming both f atter and smoother
(less astigmatic) (Manabe et al., 1986; Wilson et al., 1992; Sper-
ber et al., 1995). De oledo et al. (2003), Szczotka-Flynn et al.
(2004) and Lim et al. (2004), however, ound increasing astig-
matism with long-term ollow-up o PKP or keratoconus, pos-
sibly owing to keratoconus progression in the remaining host
corneal (rim) tissue. Recurrent ectasia has been ound in cor-
neal gra s and is diagnosed on average two decades a er the
initial PK (Patel et al., 2009). Hayashi and Hayashi (2006), on
the other hand, ound relative stability in corneal sur ace vide-
otopography o 130 consecutive PKPs or a variety o diseases
(31% keratoconus) studied with Fourier series analysis.
Corneal endothelial changes over time are not believed to be
di erent rom those expected o any PKP cornea without lens
wear (Speaker et al., 1991; Bourne and Shearer, 1995). Gra epi-
thelial barrier unction is maintained with post-PKP rigid lens
wear (Boot et al., 1991).
Collateral problems commonly encountered include blephari-
tis, meibomian gland dys unction and dry eyes associated with
acne rosacea or poor lid apposition. T ese conditions need to
be managed aggressively with lid hygiene, arti cial tears (pre er-
ably unpreserved and unit dose) or appropriate pulsed antibiotic
treatment (both local and systemic). Additional surgery may be
required, such as punctal occlusion or blepharoplasty. In general,
strenuous e orts must be made to protect the gra rom drying
and to suppress inf ammation, in order to avoid rejection episodes.
Dilated and xed pupils are occasionally a sequela o intraoc-
ular surgery (Urrets-Zavalia syndrome; u and Buckley, 1997),
but usually do not pose any problems with respect to contact
lens wear. Such patients rarely may bene t rom an arti cial
pupil contact lens, but o en this is more or cosmetic than or
visual reasons.
Co nt act Le ns Re sult s
Most trephine-cut post-PKP patients bene t optically rom
rigid contact lens wear (Ruben and Colbrook, 1979; Lass et al.,
1990; Smiddy et al., 1992; Silbiger et al., 1996; Wietharn and
Driebe, 2004; Geerards et al., 2006).
Ho et al. (1999) studied 40 post-PKP eyes (compared with 40
control eyes) and ound that post-PKP eyes were more complex
and time consuming to t success ully with rigid lenses than
were ‘normal’ eyes, requiring more diagnostic contact lenses,
more ordered contact lenses and more o ce visits than did con-
trol eyes. Contact lens wear success rate and complication rates
(both lens and gra related), however, were not signi cantly di -
erent between the two groups o eyes.

Co nclusio n
Over the past century, both PKP and various types o LK have
become accepted and requently used surgical treatments or
many corneal diseases. Although techniques remained rela-
tively stable during the second hal o the 20th century, the last
ew years have seen the introduction o a set o new techniques,
many o which hold promise or major improvements in out-
comes and increased utilization. Sutton et al. (2008) ound that
only 5.3% o patients required a rigid contact lens ollowing KP
or keratoconus. All others were able to attain at least 6 / 12 best
corrected visual acuity 6 months postoperatively.
Nonetheless, or the near term, the anterior corneal sur-
ace commonly remains distorted ollowing many corneal
gra s, particularly PKP, and there ore patients o en continue
to bene t signi cantly rom the optical enhancement a orded
by the use o contact lenses – rigid lenses in particular. T ere
are many potential post-corneal-gra complications, including
corneal neovascularization, loose / exposed sutures, glaucoma,
31 Po st -ke rat o p last y 295
cataract, wound dehiscence, microbial in ection, gra ailure
and rejection, and retinal detachment. T e use o contact lenses
can provoke additional complications, including enhanced risk
o corneal neovascularization, loose / exposed sutures, wound
dehiscence, epithelial de ects, giant papillary conjunctivitis and
other inf ammatory conditions, and microbial in ection. Many
o these problems may potentiate gra rejection and / or ailure.
T e risk / bene t ratio must there ore be considered care ully
in each individual case, and pro essional supervision should
occur at reasonable intervals, perhaps every 3–4 months, even
in asymptomatic individuals.
In conclusion, Williams et al. (1991), reporting on 60
patients wearing contact lenses or more than 2 years ollowing
PKP, ound that the majority (75%) were ‘satis ed’ with their
outcomes, but those who were dissatis ed complained o both
contact lens and gra problems.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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32
O rt ho ke rat o lo g y
PAUL GIFFO RD
Int ro d uct io n
For a multitude o reasons, many patients want to be able to see
well and to unction without the need or a re ractive correction
by glasses or contact lenses. T e popularity o re ractive surgery
procedures with some patients is a clear indicator o that desire.
Orthokeratology (OK) is one other mani estation o the ongo-
ing attempts to meet this need. T e act that the cornea is the
major optical contributor to the power o the eye, and is also the
most accessible o the re ractive elements o the eye, has made
OK an obvious candidate or initiating re ractive control.
It has long been known that the cornea can be de ormed by
the application o an external pressure, whether an acute pres-
sure as in applanation tonometry or a more sustained pressure
rom wearing rigid contact lenses. Early studies on the wearing
o polymethyl methacrylate (PMMA) lenses demonstrated that
they can induce changes in corneal curvature, re ractive error and
visual acuity. T e corneal changes were typically a central atten-
ing, which o en took weeks to return to normal. Corneal shape
changes have also been demonstrated with the wearing o rigid
gas-permeable contact lenses. In general, these changes include
a reduction in corneal toricity and a tendency or the cornea to
change rom its normal aspheric shape to a more spherical one.
T ese corneal shape changes, when occurring in routine
contact lens ttings, are normally considered an undesirable
side-e ect o a non-optimal lens t. However, Jessen (1962)
proposed the exploitation o this e ect so as to induce use ul
corneal shape changes to eliminate, or at least reduce, myopic
re ractive errors.
Although early OK procedures garnered some support, the
lack o veri able evidence on its clinical ef cacy precluded gen-
eral acceptance. However, more recently the use o new innova-
tive lens designs has given renewed impetus and interest in this
technique.
Hist o ry o f O rt ho ke rat o lo g y
OK was rst described by Jessen (1962) whereby rigid contact
lenses could be used to correct ametropia through altering cor-
neal curvature. Jessen described how rigid lenses, then manu-
actured in polymethyl methacrylate (PMMA), could be tted
steeper than corneal curvature to induce corneal steepening so
as to correct hyperopia, or atter than corneal curvature so as to
atten the cornea and correct myopia. Lenses were tted with su -
cient di erence in curvature to the cornea to promote change in
corneal curvature, but not so great as to destabilize lens tting.
Lenses were then worn during waking hours and progressively
altered in curvature as corneal shape changed until the ull re rac-
tive e ect was achieved, at which stage daytime wear was contin-
ued with the nal t lens to retain the e ect.
296
In this ormat, OK remained a niche procedure practised by
a small number o dedicated enthusiasts. Early clinical reports
indicate that outcomes were variable, with no consensus on the
most appropriate lens design, or on the number and timing o
lens re ttings (Carney, 1994). T e rst comprehensive study was
conducted by Kerns (1976, 1978), with urther studies reported
by Binder et al. (1980) and Polse et al. (1983). Although the
experimental design and breadth o these studies varied, they
nevertheless were reasonably consistent in their overall nd-
ings. As a result o those controlled clinical studies, it was estab-
lished that the re ractive e ect was unpredictable, variable and
slow. Regression was rapid so ongoing lens wear was required
to retain e ect, and there was a tendency to induce signi cant
corneal astigmatism i lens centration was not controlled.
Mo d e rn O rt ho ke rat o lo g y
T e mid 1990s saw convergence o three independent technolo-
gies that revolutionized OK. Computerization led to greater con-
trol over lens lathing and dramatically improved measurement o
corneal topography, while improvements to polymer technology
saw the introduction o gas-permeable contact lens materials.
Independently o each other, Wlodyga and Bryla (1989) and
Harris and Stoyan (1992) reported that reverse-geometry lens
designs, now made possible through computerized lathing,
could be utilized to stabilize at- tting lenses. Reverse-geome-
try lenses have secondary curves that are steeper than the back
optic zone radius (BOZR) (Fig. 32.1). When utilized in a at- t-
ting rigid contact lens, this enables peripheral realignment with
the cornea in what would otherwise be a poor- tting lens with
excessive edge li . When applied to OK this meant that larger
steps in lens attening could be made between successive lenses
without compromising t and centration. T is new approach
in OK lens tting was given the name ‘accelerated orthokera-
tology’ because it provided rapid onset (within a ew days) o
e ects that had previously taken weeks or months to achieve.
Fig . 32.1 Re ve rse -g e ome try le ns d e sig n, showing the ste e p e r se c-
o nd ary curve and re late d te ar re se rvoir.

O ve rnig ht O rt ho ke rat o lo g y
In the early days o accelerated OK, lenses were still prescribed
to be worn during waking hours, and when ull re ractive e ect
was achieved then wear o the nal ‘retaining’ lens was reduced
to the smallest amount o time that maintained the re ractive
e ect. Although this meant that patients bene ted rom some
waking hours ree rom vision correction, they were still incon-
venienced by having to wear their OK lenses at some point
during the day. Meanwhile gas-permeable lens materials had
continued to evolve, with overnight wear o conventional rigid
gas-permeable lenses achieving USA Food and Drug Adminis-
tration (FDA) approval in 1986.
T e rst suggestion o overnight lens wear in OK was made
by Harris and Stoyan (1992,) who proposed the traditional OK
approach o daily lens wear until the retainer stage was reached.
At this stage, lenses with oxygen transmissibility suf cient to
allow extended wear could be worn during sleep or three to
six nights per week, with the lenses removed on waking. Grant
(1992) reported that OK could instead be conducted rom the
outset solely through overnight lens wear with no lens wear
required during the day. Overnight wear has since become the
accepted modality or OK, with FDA approval or overnight
wear o the Paragon CR lens or OK (Paragon Vision Sciences,
Mesa, AZ, USA) rst issued in 2002.
Ho w O rt ho ke rat o lo g y Wo rks
T e original concept o OK was based on the belie that non-
alignment tted rigid lenses would bend the cornea to atten
or steepen curvature to reduce levels o myopia or hypero-
pia, respectively. T ere is now good evidence that the corneal
changes with reverse-geometry lenses are more complex than
a mechanical bending o the cornea. Swarbrick et al. (1998)
reported results o measurements o corneal shape and thick-
ness changes a er OK lens wear. T ey demonstrated that the
myopia reduction was accompanied by a attening o the cen-
tral cornea, thinning o the central cornea and thickening o
the mid-peripheral cornea. By using Munnerlyns’ ormula or
calculating laser re ractive surgery ablation depth, the authors
were able to show a close correlation between the predicted
re ractive change rom change to central corneal thickness and
actual re ractive change.
Using optical pachometry, Alharbi and Swarbrick (2003)
revealed that whereas central corneal thinning was mostly
attributed to changes in epithelial thickness, the mid-periph-
eral thickening was mostly a stromal e ect. It has been sug-
gested that cell compression, rather than cell movement or
loss, may be the primary mechanism o central epithelial
changes (Choo et al., 2004). Further research has shown that
stromal, but not epithelial, thickness changes during over-
night wear o OK lenses are related to oxygen transmissibil-
ity o the lenses (Haque et al., 2007). T ere is conjecture on
whether OK in uences posterior corneal curvature. Mild
posterior corneal curvature changes were ound by Owens
et al. (2004), which would suggest that corneal bending does
have some role in the mechanism o change. However, using
a Pentacam analysis system, sukiyama et al. (2008) showed
instead that overnight OK lens wear alters the anterior cor-
neal shape rather than the posterior corneal curvature or the
anterior-chamber depth.
32 O rt ho ke rat o lo g y 297
T e mechanism by which OK creates changes to corneal
curvature, thickness and re raction is not understood. Intuition
suggests that OK lenses impose a direct moulding e ect on the
corneal sur ace through eyelid pressure. Mount ord (1997) has
put orward an alternative hypothesis: that it is the tear reservoir
generated by the steeper secondary curves that primarily leads
to the pressure changes in the post-lens tear lm that is respon-
sible or the corneal tissue redistribution.
O ut co me s o f Acce le rat e d
O rt ho ke rat o lo g y
T e outcomes o accelerated OK can be measured with respect
to the ef cacy o the technique, the extent and time course o
regression a er lens removal, changes to corneal physiology,
and sa ety.
EFFICACY
T e ef cacy o the use o reverse-geometry lenses, worn in both
daily wear and overnight wear protocols, has been evaluated in
a number o recent studies, examples o which are given here.
Swarbrick et al. (1998) tted reverse-geometry lenses (OK74;
Contex) manu actured in Airperm material to 6 young myopic
subjects. T e lenses were worn on a daily-wear basis or 28 days,
and resulted in a myopia reduction o 1.71 ± 0.59 D. Lui and
Edwards (2000) conducted a 100-day daily-wear trial on 14 sub-
jects, again using the OK74 design in Airperm material. T ey
reported a myopic reduction o 1.50 ± 0.45 D. Nichols et al.
(2000) conducted a 60-day trial on overnight wear o the same
Contex OK lenses, with 8 subjects completing the study. T e
reduction in subjective re raction 4 hours a er awakening was
1.83 ± 1.23 D. Using Paragon CR lenses, Bernsten et al. (2005)
ound a reduction in myopia o 3.33 ± 0.96 D a er 1 month o
overnight lens wear.
T ese studies are reasonably consistent in their estimation
o the magnitude o re ractive change, and in the variability o
the response. While correction o greater amounts o myopia is
sometimes reported, and proposed by some OK lens designers,
they are not what is to be expected in the repeatable application
o current lenses.
Changes in corneal curvature and shape have also been eval-
uated in many studies, although di ering techniques have been
employed. Swarbrick et al. (1998), using the EyeSys corneal top-
ographic mapping system, ound that the apical corneal power
diminished by 1.19 ± 0.38 D. Over the central 5–6 mm zone
o the cornea there was signi cant central corneal attening,
which diminished towards the mid periphery. Lui and Edwards
(2000) used keratometry and the MS-1 videokeratographer to
report central corneal attening o 0.14 ± 0.06 mm vertically and
0.12 ± 0.07 mm horizontally. Nichols et al. (2000), using a Hum-
phrey Atlas topographer and an Orbscan slit scan topographer,
reported a signi cant attening o the apical radius o 0.20 ± 0.90
mm, that again diminished towards the periphery.
In general then, it is well established that changes in corneal
shape and re ractive error can be induced by reverse-geometry
lenses, and that the changes occur more rapidly than with ear-
lier lens designs, with signi cant structural and optical change
in as little as 15 minutes (Lu et al., 2008). On average, 75% o
the required re ractive change is achieved with 1 night o lens
wear with an end-point achieved within 7–10 nights o lens
298 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
Fig . 32.2 Mod e l o the e xp e cte d re ractive chang e and its time course
d uring we ar o re ve rse -g e ome try le nse s.
Fig . 32.3 Mod e l o the e xp e cte d re g re ssion o re ractive chang e d ur-
ing waking hours a te r ove rnig ht we ar o re ve rse -g e ome try le nse s.
wear (Swarbrick, 2006). A model o the average induced re rac-
tive change rom these reported studies, and its time course, is
shown in Fig. 32.2.
Although corneal irregularities such as a decentred treat-
ment zone are sometimes encountered, in general the corneal
changes do not lead to losses o high-contrast visual acuity, low-
contrast visual acuity or contrast sensitivity or these experi-
mentally repeatable magnitudes o treatment (Johnson et al.,
2007).
REGRESSIO N
An appealing actor o OK is that changes to re ractive e ect
and corneal curvature return to pre-leans-wearing values i
wear is ceased; however, this regression o e ect starts soon a er
lens removal so that some unwanted loss o re ractive e ect is
observed during the day between wearing intervals (Fig. 32.3).
Mount ord (1998), in a retrospective study o 48 patients,
ound that a er 90 days o overnight wear the regression o
apical corneal power over approximately an 8-hour period sta-
bilized between 0.50 and 0.75 D per day, but with signi cant
individual variation. Nichols et al. (2000) concluded rom their
study that the re ractive outcomes a er 60 days o overnight
wear were sustained over an 8-hour day. However, analysis o
their ndings shows that most changes were measured over only
a 4-hour period, and some changes – as indicated by autore rac-
tion data – did show regression up to 0.50 D (E ron, 2000). On
average, a regression o approximately 0.25–0.75 D is expected
throughout the day a er overnight lens wear, but this regression
is greater in the early stages o OK lens use. Up to 90% o recov-
ery towards the baseline re raction can be expected within 72
hours o lens discontinuation (Barr et al., 2004).
CO RRELATIO NS
T e relationship between re ractive changes and corneal curva-
ture changes has been a matter o some conjecture. Numerous
studies using early OK lens designs reported that the re rac-
tive change was greater than that expected rom corneal power
changes measured using keratometry. T e reported ratio o
these changes was o en 2 : 1 or more.
T is anomaly is most likely a consequence o the irregular
nature o the induced corneal topographic changes. It is now
apparent that the corneal shape changes are more marked in
the central cornea, and diminish towards the mid periphery
(Swarbrick et al., 1998), and hence keratometry results are
somewhat unreliable. Similarly, the reported vision improve-
ments were o en greater than would be predicted rom cor-
neal curvature changes. As well as the above explanation, these
vision reports were in uenced by a lack o standardization o
testing procedures, practice e ects rom repeated vision test-
ing (McMonnies, 2001) and bias rom the unmasked protocols
o en used (Carney, 1994).
Dif culties with correlating corneal curvature, re raction
and vision were con rmed by Nichols et al. (2000) using over-
night wear o reverse-geometry lenses. Re raction was measured
both subjectively and by autore ractor, with a larger reduction
in myopia reported or subjective re raction than or autore rac-
tion. T e authors hypothesize that this nding is a consequence
o the greater weight given to peripheral optical e ects with
autore raction.
CO RNEAL PHYSIO LO GY
Lum and Swarbrick (2007) reported the appearance o bril-
lary lines in the anterior stroma o a 29-year-old Asian woman
a er wearing overnight OK lenses or approximately 9 years.
T e brillary lines were ne, slightly curved and subepithelial,
and were arranged in a band-like annulus in the corneal mid
periphery. T e lines were not associated with epithelial stain-
ing, although a marked Fischer–Schweitzer corneal mosaic
was noted a er blinking. Fibrillary lines are a relatively com-
mon nding in normal and keratoconic corneas and have
been reported previously accompanying OK lens wear. Lum
et al. (2012) went on to map the corneal subbasal nerve plexus
(SBNP) or this patient using con ocal microscopy to establish
that the earlier reported brillary lines were the visible appear-
ance o alterations to the SBNP induced by OK lens wear. T e
SBNP was also mapped or a 21-year-old Asian woman wear-
ing OK lenses or approximately 1 year and a non-OK-lens-
wearing 28-year-old Asian woman, to reveal that the SBNP
took on a whorl pattern appearance in the OK-lens wearer,
compared with a tortuous network o central nerve bres and
thicker curvilinear mid-peripheral bres in the non-OK-lens
wearer.
Following on rom their earlier work, Lum et al. (2014)
using con ocal microscopy measured corneal nerve bre den-
sity (NFD) over a 1 mm 2 area in OK-lens-wearing subjects and
also looked at changes to corneal sensitivity. T e study, involv-
ing 16 subjects, revealed a signi cant reduction in central NFD
a er 3 months o lens wear that improved but did not return to

pre-lens-wearing values 90 days a er lens wear was ceased. Cor-
neal sensitivity was similarly reduced, but in this case returned
to pre-lens-wearing levels within 30 days o discontinuation o
wear.
It is clear rom this research that OK lens wear alters corneal
nerve structure and that corneal sensitivity is reduced, a er as
little as 1 night (Lum et al., 2013). However, there are currently
no published studies to report on whether so or rigid contact
lens wear similarly alters corneal nerve structure. T e limited
current evidence suggests that in OK these changes begin to
resolve once lens wear is ceased, leading to recovery o cor-
neal sensitivity over the short term, and corneal nerve mor-
phology returns towards pre-lens-wearing values over the
longer term.
SAFETY
Corneal complications can occur in OK, as in any orm o
contact lens wear. For example, corneal staining can be pres-
ent, particularly a er overnight lens wear. T e signi cance o
epithelial thinning, as reported a er wear o reverse-geometry
lenses, in the occurrence o serious complications remains to be
established (Swarbrick et al., 1998). Overnight wear o any con-
tact lens has previously been shown to be a major risk actor or
keratitis (Holden and Lazon de la Jara, 2007), so the nding o
complications in OK is perhaps not unexpected. Furthermore,
OK lenses have been shown to retain more bacteria than align-
ment- t rigid lenses a er bacteria-loaded overnight lens wear
(Choo et al., 2009), which may increase the risk or an in ection
in OK patients i suitable conditions are present.
Watt and Swarbrick (2007) investigated trends in micro-
bial keratitis (MK) associated with OK by per orming a meta-
analysis o cases that were reported in ophthalmic journals or
presented at con erences; 123 cases were reported rom 2001 to
2007. Most cases were ound to be in emale, East Asians aged
between 8 and 15 years. In 41 (33%) o the cases Acanthamoeba
was implicated as the causative organism, and Pseudomonas
aeruginosa in 46 (36%) cases. T eir analysis revealed a peak o
cases in East Asia, particularly in China and aiwan during a
short period when regulation o the modality was limited. Acan-
thamoeba keratitis in OK has been shown to be related to the
use o tap water or rinsing (Lee et al., 2007), so the simple act o
avoiding tap water could well have prevented a large number o
the cases that Watt and Swarbrick assessed.
In Australia, Watt et al. (2007) sent a questionnaire to
members o the Orthokeratology Society o Australia (now
the Orthokeratology Society o Oceania, OSO) and received a
response rom 33 optometrists who had been tting OK lenses
or a median period o 7.5 years. OSO membership requires
completion o an accredited certi cation course or OK. T e
authors combined their ndings with two previously reported
cases to reveal nine cases o MK (4 P. aeruginosa; 2 Acantham-
oeba spp.; 3 unknown organism). Poor patient compliance was
implicated in most cases o presumed MK in OK. Although
speculative, the low magnitude o reported cases, particularly
those involving Acanthamoeba, suggests that better regulation
o OK lens tting is bene cial in reducing rate o in ection.
More recently, Bullimore et al. (2013) investigated the risk o
MK with overnight OK by asking randomly selected practitioners
to report cases o patients who attended or unscheduled visits
or a pain ul red eye. From the 1317 (640 adults; 677 children)
patients that were ultimately sampled, eight events o corneal
32 O rt ho ke rat o lo g y 299
in iltrates associated with a pain ul red eye were reported
(2 adult; 6 children). wo o these, both occurring in children,
were classi ed as MK but did not result in loss o visual acuity.
T e overall estimated incidence o MK established by their study
was 7.7 per 10 000 years o wear overall, and 13.9 per 10 000
years o wear in children, leading the authors to conclude that
the risk o MK with overnight OK is similar to that with other
overnight-wearing modalities. By comparison, Stapleton et al.
(2008) investigated cases o MK presenting in Australia over a
12-month period to report an incidence o 19.5 cases o MK
per 10 000 years o overnight wear o so contact lenses, and
25.4 cases o MK per 10 000 years in overnight wear o silicone
hydrogel so contact lenses.
Although these studies suggest that overnight OK o ers no
greater risk than does traditional overnight lens wear, accurate
in ormation on the prevalence o serious complications in OK
is still not available, and the potential or their occurrence must
be recognized and protected against (Van Meter et al., 2008).
o this end, Cho et al. (2008) provided a comprehensive guide-
line or practitioners to improve their OK practice and mini-
mize unnecessary or preventable complications as they believe
that the key to sa e OK lens wear is to update knowledge in the
eld continually, and to practise to the highest pro essional
standards.
DETERMINANTS O F SUCCESS
A drawback to the more general acceptance o OK has been the
variability o responses and lack o predictability. Although a
number o ocular and contact lens characteristics have been
proposed as candidates or in uencing the re ractive outcome,
there have been no conclusive ndings.
Carkeet et al. (1995) carried out an analysis o a range o
ocular characteristics, including subjective re raction, corneal
thickness pro le, intraocular pressure, ocular rigidity and epi-
thelial rigidity. T e only signi cant nding was that OK success
was related to the pre tting re ractive error, with higher levels o
myopia leading to reduced re ractive change. Studies on corneal
hysteresis and corneal resistance to de ormation have ailed to
identi y reliable and consistent e ects o corneal biomechanics
on OK outcomes (Chen et al., 2009; Gonzalez-Meijome et al.,
2008).
T e ocular characteristic most accepted as being o signi -
cance to the induced re ractive change is the pre tting corneal
shape. Mount ord (1997) and others maintain that the practi-
cal limit o OK is de ned by the corneal asphericity, as urther
corneal change is unlikely when the cornea achieves a spherical
shape. A regression analysis o change in apical corneal power
and initial corneal eccentricity directly related the induced
corneal (and hence) re ractive change to corneal shape. Near-
spherical corneal shapes led to very little corneal power change
(Mount ord, 1997).
Hyp e ro p ic O rt ho ke rat o lo g y
OK was irst described by Jessen (1962) as a technique to
correct hyperopia, through steepening the corneal pro-
ile using steep- itting rigid lenses, but this approach never
gained traction, probably because lens materials o the time
induced signi icant corneal oedema (Coon, 1982). Correct-
ing myopia has since been the main ocus o OK lens manu-
acturers; however, in recent years there has been growing
300 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
interest in correcting hyperopia, with a number o lens man-
u acturers now o ering OK designs to correct hyperopia and
presbyopia.
o correct hyperopia requires central corneal steepening,
which it has been shown to be possible to achieve with 4 hours
wear o steep- tting rigid lenses tted with apical clearance
(Swarbrick et al., 2004) and overnight wear o speci cally
designed hyperopic OK lenses (Lu et al., 2007a). It has since
been shown that the time course o re ractive and corneal
topography change in hyperopic OK is analogous to that in
myopic OK, with most e ect occurring a er the rst night
o wear and regression o e ect during the day (Gi ord and
Swarbrick, 2008). Full targeted e ect and greater retention o
e ect during the day is achieved within 1 week o wear. Haque
et al. (2008) measured changes to corneal thickness using opti-
cal coherence tomography to reveal that hyperopic OK caused
an increase in central epithelial thickness. Gi ord et al. (2011),
using optical pachometry, ound that hyperopic OK did not
alter central corneal epithelial thickness but instead thinned
the mid-peripheral epithelium. T eir outcomes rom an ear-
lier study (Gi ord et al., 2009) suggest that the mechanism o
mid-peripheral epithelial thinning is corneal compression by
the lens in the paracentral region, as opposed to central post-
lens tear lm orces.
T ese corneal steepening e ects seem to be more dif cult to
induce and control compared with central corneal attening. In
particular, the treatment zone size in hyperopic OK is reported
to be smaller in comparison with that in myopic OK (Gi ord
and Swarbrick, 2009), and treatment outcomes are reported to
be more variable when targeting higher (+3.50 D) compared
with lower (+1.50 D) levels o re ractive correction (Gi ord and
Swarbrick, 2008). Although corneal steepening changes can
be produced, clinical results so ar have not been compelling
(Swarbrick et al., 2004; Lu et al., 2007a). On the positive ront,
hyperopic OK has been shown to o er a viable technique or
providing monovision correction in emmetropic presbyopes
(Gi ord and Swarbrick, 2013).
O rt ho ke rat o lo g y Le ns Fit t ing
here are numerous OK lens designs, each with di erent
approaches to lens itting, which makes this an extensive
subject to cover in a small space. Rather than describe all o
these approaches, this section instead o ers an overview o
the principles o myopic OK lenses that are common to all
designs.
INDICATIO NS AND CO NTRAINDICATIO NS
Patient selection is just as important as or other contact lens
ttings. However, in addition to the usual considerations, it is
essential that realistic expectations are established with pro-
spective patients, about the magnitude o the expected improve-
ment in unaided acuity, and potential limitations on its stability.
Patients need to be com ortable that continued overnight lens
wear is a requirement and be able to make an in ormed choice
considering the risks that overnight wear introduces compared
with alternative contact lens modalities.
T e usually accepted upper re ractive error limit is 4.50 D o
myopia, and 1.50 D o with-the-rule corneal toricity. Higher lev-
els o myopic correction are achievable, and indeed advertised
by some OK lens manu acturers; however, overall treatment
zone ( Z) diameter reduces with higher amounts o re ractive
change (Lu et al., 2007b). In cases where the pupil diameter
exceeds the Z diameter, visual halos or are may be reported.
Z diameter also varies between individuals and needs to be
taken into particular consideration or patients with large pupils
in standard illumination. As with other lens ttings, good ocu-
lar health and the ability to handle and maintain the lenses are
expected.
Perhaps most important or prospective OK candidates is
their motivation, be that achieving the ability to see clearly
without re ractive correction during habitual hours, or more
increasingly to reduce urther progression o myopia. OK
also o ers a viable alternative to those interested in re rac-
tive surgery though not willing to undergo laser treatment.
Regardless o their motivation, in reaching a decision to
proceed they need to be ully aware that OK is an ongoing
procedure requiring continued overnight wear o contact
lenses.
BASE CURVE
T e back optic radius (BOR) o the lens is t atter than corneal
curvature to correct myopia, and steeper than corneal curvature
to correct hyperopia. T e ortho ocus technique rst published
by Jessen (1962) described how the BOR should be altered rom
corneal curvature by an amount equivalent to the re ractive
change being targeted, so a −2.00 D target or a 45.00 D cornea
would require tting with a 43.00 D BOR. Most current lens
designs alter BOR by slightly more than the ‘Jessen actor’ to
accommodate what is usually described as a ‘compression ac-
tor’. T e compression actor varies across lens designs rom 0.00
D to 1.00 D.
FITTING APPRO ACHES
Fitting OK lenses is based around a sagittal height itting
philosophy, with an ideal it obtained through choosing or
designing a reverse-geometry rigid contact lens that has the
same sagittal height as the cornea at the peripheral bearing
point o the lens. here are essentially three approaches to
OK lens itting that have been adopted by di erent OK lens
designers:
Emp irical Le ns Fitting
T is is the easiest approach or the practitioner as it requires
sending only keratometry readings or topography image cap-
ture, alongside desired re ractive change, to the lens manu-
acturing laboratory. T e lab then uses this data to design and
manu acture the calculated best- t lens, which is returned to
the practitioner.
Advantages
• Easier or novice users
• Reduced set-up costs – no trial lenses required.
Disadvantages
• Practitioner is totally reliant on the manu acturer to deter-
mine lens parameter changes.
• It takes longer to achieve a nal t owing to the time it
takes the lab to manu acture and supply each lens.

Trial Le ns Fitting
rial lens tting sets allow the practitioner to hold a small
range o around 20–25 lenses that can be used to assess the t
o the lens. A computer program or table is used to predict the
best tting lens based on keratometry or corneal topography
data, which is then tested in overnight trials, be ore settling
on the best- t lens. Once best t is achieved the measured
change in re raction against the predicted change rom the
trial lens can be used to accurately determine the nal lens
parameters.
Advantages
• Patient can immediately start overnight trials and any
changes required during the t process can again be sup-
plied rom the trial set.
Disadvantages
• rial lenses assess lens t only, so re ractive error is not
necessarily corrected.
Full Diag nostic Bank
Some lens designs are available whereby the practitioner
holds stock o around 100–150 lenses, allowing lens it to
be assessed while targeting the ull re ractive correction. A
computer program or table is used to predict the best it-
ting lens based on keratometry or corneal topography data
and re ractive error. he suggested lens is then worn or
overnight trials with it and / or targeted change in re rac-
tive error altered until optimum it and vision correction is
achieved.
Advantages
• Patient is tted rom the outset with nal- t lenses.
• Practitioner has ull control over the tting process.
• Diagnostic bank can be utilized or emergency cases (i.e.
existing wearer loses or breaks a lens).
Disadvantages
• Having to hold a large number o lenses makes this the
most expensive option to set up.
PO ST-WEAR ASSESSMENT
Standard rigid lens t is gauged through visual assessment
aided by instillation o sodium uorescein so as to determine
the optimum alignment with the cornea. T is same approach
can be ollowed to improve OK lens t; however, it is the change
to corneal curvature made by the orthokeratology lens during
overnight wear that provides the most in ormation on lens- t
ef cacy. Although it is possible to select an initial OK lens rom
keratometry values, it is not possible to assess tting outcome
accurately without a corneal topographer, which makes corneal
topography an essential component in OK lens tting (Maldo-
nado-Codina et al., 2005).
Modern corneal topographers o er a unction to subtract
post-lens-wearing maps rom pre-lens-wearing maps to display
a di erence map. T ese maps use colours to determine degree o
change that has occurred rom the baseline map: green indicat-
ing no change, blue indicating areas o attening, and red indi-
cating areas o steepening.
32 O rt ho ke rat o lo g y 301
One o the ollowing patterns may be typically observed
a ter overnight myopic OK lens wear:
Bull’s Eye (O p timal Le ns Fit)
On a tangential map, a good- tting OK lens is indicated by
a central area o ‘blue’ corneal attening surrounded by an
annulus o ‘red’ corneal steepening that is again centred on the
corneal apex (Fig. 32.4A). When viewed as an axial map, the
extent o the central ‘blue’ area de nes the limits o the re rac-
tive treatment e ect (Fig. 32.4B).
Smile y Face (Flat-fitting Le ns)
Flat- tting lenses typically decentre superiorly during closed-
eye wear, which results in a superiorly displaced area o central
attening. T e annulus o paracentral steepening is similarly
displaced, giving the appearance o a smile (Fig. 32.4B).
Ce ntral Island (Ste e p -fitting Le ns)
Steep- tting lenses centre well, but ail to provide uni orm com-
pression at the corneal apex. T e result is a small area o central
corneal steepening surrounded by an annulus o attening, a
central island in what would otherwise have been a bull’s eye
appearance (Fig. 32.4C).
During the tting process, corneal topography is assessed
a er each period o overnight wear. I a smiley ace or central
island is observed then the sag height o the lens is respec-
tively increased or decreased and overnight wear repeated with
the new lens. By ollowing a bracketing process, the lens t is
gradually re ned until a bull’s eye pattern is achieved, at which
point urther alteration can be made to the re ractive target i
required, and the nal lens ordered or dispensing.
LENS DELIVERY
As or all other lens-wearing modalities techniques or lens
insertion, removal and care need to be demonstrated be ore the
patient takes the lenses, ideally accompanied by printed explana-
tory documents (Cho et al., 2008). Lens insertion is the same as
or standard RGPs (see Chapter 15), with the same instruction
needed on how to recentre a decentred lens. Many practitioners
also recommend instilling a viscous lubricating drop onto the
back sur ace o the lens be ore insertion, making sure to avoid any
trapped air bubbles in the solution. Removal techniques are also
the same as or standard corneal RGPs, except that the patient
needs to ensure that the lens is ully mobile and not bound be ore
attempting removal. A simple way to ensure lens mobility is to
have the patient instill a liquid lubricant drop and nudge the in e-
rior lens edge several times by pushing up on the lower eyelid.
T e lens can then be removed ollowing the standard method.
Any o the available RGP cleaning and conditioning solu-
tion combinations can be used or OK lenses. Due to the
overnight-wearing modality, particular emphasis needs to
be given to advice on avoiding tap water to reduce risk o
Acanthamoeba in ection, and lens cases should be replaced
requently to reduce microbial contamination (Wu et al.,
2010a). On lens insertion the case should be cleaned by rins-
ing out with resh conditioning solution, le t open to air dry
and ace down on a clean towel or tissue (Wu et al., 2010b)
during lens wear periods. he reverse-geometry design o
OK lenses creates areas that can be di icult to clean using
normal rub and rinse methods and are prone to deposit
302 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
Fig . 32.4 Post-ove rnig ht we ar corne al top og rap hy d i e re nce map s o an id e al ‘b ull’s e ye ’ d isp laye d in tang e ntial (A) and axial (B) ormat; at f tting
axial ormat ‘smile y ace ’ (C); and tig ht f tting axial ormat ‘ce ntral island ’ (D). Re d are as ind icate corne al ste e p e ning , b lue are as corne al atte ning and
g re e n are as no chang e .
build-up that can inter ere with the OK e ect. Regular use
o a deposit removal solution, such as Menicon Progent, can
help to prevent this problem rom occurring.
Aft e rcare
As is the case or all contact lenses, routine and comprehen-
sive a ercare examination is essential. In the case o OK there
are obvious di erences in wearing patterns compared with
daily-wear rigid contact lenses; however, no additional skills
are required other than pro ciency in corneal topography
assessment.
VISIT SCHEDULE
Because changes to corneal curvature are induced to provide
vision correction the a tercare visit schedule is typically more
requent than or daily-wear RGPs. Once a lens has been dis-
pensed the patient needs to be ollowed closely to veri y sta-
bility o re ractive e ect. ypically these visits should occur
at increasing intervals starting at 1 week, then 1, 3 and 6
months a ter lens dispensing. A tercare visits at 6-monthly
intervals therea ter has been recommended by Cho et al.
(2008). Visits should be scheduled as early as possible in
the morning so that the maximum e ect rom overnight
wear can be observed; however, it is use ul to have at least
one visit rom later in the day to assess daytime regression
o e ect.
ASSESSMENT O F LENS FIT
Lens t is assessed through observation o changes to corneal
topography rather than direct observation o the lens on-eye.
In act, once a success ul lens t is established there is little to

gain rom assessing the lens on-eye. Corneal topography needs
to be captured and a di erence map created against the original
baseline map. Fit is gauged by visual interpretation in the same
manner as described or lens tting. It is also use ul to compare
di erence maps created at earlier visits to assess or any changes
in OK e ect over time (Nichols et al., 2000).
REFRACTIO N
Unless it is later in the day, or a er a break rom lens wear, where
regression o e ect becomes suf cient to cause some undercor-
rection, patients will attend with ully corrected vision. T e
correct balance o re ractive change will vary across di erent
patients depending on how responsive they are to OK and how
quickly the e ect regresses during the day. As already discussed,
caution needs to be given to autore ractor results, which tend to
overestimate re ractive error a er OK owing to sampling areas
outside o the central treatment zone.
In most cases, a mild overcorrection o 0.50 to 0.75 D is
expected at lens removal, which o ers a cushion to absorb day-
time regression; however, in some patients regression is less o
an issue, allowing an alternative-night-wearing schedule to be
adopted, or even greater periods between lens wear. In general,
as long as t is ideal, an increase or decrease in re ractive e ect
is achieved by respectively attening or decreasing the base
curve o the lens.
O CULAR HEALTH
Anterior eye health needs to be assessed and monitored as usual
or RGP lens wear, but with particular attention to actors perti-
nent to overnight lens wear. Myopic OK lenses are designed to
create a at- tting optic zone, which makes them prone to bind-
ing during overnight wear. T is can lead to mild central corneal
abrasion detected by sodium uorescein staining, and in some
cases suf cient to cause epithelial erosion, particularly i a rub-
ber contact lens remover is used. T ese problems can usually be
resolved by instilling an ocular lubricant on waking and gently
nudging the lens in erior edge with nger pressure on the eyelids.
Myo p ia Co nt ro l w it h O K
Since the early use o rigid contact lenses, there have been
attempts not only to correct myopia optically but also to inhibit
the progression o myopia in children. Evidence or this e ect
has been controversial. More recently, the ef cacy o overnight
OK lens wear in inhibiting myopia progression in children has
been postulated.
WHAT THE RESEARCH SHO WS
Cho et al. (2005) were the rst to present evidence that overnight
use o OK lenses in children not only temporarily corrects myo-
pia but also restricts axial length elongation compared with an
historical spectacle-wearing control group. T ey acknowledged
that their study su ered rom similar drawbacks to early OK
studies, such as absence o appropriate control patients. Wal-
line et al. (2009), using a similar study design, instead compared
children wearing OK lenses with an historical so -contact-lens-
wearing group to nd similar outcomes.
Studies using more robust protocols and stronger controls
have since been published. Kakita et al. (2011) compared 42
32 O rt ho ke rat o lo g y 303
children wearing OK lenses with 50 children wearing spec-
tacles ollowed over a 2-year period. Axial length and myopia
increased in both groups, with 36% less o an increase in OK
compared with the spectacle wearers. A similar study design,
which was randomized and single masked with spectacle-
wearing controls, was completed by Cho and Cheung (2011)
to report a 42% reduction in axial elongation over 2 years.
Santodomingo et al. (2012) ound 32% less axial elongation
over 2 years, and Hiraoka et al. (2012) determined a 30%
control e ect over 5 years. Charm and Cho (2013) corrected
4 D o myopia with OK in children with −5.75 D or more
spherical equivalent re raction, with single-vision spectacles
correcting residual re ractive error. In comparison with sin-
gle-vision spectacle-wearing controls, the partial-OK treat-
ment group showed a 63% reduction in axial elongation over
2 years. A cross-over study per ormed or a total o 1 year
compared RGP daily wear in one eye with OK overnight wear
in the other eye o paediatric subjects, and reported no axial
growth in OK-wearing eyes over each 6-month study period.
(Swarbrick et al., 2015).
he overall consensus rom the research is that OK slows
progression o myopia to a certain extent; however, the vari-
ability in reported outcomes suggests that there are dis-
crepancies in response between individual subject cohorts.
Indeed, in their cross-over study, which reported signi i-
cantly less axial elongation in OK-wearing compared with
RGP-lens-wearing eyes in both 6-month phases o the study,
Swarbrick et al. (2015) reported that some individual sub-
jects showed no axial length growth, whereas others showed
strong axial growth with OK lens wear.
MECHANISMS FO R O K CO NTRO LLING
MYO PIA PRO GRESSIO N
When considering possible mechanisms or a myopia-control-
ling e ect, separate studies have shown that myopic OK induces
a positive shi to the spherical aberration o the eye (Joslin
et al., 2003; Hiraoka et al., 2005; Gi ord et al., 2013) and alters
the shape o the image shell that is ormed at the retina (Kang
and Swarbrick, 2011).
Studies in chicks and primates have shown that the shape
o the retinal image shell is in luential in axial elongation,
with hyperopic de ocus (image ocus posterior to the retina)
causing increase in axial length, and myopic de ocus (image
ocused anterior to the retina) inhibiting axial eye growth
(Fig. 32.5). Charman et al. (2006) were the irst to report that
OK induces a myopic shi t in peripheral re raction relative
to macular ocus. By itting children with OK lenses in one
eye and traditional rigid gas-permeable lenses (RGP) in the
ellow eye over 3 months, Kang and Swarbrick (2011) con-
irmed the inding o relative peripheral myopic de ocus in
OK-lens-wearing eyes. he ellow RGP-lens-wearing eyes
showed no change to peripheral re raction and exhibited
peripheral hyperopic de ocus as was shown at baseline prior
to lens wear. It appears that OK provides the same peripheral
image ormation that has been shown to inhibit eye growth
in animal models, while ‘standard’ contact lenses instead
leave the eye in a less- avourable state o peripheral hyper-
opic de ocus.
It has also been speculated that OK-induced changes to
spherical aberration could be responsible or the myopia-
controlling e ect. arrant et al. (2009) reported an increase
304 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
Fig . 32.5 Mod e l o re lative hyp e rop ic and myop ic p e rip he ral re rac-
tion imag e p rof le s.
in positive spherical aberration rom OK and coincidentally
ound improvement in image quality, measured as point spread
unction, at a range o near-accommodative targets. Although
they did not measure accommodative lag directly, the authors
speculated that their results were consistent with OK-induced
changes to spherical aberration resulting in a reduction to
accommodative lag, which would have the e ect o shi ting
the whole retinal image shell in a avourable myopic direction.
Gi ord et al. (2013) simultaneously captured corneal
and ocular aberrations a ter myopic OK lens wear to ind
increases to positive spherical aberration in both measure-
ments; however, over time there was less change to ocular
compared with corneal spherical aberration over time. he
authors suggested that the same accommodative response
reported by arrant et al. (2009) could explain the di erence
in e ect.
As much as the mechanism or a myopia-controlling e ect
is not ully known, the longevity o e ect also remains to be
ully understood. In a recent study, Swarbrick et al. (2015) t-
ted children with daily wear RGP lenses or 6 months wear in
one eye during the day, and overnight OK lenses in the ellow
eye. T ey then discontinued wear or 2 weeks to regress the OK
e ect and then wear was continued except that the lens-wearing
pattern was swapped between eyes. Increases in axial eye length
with the eyes wearing RGP lenses were reported, while the el-
low eyes wearing OK showed no increase. When the lens types
were swapped a er 6 months the e ect was ound to ollow the
lens. However, the authors ound that there was an apparent
acceleration in eye growth rebound e ect a er the OK-lens-
wearing eyes were swapped at the 6-month period to wearing
RGP lenses.
he apparent rebound e ect reported by Swarbrick et al.
(2015) led the authors to suggest that 6 months OK wear is
insu icient or stable myopia control, but raises the question
on the necessary required period o OK wear to achieve sta-
bilization and avoid rebound e ects. Similarly the question
on how long OK is e ective at slowing progression o myo-
pia is poorly understood, although there is some in ormation
available on the subject. Johnson (2010), using cumulative
clinical data or 62 paediatric OK wearers o at least 18
months duration, demonstrated that progression in myopic
re raction became clinically relevant (change o −0.25 D)
only a ter 42 months o OK lens wear. Hiraoka et al. (2012)
ound that the annual increases in axial length were signi i-
cantly di erent between the OK-lens and spectacle-wearing
control groups or the irst, second and third years but not
the ourth or i th years o wear.
Whatever the mechanism, research provides compelling
evidence that OK is in uential in slowing progression o myo-
pia; however, urther research is needed to elucidate the exact
mechanisms and also whether OK lens designs can be altered
to better enhance the myopia controlling e ect they have been
shown to provide. Further in ormation on myopia control and
alternative mechanisms or providing a myopia control e ect
are covered in Chapter 33.
Co nclusio n
OK has come a long way in recent years, and is gaining
increased global popularity, particularly as a clinical modality
to slow progression o myopia. Due to its reliance on measure-
ment o corneal topography, OK still remains a niche modal-
ity practised mainly by practitioners who t specialty contact
lenses. However, evidenced through increased attendance at
OK con erences around the world, and interest in the clini-
cal press, it is clear that an increasing number o practitioners
are becoming involved with OK. T e reason or this increased
interest in practitioners and patients alike is not hard to elu-
cidate, given that OK is one o the only orms o re ractive
correction that has been shown to slow progression o myopia
signi cantly. How this develops into the uture remains to be
seen, but or now there is a considerable body o knowledge
to support OK as a sa e technique to adopt in contact lens
practice.
Many studies have shown that OK is e ective in modi y-
ing re ractive error. he treatment e ect, however, is tran-
sient and requires continued overnight wear to maintain,
though some patients manage to regularly skip a night or two
o wear and still maintain an acceptable level o re ractive
correction. When correctly itted, modern reverse-geome-
try lenses are reliable in correcting up to around −4.50 D o
myopia with no more than 1.50 D o with-the-rule corneal
toricity. Improvements to lens designs have simpli ied lens
itting to help overcome the problems o predictability that
were reported in earlier studies. Some manu acturers report
success in correcting higher degrees o myopia and astig-
matism; however, there is currently no scienti ic evidence
to support these claims, so patients should be cautioned
that outcomes are less reliable when attempting higher cor-
rections. he same applies to OK correction o hyperopia
and presbyopia, which, although proven as possible, have
been shown to be reliable only in correcting low re ractive
errors.
When considering sa ety, in general, wearing OK lenses
brings similar risks as wearing any other orm o contact
lenses. However, in common with all orms o contact lenses,
overnight wear brings with it the increased risk o kera-
titis (Morgan et al., 2005; Watt and Swarbrick, 2007). It is
possible that the OK-induced changes to corneal epithelial
pro ile and corneal nerve ibres could urther increase the
risk o complications rom overnight lens wear; however,
the current limited clinical evidence suggests that this is

not the case. It is apparent rom many o the reported cases
o MK in OK that the lenses coming into contact with tap
water is a high-risk actor or in ection. As with all orms
o contact lens wear, good hygiene and regular a tercare are
paramount in ensuring sa e wear o OK lenses; but also, in
particular with OK, patients should be constantly reminded
to avoid tap water contamination so as to ensure sa e OK lens
wear.
32 O rt ho ke rat o lo g y 305
ACKNO WLEDGEMENT
Leo Carney or writing the previously published editions o this chap-
ter, which provided the oundation or this current edition.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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33
Myo p ia Co nt ro l
PADMAJA SANKARIDURG | BRIEN A HO LDEN
Int ro d uct io n
Recent years have seen an surge in interest or solutions to con-
trol the progression o myopia uelled by evidence indicating (a)
a rising prevalence o myopia all over the world and especially
many East Asian countries, which have a prevalence o 70% or
over in 17-year-old teenagers (Lee et al., 2015; Wu et al., 2015)
and (b) a concurrent increase in the number o high myopes
(≥−5.00 D). High myopia is associated with the risk o sight-
threatening complications such as myopic macular degenera-
tion, retinal detachment and glaucoma (Vitale et al., 2009; Chen
et al., 2012; Sun et al., 2012; Le et al., 2013; Koh et al., 2014;
You et al., 2014). Myopic macular degeneration has been identi-
ed to be a major cause o blindness in studies rom Japan and
aiwan (Hsu et al., 2004; Iwase et al., 2006). With an estimated
1.5 billion people considered to be a ected, myopia is the most
important cause o distance visual impairment and is associated
with signi cant health and socioeconomic burden.
A model projecting uture prevalence rates or myopia, high
myopia and myopic retinopathy based on current prevalence
rates has suggested that myopic retinopathy is likely to be a lead-
ing cause o vision loss by 2050 (Holden et al., 2016). Clearly, it
is desirable to reduce: (a) the number o eyes reaching high lev-
els o myopia to prevent or decrease the risk o myopia-related
sight-threatening complications, (b) the burden associated with
progressing myopia (e.g. less requent change o optical devices)
and (c) vision impairment due to uncorrected myopia. Currently,
myopia management mostly involves correction with spectacles
and contact lenses and to a lesser extent with re ractive surgery
and orthokeratology. T ese approaches correct or the re ractive
error and eliminate blurred vision at distance but, with the excep-
tion o orthokeratology and possibly re ractive surgery, do not
arrest or slow the axial length increase that leads to progression.
Is it possible to stem the rising burden by controlling or slow-
ing eye growth? Myopia is believed to be a complex condition
with both genetic and environmental actors playing a role in
its onset and progression. Although the role o the many ac-
tors and their interactions are not ully understood, ortunately
research evidence has been accumulating, indicating that it is
well within the reach o the practitioner to slow the progress o
myopia.
In this regard, there is compelling evidence rom animal
studies to demonstrate that environmental actors such as orm
deprivation and optical de ocus can be used to manipulate pre-
dictably the development and progression o re ractive errors.
In late 1970s, Wiesel and Raviola sutured the lids o monkeys
to induce orm deprivation and showed that it results in axial
elongation and consequently myopia (Wiesel and Raviola, 1977).
Later experiments that blocked / restricted light to certain elds
o the eye and varied ambient illumination showed that myopia
could be induced in experimental animal models (Wallman et al.,
306
1987). Also, signi cantly, experiments demonstrated that optical
de ocus (plus and minus lenses creating myopic and hyperopic
de ocus) could be used to alter eye growth in a highly regulated
manner involving both direction and magnitude (Diether and
Schae el, 1997; Schae el et al., 1988; Smith et al., 2013).
In addition, over the years there have been a number o anec-
dotal reports, strategies and interventions trialled in humans
with various optical and pharmaceutical approaches that show
that it is easible to slow the progress o myopia. For example, a
number o spectacle interventions involving bi ocal and multi-
ocal spectacle lenses provide evidence that it is easible to con-
trol its progression (Gwiazda, 2009; Cheng et al., 2014; Leung
and Brown, 1999).
Contact lenses clearly have a role to play. As early as the
1970s, it was suggested that rigid contact lenses could play a role
in slowing the progression o myopia by either processes related
to corneal attening or other unknown mechanisms. More
recently, a number o novel contact lens designs were assessed
in clinical trials or their e cacy in slowing the progression o
myopia and ound to have varying levels o success. Overnight
orthokeratology, used to eliminate myopia temporarily, was also
ound to slow the progress o myopia (Cheung et al., 2004). T is
chapter reviews the various contact lens approaches that have
been trialled to date and also discusses a tting and manage-
ment strategy. Methods o myopia control by tting and reshap-
ing the cornea with orthokeratology lenses are presented in
detail in Chapter 32.
Pat ie nt Se le ct io n and Risk Fact o rs
T ere is no clear in ormation on when myopia ceases to prog-
ress. Some studies report that myopia stabilizes in the late teens,
but there is also in ormation indicating that, in certain eyes,
myopia continues to progress, albeit slowly, even af er the teen-
age years and even in young adults rom their twenties and well
into their thirties (Lv and Zhang, 2013). In addition, there exist
data showing that onset o myopia can also occur in the early to
late twenties, especially during the university years (Kinge and
Midel art, 1999).
T us, provided that there is no contraindication to contact
lens wear, and the lens provides good, or acceptable, vision at
all distances, any individual with myopia is a candidate or a
myopia control contact lens. However, some myopes (e.g. young
children) show greater progression compared with others and
there ore it is essential to understand and identi y the ‘at-risk’
group or aster progression to ensure better outcomes.
Evidence indicates that the younger the onset o myopia,
the greater is the risk o progression o myopia (Donovan et al.,
2012; Sankaridurg and Holden, 2014). Fig. 33.1 provides an esti-
mated progression model or spherical equivalent (SE) re rac-
tive error or Asian children with myopia derived rom 633

Fig . 33.1 Prog re ssion mod e l for sp he rical e q uivale nt re fractive e rror
for Asian child re n with myop ia.
children aged 7–15 years and wearing single-vision spectacles.
T ese data indicate that younger children have a higher rate o
progression compared with older children, with progression
decreasing with each passing year. T us a child with onset o
myopia at 7 or 8 years may reach higher levels o myopia much
earlier than a child with onset o myopia at 12 years. o limit
the rise in prevalence o high myopia, (i.e. myopia o −5.00 D or
more), one needs to consider managing children with myopia,
especially those that are less than 9 years o age, with an appro-
priate myopia control strategy.
Other than age, ethnicity and parental myopia have also been
ound to increase the risk o progression o myopia. Children o
Asian descent show a greater shif towards a more myopic spheri-
cal equivalent re ractive error compared with predominantly Euro-
pean or Caucasian children (Donovan et al., 2012; French et al.,
2013a, b). For a child with myopia with an estimated mean age o
9.3 years, the predicted annual progression was −0.82 D / year or
children o Asian descent and −0.55 D / year or children o Euro-
pean descent (Donovan et al., 2012).
In a group o non-myopic children, grouped by parental
history o myopia, those with two parents who were myopic
showed a more myopic shif in re raction over 1 year compared
with those with only one myopic parent or no myopic parents
(Lam et al., 2008). Other studies have also ound that paren-
tal myopia was a signi cant risk actor, with adjusted analyses
showing myopic children with two myopic parents progress-
ing aster compared with those with only one myopic parent
or those with no parental myopia (Kurtz et al., 2007; Loh et al.,
2015). Although parental myopia is generally considered to be
a risk actor or both development and progression o myopia,
its role in progression is not clear, with the ew studies ailing to
demonstrate an e ect o parental myopia on development and
progression (Edwards, 1998; Yang et al., 2009).
In addition to the above-mentioned risk actors, gender, out-
door / indoor time and peripheral re ractive errors are also con-
sidered to have a role in the progression o myopia.
A number o studies have reported the prevalence o myopia
to be higher in emales than in males (You et al., 2012; Wu et al.,
2013) but others ailed to nd such an association (Chen et al.,
2013; Guo et al., 2013). Faster progression was also reported in
emales (Liao et al., 2014). Based on a meta-analysis o progres-
sion data rom spectacle wearers, Donovan et al. (2012) reported
that, or a baseline age o 8.8 years, estimated annual progression
was −0.80 D / year or emales and −0.71 D / year or males (Don-
ovan et al., 2012). T e reasons or this higher progression rate in
emales are not understood, but it is suggested that girls may have
33 Myo p ia Co nt ro l 307
a more myopiagenic activity pattern (increased near work and
less outdoor time) compared with boys (French et al., 2013a).
Indoor / outdoor time is seen to be associated with both
onset and progression o myopia. Factors such as being indoors,
excessive near work and not looking at distant targets have long
been held to be myopiagenic. Also, groups such as young school
age children, university graduates, occupations requiring close-
and near-work activities such as microscopy are considered to
be at higher risk o progression (McBrien and Adams, 1997;
ing et al., 2004). Whereas some studies ound protective asso-
ciations or time outdoors reducing the risk o myopia, others
have not ound such an association (Rose et al., 2008; Jones-
Jordan et al., 2012). However, a prospective, randomized clini-
cal trial ound that 80 minutes o outdoor time during school
recess each day or a year reduced the incidence o new myo-
pia by nearly 50% and also slowed the progress o myopia (Wu
et al., 2013).
De ocus at the peripheral retina is said to contribute to pro-
gression with those with hyperopic de ocus at the periphery at
greater risk (Hoogerheide et al., 1971; Mutti et al., 2007). Rela-
tive peripheral hyperopia is commonly ound in myopic eyes
(Atchison et al., 2006; Lin et al., 2010) and is possibly or weakly
linked to progression (Kang et al., 2012; Radhakrishnan et al.,
2013) or with less central myopia progression (Berntsen et al.,
2013). In addition to the above actors, it has been suggested
that near phorias, especially esophoria (Goss and Rainey, 1999;
Gwiazda et al., 2004), eso xation disparity, high accommoda-
tive convergence / accommodation (AC / A) ratio (Price et al.,
2013) and lag o accommodation (Gwiazda et al., 2004; Price
et al., 2013) have a role to play, but other studies have not ound
any correlation between lag and progression (Mutti et al., 2006;
Weizhong et al., 2008; Berntsen et al., 2011).
Fig. 33.2 depicts the Brien Holden Vision Institute (BHVI)
scorecard based on the well-established risk actors o age,
parental myopia and outdoor time or evaluating the risk o
progression. T e scorecard provides a guideline or the practi-
tioner to categorize individuals based on the risk pro le so that
management with a suitable approach and ollow-up visits can
be tailored to the individual.
Typ e s o f Co nt act Le nse s
Over the years, a number o optical strategies using contact
lenses have been assessed or their e cacy in controlling the
progression o myopia. T is section reviews the various strate-
gies and the results. A summary is presented in able 33.1.
SINGLE-VISIO N RIGID LENSES
Clinical studies rom the 1990s reported that daytime lens wear
with single-vision rigid contact lenses (as opposed to ortho-
keratology lenses, which are discussed in Chapter 32) showed
less progression compared with matched spectacle lens wearers.
Some corneal attening was ound with rigid lens wearers, but
the authors concluded that the re ractive power change attrib-
uted to corneal attening could not ully explain the signi cant
di erence in progression between the rigid lens wearers and
the spectacle lens wearers (Grosvenor et al., 1991). However,
this nding was not supported by evidence rom randomized
clinical trials. In a study involving 564 children randomized to
either rigid lenses or spectacles, at the end o 24 months there
was no di erence in the progression o myopia in those wearing
308 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns

Fig . 33.2 The Brie n Hold e n Vision Institute (BHVI) score card for e valuating risk o f annual p rog re ssion of myop ia.

TABLE
33.1 Summary o f Evid e nce fo r Myo p ia Co nt ro l w it h Co nt act Le nse s
Sig nificant
Pe rce nt Durat io n Diffe re nce Diffe re nce in
Co nt ro l Re d uct io n o f St ud y Be t we e n Dio p t ric Value Evid e nce fo r Myo p ia
Le ns Typ e Aut ho rs Gro up vs Co nt ro l (ye ars) Gro up s (D) Co nt ro l
Rig id contact Katz e t al. Sp e ctacle −4 2 No 0.05 No e vid e nce or myop ia
le ns (2003) control.
Walline e t al. So t contact 29 3 Ye s 0.63 unad - Some chang e b ut not
(2004) le ns juste d sub stantiate d b y axial
g rowth p atte rns
So t contact Horne r e t al. Sp e ctacle −18 3 No 0.18 No e vid e nce or myop ia
le ns (1999) control.
Walline e t al. Sp e ctacle −17 3 No 0.22 ad juste d , Prog re ssion may b e in-
(2008) 0.19 unad - ue nce d b y mate rial,
juste d mod e o le ns we ar
and le ns p owe r p rof le
Bi ocal Walline e t al. So t contact 50 2 Ye s 0.50 ad juste d Slow p rog re ss o
contact (2013) le ns myop ia.
le nse s Alle r & Wild soe t So t contact 72 1 Ye s 0.56 unad -
(2006) le ns juste d
Pe rip he ral Hold e n e t al. So t contact 39 43 months Ye s 0.64 unad - Slow p rog re ss o myop ia
d e ocus (2012) le ns juste d
manag e - Sankarid urg Sp e ctacle 34 1 Ye s 0.29 ad juste d
me nt e t al. (2011)
Simultane ous Lam e t al. So t contact 25 2 Ye s 0.20 unad - Slow p rog re ss o myop ia
Dual ocus (2014) le ns juste d
Anstice & Phillips So t contact 37 10 months Ye s 0.25
(2011) le ns

rigid lenses compared with those wearing spectacles (Katz et al.,
2003). In a later 3-year trial where children were randomized
to either rigid or sof lenses, there was a signi cant di erence
in the rate o progression, with rigid lenses having a slower rate
(spherical equivalent −1.56 ± 0.95 D) versus −2.19 ± 0.89 D with
sof lenses (Walline et al., 2004). However, the reduction in rate
o change in myopia was not re ected in the axial length change
between the groups. It was indicated that in part this may have
been due to the corneal attening that occurred with the rigid
lenses.
SINGLE-VISIO N SO FT LENSES
Data rom prospective, clinical trials do not show a di erence in
the rate o progression o myopia with single-vision sof contact
lenses compared with spectacles. In one randomized trial con-
ducted or 3 years, in adolescents aged 11–14, no signi cant di -
erence was ound in the spherical equivalent change in myopia
between spectacle lens wear versus contact lens wear (Horner
et al., 1999). Similarly, a later large-scale, randomized clinical trial
involving children aged 8–11 years with myopia randomized to
either spectacles or sof contact lenses (1-Day Acuvue or Acuvue
2, Vistakon, Jacksonville, Florida) ound no signi cant di erence
in the rate o progression o myopia between the two groups. T e
adjusted di erence between the groups was −0.22 D, with slightly
higher progression or contact lens wearers (Walline et al., 2008).
However, while the above-mentioned studies do not show that
sof contact lenses in uence myopia progression, their role can-
not be conclusively ruled out as actors such as lens material, t
and power pro le have been indicated or have been ound to
in uence myopia.
Le ns Mate rial and O xyg e n Transmissib ility
Studies comparing low Dk / t and high Dk / t lenses on an
extended-wear basis have consistently observed an increase in
myopia in eyes wearing low Dk / t lenses and this was attributed

to the hypoxic state, with the low Dk / t lenses leading to corneal
hypoxia and swelling, which resulted in an increase in myopia
(Dumbleton et al., 1999; Blacker et al., 2009; Jalbert et al., 2004).
In a 9-month study, eyes in the extended-wear low Dk / t group
demonstrated an increase in myopia o −0.30 D in 9 months,
compared with no change in the eyes wearing silicone hydrogels
or up to 30 nights (Dumbleton et al., 1999). T e phenomenon
was recognized with the term ‘myopic creep’. No such phenom-
enon was observed during daily wear o lenses.
Le ns Profile
More recently, it was observed that the power pro les across the
optic zones o commercially available sof contact lenses vary
greatly (Wagner et al., 2015). Many lenses showed an increas-
ing minus power or negative spherical aberration towards the
periphery o the optical zone. T e power distribution or the lens
pro le is said to a ect the peripheral re raction and possibly the
growth o the eye (Shen et al., 2010; Kwok et al., 2012).
Practitioners need to be aware o the potential in uence o
lens material, mode o lens wear and the optical pro le o the
lens on myopia progression and make an in ormed decision on
a lens type that they deem is suitable or a given eye.
BIFO CAL / MULTIFO CAL LENSES
Data rom case reports, cross-over studies and comparative
group longitudinal studies support the use o bi ocal / multi o-
cal contact lenses to slow the progression o myopia. T e lens
that eatures commonly is a centre-distance, concentric design,
simultaneous vision bi ocal with an add power o +1.50 D to
+2.00 D. A number o mechanisms have been proposed to
explain the myopia control e ect o bi ocals and they include:
(a) bi ocals serve to correct the accommodative lag, which is
considered to be a stimulus or eye elongation; (b) bi ocals serve
to alter the peripheral retinal image orwards, as peripheral reti-
nal hyperopia is considered a risk actor or progression; and
(c) bi ocals impose sustained myopic de ocus across the retina,
which is considered to be inhibitory or eye growth.
In a case study (Aller and Wildsoet, 2008) o 12-year-old iden-
tical twins with myopia, each o the twins were randomly tted
with single-vision contact lenses or bi ocal contact lenses and
ollowed or 2 years. At approximately 13 months, the twin t-
ted with the bi ocal contact lens showed a 0.13 D reduction in
myopia, compared with an increase in myopia o 1.19 D in the
twin tted with single-vision contact lenses. In the second year,
the twin tted with the bi ocal contact lens showed progression
o −0.28 D. T e twin with the single-vision contact lens was
switched to a bi ocal contact lens and then showed a reduction
in myopia o 0.44 D. T e bi ocal lens was said to be a multizone
simultaneous vision design and speci cally a distance centre with
alternating near and distance zones and an add power o +2.00 D.
Howell (2008) reported on a series o children who were ini-
tially tted with multi ocal spectacle lenses in year 1 and then
switched to a centre-distance multi ocal lens design o +1.50 D
add in year 2. T e rate o progression with the multi ocal contact
lenses was said to be slowed by nearly 68% (−0.56 ± 0.17 D in year
1, versus −0.18 ± 0.23 D in year 2). Although promising, it is not
clear whether the result was adjusted or progression with age.
More recently, myopic eyes tted with a centre-distance
bi ocal contact lens showed 50% less progression or spheri-
cal equivalent re ractive error (−1.03 ± 0.06 D or single-vision
contact lens wearers and −0.51 ± 0.06 or the sof multi ocal lens
33 Myo p ia Co nt ro l 309
wearers) and a 29% reduction in axial length during a 2-year
treatment period, compared with a group tted with single-
vision contact lenses. T e bi ocal lens was a centre-distance bi o-
cal contact lens (Proclear Multi ocal, CooperVision, Fairport,
NY) with an add power o +2.00 D. T e authors concluded that
the treatment e ect, the e ect seen with these lenses, supported
the results reported with bi ocal contact lenses, simultaneous
dual- ocus lenses and lenses designed to control peripheral
hyperopia (Walline et al., 2013). In yet another randomized
clinical trial, 86 myopic children aged 8–18 years were ran-
domized to wear either an Acuvue single-vision or an Acuvue
bi ocal contact lens (Vistakon, Jacksonsville, FL); af er a year o
lens wear, there was a 72% reduction in cycloplegic spherical
equivalent (−0.78 ± 0.45D with single vision and −0.22 ± 0.34D
with bi ocals) and a 79% reduction in axial length (Aller and
Wilssoet, 2006). T e study utilized our di erent add powers
selected or each individual based on their associated esophoria
at near (Personal communication, Dr T omas Aller, CA).
SIMULTANEO US DEFO CUS O R DUAL-FO CUS
LENSES
As stated in the previous section, a lens that induces simultaneous
myopic de ocus across parts o the retina whilst maintaining a
simultaneous clear image to maintain good vision is said to slow
the progress o myopia (Anstice and Phillips, 2011). In marmo-
sets, imposing negative (hyperopic) and positive (myopic) de ocus
using concentric contact lenses resulted in less eye growth in eyes
with such multizone lenses compared with eyes wearing single-
vision control lenses (Benavente-Perez et al., 2012).
In a 20-month, contralateral, cross-over clinical trial involv-
ing 40 children, eyes randomized to the dual- ocus lens or the
rst 10 months showed a 37% decrease in progression o myopia
with respect to spherical equivalent and axial length progres-
sion decreased by 49%. In the second 10 months, eyes that wore
the dual- ocus lenses showed less progression compared with
the eyes wearing single-vision lenses (Anstice, 2009; Anstice
and Phillips, 2011). In a more recent clinical trial, concentric
alternating distance correcting and de ocusing zones that were
said to provide simultaneous myopic de ocus at the retina were
assessed in a randomized, double-masked study conducted or
2 years. Over the 2 years, the groups wearing the simultane-
ous de ocus lenses showed 25% less progression o myopia or
spherical equivalent (0.59 ± 0.49 D with de ocus incorporated
lenses and 0.79 ± 0.56 D or single-vision lenses) and 32% less
progression in axial length compared with the group wearing
single-vision lenses (Lam et al., 2014).
A commercially available contact lens, MiSight®(Coopervision,
Pleasantville, CA), is available or myopia control. Publications
relating to MiSight®re er to the dual- ocus contact lens tested in the
DIMENZ trial (Anstice, 2009) and there ore the lens design may
have its origin in that dual- ocus contact lens. T e MiSight®lens is
available in a limited number o countries as a daily disposable con-
tact lens (see http://coopervision.com.my/contact-lenses/misight)
and has a treatment zone power o +2.00 D that appears as concen-
tric rings (Fig. 33.3) (Kollbaum et al., 2013).
LENSES THAT MANAGE PERIPHERAL
HYPERO PIC RETINAL DEFO CUS
Contact lenses designed to reduce peripheral hyperopic de ocus
have been shown to slow the progress o myopia. Myopic eyes,
310 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
both in an uncorrected state and when corrected with conven-
tional optical approaches, demonstrate relative hyperopia at
the periphery relative to centre (Atchison et al., 2006) and, in
animal models, peripheral hyperopia was seen to lead to axial
myopia (Smith et al., 2009).
reatment contact lenses with a clear central zone and a rela-
tively positive power in the periphery (+1.00 D at 2 mm semi-
chord and +2.00 D at the edge o the treatment zone o 9 mm)
aimed at reducing peripheral hyperopic de ocus were assessed
prospectively in a clinical trial involving children with myopia
and compared with children wearing single-vision spectacle
lenses. A schematic diagram is given in Fig. 33.4. At the end o
1 year, eyes wearing lenses that were designed to reduce de ocus
and / or create myopic de ocus at the retinal periphery slowed
progression o myopia by 34% or spherical equivalent re rac-
tive error (−0.86 D with spectacles versus −0.57 D or contact
lenses) and 33% or axial length (Sankaridurg et al., 2011). In
another study, children with myopia and aged 8–14 years were
randomized to a test lens designed to reduce peripheral de ocus
(clear central zone to correct or distance and a relative posi-
tive power o +1.50 D in periphery) or a single-vision sof con-
tact lens or 43 months. At the end o 43 months, progression
was 39% less or spherical equivalent (−0.99 ± 0.58 D, with the
test lens compared with 1.63 ± 0.66 D with the control group)
and 41% less or axial elongation (Holden et al., 2012). Also,
the leading hypothesis or the slowing in eye growth seen with
orthokeratology lenses attributes the e ect to correction o
peripheral hyperopic de ocus (Kang et al., 2013).
Fig . 33.3 Conce ntric ring s visib le on the MiSig ht ® le ns with the Ho
o p tical q uality analyse r.
Fig . 33.4 Myop ic e ye corre cte d with (A) conve ntional le nse s, and (B) le nse s that corre ct p e rip he ral re tinal d e focus.
In addition to the above-mentioned lenses, there are
a number o other technologies that are currently being
assessed or their e icacy in slowing the progress o myopia
with the use o contact lenses. Only preliminary and limited
data are available at the present time and these are brie ly
described below.
LENSES WITH PO SITIVE SPHERICAL
ABERRATIO N
Contact lenses that incorporated two levels o positive spheri-
cal aberration were examined or their e cacy in slowing the
progression o myopia compared with two control groups
wearing spherical sof contact lenses or spectacle lenses in a
randomized controlled trial involving 466 children with myo-
pia. T e study was conducted or 2 years and it was said that
the e ect o treatment in controlling axial elongation was
greater in the lens with higher spherical aberration. Positive
spherical aberration is said to have the potential to slow myo-
pia progression by slowing the axial growth o the eye (Cheng
and Brennan, 2013)
LENSES WITH AN EXTENDED DEPTH O F FO CUS
In an ongoing clinical trial involving children with myopia,
specially designed sof contact lenses with an extended range
o ocus that corresponded to near, distance and ar distances
were able to slow the progression o myopia by nearly 50% at
6 months. wo lens designs are currently under investigation.
T e contact lenses are considered to slow the progress o myo-
pia by (a) the slope o the retinal image quality degrading or
points beyond the ar ocus and thus reducing the incentive or
the eye to grow in that direction and (b) creating simultaneous
myopic de ocus across a large section o the retina (Bakaraju
et al., 2015).
Fit t ing a Myo p e w it h Co nt act Le nse s
It is without doubt that specially designed contact lenses can be
used to control the progression o myopia. However, approach-
ing a young myope, usually a young child, and their carer with
the option o contact lens wear requires that the practitioner
provides a clear list o the bene ts that contact lens wear o ers
over commonly prescribed spectacles. Contact lens wear in
children has been shown to improve quality o li e (Walline
et al., 2007a), with children and teens reporting improvement
in their appearance and participation o activities. Also, young
children have been shown to care and manage lens wear inde-
pendently. More speci cally, with respect to controlling the pro-
gression o myopia, trends indicate that contact lenses may be
 33 Myo p ia Co nt ro l 311

able to deliver a better mean reduction in myopia progression in
comparison with spectacle lenses. able 33.2 summarizes stud-
ies that have demonstrated a mean reduction in progression o
spherical equivalent seen with spectacles designed to control
myopia. Unlike a spectacle lens, where the eye moves indepen-
dently o the spectacle lens, contact lenses are aligned with the
movements o the eye and are likely to deliver the stimulus e ec-
tively. Also, compliance with lenses such as progressive addition
spectacles has been identi ed as a problem, or instance with
children not looking through the specially designed near por-
tion or near viewing.
MEASUREMENTS AND EXAMINATIO N
When considering tting children and young adults with con-
tact lenses, a cycloplegic re raction to determine the amount
o re ractive error accurately is recommended. T ere exists a
number o studies showing that a non-cycloplegic re raction
is inaccurate and unreliable, mostly due to the in uence o
accommodation, and may show a more than normal myopic
re ractive error (Fotedar et al., 2007; Hu et al., 2015) T e errors
that may occur could be two old: (a) a non-myope could be
erroneously classi ed as a myope and (b) a myope could be
categorized as having higher amount o myopia than actually
exists.
he external eye dimensions, especially the radius o cur-
vature o the cornea, show minimal changes rom the age o
7 years (Gordon and Donzis, 1985; Zadnik et al., 2003; Wong
et al., 2010). here ore, children as young as 6–7 years old
can be itted with contact lenses that are currently available
on the market without the need or having specially designed
lenses (Fig. 33.5). Also, modern contact lens technology has
evolved to an extent that there is little need or keratometry
or corneal topography measurements to help with the lens
selection, with the exception o rigid lens itting. However,
where easible it is advisable to take these measurements as
they are use ul in determining corneal toricity, and serve as
a baseline record or evaluation o any uture changes in cor-
neal topography and also or di erential diagnosis o condi-
tions such as keratoconus.
With respect to measurement o peripheral re ractive errors,
it is well documented that myopic eyes experience relative
hyperopia at the peripheral retina in the horizontal merid-
ian (Atchison et al., 2006; Lin et al., 2010). Peripheral re rac-
tive errors have been measured with a number o techniques
including retinoscopy, autore raction, photore raction and
aberrometry. T e most requently used instrument is the Shin
Nippon autore ractor as its open- eld designs allows or rela-
tively easier measurement o peripheral re ractive errors. T ere
have also been specially designed instruments such as the
BHVI Eye Mapper (Fig. 33.6) that enable rapid measurement
o peripheral re ractive errors, but these are presently available
only in research acilities. It is hoped that the lenses designed or
peripheral retinal de ocus management are able to su ciently
reduce hyperopic de ocus and / or induce myopic de ocus across
the majority o myopes without the need to custom measure
and t each individual.
Care ul consideration should be given to the history and
assessment o the ocular health status as conditions such as
allergic conjunctivitis and vernal conjunctivitis are more
requently seen in children and may be exacerbated by lens
wear. Examination o the anterior segment o the eye should
include lid eversion and examination o the upper tarsal
conjunctiva.
In addition, assessment o the ocular health o a myope
should include an assessment o the retina at baseline and at
regular intervals thereaf er. Retinal examination should pre er-
ably be under dilation to rule out or document any peripheral
retinal changes / degeneration that are requently seen in myo-
pic eyes.

TABLE
33.2 Summary o f Evid e nce fo r Myo p ia Co nt ro l w it h Sp e ct acle Le nse s
Pe rce nt Durat io n Sig nificant Diffe re nce in
Co nt ro l Re d uct io n vs o f St ud y Diffe re nce Dio p t ric Value Evid e nce fo r
Le ns Typ e Aut ho rs Gro up Co nt ro l (ye ars) Be t we e n Gro up s (D) Myo p ia Co nt ro l
Prog re ssive Le ung & Brown Sp e ctacle 38 (+1.50 D) 2 Ye s 0.47 Slow p rog re ss o
ad d ition (1999) 46 (+2.00D) 0.57 myop ia
sp e ctacle s Ed ward s e t al. Sp e ctacle 11 2 No 0.14
(2002)
Yang e t al. Sp e ctacle 17 2 Ye s 0.26
(2009)
Gwiazd a e t al. Sp e ctacle 13 3 Ye s 0.20
(2003)
CO MET2 (2011) Sp e ctacle 24 3 Ye s 0.28
Be rntse n e t al. Sp e ctacle 33 1 Ye s 0.18
(2012)
Exe cutive Che ng e t al. Sp e ctacle 42 (+1.50 D) 3 Ye s 0.81 Slow p rog re ss o
Bi ocals (2014) 51 (+1.50 D, 1.05 myop ia
3 Δ BI)
Pe rip he ral Sankarid urg Sp e ctacle 15 (Typ e III) 1 No 0.12 No e vid e nce or
d e ocus e t al. (2010) ove rall g roup
manag e -
me nt
Pe rip he ral d e - Hase b e e t al. Sp e ctacle 14 (+1.00D) 2 No 0.19 Slow p rog re ss
ocus p lus (2014) 20 (+1.50D) 0.27 with hig he r
Prog re ssive ad d
ad d ition

CO MET2 = Corre ction of Myop ia Evaluation Trial 2.

312 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
Fig . 33.5 A we ll-ce ntre d silicone hyd rog e l contact le ns on the e ye of
a child .
LENS SELECTIO N AND FITTING
T e initial selection o the distance power o the lens is ideally
based on the cycloplegic spherical equivalent re ractive error
with appropriate adjustments or vertex distance correction.
T e currently available mypoia-control lens designs are spheri-
cal lenses and can correct only low amounts o astigmatism.
I the individual, or in the case o a child, i the par-
ent / guardian, is motivated to control the progression o
myopia, lenses that have been shown to slow myopia can be
considered. At the present time, MiSight ® is the only com-
mercially available contact lens that is directed towards myo-
pia control, but its availability is restricted to ew countries.
Use o lenses such as bi ocal / multi ocal lenses or myopia
control would be deemed to be o -label and hence consid-
eration should be given to the local regulations with respect
to such use. Also, the situation must be ully explained to the
wearers and / or their carers. he lens material will be either
hydrogel or silicone hydrogel and should be considered or
daily wear, and pre erably lenses will be daily disposables in
younger individuals and children. With respect to the lens
design, with the exception o lenses that extend the depth o
ocus, other lenses have a number o zones, with one or more
zones directed to a power that is the distance power o the
eye and the remaining zones having a relatively plus power
compared with the distance power zones. Where applicable,
it is pre erred that the manu acturer’s guidelines are ollowed
with respect to choosing a lens design that is appropriate or
the need o the individual. In some instances the manu ac-
turer may require the practitioner to choose the appropri-
ate lens power and design based on the risk pro ile o the
individual. However, as many o the lenses are multi ocal
in nature, similar to lens itting in presbyopes, the wearer
may experience luctuations in image quality based on the
zone size, pupil size, illumination levels and object distance;
there ore, the practitioner may have to, in certain situations,
optimize the visual per ormance.
Prior to any adjustments to the lens power based on visual
per ormance, the lens on the eye should be evaluated or t. T e
lens should be well centred with adequate limbal coverage and
minimal movement. Any decentration or excessive movement
Fig . 33.6 The BHVI Eye Map p e r use d for rap id me asure me nt of ce n-
tral and p e rip he ral re fractive e rrors. (Courte sy of Brie n Hold e n Vision
Institute .)
o the lens may result in (a) uctuating vision and / or (b) poor
vision due to induced aberrations.
Once the lens t on-eye has been evaluated, the visual per-
ormance needs to be care ully assessed with a care ul overre-
raction. Although the rst instance o wearing a multi ocal lens
may be unsettling, a vast majority o lens wearers adapt to the
vision rapidly and, there ore, there should be an adaptation time
o approximately 15 minutes or more be ore visual per ormance
is evaluated. It is also advisable to allow the wearer to experience
a range o situations (e.g. walking down a corridor, looking at a
distant view, reading or near tasks) be ore any evaluation is con-
ducted. As a rule, an overre raction should be per ormed using a
trial rame (always recommended in young wearers) rather than
a phoropter, as any vertex distance variations, tilted eye / ace
position behind the phoropter may alter optical per ormance.
Also, or a person behind a phoropter, it is not possible to adopt
the head and eye position that naturally occurs or near tasks
(i.e. head bowed down) and, there ore, there may be additional
variations introduced or near tasks. As with any multi ocal
lens tting, a small dioptric change such as ±0.25 D may lead
to a signi cant change in visual per ormance and thus needs
to be care ully approached. Ideally, one should stay close to the
cycloplegic or objective re ractive error. I a change is needed it
should be based on a signi cant improvement in visual acuity
(one line or more) rather than subjective impressions o better
clarity.
HANDLING O F LENSES
Many eye-care practitioners are likely to be experienced in
tting teens or older individuals with contact lenses but not
younger children, as this group normally does not seek contact
lenses except in certain special circumstances such as paediatric
aphakia, corneal scars, keratoconus, amblyopia therapy, post-
surgical lens tting etc.

It is clear rom the literature that children aged 7 years and
beyond are capable o handling and wearing most contact lens
modalities (Walline et al., 2008; Li et al., 2009; Sankaridurg et al.,
2011). A small di erence in total chair time or children compared
with teens was ound to be due to the longer time spent teach-
ing children lens insertion and removal (Walline et al., 2007b). A
recent study ound that teenagers were able to con dently handle
contact lenses, with a signi cant di erence in subjective rating
or quality o li e, satis action, appearance, activities, etc. com-
pared with those wearing spectacle lenses (Plowright et al., 2015).
Where children are involved, it is common practice to train
both the carer and the child in lens insertion and removal tech-
niques. However, it is equally important to ensure that the child
is ully capable o independently managing all other aspects o
lens wear, including disin ection and care procedures. In addi-
tion, they should also be educated in dealing with common
problems such as an irritated and / or red eye, lens mislocation,
etc. be ore they are discharged rom the clinic.
Co nt inuing Care and Co mp licat io ns
It is advisable to examine the individual within the rst ew weeks
o the lenses being dispensed to ensure that they are com ortable
with lens wear and, in the case o children, to ensure that their /
their carers’ expectations with respect to lens wear are being met.
T ereaf er, all lens wearers must be evaluated at regular
intervals, but even more so in young and progressing myopes,
as any progression o myopia is likely to result in blurred vision.
With children, ollow-up visits at 3-monthly intervals with no
more than 6-month periods between visits is pre erable. At the
ollow-up visits, any drop in visual acuity o one line or more, or
overre raction greater than 0.25 D, would require a re raction to
determine progression and change o lenses as needed.
In children, in the short term, the most requently observed
clinical nding was corneal staining (ranging rom 6 to 21%)
33 Myo p ia Co nt ro l 313
(Li et al., 2009). Over a slightly longer duration (i.e. 2 years) and
involving wear o silicone hydrogels on a daily wear basis, mechan-
ical events such as contact lens papillary conjunctivitis, superior
epithelial arcuate lesions and corneal erosions were the most re-
quently seen problems. T ere were no serious incidents reported.
Corneal in ltrative events were ew and mostly asymptomatic
(Sankaridurg et al., 2013).
Co nclusio n
It has been shown that contact lenses can serve as a plat orm
or a number o optical approaches aimed at slowing eye
growth in myopia. T e easibility o myopia control contact
lenses to slow the progress o myopia has been substantiated
with a number o independent clinical trials. T ese treatments
are generally directed at children and young adults as it is dur-
ing those years, that myopia is seen to progress rapidly. Contact
lenses are well accepted, shown to improve esteem and quality
o li e compared with spectacles, generally proven to be sa e or
use in children and are an e ective mode o delivering myo-
pia control strategies. T e key to prescribing myopia control
contact lenses is to (a) understand, appreciate and monitor the
expectations o the individual with respect to myopia control
strategies; (b) ensure that the individual and / or carers ully
understand the advantages and disadvantages associated with
contact lens wear and myopia control strategies; (c) choose a
strategy that ts with the expectation o the individual and / or
carers; (d) continuously monitor to ensure success in lens wear;
and (e) emphasize at all times the need or cleanliness, hygiene,
good lens care and daily or regular replacement, especially
where children are involved.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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34
Diab e t e s
CLARE O ’DO NNELL
Int ro d uct io n
Diabetes mellitus is one o the most common systemic diseases
in the world and it occurs when the pancreas does not produce
enough insulin or when the body cannot e ectively use that
insulin. Hyperglycaemia (elevation o blood glucose concentra-
tion) is a common e ect o uncontrolled diabetes and over time
this leads to damage to, and dys unction and ailure o many o
the body’s organs including the eye. It is classi ed into two main
types: type 1 (previously known as insulin-dependent) diabetes
and type 2 ( ormerly known as non-insulin-dependent) dia-
betes. T e prevalence o diabetes is increasing and, in 2014, an
estimated 9% o adults aged 18 years and older had diabetes.
ype 1 diabetes accounts or approximately 10% o primary dia-
betes, whereas type 2 diabetes accounts or 90% (World Health
Organization, 2015).
Although the retinal complications o diabetes are well docu-
mented, what is perhaps less well appreciated is that poorly con-
trolled diabetes can adversely a ect all ocular tissues. In order
to understand the possible e ects o diabetes on the eye during
contact lens wear, it is necessary to consider how the anterior
eye o diabetic patients may di er rom that o non-diabetic
patients.
The Ant e rio r Eye
Retinopathy is the ocular complication that most commonly
causes loss o vision in diabetic patients (Fig. 34.1); however,
various abnormalities a ecting the anterior eye have also been
described (see O’Donnell and E ron, 2012 or review).
O RBIT
Patients with poorly controlled diabetes are more susceptible to
bacterial and ungal in ections o the orbit than are non-diabetic
individuals. Mucormycosis is a rare but potentially atal ungal
in ection and those a ected may present with ophthalmoplegia,
loss o vision, pain and proptosis.
EYELIDS
Xanthelasma is a condition in which yellow deposits appear on
the eyelid, and is thought to be due to abnormalities in lipid
metabolism. Xanthelasmata can occur at an earlier age and
more requently in patients with diabetes than in non-diabetic
patients (Waite and Beetham, 1935) (Fig. 34.2).
Ptosis can be an early sign o undiagnosed diabetes, the
underlying cause being chronic tissue hypoxia. Blepharitis, styes
and meibomian cysts are also more commonly ound in the dia-
betic population.
314
TEAR FILM
Studies suggest that diabetic patients complain o dry eyes
more requently than do non-diabetic individuals (Ramos-
Remus et al., 1994; Akinci et al., 2007). Reduced tear secre-
tion is o en ound in association with diabetes, and is perhaps
related to dys unction o the autonomic nervous system serv-
ing the lacrimal gland (Ramos-Remus et al., 1994; Dogru et al.,
2000). Dogru et al., (2000) reported that tear break-up time
is signi cantly lower in diabetic patients who have decreased
corneal sensitivity. Increased levels o secretory immunoglob-
ulin A, lysozyme and glucose (Gassett et al., 1968) have been
observed in the tear lm o patients with diabetes. It has been
suggested that increased tear glucose concentration could pro-
mote lens spoilation and the growth o microorganisms in dia-
betic contact lens wearers. T e in uence o high tear glucose
levels may alter the biomechanical properties o the cornea in
diabetic patients.
CO NJ UNCTIVA
Microaneurysms, capillary proli eration and vessel dilations
have been noted in the conjunctivae o diabetic patients. T ese
eatures are not unique to diabetes; they can occur in association
with other systemic diseases such as hypertension and arterio-
sclerosis (L’Esperance and James, 1983). Conjunctival oxygen
tension may be reduced in patients with advanced diabetic eye
disease compared with those with milder retinal changes (Isen-
berg et al., 1986). Kruse et al. (2006) suggested that diabetic
patients have an increased risk o developing acute in ectious
conjunctivitis and Dogru et al. (2000) noted a reduction in gob-
let cell density in diabetic eyes.
CO RNEA
T e ultrastructural and biochemical status o the cornea is
altered in patients with diabetes (McNamara, 1997; O’Donnell
and E ron, 1998; Wiemer et al., 2007, O’Donnell and E ron,
2012); some o the changes that have been described are sum-
marized in able 34.1.
Below is an account o alterations to the structure and unc-
tion o the cornea that are o more direct clinical relevance to
contact lens wear.
Ep ithe lium
T e corneal epithelium is known to be particularly suscep-
tible to mechanical trauma in diabetic patients (O’Leary and
Millodot, 1981). Recurrent corneal epithelial de ects, super-
cial punctate keratitis and prolonged epithelial healing rates
have also been reported, particularly a er ophthalmic surgery.
 34 Diab e t e s 315

TABLE Bio che mical and St ruct ural Chang e s

34.1 Asso ciat e d w it h Diab e t e s
St ruct ure Chang e s
Te ars De cre ase d se cre tion and instab ility
Incre ase d lysozyme
Incre ase d se cre tory immunog lob ulin A
Incre ase d g lucose conce ntration
Ep ithe lium Ple omorp hism
Incre ase d ce ll size
Thicke ne d b ase me nt me mb rane
De cre ase d ad he sion o ce lls to b ase me nt
me mb rane
De cre ase d p e ne tration o anchoring b rils
into stroma
Ne rve s De cre ase d corne al se nsitivity
Structural alte rations
Stroma Incre ase d thickne ss
Glycosylation o collag e n
Incre ase in inte rmole cular sp acing o col-
lag e n b rils
Incre ase d autof uore sce nce
De sce me t’s laye r Fold s
Incre ase d thickne ss
Fig . 34.1 Diab e tic re tinop athy. End othe lium Polyme g e thism
Ple omorp hism
Re d uce d Na-K-ATPase activity

et al., 2012). Researchers have reported structural changes to

corneal nerves (Malik et al., 2003; Kallinikos et al., 2004) and
others have related these changes to the reductions observed
in corneal sensitivity (Rosenberg et al., 2000). T e alterations
in nerve structure appear to be more pronounced in patients
with diabetic polyneuropathy (Malik et al., 2003; Dehghani
et al., 2014) and patients with diabetic retinopathy (Mocan
et al., 2006). Quattrini et al. (2007) showed that corneal con o-
cal microscopy can quanti y small- bre damage rapidly and
non-invasively and can detect earlier stages o nerve damage
compared with currently used techniques, suggesting this
Fig . 34.2 Diab e tic p atie nt with b ilate ral xanthe lasmata. potentially makes it ideal to diagnose and assess the progres-
sion o diabetic neuropathy.

Inadequate adhesion o cells to an abnormal underlying base- End othe lium

ment membrane, reduced corneal oxygen consumption and
reduced corneal sensitivity have been implicated in many o the
corneal epithelial complications observed.
Corne al Ne rve s
Diabetes can cause a signi cant reduction in corneal sensitivity
(O’Leary and Millodot, 1981; Pritchard et al,. 2012). T is sen-
sory de cit is thought to occur owing to a di use polyneuropa-
thy. T e extent o the reduction appears to relate to the duration
o the diabetes, the age o the patient and the degree o diabetic
metabolic control. Corneal nerves play an important role in the
maintenance o a healthy cornea by providing a trophic in u-
ence and warning o corneal insult. Reduced corneal sensitiv-
ity has been linked with the development o corneal ulcers in
diabetic patients (Lockwood et al., 2006), and it is generally
accepted that contact lens wear should be approached with cau-
tion in any patient with corneal hypoaesthesia. Such patients
should be advised to remove lenses and to seek advice i they
experience any discom ort.
Corneal con ocal microscopy has been used to evaluate
the alterations that occur in patients with diabetes ( avakoli
Studies o corneal endothelial morphology in diabetic humans
and animals have revealed increased levels o polymegethism
and pleomorphism (Fig. 34.3).
Most researchers have ailed to demonstrate signi cant
reductions in endothelial cell density among diabetic patients
(O’Donnell and E ron, 2004a), which contrasts with the nd-
ings o Lee et al. (2006).
T e appearance o olds in Descemet’s membrane has been
reported in diabetic patients (Waite and Beetham, 1935) (Fig.
34.4). When associated with diabetes, vertical olds o en appear
in the central corneal endothelium o both eyes. Folds due to
diabetes appear to be enduring, unlike olds due to contact lens-
induced corneal oedema, which disappear a er lens removal
(O’Donnell et al., 2001).
Corne al Hyd ration Control
Corneal thickness is o en increased in diabetic patients (Ska
et al., 1995; McNamara et al., 1998; Lee et al., 2006). Abnormal
unction o the corneal endothelium has been postulated as the
cause, perhaps as a direct result o the accumulation o glucose
and sorbitol (McNamara, 1997).
316 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns
Fig . 34.3 End othe lial p olyme g e thism.
Fig . 34.4 A sing le d iag onally o rie nte d e nd othe lial old . (Courte sy of
Ste ve Zantos.)
Increased corneal epithelial and endothelial permeability
to luorescein has been reported in patients with diabetes
compared with non-diabetic control individuals. It has been
suggested that the limiting layers o the diabetic cornea unc-
tion normally during everyday conditions, but may have a
reduced ability to cope with the stress induced by ophthalmic
surgery or long-term contact lens wear (McNamara, 1997).
In a study analysing the e ects o so t contact lens wear in
diabetic and non-diabetic control individuals, Leem et al.
(2011) concluded that corneal thickness and endothelial cell
density are more a ected by diabetes mellitus whereas cor-
neal endothelial cell morphology is more a ected by contact
lens usage.
Investigators have used pachymetry to monitor the recovery
response to oedema induced by contact lenses o low oxygen
transmissibility. T is approach has demonstrated reduced abso-
lute corneal swelling (McNamara et al., 1998; O’Donnell and
E ron, 2006) and prolonged recovery times rom oedema in
diabetic patients compared with normal controls. Since the rate
o recovery rom corneal oedema is reduced in diabetic patients,
it has been suggested that care should be taken when prescrib-
ing contact lenses or such patients. However, it could be argued
that these studies do not identi y any obvious problems aris-
ing in diabetic patients wearing contact lenses with high oxygen
transmissibility on a daily-wear basis.
Microb ial Ke ratitis
Schein et al. (1989) ound that diabetic patients using con-
tact lenses have an increased risk o developing microbial
keratitis, although the magnitude o the increased risk was
not stated. Keay et al. (2009) evaluated the clinical signs,
symptoms and the ocular and systemic comorbidities in a
large series o contact lens-related microbial keratitis. heir
study showed that microbial keratitis was more common in
those with poor general health. Diabetic contact lens wearers
should be advised to seek immediate advice i they develop
a pain ul red eye or other symptoms suggestive o corneal
ulceration.
IRIS
Iris changes associated with diabetes include the deposition o
glycogen vacuoles in the iris pigment epithelium, pigment dis-
persion, iris atrophy and iris neovascularization.
PUPIL
Pupil size and pupil reactions may be altered in diabetic patients
with poor metabolic control. T e pupil may be more di cult to
dilate in diabetic patients with neuropathy.
LENS
It has been suggested that diabetes-induced changes occur-
ring in the aqueous humour, cornea and crystalline lens could
play a role in re ractive uctuations although there is uncer-
tainty about the exact mechanism o such changes. Changes
in re ractive error in uncontrolled or undiagnosed diabetic
patients have been reported. Huntjens et al. (2012) showed that
short-term uctuation in blood glucose levels did not induce
short-term changes in re ractive error, ocular aberrations or
the anterior ocular biometric parameters, although another
study showed that diabetic patients demonstrated smaller
anterior chamber depths, more curved lenses, greater lens
thickness and lower lens equivalent re ractive index (Adnan
et al., 2015). A reduced amplitude o accommodation has also
been shown in individuals with diabetes when compared with
age-matched controls, suggesting that individuals with diabe-
tes will experience presbyopia earlier in li e than people with-
out diabetes (Waite and Beetham, 1935; Adnan et al., 2014).
Cataracts are a well-known cause o visual impairment in
people with diabetes.

PANRETINAL PHO TO CO AGULATIO N
Corneal complications such as reduced corneal sensitivity, cor-
neal erosions and keratitis have been reported ollowing pan-
retinal photocoagulation (PRP). (T is procedure has also been
associated with other complications such as visual eld loss,
persistent mydriasis, iritis, iris atrophy, lens opacities, shallow-
ing o the anterior chamber and accommodative palsy.) Corneal
endothelial cell loss a er PRP has also been documented.
O cular Re sp o nse t o Co nt act Le nse s
Given the alterations to the anterior segment that accompany
diabetes, an important issue to be addressed is whether or not
contact lenses should be prescribed or diabetic patients or
re ractive correction. Reports o ocular complications in dia-
betic patients who wear contact lenses do exist; however, a num-
ber o these concern patients with advanced diabetic eye disease
using extended-wear contact lenses.
T e results o a prospective, controlled study have dem-
onstrated that daily-wear so contact lenses can be a viable
mode o vision correction or patients with diabetes. O’Donnell
et al. (2001) and March et al. (2004a) suggest that practitio-
ners should not expect to see adverse clinical signs in diabetic
contact lens wearers that are any di erent rom those seen in
non-diabetic lens wearers. I adverse signs are detected in a dia-
betic lens wearer, they should not be attributed solely to the act
the patient has diabetes, and the predisposition o the diabetic
patient to corneal in ection should always be borne in mind.
SPECIAL CO NSIDERATIO NS
Roughening o the ngertips caused by home blood glucose
monitoring could lead to damage to the lens sur ace during
cleaning, and patients should there ore be reminded to inspect
contact lenses or damage prior to lens insertion. Fingernails
should be kept short and smooth to reduce the risk o corneal
erosion (O’Donnell and E ron, 1998).
PRESCRIBING CO NTACT LENSES
Although there are established trends in contact lens prescrib-
ing or the general population, clinical opinion is divided as
to which type o contact lens is most appropriate or diabetic
patients. In view o the ragility o the corneal epithelium, rigid
contact lenses were previously not recommended or diabetic
patients since corneal abrasion occurs more requently with
these lenses. However, rigid lenses do have certain advantages
over so lenses. T e likelihood o toxins and potential patho-
gens becoming trapped beneath the lens is reduced with a rigid
lens compared with a so lens, and rigid lenses are also more
durable and less prone to tearing or splitting.
T e results o a survey conducted in the UK indicated that
practitioners believed that rigid lenses are the sa est orm o con-
tact lens or diabetic patients (Veys et al., 1997). However, this
survey was conducted prior to the availability o silicone hydro-
gel contact lenses. T e reason or rigid lenses being avoured or
diabetic patients was a perceived reduced risk o in ection with
these lenses compared with so lenses. Practitioners stated that
important actors to be considered when tting contact lenses
to diabetic patients include the degree o metabolic control and
the contact lens wear time.
34 Diab e t e s 317
CO MPLIANCE
O’Donnell and E ron (2004b) investigated the notion that dia-
betic contact lens wearers may represent a special group dis-
playing higher levels o compliance with their lens care regimen
as a result o learned behaviour relating to maintenance o their
diabetic condition. o test this hypothesis, a prospective, single-
centre, controlled, masked study was per ormed whereby 29
diabetic contact lens patients and 29 non-diabetic control indi-
viduals were issued with disposable contact lenses and a multi-
purpose lens care regimen. All participants were given identical
instruction on lens care and maintenance. Compliance levels
were assessed at a 12-month a ercare appointment by dem-
onstration and questionnaire. wenty- our di erent aspects o
compliance were scored, 12 by observation and 12 by question-
naire report, o which only two showed a signi cant di erence
between the diabetic and control groups. Although the com-
bined population o contact lens wearers was generally com-
pliant, there were examples o non-compliance in both groups.
Neither the duration o diabetes nor the degree o metabolic
control appeared to have a signi cant e ect on compliance. T e
results suggest that eye care practitioners cannot assume that
diabetic patients will be more compliant with contact lens care
and maintenance than non-diabetic patients.
Gluco se Se nsing in t he Ant e rio r Eye
Since tear glucose concentration has been shown to mirror blood
glucose concentration, it has been proposed that the measure-
ment o tear glucose concentration could be used to monitor
metabolic control non-invasively in diabetic patients. As contact
lenses are bathed in tears, it has been suggested that measurement
o tear glucose concentration could be carried out using contact
lenses with glucose-sensing properties. However physiological
actors mitigate against the use o tear glucose measurement as a
viable surrogate or blood glucose measurement. First, the con-
centration o glucose in the tears is much less than that in the
blood, which in broad terms means that a tear glucose sensor
must be much more sensitive than a blood glucose monitor. Sec-
ond, changes in tear glucose concentration lag behind changes in
blood glucose concentration, and delay times between detection
and read-out o 20 minutes or so have been recorded with some
devices (Lane et al., 2006; Farandos et al., 2015). T is is prob-
lematic in relation to acute glycaemic control where almost
instantaneous determination o blood glucose levels may be
required to implement timely strategies to avoid hypoglycemia.
Notwithstanding the limitations outlined above, there have
been many attempts to develop contact lens glucose monitoring
devices over the past decades. March et al. (1982) described the
concept o using a scleral lens to determine aqueous humour
glucose concentration as a surrogate measure o blood glucose
concentration. T ey conceived o a scleral lens that houses a
light source, polarizers, electro-optic units and a light detec-
tor which measures the optical rotation o the aqueous humour
(March et al., 1982; Rabinovich et al., 1982). March et al.
(2004b) used glucose-sensitive compounds in a hydrogel lens.
An array o 488 nm light-emitting diodes in a hand-held device
was used to illuminate the contact lens and the magnitude o
the resultant uorescent light was measured by a detector in the
device. A correlation between the contact lens uorescence and
blood glucose concentration was demonstrated, albeit with the
expected time lag.
318 PART 5 Sp e cial Le nse s and Fit t ing Co nsid e rat io ns

March et al. (2000) investigated the possibility o using an

intraocular lens impregnated with uorescent compounds to
monitor blood glucose concentration. Domschke et al. (2006)
used a holographic sensor embedded in a daily disposable hydro-
gel lens. When glucose bound to components in the device, the
colour o the light re ected o the hologram changed when illu-
minated by a laser. A trial o one patient showed a correlation
between blood glucose concentration and the holographic signal.
Chu and colleagues (2011) developed and tested an electronic
biosensor embedded in a rigid contact lens on a rabbit eye. T e
biosensor showed a good correlation between the output current
and glucose concentration. T is concept was limited by a need or
the lens to be wired to provide input voltage and output reading.
Although many o these examples demonstrate proo o con-
cept, none o the devices has been commercialized, although the
possibility o a contact lens sensor that is powered externally
and permits wireless read-out using an auxiliary device has gen-
erated considerable interest rom Google, Novartis and Micro- Fig . 34.5 De ormation o the knuckle s and f ng e r joints in a p atie nt
with rhe umatoid arthritis.
so (Otis and Parviz, 2015; Parviz and an, 2015).

Co nt act Le ns We ar in Pat ie nt s w it h
O t he r Syst e mic Dise ase
Patients with any systemic disease known to adversely a ect
the anterior eye potentially ace problems during contact lens
wear. Conditions such as thyroid de ciency, hyperthyroidism,
rheumatoid arthritis, atopic eczema, psoriasis and acne rosacea
may a ect suitability or contact lenses. In general, these condi-
tions, when managed, do not contraindicate contact lens wear
but may in uence the lens type or the wear schedule selected.
Patients with allergies can achieve success with contact lenses
but may require more- requent lens replacement or more- re-
quent a ercare examinations, as these patients are more suscep-
tible to lens-induced discom ort and lid problems. Wol sohn
and Emberlin (2011) have suggested that daily disposable con- Fig . 34.6 Pink d iscolouration o hyd rog e l contact le nse s (in the rig ht
sid e o the le ns case ) can b e ob se rve d with me d ications such as ri amp i-
tact lenses can o er a barrier to airborne antigens. T ere is no cin. The le t sid e o the le ns case contains an una e cte d le ns.
contraindication to tting contact lenses to patients who are
human immunode ciency virus (HIV)-positive, provided that HANDLING PRO BLEMS
the anterior eye is healthy. Practitioners should wear protec-
tive gloves i they have open skin lesions. I the patient has pro- Restrictions o mobility, as in rheumatoid arthritis or ‘diabetic
gressed to acquired immunode ciency syndrome (AIDS), the hand syndrome’, may make the handling o contact lenses di -
increased risk o opportunistic in ection should be considered cult (Fig. 34.5).
and contact lens tting approached with extreme caution. Patients should be encouraged to handle their own lenses
whenever possible. When handling becomes impossible, a rela-
tive or carer may provide assistance, and periods o extended or
CO RNEAL SCARRING O R THINNING
continuous wear may be appropriate.
Where a patient su ers rom any condition resulting in an irreg-
ular corneal sur ace, contact lenses may prove to be the only O CULAR SIDE-EFFECTS O F THERAPY
practical method o vision correction. In such cases, rigid lenses
are usually the rst choice (O’Callaghan and Phillips, 1994). T e ocular complications o both prescription and over-the-
Care ul slit-lamp examination together with a detailed history counter medications – such as decongestants, antihistamines
will alert the practitioner to those patients susceptible to corneal and oral contraceptives – should be taken into consideration
per oration. when contact lens wear is being considered. Possible side-e ects
o medications include dry eye, photosensitivity, alterations to
pupil size or unction, corneal and contact lens deposition,
KERATO CO NJ UNCTIVITIS SICCA
punctate keratopathy, subconjunctival haemorrhage and discol-
Patients with systemic conditions resulting in dry eye may oration o contact lenses (Fig. 34.6).
require ocular lubricants, tear supplements, dietary and envi-
ronmental modi cations and ultimately punctal occlusion. As
the success ul wearing o any orm o contact lens requires a
Co nclusio n
well-lubricated sur ace, contact lens materials o ering good When considering whether to proceed with contact lens tting
wettability should be selected. in patients with diabetes or other systemic disease a ecting

the anterior eye, the practitioner needs to conduct a risk–
bene t analysis with the patient. Where an increased risk o
ocular complications has been ascertained, the patient should
be ully in ormed o the risks and the bene ts o contact lens
wear. T e importance o the patient complying with recom-
mendations or lens care and maintenance, wearing sched-
ules and attending ollow-up visits should be emphasized. A
thorough understanding o the ocular and systemic history,
care ul examination during tting and ollow-up to exclude
the possibility o external eye disease, and the use o superior
34 Diab e t e s 319
contact lens products will increase the likelihood o success
or all prospective contact lens wearers. Additionally, there is
promise that in the uture contact lenses manu actured rom
hydrogel polymers embedded with glucose-sensing agents or
nanoscale digital electronic technology may be used by dia-
betic patients to help monitor their diabetic metabolic control
less invasively.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
This pa ge inte ntiona lly le ft bla nk
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thelial cell morphometry and corneal thickness in
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320.e 1
 PART

6
Pat ie nt Examinat io n and
Manag e me nt

PART O UTLINE
35 History Taking 323
Jame s S W Wolffsohn
36 Diag nostic Instrume nts 327
Lynd on W Jone s, Sruthi Srinivasan, Alison Ng and
Marc Schulze
37 Pre liminary Examination 346
Ad rian S Bruce
38 Patie nt Ed ucation 356
Sarah L Morg an
39 Afte rcare 364
Lore tta B Szczotka-Flynn and Nathan Efron
40 Comp lications 385
Nathan Efron
41 Dig ital Imag ing 410
Ad rian S Bruce and Milton M. Hom
42 Comp liance 420
Nathan Efron
43 Practice Manag e me nt 427
Nizar K Hirji
T h is p a g e in t e n t io n a lly le ft b la n k
35
Hist o ry Taking
JAMES S W WO LFFSO HN
Int ro d uct io n
History and symptoms are critical in determining whether an
individual is suitable or contact lens wear, to aid selection and
to in orm management. T e aim is to elicit relevant in orma-
tion comprehensively but in as concise a manner as possible,
as time is limited in a clinical setting, but missing in ormation
can result in suboptimal clinical decisions. Clinical records
have been ound to underestimate actual care provided, sug-
gesting record keeping is not always as comprehensive as it
should be (Shah et al., 2010). A web-based survey, developed
by the British University Committee o Contact Lens Educa-
tors (BUCCLE – which comprises o all the academic-based
contact lens educators in the UK and Ireland), o 256 respon-
dents with a wide range o experience, mainly rom the UK
and Eire, in ormed the recommendations in this chapter
(Wol sohn et al., 2015).
T e objectives or a new patient include:
• to determine the suitability or contact lens wear based on:
• an analysis o patient-speci ic indications and
contraindications
• a risk–bene t analysis or the individual patient
• to guide the patient as to the most suitable lens modality
and type based on:
• their li estyle (including occupation)
• aspirations or lens wear and nancial outlay
• the outcome o their ocular health examination
• re raction
• binocular vision
• to ensure that expectations are realistic, such as:
• visual outcomes
• range o clear ocus in presbyopes
• myopia control in children
• wearing time
• lens care requirements
• to collate baseline patient in ormation:
• to justi y clinical decision-making
• to allow uture changes to be examined at a ercares
• to ensure that the compliance implications o contact lens
wear are communicated.
Pointer (2014) examined the open question regarding issues
with the patient’s eyesight that is typical at the beginning o a
consultation and demonstrated that uninterrupted statements
o greater than 30 seconds were unlikely to provide use ul
additional in ormation. How a contact lens consultation his-
tory and symptoms is conducted will depend on whether it is
an initial tting, where past history, motivation and intended
wearing pattern and environment will be the ocus, or an a er-
care session, where symptoms, changes in health and compli-
ance aspects are oremost. Hence ‘history and symptoms’ in
an initial questioning changes to ‘symptoms and (changes in)
history’ or an a ercare session. Comprehensive capture o rel-
evant in ormation in a limited time will require a structured
approach, ability to di erentially diagnose and appropriate use
o abbreviations.
Ind icat io ns and Co nt raind icat io ns fo r
Co nt act Le ns We ar
Contraindications are o en interpreted as a reason not to t
contact lenses, but in most cases, with re ection on the manage-
ment o the condition or a change in contact lens choice, suc-
cess ul and sa e wear may be achieved.
Patients with compromised ocular health such as meibomian
gland disease (Nichols et al., 2011), low tear stability (DEWS,
2007) or recurrent epithelial erosion need the condition to be
managed be ore so or corneal RGP lenses are tted, but thera-
peutic lenses could be part o that management in extreme
cases. Poor tear lm can be exacerbated by contact lens wear.
T is is due to the thickness o lenses relative to the tear lm and
the lens material or design’s interaction with the ocular sur ace
and adnexa (such as the eyelids) changing the composition o
the tear lm through stimulating in ammation and binding to
protein and lipids (Mann and ighe, 2013).
As patient compliance with practitioner instruction will be a
major concern in patient management, it is important to judge
the prospective patient’s ability to understand the ull implica-
tions o lens wear. It is also important that the patient’s expec-
tations that drive motivation are realistic and achievable. A
particularly exacting personality type may nd the adaptation
period and the initial learning o handling techniques too intru-
sive and outweigh the overall bene ts o lens wear. Manual dex-
terity to insert and remove lenses and maturity, mental capacity
or willingness or compliant use may also increase the risks o
wear beyond the potential bene ts.
It is debatable whether the nancial aspects o not only the
tting, but also the continuing clinical care and the ongoing costs
o lens care solutions and lens replacements should be taken into
consideration. Fitting lenses to a patient without the nancial
means to care or them will inevitably lead to non-compliance
and increase the potential or adverse events to occur. However,
presumed compliance by an eye-care practitioner is known to
be a poor indicator o real compliance (Bui et al., 2010) and the
patient’s nancial situation is rarely actually known.
It is important to judge the motivation to wear contact lenses
and the personality type o the potential wearer. Contact lenses
are considered to give a more normal cosmetic appearance and
may contribute signi cantly to overall appearance, particularly
when the re ractive error is high. In addition, there are cases
where lenses can be used speci cally to conceal signi cant
323
324 PART 6 Pat ie nt Examinat io n and Manag e me nt
cosmetic de ects such as iris anomalies, corneal opacities,
inoperable squint or microphthalmos. Also i patients have
extremely at, steep or irregular corneas or the ocular sur ace
needs protection then therapeutic contact lenses may be appro-
priate, such as scleral lenses.
Hist o ry-t aking St ruct ure
raditionally ophthalmic history taking would be structured so
as to include the ollowing elements.
REASO N FO R VISIT
T e reason or the visit should be ascertained. Reasons include
the motivation or lens wear including cosmesis, scheduled a er-
care (which may also report symptoms) or unscheduled visit
due to symptoms. T e management o symptoms includes the
determination o any underlying pathology through di erential
diagnosis, optimization o lens t i inadequate and nally altera-
tion o lens eatures such as material, replacement requency, care
regimen or other actors or example the use o arti cial tears,
nutrition and environmental modi cations (Papas et al., 2013).
Various mnemonics have been suggested or the investigation
o pain in the medical literature – such as LOF SEA (location,
onset, requency, type, sel -treatment, e ect on patient, associated
symptoms), SQI ARS (site and radiation, quality, intensity, tim-
ing, aggravating actors, relieving actors, secondary symptoms)
and SOCRA ES (site [unilateral or bilateral], onset [gradual or
acute], character [such as throbbing], radiation, association [any
other signs], time course [duration], exacerbating / relieving
actors and severity). Systemic issues such as u should not be
orgotten as these can be linked with the development o compli-
cations (Sankaridurg et al., 1996). It is important to enquire about
possible precipitating / aggravating actors such as history o or-
eign-body insertion or trauma, photophobia, any eye itchiness
or seasonal variation, or anyone in the amily who has similar
eye problems (e.g. transmission o viral conjunctivitis can occur
rom sharing towels). Di erential diagnosis o reported pain or
discom ort by eye-care practitioners is airly comprehensive
(Wol sohn et al., 2015) and ar superior to that ound in phar-
macy practice (although these studies used actual questioning o
a mystery shopper; Bilkhu et al., 2013, 2014).
O CULAR HISTO RY FO R THE PATIENT WHO IS O R
HAS BEEN A CO NTACT LENS WEARER
T is includes:
• the last eye-test date and last contact lens a ercare
• brand / type o lens worn – note lens brand and care sys-
tem recall is generally poor, but is much enhanced using
photo-prompts (Dumbleton et al., 2011a)
• lens modality
• cleaning regimen (and ease o compliance) – risk actor
or microbial keratitis (use o a multipurpose solution has
a higher risk than hydrogen-peroxide-based solutions –
Stapleton et al., 2012)
• the time since tting (and why care is no longer being
provided by the original lens tter) or discontinuing (and
what led to this)
• average daily wearing time (hours per day; days per week)
• com ortable wearing time
• any napping or overnight wear – extended / continuous
wear are risk actors or corneal in ltrates and microbial
keratitis (Morgan et al., 2005; Chalmers et al., 2012; Staple-
ton et al., 2012)
• the number o hours o wear at the time o consultation
and how long it has been since the last a ercare – which
help to determine the signi cance o any clinical signs
seen during subsequent ocular examination such as cor-
neal-solution-induced staining (Gorbert et al., 2014), as
well as indicating likely uture patient compliance.
O CULAR HISTO RY FO R ALL PATIENTS
T is includes:
• the last eye-test date
• any problems with their eyes such as discom ort / pain (i
not already reported in the reasons or visit)
• any previous ocular surgery or trauma – such as laser re-
ractive surgery that will a ect corneal topography and
sensitivity, as well as tear lm stability (Nettune and P ug-
elder, 2010; Viso et al., 2011).
• previous ocular in ections such as iritis or herpes simplex
(Mucci et al., 2009)
• whether they have ever been to hospital / GP about their
eyes
• any problems with their vision speci cally at distance / in-
termediate / near
• pregnancy or lactation – due to hormonal changes, there
is increased risk o corneal oedema and mucus build-up
potentially a ecting com ort (Gotovac et al., 2013).
MEDICAL HISTO RY
T is includes:
• general health
• any allergies (atopy) particularly i there is an ocular com-
ponent (Wol sohn et al., 2009)
• diabetes – this should not prevent success ul so contact
lens wear, but requires more requent monitoring owing to
the potential or increased ragility o the epithelial tight
junctions and decreased corneal sensitivity (O’Donnell
et al., 2001) (See Chapter 34)
• thyroid problems – and other conditions that a ect eyelid
position or tone impacting the tear lm (Pillar and Richa,
2014)
• system in ammatory conditions – such as sarcoidosis,
which may be associated with ocular in ammation (uve-
itis; Weisinger et al., 2006)
• dermatological conditions – such as seborrheic dermatitis,
atopic eczema and acne rosacea, all o which are strongly
associated with anterior / posterior blepharitis (Auw-Hae-
drich and Reinhard, 2007).
MEDICATIO N
In ormation should be gathered as to any prescribed medication
taken or systemic conditions (o en not reported; Wol sohn and
Hurcomb, 2002) as well as topical ocular medication and sel -
medication (such as over-the-counter). Full reporting should
include the dose and requency as well as the pharmaceutical
name. Asking patients to bring a list o their current medica-
tion saves valuable contact time with the patient and reduces
the risk o inaccuracies (McKinley et al., 2004; Wol sohn et al.,
2015). T ere is little point in recording medication unless the
potential e ects on patient management are explored such as

drug interactions and ocular side-e ects. T is is best achieved
by using so ware, which can be more up to date than a practi-
tioner’s memory and aid patient recollection o pharmaceuti-
cal names. Preservatives in ocular medication are renowned or
causing allergic reactions, which may explain the development
o a red eye. Many systemic pharmaceuticals have dry eye listed
as a possible complication, such as (Askeroglu et al., 2013):
• antihistamines
• nasal decongestants
• tranquilizers
• certain blood pressure medicines
• Parkinson's medications
• antidepressants
• birth control pills and hormone replacement therapy –
although the evidence or these is contradictory (Bren-
nan and E ron, 1989; omlinson et al., 2001).
FAMILY HISTO RY
aking a care ul amily history may identi y that the patient has
an as yet undiagnosed condition or one that may develop with
ageing (hence record the age o onset and amily relationship)
such as:
• keratoconus – has a well-established genetic link, but a
amily history is not linked to severity (Szczotka-Flynn
et al., 2008)
• myopia – has a generic link, but this does not in uence
progression (Bullimore et al., 2002)
• atopy (Buckley, 1998)
• corneal dystrophies (Delleman, 1978)
• dry eye (Henrich et al., 2014)
• diabetes – the type should be noted (Cahill, 1979).
SO CIAL HISTO RY
Instead o asking about occupation and hobbies where responses
such as ‘retired’ or ‘student’ explain little o the patient’s visual
demands and risks, questions such as ‘What do you do during
you working day?’ and ollow up with ‘So what do you do when
you are not at work?’ may be more e ective. Certain occupa-
tions and hobbies may require eye protection as well as contact
lenses. T e in ormation documented should cover:
• occupation – higher socioeconomic status is a risk actor
or microbial keratitis (Stapleton et al., 2012)
• visual tasks
• daily environment – although research is inconclusive
about the e ect o the environment on contact lenses (Pa-
pas et al., 2013), dusty environments and exposure to ul-
traviolet light should in uence contact lens choice (Yam
and Kwok, 2014)
• hobbies
• typical working distances
• computer screen use
• driving
• smoking – which is a risk actor or corneal in ltrates and
microbial keratitis (Morgan et al., 2005; Chalmers et al.,
2012; Stapleton et al., 2012).
Pat ie nt Ed ucat io n, Risk / Be ne fit
Analysis and Info rme d Co nse nt
It is important to get in ormed consent when tting patients new
to lenses as well as when patients are being re tted. Essentially
35 Hist o ry Taking 325
this requires that the patient has a reasonable understanding o
the main bene ts o contact lens wear, as well as the potential
risks that accompany lens wear.
Part o this process involves educating the patient on the
various lens types and any that might be particularly suited
(or unsuited) to the patient’s particular needs. In ormation on
wearing schedules and use o lenses in overnight wear, appro-
priate lens care systems and replacement intervals are all rele-
vant actors in the patient’s decision to proceed with lens tting.
Although there are many positive eatures to contact lenses,
including visual, cosmetic and potentially psychological ben-
e ts, the patient must also be warned o possible adverse events.
As there are so many actors that might be relevant to the
decision on contact lens wear, it is dif cult to know how much
in ormation to provide. In general, it is not necessary to disclose
every possible risk, but only those that a reasonable person or a
member o the pro ession would expect to be told (Rosenwas-
ser, 1991). Patients may need speci c advice on aspects such as
driving with monovision or where a particular undesirable out-
come is not unexpected. Equally, it should be remembered that
a minor can neither give in ormed consent nor contract to pay
or services.
In some countries, it is common practice to ask the patient
to sign a consent orm, but the legal protection that this a ords
is questionable.
Pat ie nt Co mp liance
Encouraging compliance is a key element o any a ercare symp-
tom and history taking. T is topic is dealt with in detail in
Chapter 42; however, a brie overview is provided here o some
important compliance issues that may be discussed during his-
tory taking.
Non-compliance is common throughout the world (Morgan
et al., 2011) and perceived compliance is not a good indicator
o actual patient behaviours (Bui et al., 2010). Non-compliance
has consequences that range in severity rom reduced com-
ort on insertion and at the end o the day (Dumbleton et al.,
2013), dryness and in erior vision (Dumbleton et al., 2010) to
an increased risk o microbial keratitis rom sleeping in lenses
not prescribed or that purpose (Stapleton et al., 2008). Other
physiological signs o non-compliance include deposition on
the contact lenses (Collins and Carney, 1986a,b; Michaud and
Giasson, 2002), corneal staining (Collins and Carney, 1986a,b;
Nichols et al., 2002) and increases in papillae and hyperaemia
(Michaud and Giasson, 2002; Cardona and Llovet, 2004). Risk-
taking tendencies have been linked to compliance and, while
not an easy direct question, they may become apparent rom
hobbies (Carnt et al., 2011).
T e key aspects to emphasize are (Dumbleton et al., 2013):
• Failure to replace lenses when scheduled – reuse o daily
disposable contact lenses is motivated largely by wanting to
save money (60%) and occurs in 9% o patients (varying
by country, rom 18% in Australia, 12% in USA, 7% in UK
to 4% in Norway). Over hal o patients wearing ortnightly
and monthly lenses have been ound not to ollow the man-
u acturer’s or optometrist’s replacement schedule recom-
mendation (Dumbleton et al., 2011a; Hickson-Curran et al.,
2011). In both these studies, ailure to replace lenses when
scheduled was linked with lower reported com ort on inser-
tion and on lens removal (Dumbleton et al., 2011b, 2013).
• Sleeping in contact lenses – 75% o daily disposable con-
tact lenses admit to napping in their lenses and 28% to
326 PART 6 Pat ie nt Examinat io n and Manag e me nt
sleeping in them at least once a month. Sleeping in lenses
at least once a week to a ortnight increases the relative risk
o moderate to severe microbial keratitis (Stapleton et al.,
2008, 2012).
• Inappropriate lens purchase and supply – internet pur-
chase o lenses, rather than rom a contact lens practice,
appears to prevent patients rom receiving the education,
clinical care and ollow-up required and has been shown
to be associated with a greater risk o developing microbial
keratitis (Stapleton et al., 2008, 2012).
• Use o tap water and ailure to wash hands – generally pa-
tients report that they have been poorly instructed on the
use o storage cases and tap water, and have a general lack
o awareness with respect to hygiene such as handwashing
(Dumbleton et al., 2013).
• Failure to clean and replace cases regularly – poor case hy-
giene has also been associated with a greater risk o microbial
keratitis (Stapleton et al., 2008, 2012). T e lens storage case
is rarely cleaned (only 25% o patients clean every or most
days), tap water is generally used (67%), the cap is le on by
76%, and the case was only dried open, ace down as recom-
mended in 10% o patients in the study by Wu et al. (2011a,
2011b). In a North American study, the case was replaced
only monthly in 12% o patients (Dumbleton et al., 2013).
• Inappropriate use o care systems – in requent use o care
systems has been shown to be a risk actor or both mi-
crobial keratitis and sterile keratitis in daily wear users
(Stapleton et al., 1993), as has ailure to wash hands (Dart
et al., 2008; Rad ord et al., 2009). Failure to rub and rinse
lenses also carries a greater risk o developing microbial
keratitis (Butcko et al., 2007) and leads to higher rates o
signs and symptoms (Dumbleton et al., 2011b). In both the
relatively recent outbreaks o Fusarium keratitis and Acan-
thamoeba keratitis, topping up, rather than the required
complete replacement o solutions each day, was shown to
be associated with a greater risk o in ection (Chang et al.,
2006; Joslin et al., 2007). Use o tap water to rinse is linked
with higher rates o Gram-negative bacterial contamina-
tion ( ilia et al., 2014).
• Swimming or showering in contact lenses – swimming
allows accumulation o microbial organisms on or in the
lens, especially those made o rst-generation silicone hy-
drogel materials, which increases the risk o Acantham-
oeba in ection (Choo et al., 2005; Beattie et al., 2006). T e
e ect can be reduced by the use o swimming goggles (Wu
et al., 2011c).
Veri cation o elements o compliance can be achieved by ask-
ing patients to describe or demonstrate lens cleaning, lens case
cleaning and handwashing (Wol sohn et al., 2015). Given the
limited contact time with patients and partial patient oral reten-
tion (Court et al., 2008), comprehensive but concise written
guidance should be provided to all patients (Wol sohn et al.,
2015) at every visit (Claydon and E ron, 1994; E ron, 1997).
T is has been ound to be one o the ew ways to improve com-
pliance success ully ( ilian et al., 2014), along with prescribing
o daily disposable contact lenses (Morgan et al., 2011).
Co nclusio n
T e initial assessment and history taking orm the cornerstone
upon which all subsequent clinical decisions will be built. It is
important that this aspect o patient care is conducted thor-
oughly and to the highest standards. ime spent on this initial
stage o the patient assessment may prevent much wasted time
later in the management o the patient, when clinical decisions
have been made unadvisedly.
Sound and thorough record keeping will ensure both good
continuity o care and a good de ence in the event o patient
complaint.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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36
Diag no st ic Inst rume nt s
LYNDO N W JO NES | SRUTHI SRINIVASAN | ALISO N NG | MARC SCHULZE

Int ro d uct io n
T e purpose o this chapter is to review a number o the clini-
cal instruments that are o utility in the preliminary examina-
tion and ongoing care o contact lens patients. T e emphasis
will be on the design and principles o operation, with some
comments on clinical use. Further details on the application
o these instruments in contact lens practice can be ound in
Chapter 37. T e instruments discussed here orm only a subset
o the ull range o instruments that should be available to eye-
care practitioners or examining all aspects o ocular health and
visual unction. General ophthalmic instruments that are used
requently (e.g. re racting equipment, retinoscopes, ophthalmo-
scopes) and periodically (e.g. tonometers, visual eld analysers,
colour vision and binocular vision assessment apparatus) in the
course o a contact lens examination will not be considered here.

O b se rvat io n o f t he Eye
Perhaps the most undamental procedure in a contact lens con-
sultation is the examination o the anterior ocular structures.
T e standard technique or examining the eye in detail is slit-
lamp biomicroscopy, which has been available to practitioners
since the invention o contact lenses over a century ago. More
recently, high-powered observation tools have become available
that allow examination o the living cornea at a cellular level.
BURTO N LAMP
A number o manu acturers make a special hand-held magni y-
ing device or contact lens work. T is device is usually re erred
to as a ‘Burton lamp’, a er the company that manu actured the
original version (Burton Manu acturing Co., USA). T e Bur-
ton lamp is essentially a large magni ying lens o about +5.00 D
housed in a broad rame, within which are mounted a combina-
tion o 4 W white light and ultraviolet light uorescent tubes,
each 11 cm long. T e operator can switch between the two light
sources or white light and uorescein stain examinations. A
key advantage o this instrument is that both eyes o the patient
can be viewed simultaneously, acilitating interocular compari-
son, which can be particularly use ul in the course o rigid con-
tact lens tting (Fig. 36.1).
EXAMINATIO N O F THE TEAR FILM
A ‘healthy’ tear lm is essential or success ul contact lens wear,
and a number o techniques are available or its assessment.
Te ar Q uality and Thickne ss
T e earscope-plus (Keeler, UK) can be used to observe cer-
tain characteristics o the tear lm non-invasively (Guillon,
Fig . 36.1 Examining the e ye s using a Burton lamp . (Courte sy of Philip
Morg an.)
1997) (Fig. 36.2A). T is instrument takes the orm o a small
white dome with a central sight hole, surrounded by a cold light
source. It can be held directly in ront o the eye, or used in
conjunction with a slit-lamp biomicroscope to gain higher mag-
ni cation (Fig. 36.2B). T e thickness distribution, quality and
reedom o movement o the tears can be assessed by observ-
ing the re ected light rom the eatureless white dome, and the
integrity o the aqueous and lipid phases can be in erred rom
colour ringe inter erence patterns (Guillon, 1998a, 1998b).
T e earscope-plus has been discontinued and, although
several are still in circulation, another instrument that can pro-
vide qualitative observation o the lipid layer is the OCULUS
Keratograph®5M (Oculus, Wetzlar, Germany). T e inter erence
colours o the lipid layer and their structure are made visible
using white light illumination and this pattern can be recorded.
T e thickness o the lipid layer is then assessed based on the
structure and colour o this image, without using a dedicated
inter erometer.
T e LipiView® inter erometer was recently developed by
earScience®(Morrisville, NC, USA) to evaluate the tear lm
in patients with meibomian gland dys unction (MGD) and
dry eye (Blackie et al., 2009; Finis et al., 2013). T is instru-
ment (Fig. 36.3) uses inter erometry to measure lipid layer
thickness between blinks non-invasively, and gives a quantita-
tive assessment in inter erometric colour units. Partial blinks
can be assessed, along with the change in lipid layer thickness
and appearance. It is also o value to image the tear lm be ore
and a er treatment o MGD and it can indicate the presence o
327
328 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 36.2 (A) The Te arscop e -p lus. (B) Examining the e ye with the Te arscop e -p lus in conjunction with a slit-lamp b iomicroscop e to ob tain hig he r
mag ni cation. (Courte sy o f Philip Morg an.)
Fig . 36.3 Te arScie nce Lip iVie w inte r e rome te r in use . (Courte sy of
Ce ntre for Contact Le ns Re se arch and Te arScie nce Inc.)
MGD (Finis et al., 2013), which could result in reduced com ort
and potentially increased deposition in contact lens wearers.
Te ar Bre ak-up
Rapid tear break-up can lead to symptoms o dryness and dis-
com ort in both lens wearers and non-lens wearers. ear lm
break-up can be assessed by instilling uorescein into the tear
lm and timing how long it takes or breaks in the even, uores-
cent glow to appear. T e problem with this uorescein break-up
time (FBU ) approach is that it is ‘invasive’, in that the instilla-
tion o uorescein in itsel alters the quality and quantity o the
tear lm (Mengher et al., 1985; Cho and Brown, 1993; Sweeney
et al., 2013).
T e pre erred approach is to determine the non-invasive tear
lm break-up time (NIBU ). T is can be achieved by optically
projecting a grid pattern onto the cornea and timing how long
it takes or the grid to become disrupted. Numerous ‘specialist’
Fig . 36.4 O CULUS Ke ratog rap h 5M. (Courte sy of Ce ntre for Contact
Le ns Re se arch and O culus.)
devices employing this principle have been produced (Keir and
Jones, 2013; Sweeney et al., 2013), including the instrument
stand-mounted ‘NIBU dome’ or ‘Mengher grid’ (Mengher
et al., 1985) and hand-held devices such as the keratometer-
mounted Hir-Cal grid (Hirji et al., 1989), the Loveridge grid
(Loveridge, 1993) and the earscope-plus with NIBU grid
attachment (Guillon, 1997). One option to observe the tear lm
break-up without purchasing a dedicated device is to project the
Placido rings rom a corneal topographer onto the ront sur ace
o the cornea and manually count the seconds or the projected
grid to distort (Srinivasan et al., 2008, 2010; Sweeney et al.,
2013). Previous attempts have been made to automate this mire
distortion (Goto et al., 2003, 2004; Kojima et al., 2004). More
recently, the Keratograph 5M (Oculus; Fig. 36.4) has developed
an automated tear lm scanning process that allows automatic,
examiner independent determination o tear lm break-up
time, providing a graphic representation re erred to as a ‘tear
 36 Diag no st ic Inst rume nt s 329

Fig . 36.5 Te ar b re ak-up time as me asure d with the O CULUS Ke ratog rap h 5M. The he atmap on the rig ht id e nti e s the are as o te ar b re ak-up as
auto-d e te cte d b y the K5M. The colour-cod ing corre sp ond s to the time until b re ak-up , using a ‘tra c-lig ht-b ase d ’ scale rom ve ry short (re d ) to ve ry
long (g re e n). The associate d se ctions o b re ak-up on the re cord e d vid e o (le t p ane l) are shown b y the re d se ctions.

map’, which shows the location o the tear break-up (Best et al.,
2012; Hong et al., 2013, 2014; Lan et al., 2014). Colour coding
indicates the regions o break-up: green indicates a stable tear
lm, yellow indicates a thinning tear lm and red indicates tear
lm regions that are unstable (Fig. 36.5).
O smome try
A clinical test that has been suggested as being highly diagnostic
involves measuring tear lm osmolarity ( omlinson et al., 2006;
Khanal et al., 2008). T is is o en considered a ‘gold standard’
in the evaluation o patients with dry eye (Farris et al., 1986;
Farris, 1994; omlinson and Khanal, 2005), owing to the hyper-
tonic tear lm ound in dry-eyed individuals (Gilbard et al.,
1978, 1987, 1989; Farris et al., 1983; Lemp, 1995). A hypertonic
tear lm causes ocular sur ace damage and may lead to discom-
ort (Gilbard et al., 1978, 1987; Lemp, 1995). Even though tear
osmolarity has been considered a valuable method or diag-
nosing dry-eye syndrome or several decades, until recently it Fig . 36.6 Te arLab osmome te r showing the syste m p e n that hold s the
has not been used widely as a clinical tool owing to the lack o te st card and d ocking station (syste m re ad e r) that p rovid e s the osmolar-
ity re ad out. (Courte sy of Ce ntre for Contact Le ns Re se arch and Te arLab
available equipment and the act that most osmometers require Corp oration.)
a large volume o tears (typically 5–10 µl) (White et al., 1993;
Miller et al., 2003), which limits their use in many dry-eye sub-
jects, particularly those with severe disease in which tear vol- portable countertop unit that calculates and displays the osmo-
ume is very low. larity test result. T e reader automatically converts the tear uid
Historically, measuring tear lm osmolarity was undertaken sample data into an osmolarity measurement and displays the
using a reezing-point depression method ( omlinson and Kha- reading on the LCD display. T is rapid acquisition o osmolarity
nal, 2005; Stahl et al., 2012), most requently using the Cli on has resulted in an expansion o the utility o osmolarity deter-
instrument. However, this instrument requires considerable mination in clinical practice ( omlinson et al., 2010; Versura
expertise, is time consuming and the equipment is di cult to et al., 2010; Jacobi et al., 2011; Versura and Campos, 2013).
maintain (Farris et al., 1986; Nelson and Wright, 1986; White
et al., 1993). A new osmometer has recently become available Te ar Me niscus He ig ht
that requires much less uid (Sullivan, 2005; Versura and Cam- An adequate volume o tears is a prerequisite or a healthy ocu-
pos, 2013; Yoon et al., 2014). T is ‘lab-on-a-chip’-based osmom- lar sur ace (Holly and Lemp, 1977; Miller et al., 2004) and a
eter ( earLab: earLab Corporation, San Diego, CA, USA) (Fig. reduction in the volume o tears gives rise to a greater chance
36.6) uses electrical impedance and requires only 50 nanolitres o symptoms o ocular dryness (Doughty et al., 2001). Estima-
o tear uid (Sullivan, 2005; omlinson et al., 2010; Jacobi et al., tion o tear volume is o en undertaken using Schirmer strips
2011; Versura and Campos, 2013). A test card is inserted into a (Lamberts et al., 1979; Yokoi et al., 2000), or phenol red threads
‘pen-shaped’ holder, which is gently placed in contact with the ( omlinson et al., 2001) or estimating the volume o tears in
tear lm or approximately 30 seconds. T is is then placed into a the in erior tear meniscus (Lim and Lee, 1991; Golding et al.,
330 PART 6 Pat ie nt Examinat io n and Manag e me nt
1997; Oguz et al., 2000; Patel and Wallace, 2006; Santodomingo-
Rubido et al., 2006; Savini et al., 2006). T e in erior tear menis-
cus contains about 90% o the tear volume (Holly, 1985) and
tear meniscus volume is classically determined by estimating
the tear meniscus height ( MH) (Patel and Blades, 2003; Patel
and Wallace, 2006; Santodomingo-Rubido et al., 2006; Savini
et al., 2006). Studies have shown that MH estimation is a good
clinical indicator in dif erentiating dry-eyed versus non-dry-
eyed patients, as it is a direct measure o the quantity o the tear
lm (Lim and Lee, 1991; Mainstone et al., 1996; Golding et al.,
1997; Pult et al., 2011; Altan-Yaycioglu et al., 2013; ung et al.,
2014).
T e most common and simple method to determine MH
is visualizing the MH using a slit-lamp biomicroscope with an
eyepiece containing a graticule (Lamberts et al., 1979; Lim and
Lee, 1991; Papas and Vajdic, 2000; Miller et al., 2004; Nichols
Fig . 36.7 Te ar me niscus he ig ht (TMH) as me asure d with the O CULUS
K5M. The rule r tool allows me asure me nt o the TMH at any location
along the lowe r lid marg in. To acilitate vie wing o the me niscus, the
mag ni cation o the acq uire d imag e can b e ad juste d .
Fig . 36.8 O p tical cohe re nce tomog rap hy (O CT) imag e o the lowe r-lid te ar me niscus o a 24-ye ar-old e male showing the te ar me niscus he ig ht.
Imag e cap ture d o n the Top con DRI O CT-1, which use s swe p t source te chnolog y. (Imag e co urte sy of Nicholas Rumne y.)
et al., 2004; Patel and Wallace, 2006; Santodomingo-Rubido
et al., 2006). However, estimation o the upper border o the
MH is di cult and several studies have achieved this by add-
ing a small volume o uorescein to the tears (Lamberts et al.,
1979; Port and Asaria, 1990; Lim and Lee, 1991; Mainstone
et al., 1996; Golding et al., 1997; Oguz et al., 2000; omlinson
et al., 2001). Enhancing the visualization o the upper MH
border by the addition o uorescein is clearly invasive and may
inter ere with the tear volume determined, resulting in an over-
estimation o the MH.
o overcome such di culties, a number o non-invasive
approaches to measuring MH have evolved, including vid-
eography o the meniscus (Golding et al., 1997; Oguz et al.,
2000; Doughty et al., 2001, 2002), optical pachymetry (Port and
Asaria, 1990; Patel and Port, 1991) and meniscometry (Fran-
cis et al., 2005; Stahl et al., 2006; Uchida et al., 2007; Bandlitz
et al., 2014). Various multi unction devices now exist that can
routinely photograph the MH and include built-in so ware to
determine the MH. One o these, the OCULUS Keratograph®
5M (Oculus), photographs the lower MH and its height can
then be determined using a built-in ruler (Fig. 36.7) (Arriola-
Villalobos et al., 2015; Koh et al., 2015).
Optical coherence tomography (OC ) has been used to
determine MH accurately (Jones et al., 2002; Johnson and
Murphy, 2005; Savini et al., 2006; Wang et al., 2006a; Bitton
et al., 2007; Keech et al., 2009; Shen et al., 2009; Ibrahim et al.,
2010, 2012; Czajkowski et al., 2012; Ohtomo et al., 2014).
Once the tear prism is visualized, images can be scanned and
stored and the height within the OC slice is calculated (Fig.
36.8). OC of ers an advantage in that it is the only available
method to view the tear prism in cross-section to determine
cross-sectional area (allowing or tear volume calculation)
(Wang et al., 2006a, 2008; Palakuru et al., 2008; Chen et al.,
2009, 2011; Garcia-Lazaro et al., 2012; ung et al., 2014) and
can also be used to determine the MH o the upper lid (Wang
et al., 2006a; Shen et al., 2009; ao et al., 2010; Chen et al.,
2011).

EXAMINATIO N O F THE MEIBO MIAN GLANDS
T e various reports rom the meibomian gland workshop con-
ducted by the ear Film and Ocular Sur ace Society clearly dem-
onstrated the importance o having adequately unctioning
meibomian glands or ocular sur ace health and contact lens com-
ort (Nichols et al., 2011; omlinson et al., 2011). Evaluation o the
meibomian glands has historically been obtained by practitioners
merely pressing on the glands to view the expression o meibum.
However, this is o en di cult to do in a reproducible ashion. T e
Mastrota paddle (OcuSOF , Rosenberg, X, USA) (Fig. 36.9) is
designed to gently and ef ectively express meibum rom the mei-
bomian glands (Pitts and Lievens, 2009; Hatley and Lighthizer,
2015). It is positioned between the eyelid and the eye, parallel to
the glands, while a nger or cotton-tip applicator applies gentle
pressure to the outer lid. T is procedure can be carried out with
or without anaesthesia. T is tool is use ul or the examination o
meibomian glands and grading o meibomian gland unction.
Although it is possible to evaluate correct unctioning o the
meibomian glands by applying digital pressure to the eyelid, the
handheld Meibomian Gland Evaluator ( earScience) (Korb and
Blackie, 2008, 2013) of ers the advantage o standardizing this
technique, regulating the consistency o pressure at 1.25 g / mm 2
(Fig. 36.10).
One o the most e ective ways o evaluating the meibo-
mian glands is to visualize and photograph their appearance
using meibography (Yokoi et al., 2005; Pult and Nichols,
2012; Wise et al., 2012). his method, which is typically
based on in rared illumination, is capable o assessing the
number o partial glands or total meibomian gland drop-out
(Jester et al., 1982; Mathers et al., 1991, 1994; Nichols et al.,
2005). Although meibography has been conducted or many
years in a research setting, a number o non-invasive, clini-
cian- riendly devices have recently been released, making
meibography possible as a routine procedure within clinical
practice (Yokoi et al., 2005; Pult and Nichols, 2012; Pult and
Riede-Pult, 2012; Srinivasan et al., 2012; Wise et al., 2012;
Arita et al., 2013; Ban et al., 2013; Ngo et al., 2014). wo o
these devices include the Keratograph 5M (Oculus) (Srini-
vasan et al., 2012; Finis et al., 2015; Ngo et al., 2014) (Fig.
36.11) and the recently released LipiView II with Dynamic
Meibomian Imaging ( earScience).
Fig . 36.9 Mastrota p ad d le b e ing use d to e valuate the unctioning o
the me ib omian g land s.
36 Diag no st ic Inst rume nt s 331
O BJ ECTIVE O CULAR REDNESS ASSESSMENTS
In clinical practice, ocular indings are typically assessed
subjectively by means o image-based grading scales (E ron,
1998, 2012a; Papas, 2000; E ron et al., 2001b; Schulze et al.,
2007; BHVI, 2011; Sickenberger, 2014). Despite the obvi-
ous convenience o their use, the inter- and intra-observer
variability between repeated assessments has been open to
criticism (Bailey et al., 1991; Papas, 2000; Fieguth and Simp-
son, 2002; Murphy et al., 2006; Schulze et al., 2008; Amparo
et al., 2013). o overcome this limitation, various objective
assessment methods have been proposed, including image
analysis (Papas, 2000; Fieguth and Simpson, 2002; Schulze
et al., 2008; Amparo et al., 2013) and photometric measure-
ments (Schulze et al., 2007; Sorbara et al., 2007). Despite the
advantages o these techniques, they are not easily achievable
in clinical practice and remain largely used within research
studies.
he Keratograph 5M (Oculus) uses modi ied optics to
image the patient’s cornea and also the visible nasal and
temporal bulbar and limbal conjunctiva while the patient
is looking straight ahead at the centre o the Placido disk
rings (Jerchel et al., 2012; Oculus, 2013). he curved Kera-
tograph head, with its concentric Placido disk rings, allows
or consistent and uni orm illumination across the visible
conjunctiva (Jerchel et al., 2012; Wu et al., 2015). he built-
in so tware automatically detects the visible nasal and tem-
poral conjunctiva, and estimates redness by quanti ying the
area covered by vessels relative to the overall detected area
(Jerchel et al., 2012; Wu et al., 2015). he Keratograph 5M
output provides bulbar as well as limbal redness grades on
a 0 (none) to 4 (severe) scale, in 0.1 increments, or both
the nasal and temporal conjunctiva. In addition, an overall
bulbar redness score based on a weighted average o nasal
and temporal redness and the analysed area (in mm 2) are
displayed (Fig. 36.12) (Oculus, 2013).
T e Keratograph 5M allows a direct comparison o the
acquired image to a published grading scale (the JENVIS 0–4
scale) (Sickenberger, 2014), which can help acilitate com-
munication o the results with patients (Oculus, 2013). T e
hyperaemia results using this technology appear to be highly
correlated to subjective grading (Jerchel et al., 2012), and have
Fig . 36.10 Meib omian Gland Evaluator in use. This d e vice app lies a
stand ard ize d p re ssure to the meib omian g land s to e valuate their unc-
tion. (Courtesy of Centre for Contact Lens Research and Te arScie nce Inc.)
332 PART 6 Pat ie nt Examinat io n and Manag e me nt

less variability than subjective assessments obtained by means
o traditional grading scales (Jerchel et al., 2012; Wu et al.,
2015).
SLIT-LAMP BIO MICRO SCO PY
T e slit-lamp biomicroscope plays an essential role in the pre-
liminary assessment and a ercare o the prospective and exist-
ing contact lens wearer. T e opportunities or using the slit
lamp within the routine eye examination are numerous and
diverse. With the appropriate application o supplementary
lenses and / or viewing techniques, the instrument may be used
to assess the condition o the vitreous, lens and retina rom pos-
terior pole to the ora serrata. Various ancillary instruments will
permit examination o the anterior-chamber angle, measure-
ment o intraocular pressure, corneal sensitivity and assess-
ment o corneal thickness. T is review will concentrate on the
instrument itsel : see Chapter 37 or an account o the use o the
slit-lamp biomicroscope in contact lens practice.
T e instrument consists o a separate illumination system
(the slit lamp) and viewing system (the biomicroscope), which
have a common ocal point and centre o rotation (Fig. 36.13). A
height control moves both systems simultaneously, whilst ocus-
ing and lateral movements are achieved via a joystick. T is com-
mon control eature acilitates rapid and accurate positioning o
the slit beam on the area o interest and ensures that the micro-
scope and illumination system are simultaneously in ocus.
Illumination Syste m
Virtually all slit-lamp manu acturers have adopted the Koeller
illumination system, which is optically almost identical to that
o a 35 mm slide projector (Henson, 1996a). A bright illumi-
nation system (producing approximately 600 000 lux) is a un-
damental requirement or a slit lamp i subtle conditions are

Fig . 36.11 Me ib og rap hy o the up p e r (top p ane l) and lowe r (b otto m p ane l) lid . O n the rig ht sid e o e ach p ane l are the orig inal imag e s as acq uire d
with the Ke ratog rap h 5M, and on the le t are e nhance d ve rsions o the same imag e s to b e tte r visualize the g land s.

Fig . 36.12 Automate d b ulb ar and limb al conjunctival re d ne ss ob taine d with the O CULUS Ke ratog rap h K5M. The d ata outp ut includ e s g rad e s (0–4
rang e ; 0.1 incre me nts) or nasal and te mp oral b ulb ar and limb al re d ne ss, as we ll as ove rall b ulb ar re d ne ss and the conjunctival are a that was d e te cte d
and analyse d .

Fig . 36.13 The slit-lamp b iomicroscop e . Note the se p arate controls
or the illumination syste m and the mag ni cation syste m.
to be seen clearly. Although halogen or xenon lamps are more
expensive than tungsten lamps, they are the pre erred illumi-
nation source as they provide a brighter light, last longer, have
better colour rendering and generate less heat. Illumination
brightness is controlled by a rheostat or multiposition switch
such that brightness can be adjusted to obtain the correct bal-
ance between patient com ort and optimal visibility o the area
o interest.
T e slit within the illumination system must have sharply
demarcated edges and desirable eatures include the ollowing:
• T e slit width and height must be easily adjustable such
that any shaped patch rom a slit to a circle may be project-
ed, as this will increase the variety o illumination methods
possible.
• A graduated slit width is particularly use ul when measur-
ing the size o a lesion.
• An ability to rotate the lamp housing such that the slit may
be used in meridians away rom the vertical is use ul, par-
ticularly i a protractor scale is included. Such a system en-
ables, or example, the angle o rotation o a so toric lens
away rom the vertical to be accurately measured.
• T e slit beam must have the acility to be displaced or of -
set sideways (‘decoupled’). T is ability to break the linkage
between the illumination and observation systems acili-
tates indirect illumination techniques.
A number o lters can be incorporated into the illumina-
tion system; these serve to enhance the visibility o certain
conditions:
• Green (‘red- ree’) lter – enhances contrast when looking
or corneal and iris vascularization, since red vessels ap-
pear black i viewed through such a lter. In addition, it
may be used to increase the visibility o rose Bengal stain-
ing on both the cornea and conjunctiva.
• Neutral-density lter – reduces beam brightness and in-
creases com ort or the patient.
• Polarizing lter – reduces unwanted specular re ections
and can be use ul to enhance the visibility o subtle de ects.
• Dif using lter – dif uses the illumination source over a
wide area and is used to provide broad, un ocused illumi-
nation or low-magni cation viewing o the general ocular
sur ace.
36 Diag no st ic Inst rume nt s 333
Fig . 36.14 Custom-d e sig ne d b arrie r lte r in p osition on the Nikon FS3
slit-lamp microscop e . The slid e r or the zoom mag ni cation syste m is
also cle arly se e n.
• Cobalt blue lter – provides a suitable means o exciting
sodium uorescein or examination o ocular sur ace in-
tegrity. Illumination o uorescein with cobalt blue light
o 460–490 nm produces a greenish light o maximum
emission 520 nm. Any abraded area will absorb uores-
cein and display a uorescent green area against a general
blue background. T e lter is occasionally used on its own
to aid in the diagnosis o keratoconus. A requent nding
in this corneal ectasia is Fleischer’s ring, which is ormed
by an annular iron deposition within the stroma at the
base o the cone. T e iron pigment is o en di cult to see
in white light, but will usually appear in greater contrast
when viewed through the cobalt blue lter.
• Kodak Wratten number 12 (yellow) lter – this lter is not
contained within the illumination system but rather is used
as a supplementary barrier lter that is placed in ront o
the viewing system. It signi cantly enhances the contrast
o any uorescent staining observed with the cobalt blue
lter as it allows transmission o the green uorescent light
but blocks the blue light re ected rom the corneal sur ace
(Back, 1988). Some newer slit lamps incorporate it within
the viewing system, but or most practitioners it is used as
an ‘add-on’ device that is placed over the observation lens
when required. Custom-made barrier lters or certain slit
lamps are available rom some manu acturers (Fig. 36.14).
Inexpensive hand-held versions may be constructed by us-
ing a cardboard mask and Lee lters number 101 yellow.
The Microscop e
A key prerequisite or a slit-lamp biomicroscope is a viewing
system that provides a clear image o the eye and has su cient
magni cation or the practitioner to view all structures o inter-
est. Magni cation is an important consideration, and ideally
magni cations o up to 40× should be possible; this may be
achieved through interchangeable eyepieces and / or variable
magni cation o the slit-lamp objective (Henson, 1996a). More
recently, the addition o digital cameras and subsequent image
analysis has resulted in magni cations o up to 200× being pos-
sible (Yuan et al., 2015), allowing very ne details o the cornea
334 PART 6 Pat ie nt Examinat io n and Manag e me nt
and other external structures to be visible. Magni cation greater
than this level is usually unnecessary and is o en counterpro-
ductive, as small involuntary eye movements will render the
image too unstable to view. Ideally the practitioner should be
able to change magni cation swi ly and easily, which gives slit
lamps with three or more objectives an advantage. Zoom sys-
tems have the added advantage o allowing the practitioner to
ocus on a particular structure without losing sight o it during
changes in magni cation. O course, the magni ed image must
also be clear, and the importance o choosing a slit lamp with
a high-quality optical system cannot be overemphasized. Ide-
ally the microscope should have excellent resolution and a good
depth o eld. However, these actors are inversely linked and so
a compromise must be accepted.
Mastering all o the possible illumination techniques with
the slit lamp is essential i the instrument is to be used to its ull
potential. Practice with the instrument is critical to becoming
com ortable with its subtle but extensive variety o uses. Readers
are advised to consult other texts or in ormation concerning
the use o the many and varied illumination techniques avail-
able with the slit lamp (Zantos and Cox, 1994; Jones and Jones,
2000).
HIGH-PO WERED MICRO SCO PY
Conventional microscopy collects all the light re ected back
through the object. As a result, in ormation out o the ocal
plane, above and below areas o interest, creates noisy and
blurred images in all but the thinnest specimens at high mag-
ni cation (Cavanagh et al., 2000). Over the past 25 years two
techniques (specular and con ocal microscopy) have emerged
that have enabled researchers and clinicians to examine the
structure o the cornea in vivo at very high magni cation.
Sp e cular Microscop y
T e specular microscope allows viewing o objects illuminated
rom above, and the objective lens also acts as the condenser
lens. Light passes rom inside the microscope out through the
objective lens to arrive at a ocus near the ocal plane o the
lens. I this position coincides with a re ecting sur ace then the
ocused light is re ected back through the objective lens and is
viewed through the eyepiece o the microscope (Hodson and
Sherrard, 1988). T e rst specular microscopes used or oph-
thalmic research were utilized by David Maurice in the 1960s in
his work investigating corneal unction. T is technique enabled
high-magni cation images o both the epithelium and endothe-
lium to be made, which had previously been di cult owing to
their transparency. Early versions o the specular microscope
used a contact dipping cone objective lens that was optically
coupled to the cornea to provide higher magni cation and res-
olution. However, most modern clinical specular microscopes
can achieve equally high magni cation without the need or
ocular contact. T ese instruments are primarily used to view
and photograph the corneal endothelium. T e endothelial cells
can be imaged because the re ractive index o the endothelial
cells is higher than that o the aqueous humour. By direct view-
ing with the specular microscope an overall impression o the
condition o the endothelium can be established immediately.
ypically the eatures looked or are the regularity o the
endothelial mosaic, the size o the individual cells, the presence
o intracellular vacuoles and abnormal eatures such as cor-
neal guttae and keratic precipitates (Rio-Cristobal and Martin,
2014). From the images obtained, actors such as the number
o cells per unit area, cell shape and cell area can be calculated,
enabling the clinician to assess the endothelial appearance com-
pared with that expected o normal age-matched individuals.
Results rom these investigations (Hodson and Sherrard, 1988)
have shown that the endothelial cell population density drops
rom approximately 4500 cells / m 2 at birth to 2000 cells / mm 2
in old age, and that their shape and size change dramatically
over this time. At birth the endothelial mosaic is very regu-
lar and the cells are almost circular in shape. With time they
become increasingly angular in shape and varied in size, a con-
dition termed ‘polymegethism’ (see Chapter 40). In addition to
age-related changes, the specular microscope has been used to
investigate endothelial changes in a number o disease condi-
tions, including posterior polymorphous dystrophy, Fuchs’ dys-
trophy, corneal surgery, re ractive surgery and contact lens wear
(Hodson and Sherrard, 1988). In addition, deep stromal opaci-
ties such as glass oreign bodies, pigment deposits and corneal
dystrophies can be imaged (Brooks et al., 1992).
Confocal Microscop y
Con ocal microscopy is unlike conventional microscopy
because de ocus causes the image to disappear rather than
appear as a blurred image. T e properties o the con ocal
microscope stem rom its ability to ocus the illuminating light
and the ocal plane o the microscope objective on precisely the
same point (Böhnke and Masters, 1999). In most modern con-
ocal microscopes a point light source is ocused on to a small
volume within the specimen and a con ocal point detector is
used to collect the resulting signal. T is results in a reduction
o the amount o out-o - ocus signal rom above and below
the ocal plane, producing a marked increase in both lateral
(x, y) and axial (z) resolution (Cavanagh et al., 2000). Only
one tiny area o the specimen is observed by each point source,
so a use ul ull eld o view must be gained by mechanically
scanning the area o interest. By varying the plane o ocus
o both the source and detector within the tissue, the speci-
men can be optically ‘sectioned’ non-invasively, and detailed
in ormation on corneal structure determined (Beuerman and
Pedroza, 1996). Detailed descriptions o the optical principles
involved in con ocal microscopy can be obtained in various
reviews (Böhnke and Masters, 1999; Cavanagh et al., 2000;
E ron et al., 2001a).
T e microscope objectives most commonly used are non-
applanating water immersion objectives that are optically
coupled to the cornea using a methylcellulose gel (Böhnke and
Masters, 1999). o obtain the maximum axial resolution (and
hence optical sectioning) it is necessary to use a microscope
objective with a large numerical aperture (which describes the
light-gathering ability o the objective). However, such devices
have a reduced eld o view and shorter ree working distances,
which reduces the distance that the microscope can ocus into
the specimen rom the sur ace (Böhnke and Pedroza, 1999).
Tandem Scanning Confocal Microscopy. First-generation con-
ocal microscopes used a modi ed Nipkow disc, which is a thin
wa er with hundreds o pinholes that are arranged in a spiral pat-
tern (Cavanagh et al., 2000). When a portion o the disc is placed
in the internal light path o the con ocal microscope, the spinning
disc produces a scanning pattern o the subject. As the subject is
inspected, light is re ected back through the microscope objec-
tive. T e light that was re ected rom in ront o or behind the

ocal plane o the objective approaches the disc at an angle rather
than perpendicularly. T e pinholes o the disc permit only per-
pendicularly oriented rays o light to penetrate. T is enables the
microscope to view a very thin optical section o tissue. Because
the illumination and detection o light through conjugate pinholes
occur in tandem, this microscope was named the tandem scan-
ning con ocal microscope. T e disadvantages o this system are a
lack o a wide selection o objective lenses, an inability to control
the signal-to-noise ratio directly at dif erent tissue depths and the
dramatic loss o light due to the act that Nipkow discs transmit
less than 1% o the available light (Cavanagh et al., 2000). T is
latter problem necessitates the use o a low-light-level camera to
acquire the images, which limits rame speed acquisition.
Slit-scanning Confocal Microscopy. More recently, a vari-
able-slit real-time scanning con ocal microscope has been de-
scribed (Masters et al., 1994). In this design, two independent-
ly adjustable slits are located in conjugate planes. A rapidly
oscillating two-sided mirror is used to scan the image o the
slit over the plane o the cornea to produce optical sectioning
in real time. T is design has the advantages o optimal image
contrast, enhanced clarity and decreased scan time, but it is
more expensive than Nipkow-based systems, and z-axis quan-
ti cation is not currently possible (Cavanagh et al., 2000).
Confocal Microscopy through Focusing. Regardless o the
technique used to obtain the images, the major problem as-
sociated with con ocal microscopy relates to the interpretation
and quanti cation o the data obtained. A relatively new tech-
nique called con ocal microscopy through ocusing attempts
to overcome this, by rapidly moving the ocal plane o the ob-
jective lens through the entire cornea at a speed o approxi-
mately 80 µm / s, while x–y images are acquired at the ocal
plane. T is means that approximately 450 sequential images
(which are separated by approximately 1 µm) are acquired
over the time taken to traverse the cornea (approximately 15
seconds). T e cornea is then reconstructed using image-pro-
cessing techniques, and an image is produced that is similar
to a histological section, albeit in three dimensions in a living
cornea (Fig. 36.15).
Rostock Cornea Module. Heidelberg Engineering, in collabora-
tion with Rostock University, Germany, has developed a novel
digital con ocal laser scanning microscope, a combination o Hei-
delberg retina tomograph (HR ) and the Rostock cornea module
(RCM) (Stave et al., 2002; Zhivov et al., 2006; Patel and McGhee,
2007). T e RCM uses the back-scattered light, similar to other
con ocal microscopes, with an interaction with the specimen
producing a light signal that proceeds towards the detector. T is
device allows the operator to image cellular structures sharply
and move through the dif erent layers o the entire cornea, rom
epithelium to the endothelium. T e RCM also enables the im-
aging o the peripheral areas o the cornea and conjunctiva. T e
instrument allows a scan depth o a maximum o 1500 µm, with
an image size o 400 × 400 µm. T e unit has an interchangeable
63× standard microscopic lens, of ers a choice o manual depth
position adjustment and has an automatic brightness adjustment
system. T e CCD camera allows a permanent monitoring o the
corneal contact on the screen. T e RCM technology provides
better image quality and produces a precise depth measurement
compared with con ocal slit-scanning microscopes (Eckard et al.,
2006) Recently, a more compact version o the same instrument,
36 Diag no st ic Inst rume nt s 335
the HR III with Rostock cornea module, has been introduced
(Fig. 36.16).
Using such techniques, con ocal microscopy has provided
valuable data on the structure and appearance o the cornea
in many disease processes, including dystrophies, keratitis
and endothelial disease. In addition, corneal changes ollow-
ing re ractive surgery, corneal cross-linking, keratoplasty, in
diabetes and due to contact lens wear have been documented
(Moller-Pedersen et al., 1997; Böhnke and Masters, 1999;
Cavanagh et al., 2000; E ron, 2007, 2011, 2012b; Caporossi
et al., 2012).
Me asure me nt o f Co rne al Se nsit ivit y
T e cornea is richly innervated and is one o the most sensi-
tive tissues in the body. Corneal sensitivity is a use ul indica-
tor o corneal disease and can help to determine physiological
stress rom wearing contact lenses (Brennan and Bruce, 1991;
Millodot, 1994). Interest in assessing corneal sensitivity has
increased over recent years, particularly in light o ndings indi-
cating that corneal sensitivity is signi cantly reduced in cases o
dry eye and ocular sur ace disease (Xu et al., 1996; Adatia et al.,
2004; Gallar et al., 2009; Achtsidis et al., 2013).
CO NTACT AESTHESIO METRY
Measurement o corneal sensitivity in the clinical setting has
traditionally been achieved using a Cochet–Bonnet aesthesi-
ometer (Fig. 36.17). T is device can be hand held or mounted
on a slit lamp, and uses a single nylon thread to produce vari-
ous orces, by varying its length in 0.5 cm steps (the longer the
thread, the lighter is the orce). T e lament is lightly placed
on to the cornea by the clinician using a support that allows
manipulation in the x–y–z planes, whilst the cornea is being
viewed through the slit lamp. T e subject reports when they
can eel the thread touching the ocular sur ace, and the length
o thread at which this occurs is recorded. T e corneal touch
threshold is de ned as the length o the nylon lament at
which the subject responds to 50% o the number o stimula-
tions. T is length is converted into pressure using a calibra-
tion curve and the reciprocal o this value gives the corneal
sensitivity. Using this technique, it has been demonstrated that
corneal sensitivity varies with sur ace location and is altered
by age, iris colour, ambient temperature, time o day, contact
lens wear and pregnancy (Millodot, 1994).
A number o actors complicate the use o such a device and
can result in variations in the results obtained (Murphy et al.,
1998). T ese include physical aversion to the approach o the
device, problems with mounting the device accurately in the slit
lamp and the impact o ambient humidity on the stif ness o the
thread (Brennan and Bruce, 1991).
NO N-CO NTACT AESTHESIO METRY
Over the last 15 years a number o devices have been tested and
developed to overcome the problems described above with con-
tact aesthesiometry. All o these research instruments use non-
contact means o stimulating the cornea. Initially, mechanical
stimulation alone was investigated, but more recently aesthe-
siometers have been produced that stimulate the cornea using
a variety o thermal, chemical or mechanical stimuli. T ese
have included non-contact pneumatic devices that deliver
336 PART 6 Pat ie nt Examinat io n and Manag e me nt

Fig . 36.15 Con ocal microscop e imag e s o the corne al laye rs o a normal e ye o a human p atie nt. (A) Sup e r cial e p ithe lium; (B) inte rme d iate e p i-
the lium; (C) b asal e p ithe lium; (D) sub b asal ne rve b re laye r; (E) stroma; (F) e nd othe lium.

compressed air as the stimulus (Murphy et al., 1998; Vega et al., With time, it is possible that devices based on these
1999) and a device that measures both mechanical stimulation approaches will become commercially available, and aesthe-
via an air puf and chemical stimulation via the administration siometry will become an important technique in contact lens
o varying concentrations o carbon dioxide (Belmonte et al., practice.
1999; Gallar et al., 2004; Situ et al., 2007, 2008, 2010; Golebio-
wski et al., 2008, 2011, 2013; Basuthkar Sundar Rao and Simp-
son, 2014).

Fig . 36.16 The HRT III con ocal lase r scanning microscop e .
Fig . 36.17 The Coche t–Bonne t ae sthe siome te r b e ing use d to me a-
sure corne al se nsitivity. A ne nylon thre ad o a se t le ng th is ad vance d
toward s the e ye and the p atie nt is aske d to re p ort whe n the y rst e e l
the thre ad touching the corne al sur ace .
Asse ssme nt o f Ant e rio r-se g me nt
Mo rp ho lo g y
‘Morphology’ stems rom Greek and relates to the ‘study o
shape’. Over the past two decades, improvements in comput-
ing technology has resulted in an explosion o the number o
devices to determine the morphology o the anterior segment,
including the cornea, sclera, anterior chamber and lens. T is
section will concentrate on describing the devices available to
determine various aspects o the shape o the cornea, limbus
and sclera.
Devices that determine corneal shape are o en re erred to
as ‘corneal tomographers’. omography stems rom the Greek
words or ‘slice’ (tomos) and ‘describing’ (graphia) (Ambro-
sio et al., 2013). Anterior-segment tomography provides the
topography o both the ront and back corneal sur aces. A wide
variety o methods exist, including those based on horizon-
tal slit scanning (Liu et al., 1999; Rao et al., 2002; Cairns and
McGhee, 2005; Swartz et al., 2007; Oliveira et al., 2011), rota-
tional Scheimp ug scanning (Liu et al., 1999; Li et al., 2002; Rao
et al., 2002; Charles et al., 2005; Oliveira et al., 2011) and optical
36 Diag no st ic Inst rume nt s 337
Fig . 36.18 The Top con KR-8800 Auto Ke rato -Re ractome te r. (Courte sy
of Ce ntre for Contact Le ns Re se arch and Top con Me d ical Syste ms Inc.)
coherence tomography (OC ) (Hrynchak and Simpson, 2000;
Wang et al., 2002, 2011; Swartz et al., 2007; Haque et al., 2008;
Matalia and Swarup, 2013; Rio-Cristobal and Martin, 2014).
T ese devices can broadly be divided into those that determine
only anterior corneal shape, those that can determine anterior
and posterior corneal shape and nally technologies that can
provide in ormation on the cornea, limbus and sclera.
ANTERIO R CO RNEAL SHAPE
Ke ratome try
Knowledge o corneal curvature is primarily o interest as an
aid in determining the initial contact lens to be placed on the
eye in cases o rigid contact lens tting. In addition, an indica-
tion o rapid changes in curvature can be indicative o a com-
promised cornea and also aid in the diagnosis o keratoconus.
Measurement o the radius o curvature o the cornea is based
on the act that the ront sur ace o the cornea acts as a convex
mirror. T e re ection o an object (or mire, rom the French
or ‘target’) o known size at a known distance is viewed using
a short- ocus telescope, and a relatively simple equation allows
the corneal ront sur ace radius o curvature to be determined
directly rom the instrument. T e corneal power that results
rom a given radius is o en also indicated on the keratometer;
alternatively, this can be calculated (see Appendix D). T e opti-
cal principles o keratometry, the various types o keratometer
available and their speci c mode o operation may be obtained
rom other sources (Stone and Rabbetts, 1994; Henson, 1996b).
T e actual region over which the standard keratometer mea-
sures corneal radius is that o two small areas approximately 1.5
mm on either side o the central xation point (Stone and Rab-
betts, 1994). Dif erent types o keratometer use dif erently sized
mires at dif ering separations. It is thus o no surprise that di -
erent keratometers may give dif ering radius values on the same
eye. Most keratometers in clinical practice now use automated
keratometry, using in rared devices that rapidly and automati-
cally determine central keratometry and re ractive error simul-
taneously (Fig. 36.18).
In addition to determining the central radius o curvature,
it is use ul to measure peripheral radius values, particularly in
complicated conditions such as post-penetrating keratoplasty
338 PART 6 Pat ie nt Examinat io n and Manag e me nt
and post-re ractive surgery. Conventional keratometers have
traditionally been adapted by using peripheral xation points
(Stone and Rabbetts, 1994). However, in reality keratometers
cannot be used to determine corneal curvature accurately i the
sur ace being measured does not have a constant radius o cur-
vature or is not radially symmetrical (Stone and Rabbetts, 1994).
For this reason, dedicated instruments using other technologies
have been developed to measure overall corneal topography.
Corne al Top og rap hic Analysis
T e aim o corneal topography (or keratoscopy) is to describe
accurately the shape o the corneal sur ace in all meridians
(Mandell, 1992; Guillon and Ho, 1994). In most cases, the tech-
nique uses a similar principle to keratometry, in that it deter-
mines the size o the image o a target re ected in the corneal
sur ace, the primary dif erence relating to the act that or kera-
toscopy a series o circular concentric targets are used (a Placido
disc image). T is arrangement allows both central and periph-
eral curvature to be determined. Historically, a photographic
record o the corneal re ection images was made (photokera-
toscopy) and measurements calculated subsequently (Veys and
Davies, 1995).
Modern-generation topographers capture the image elec-
tronically on a computer and use sophisticated image-process-
ing so ware to provide immediate analysis o the re ected image
(videokeratoscopy). Using this technique it has been clearly dem-
onstrated that the cornea is aspheric and can best be described
as a attening ellipse, whose rate o attening is asymmetrical
about its centre (Guillon and Ho, 1994). T e history and detailed
description o the development and operation o topographers
and their clinical applications are described elsewhere (Guillon
and Ho, 1994; Dave, 1998; Klyce et al., 1998; Klyce, 2001).
T e simplest o topographers are re ective devices, which
measure topography based on the re ection o mires rom the
anterior-sur ace tear lm, which are essentially identical in
shape to the corneal sur ace.
Qualitative Assessment. T e most basic re ective device or
assessing corneal topography is the Placido disc, which is sim-
ply a series o concentric black and white rings on a at circular
disc with a central sight hole. T e disc is positioned in ront o
the cornea and the re ections are observed. Using this method,
only gross irregularities in the corneal sur ace and very high
astigmatism can be detected. Improved versions o the Placido
disc include the internally illuminated Klein keratoscope, Lov-
eridge grid (Loveridge, 1993) and earscope-plus with corneal
topography grid attachment (Guillon, 1997).
Quantitative Assessment. Quantitative re ective devices (Fig.
36.19) utilize the same basic principle o projecting a grid on to
the cornea. T e images are captured with a video camera and
a computational approach is adopted to analyse the data and
derive a description or the corneal shape. T e choice o com-
putational method is important as this will largely dictate the
accuracy and validity o the keratoscope. T e most requently
utilized computational approach is the ‘slope o sur ace’ method
(Guillon and Ho, 1994). Basically, devices that use this tech-
nology measure slope directly as a unction o distance rom a
central re erence axis and derive curvature rom these results.
It is important to note that these distance-based instruments
are only estimating the average shape o the cornea, since the
algorithms are based on a radially symmetrical sur ace, which
Fig . 36.19 The Me d mont E300 corne al top og rap he r. This is an e x-
amp le o a small cone top og rap he r that use s a re f e ctive te chniq ue to
ob tain top og rap hic d ata. (Courte sy of Ce ntre for Co ntact Le ns Re se arch
and Me d mont Inte rnational Pty Ltd .)
does not accurately describe the cornea. T ese axial or sagit-
tal measurements result in an underestimation o the radius o
curvature in areas that may be steeper than the central cornea,
and an overestimation in areas that are atter. More recently, the
algorithms have been modi ed and are now generally based on
the radius o curvature, in an attempt to provide a better esti-
mate o the local shape o the cornea.
T e images (or ‘maps’) produced by re ective or Placido-
based keratoscopes display the power distribution o the cor-
neal sur ace using colour-coded displays, in which greens and
yellows represent powers characteristic o those ound in nor-
mal corneas, blues or cooler colours represent atter areas (low
powers) and reds or hotter colours represent steep areas (high
powers) (Klyce et al., 1998). T ese maps permit recognition o
corneal shape through pattern recognition and swi ly reveal
the presence o abnormal powers (Fig. 36.20). All devices dis-
play simulated keratometry values, which are analogous to stan-
dard keratometry values, and simultaneously display the power
and axis o the attest meridian.
A number o manu acturers now produce hand-held topog-
raphers. T ese portable devices can prove very use ul or exam-
ining children, older people or those with restricted mobility,
and or use in of -site consultations.
ANTERIO R AND PO STERIO R CO RNEAL SHAPE
Re ective devices, described above, are limited to determining
the shape o the anterior corneal sur ace only. A range o instru-
ments are available which allow tomographic imaging – a process
whereby a series o two-dimensional images are reconstructed into
three-dimensional images using technology such as slit scanning,
Scheimp ug imaging and optical coherence tomography (OC ).
In eyes that continue to progress to corneal ectasia, changes
in the posterior cornea are considered to be an early indicator
o the condition, prior to the anterior cornea showing signs o
change ( omidokoro et al., 2000; Belin and Ambrosio, 2013;
de Sanctis et al., 2013). T ere ore, assessment o the posterior
corneal shape and topographic thickness are becoming increas-
ingly valuable in clinical practice.
 36 Diag no st ic Inst rume nt s 339

Fig . 36.20 Corne al top og rap hy map o a hig hly myop ic e ye with astig matism, take n with the Ke ratog rap h 5M. The ste e p corne al curvature and
astig matism can b e cle arly se e n on this tang e ntial map .

Slit-scanning De vice s
Currently, the only device that uses horizontal slit-scanning meth-
ods to obtain anterior-segment data is the Orbscan II (Bausch &
Lomb). T is device combines both Placido disc and slit-scanning
technologies to obtain topographic measurements o both ante-
rior and posterior corneal sur aces, in addition to the anterior lens
and iris (Cairns and McGhee, 2005; Swartz et al., 2007; Oliveira
et al., 2011; Rio-Cristobal and Martin, 2014; Pinero, 2015). T e
instrument scans across the anterior corneal sur ace, obtaining 40
sequential slit images, whilst simultaneously recording eye move-
ments and re ection data rom a Placido disc device. T e data
are then reassembled into a three-dimensional reconstruction o
the anterior and posterior corneal sur ace (Cairns and McGhee,
2005; Swartz et al., 2007; Oliveira et al., 2011; Rio-Cristobal and
Martin, 2014; Pinero, 2015).
he instrument di ers rom traditional keratoscopes in
that it uses a combination o slit-scan triangulation and sur-
ace re lection to determine corneal shape. Speci ically, this Fig . 36.21 The O CULUS Pe ntacam HR in use . (Courte sy of Ce ntre for
instrument uni ies triangulated and re lective data to obtain Contact Le ns Re se arch and O culus.)
accurate measurements o elevation, slope and curvature. In
addition to conventional axial and tangential maps, shape
data can be displayed as an elevation map, in which the rela- technique enables landscape and architectural photographers
tive height o the cornea is compared with a spherical re er- to use large- ormat cameras with very long ocal lengths (and
ence sur ace. Elevations above the re erence sphere are red shallow depth o ocus) to dramatically extend depth o eld
coloured and depressions below the re erence sphere are without using a small aperture.
coloured blue. T e Pentacam (Oculus) was the rst instrument to use a
rotational Scheimp ug camera to provide three-dimensional,
Sche imp flug Imag ing De vice s non-contact imaging o the anterior segment (Ambrosio et al.,
Scheimp ug imaging devices operate on a method patented by 2013). T e instrument (Fig. 36.21) uses a 475 nm blue light
T eodor Scheimp ug (an Austrian Army Captain, who used source and two camera systems to capture an image. T e rota-
it to correct perspective distortion in aerial photographs) in tional Scheimp ug camera takes up to 50 cross-sectional images
1904. Compared with traditional photographic techniques on an angle rom 0 to 180° in a single scan, acquiring 25 000
where the three planes (the lm, the lens and the plane o data points in approximately 2 seconds. T e second camera is
ocus) are parallel to one another, in Scheimp ug imaging the static and used to monitor eye xation and detects pupil size.
planes are not parallel. Instead, the plane o the lens is tilted T e so ware supplied with the Pentacam utilizes an algorithm
such that it intersects both the lm plane and ocal plane, that corrects or any image distortion that is encountered rom
which extends the depth o ocus, allowing imaging rom the the optics o the camera system and the optics o the anterior
anterior corneal sur ace to the posterior lens sur ace. T is segment being imaged (Wegener and Laser-Junga, 2009). As the
340 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 36.22 Pe ntacam d ata rom a ke ratoconic with a ce ntrally locate d cone . (Imag e courte sy of Lace y Haine s.)
instrument uses a rotating camera, accurate measurements can
be obtained rom highly irregular corneas that re ective Plac-
ido-based systems struggle to image accurately.
For the purposes o corneal shape assessment, the Pentacam
presents the data in the orm o anterior and posterior sagit-
tal (axial) and tangential curvature, re ractive power maps and
anterior and posterior elevation maps (Fig. 36.22). Similar to
the Orbscan, the maps generated are colour coded according
to elevations or depressions relative to a re erence body, which
may be selected as a best- t sphere, an ellipse o revolution or
toric.
Several studies have shown the Pentacam to have greater
accuracy in the assessment o posterior corneal elevation than
the Orbscan in postoperative corneas, as light scattering could
af ect Orbscan image acquisition (Boscia et al., 2002; Ha et al.,
2009; Rio-Cristobal and Martin, 2014).
CO RNEAL AND SCLERAL SHAPE
Eye Surface Profile r (Eag le t-Eye )
T e re ractive and therapeutic indications or tting large-
diameter rigid gas-permeable lenses, semiscleral and scleral
contact lenses are varied. For optimum per ormance and ocu-
lar health, these lenses require speci c tting principles to be
adhered to. o assist with the tting procedure, an understand-
ing o the corneal and scleral shape pro le is imperative. ypical
methods o assessing the topography o the ocular sur ace have
previously been limited to corneal topography, which is o little
bene t when tting scleral lenses, as they rest on the sclera and
vault the cornea (Schornack and Patel, 2010).
T e Eye Sur ace Pro ler (ESP) (Eaglet-Eye, 2015) is the rst
instrument capable o measuring the curvature and sagittal
height up to 20 mm diameter, which covers the cornea, corneo-
limbal junction and sclera (Fig. 36.23). T e instrument uses a
double projection Fourier trans orm pro lometer that is capa-
ble o determining the curvature and elevation o the anterior
eye beyond the corneal region. Imaging the anterior eye shape
requires the instillation o sodium uorescein, onto which a
grid pattern is projected. As Fourier trans orm pro lometry is
a projection technique, the anterior sur ace o the eye is visual-
ized directly. T is minimizes any topographic distortions that
are encountered with re ection techniques such as those that
use Placido discs (Simón-Castellvi et al., 2010).
Ante rior-se g me nt O p tical Cohe re nce
Tomog rap hy (AS-O CT)
OC is a non-contact optical imaging technique that is capable
o high-resolution micrometer-scale cross-sectional imaging o
biological tissue using in rared light (Böhnke and Masters, 1999;
Hrynchak and Simpson, 2000; Swartz et al., 2007; Simpson and
Fonn, 2008; Ramos and Huang, 2009; Maeda, 2010; Wang et al.,
2011; Rio-Cristobal and Martin, 2014).
T e technique uses Michelson inter erometry to compare
a partially coherent re erence beam to one re ected rom tis-
sue. T e two beams are combined and inter erence between the
two light signals occurs only when their path lengths match to
within the coherence length o light. T e magnitude and dis-
tance within the tissue o the re ected or back-scattered light
at a single point are determined using a mirror system to orm
a re ectivity pro le (or an A-scan, analogous to ultrasound)
(Izatt et al., 1994; Fujimoto et al., 1995, 1998). A tomographic

Fig . 36.23 (A) Eye Sur ace Pro le r (Eag le t-Eye ); (B) Sag ittal he ig ht map across the corne al, limb al and scle ral re g ions imag e d using the ESP. (Imag e
courte sy of Le e Hall.)
image, a B-scan, is generated by assembling multiple A-scans.
T e technique o 2D-OC is thus analogous to ultrasound
B-mode imaging, except that it uses light rather than sound,
and provides the data or the computer analyser by utilizing
the dif erential re ectivity to coherent laser light, o transparent
ocular tissues. Re ections occur at boundaries between mate-
rials o dif ering re ractive indices, and the greater the dif er-
ence in index the greater is the amplitude o the re ected signal.
T e 2D-OC scans are subsequently processed by a computer,
which corrects or any axial eye movement arte acts that have
occurred during the acquisition time. T e B-scan represents a
cross-sectional view o the structure under investigation, simi-
lar in appearance to a histological section.
OC was initially used to image retinal complications,
in which tissues had become separated or changed in struc-
ture. T ese include macular oedema, macular holes, posterior
36 Diag no st ic Inst rume nt s 341
vitreous detachment, retinal detachment, retinoschisis and
optic nerve head changes (Hrynchak et al., 2000; Bajwa et al.,
2015). Imaging o the anterior segment with OC was rst
described in 1994 (Izatt et al., 1994). All o the original papers
using OC to examine the anterior ocular sur ace relied upon
the modi cation o OC devices that were developed to image
the retina.
Commercially available OC s with anterior-segment (AS)
imaging capabilities are now commonplace. With resolutions
between 2 and 20 µm, AS-OC is increasingly being used to
examine the cornea and has proven use ul in determining epi-
thelial and total corneal thickness changes ollowing re ractive
surgery, assessing corneal central and average thickness in cases
o ocular hypertension and glaucoma, and in patients with cor-
neal oedema (Hrynchak and Simpson, 2000; Maldonado et al.,
2000; Wang et al., 2002, 2006b; Lee et al., 2003; Haque et al.,
342 PART 6 Pat ie nt Examinat io n and Manag e me nt
2004, 2008; Iester et al., 2009; Dorairaj et al., 2012). AS-OC
is a use ul tool to diagnose and document changes in corneal
health. It can be used to monitor corneal in ections, dystrophies
and degenerations (Konstantopoulos et al., 2008; Vajzovic et al.,
2011; Utsunomiya et al., 2014), and in the assessment o glau-
coma risk actors such as central corneal thickness and narrow
anterior-chamber angles (Lee et al., 2003; Iester et al., 2009;
Dorairaj et al., 2012).
For the contact lens practitioner, AS-OC can be very use ul
during both contact lens tting and assessment. Peripheral cor-
neal and corneo-scleral topography can assist in the prediction
o so lens t, and the interaction o the lens edge with the con-
junctiva can be quantitatively assessed (Hall et al., 2011; Shen
et al., 2011; Wolf sohn et al., 2013; urhan and oker, 2015).
T is technology can also assist with complex contact lens design
and tting, including keratoconic RGP tting (Elbendary and
Abou Samra, 2013) and when designing and tting large diam-
eter RGP and scleral contact lenses (Gemoules, 2008; van der
Worp, 2010; Choi et al., 2014). T e ability to measure the space
between the cornea and the back sur ace o the scleral lens (the
vault) using on-screen calipers and visualize the position o the
landing zone o the lens on the conjunctiva permits rapid and
accurate t modi cations (van der Worp, 2010; Sonsino and
Mathe, 2013; van der Worp et al., 2014).
T ree types o OC s are available or anterior-segment imag-
ing: time domain, spectral domain and swept source scanning.
T e dif erences in data acquisition and processing or these
technologies will be brie y discussed.
Time-domain OCT. In time-domain OC ( D-OC ), a mov-
able re erence mirror is used to re ect the light source to gen-
erate a series o images. By taking a series o 2000 A-scans per
second, a re ectivity pro le is generated and the depth o ocu-
lar tissues is determined (Penner and Guillermo, 2007; Maeda,
2010).
One example o such a device is the Visante®AS-OC (Carl
Zeiss Meditec, Inc.). T e Visante OC uses 1310 nm light,
which allows or deeper penetration into the tissues to allow
greater cross-sectional visualization and imaging o the anterior
chamber (Fig. 36.24) (Penner and Guillermo, 2007; Ramos and
Huang, 2009) without occlusion o the angle by the scleral spur.
Measurement tools incorporated into the device enable direct
measurement o a variety o anterior-segment ocular structures,
including corneal thickness, corneal ap thickness and residual
stromal thickness ollowing laser in situ keratomileusis (LASIK)
surgery, anterior-chamber depth (ACD), anterior-chamber
angles and anterior-chamber diameter. T e instrument can also
be used to model the positioning o implantable contact lenses
and intraocular lenses.
Spectral-domain (Fourier-domain) OCT. Whereas D-OC
uses a moving re erence mirror to re ect near-in rared light,
spectral-domain OC (SD-OC ) (also re erred to as Fourier-
domain; FD-OC ) uses a xed re erence mirror to re ect the
light source. T e inter erence between the ocular tissue and the
re erence re ections is detected by a spectrometer; it is then
Fourier trans ormed to generate an A-scan (Ramos and Huang,
2009; Arita et al., 2013; Rio-Cristobal and Martin, 2014). SD-
OC s use wavelengths o 820–879 nm, which allows improved
axial resolution o images (5 µm compared with 17 µm). How-
ever, the longer wavelength used in D-OC s allows deeper
tissue penetration, to image anterior-segment structures better
Fig . 36.24 Imag ing mod e or the Visante ante rior-se g me nt op tical
co he re nce tomo g rap hy (AS-O CT), d e monstrating various ante rior-se g -
me nt p arame te rs.
(Sarunic et al., 2008; Ramos and Huang, 2009; Maeda, 2010;
Rio-Cristobal and Martin, 2014). As the production o A-scans
are not dependent upon a moving re erence mirror, the speed
o image acquisition with SD-OC s is comparatively aster than
D-OC , acquiring 25 000– 50 000 A-scans per second (Ramos
and Huang, 2009; Maeda, 2010). An additional eature o SD-
OC is the production o a series o parallel B-scans rom which
3D images can be generated akin to three-dimensional topog-
raphy, which can then be rotated and otherwise manipulated.
Examples o SD-OC devices include the 3D OC -1000,
-2000 and Maestro ( opcon Medical Systems Inc., Oakland,
CA, USA), Cirrus HD-OC (Carl Zeiss Meditec, Inc., Dub-
lin, OH, USA), iVue-100 (Optovue, Fremont, CA, USA), and
SPEC RALIS®SD-OC (Heidelberg Engineering GmbH, Hei-
delberg, Germany).
Swept-source OCT. SD-OC is one type o FD-OC (Sarunic
et al., 2008; Maeda, 2010). A second type o FD-OC is swept-
source OC (SS-OC ), which uses a longer wavelength o 1050
nm, permitting deeper penetration into tissues and allowing
imaging with enhanced visualization o the anterior segment.
SS-OC is the latest technology used in commercially available
OC instruments. T is technology uses a tunable laser that scans
through a range o wavelengths o the light source to generate
an inter erogram. T e inter erogram is Fourier trans ormed to
produce an A-scan, and several A-scans are assembled to orm
the cross-sectional B-scan. T e scans are o high resolution,
with photodetectors replacing CCD cameras to urther increase
resolution to 1 µm and overall scan acquisition time is aster
than with SD-OC (up to 108 000 scans per second), which re-
duces any arte acts arising rom eye movements (Maeda, 2010;
Karnowski et al., 2011). For this reason, this instrumentation is
also re erred to as high-speed swept-source OC (Karnowski
et al., 2011). Anterior-segment OC imaging modules also in-
corporate anterior and posterior corneal topography. Commer-
cially available instruments currently include the opcon DRI
OC riton ( opcon Medical Systems Inc.; Fig. 36.25) and the
SS-1000 CASIA OC ( omey Corporation, Nagoya, Japan).
Developments in AS-OC technology have signi cantly
enhanced clinicians’ ability to image the anterior segment and

Fig . 36.25 Top con DRI O CT Triton, Swe p t source O CT. (Co urte sy of
Top con Me d ical Syste ms Inc.)
such devices are rapidly becoming an irreplaceable tool within
clinical practice or those involved in contact lens tting and
anterior-segment disease management.
De t e rminat io n o f Co rne al Thickne ss
Historically, measurement o central corneal thickness was most
commonly used to assess corneal oedema ollowing contact lens
wear and in keratoconic patients both or diagnosis and to mon-
itor the progression o corneal thinning. However, the growth
o re ractive surgery has resulted in an ever-increasing need or
accurate assessment o corneal thickness across the entire cor-
nea. T is thickness measurement is use ul in the diagnosis o
patients at greater risk o developing ectasia (Rad et al., 2004;
Caster et al., 2007), or customized corneal laser treatments
(Reinstein et al., 2012) and in corneal cross-linking surgery
(Padmanabhan and Dave, 2013; Chunyu et al., 2014). In addi-
tion, the importance o corneal thickness in the diagnosis and
ongoing treatment o patients with glaucoma (Lee et al., 2003;
Iester et al., 2009) has resulted in corneal thickness assessment
becoming a routine assessment in clinical practice.
O PTICAL PACHYMETRY
Optical pachymetry is based on the measurement o the apparent
thickness o an optical section o the cornea, and its popularity
is largely based on the commercial availability o a pachymeter
attachment or the Haag–Streit slit lamp. First, a split-image
device is inserted into one eyepiece o the slit lamp. T e method
depends upon the relative rotation o two glass plates, which
are placed one on top o the other. Rotation o the upper plate
moves the upper hal o the image o the cornea with respect to
the xed lower hal . When the endothelium o the upper eld is
aligned with the epithelium o the lower eld, the angle o rota-
tion o the upper plate is read of an externally positioned scale.
36 Diag no st ic Inst rume nt s 343
Fig . 36.26 A comp ute rize d op tical p achyme te r. The p achyme te r is
co nne cte d to a p ote ntiome te r that is d ire ctly linke d to a custom writte n
so tware p rog ram that analyse s the d ata. (Courte sy of Ce ntre for Con-
tact Le ns Re se arch and Vistakon / Johnson & Johnson.)
T is measurement is proportional to the apparent thickness o
the cornea, with true corneal thickness being determined by
means o a conversion table.
Although per ectly acceptable or clinical purposes, the
arrangement described above is too inaccurate or research pur-
poses. A number o modi cations to the technique (Chan-Ling
and Pye, 1994) have resulted in an accuracy o approximately 5
µm being reported. wo such modi cations include the use o
two or our small light sources to ensure that the incident beam is
normal to the corneal sur ace (Mishima and Hedbys, 1968), and
an arrangement whereby the rotation o the glass plate is cou-
pled to a potentiometer such that the angle o rotation is directly
converted into an electrical signal, allowing it to be immedi-
ately input into a computer program (Fig. 36.26). T is enables
more rapid data collection, e cient le management and more
accurate, repeatable data collection. More detailed in ormation
concerning these modi cations and potential errors in optical
pachymetry can be obtained rom other sources (Chan-Ling
and Pye, 1994; Henson, 1996a, 1996b). Optical pachymetry
remains a standard method to determine corneal thickness,
particularly in contact lens studies examining corneal swelling
(Holden et al., 1984; Stapleton et al., 1998; Fonn et al., 1999; Gi -
ord et al., 2011; Agarwal et al., 2012; Moezzi et al., 2015).
ULTRASO NIC PACHYMETRY
With the rapid increase in interest in re ractive surgery and
the knowledge o the impact o corneal thickness on intraoc-
ular pressure readings (Lee et al., 2003; Iester et al., 2009), it
has become necessary or re ractive surgeons to obtain rapid,
repeatable measurements o corneal thickness. In many cases
this measurement is undertaken by support staf , who o en
have minimal slit-lamp skills. T ese actors have resulted in the
development o simpler methods or the assessment o corneal
thickness, and ultrasonic pachymetry has become the method
o rst choice in many practice settings (Rio-Cristobal and Mar-
tin, 2014) and has also been extensively used in a research set-
ting (Gherghel et al., 2004; Javaloy et al., 2004; McLaren et al.,
2004; Swartz et al., 2007; Zhao et al., 2007a; Almubrad et al.,
344 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 36.27 An ultrasonic p achyme te r e valuation. The e ye is anae sthe -
tize d and the p rob e to uche d to the corne a. Re ad ing s are d ig itally re -
cord e d once the ang le o inclination o the p rob e is corre ct.
2011; Williams et al., 2011; Agarwal et al., 2012; Maresca et al.,
2014; Rio-Cristobal and Martin, 2014).
T e ultrasonic pachymeter is based on traditional A-scan
ultrasonography, where the recording is in one dimension
only, as compared with B-scan instruments, which provide a
two-dimensional view o the eye. Ultrasound is transmitted to
the eye rom a transducer. Sound is re ected back to the trans-
ducer rom tissue inter aces, which possess dif erent acoustic
impedances, enabling the distance rom the ultrasound probe
at the anterior epithelial inter ace to determine the distance
between itsel and the endothelium–aqueous inter ace. T e
transducer determines the time dif erence between the pulse
signals obtained at the two inter aces and computes the corneal
thickness based on this time delay and the velocity o sound in
corneal tissue, which is approximately 1580 m / s at body tem-
perature (Chan-Ling and Pye, 1994). A direct measurement o
corneal thickness is then displayed on a digital readout. Prior to
undertaking ultrasonic pachymetry, the cornea is anaesthetized
and the patient is slightly reclined (Fig. 36.27).
Potential sources o error in measuring corneal thick-
ness include holding the probe at an oblique angle to the cor-
nea and measuring away rom the central corneal apex, both
o which would result in elevated readings o central corneal
thickness (because corneal thickness increases rom the centre
to the periphery). T e majority o modern instruments include
a mechanism whereby a reading is not displayed i the probe
is positioned such that there is excessive deviation rom the
perpendicular.
ANTERIO R-SEGMENT O PTICAL CO HERENCE
TO MO GRAPHY (AS-O CT)
T e technology behind AS-OC techniques has been described
previously. Anterior-segment OC provides non-contact
topographic corneal thickness measures and has been exten-
sively used to report central and peripheral total corneal thick-
ness values in normal subjects, diseased corneas, pre- and
post-surgery, epithelial thickness and or those at risk o glau-
coma (Maldonado et al., 2000; Wang et al., 2002; Lee et al., 2003;
Fishman et al., 2005; Leung et al., 2006; Zhao et al., 2007b; Li
et al., 2008; Iester et al., 2009; Prakash et al., 2009; Prospero
Ponce et al., 2009; Dorairaj et al., 2012; Li et al., 2012; Neri
et al., 2012; Qin et al., 2013; Kanellopoulos and Asimellis, 2014)
(Fig. 36.28). AS-OC also permits the measurement o corneal
thickness with a contact lens in situ, making it an accessible pro-
cedure or monitoring corneal swelling in contact lens wearers
(Martin et al., 2007).
SLIT-SCANNING DEVICES
As previously described, in addition to assessing the shape
o the anterior sur ace o the cornea, the Orbscan II instru-
ment determines posterior sur ace shape. Corneal thickness is
determined by calculating the dif erences in elevation between
the anterior and posterior sur aces o the cornea to generate a
pachymetry map (Yaylali et al., 1997; Liu et al., 1999; Auf arth
et al., 2000; Chakrabarti et al., 2001; Rao et al., 2002; Rad ord
et al., 2004; Arce et al., 2007; Ortiz et al., 2014). Central cor-
neal thickness (CC ) measurements using the Orbscan II are
approximately 7% greater than those obtained using the gold-
standard technique, ultrasound pachymetry (Doughty and
Jonuscheit, 2010). As a result, an acoustic actor (AF) can be
applied to the de ault output values so that the CC values
obtained with the Orbscan are in closer agreement with values
obtained using ultrasound pachymetry. A correction actor o
0.92 is the de ault selected by the manu acturer and is applied
to the entire map. However, its use is controversial as it can
cause the CC value to be up to 7% lower than ultrasound
pachymetry (Doughty and Jonuscheit, 2010). As the level o
agreement between ultrasound pachymetry and CC mea-
surements obtained by Orbscan II is limited, several authors
have suggested not applying the AF (Lu et al., 2006; Jonuscheit
and Doughty, 2007; Martin et al., 2011).
SCHEIMPFLUG SCANNING
Scheimp ug cross-sectional imagers such as the Penta-
cam use a rotating Scheimp ug camera to capture a series
o optical cross-sections o the anterior segment, which are
then merged to orm a 3D reconstruction. Pachymetry using
Scheimp ug scanning instruments are obtained rom raw
corneal elevation data. Subsequent analysis o these images
permits assessment o corneal thickness (Barkana et al., 2005;
Lackner et al., 2005; Amano et al., 2006; Fujioka et al., 2007;
Mencucci et al., 2012; Park et al., 2012; Belin and Ambrosio,
2013; Guler et al., 2014; Reddy et al., 2014; Wong et al., 2014).
Several studies have shown good agreement between CC
values obtained with the Pentacam and ultrasound pachym-
etry (Oliveira et al., 2011).
CO NFO CAL MICRO SCO PY
T e con ocal microscope can obtain three-dimensional corneal
data. Using a two-dimensional depth intensity pro le, epithe-
lial and corneal thickness can be estimated by measuring the
distance between peaks corresponding to the epithelial and

Fig . 36.28 Corne al thickne ss e valuation b y AS-O CT. (Imag e courte sy of Nicholas Rumne y.)
Fig . 36.29 Le nStar LS 900 b iome te r. (Co urte sy of Ce ntre for Contact
Le ns Re se arch and Haag -Stre it.)
endothelial layers (Li et al., 1997). T is technique can thus be
used to accurately determine corneal thickness in health and
disease (Javaloy et al., 2004; McLaren et al., 2004; Williams et al.,
2011; Al Farhan et al., 2013; Rio-Cristobal and Martin, 2014).
SPECULAR MICRO SCO PY
T e contact and non-contact specular microscope is able to
determine the location o the epithelium and endothelium.
By determining the distance between these two corneal lay-
ers, the thickness o the cornea can be estimated (Modis et al.,
2001; Zhao et al., 2007a; Hamano et al., 2008; Al-Ageel and Al-
Muammar, 2009; Almubrad et al., 2011).
36 Diag no st ic Inst rume nt s 345
LENSTAR LS 900
T e LenStar LS 900 (Haag-Streit AG, Koeniz, Switzerland) uses
non-contact optical low-coherence re ectometry to provide a
complete biometrical assessment o the patient’s eye in a single
measurement procedure, including keratometry, lens thickness,
anterior-chamber depth (lens position), axial length and retinal
thickness (Buckhurst et al., 2009). It can also provide assessment
o central corneal thickness (Gursoy et al., 2011; Kolodziejczyk
et al., 2011; ai et al., 2013; Bayhan et al., 2014; Borrego-Sanz
et al., 2014; Simsek et al., 2016) (Fig. 36.29).
In summary, many multi unctional devices share simi-
lar eatures and can determine similar physiological param-
eters such as corneal pachymetry. It is important to note that
the values obtained are generally not interchangeable between
instruments.
Co nclusio n
It is clear that the consulting room o the contact lens practitio-
ner will become increasingly sophisticated as the emerging tech-
nologies described in this chapter gain increasing acceptance,
leading to these instruments becoming more af ordable. It is
likely that the af ordability is directly in uenced by the reduced
time taken to t complex lenses such as semiscleral, scleral
and hybrid lenses. Notwithstanding these remarkable develop-
ments, it is likely that observation o the anterior segment using
the slit-lamp biomicroscope will remain the cornerstone appa-
ratus or the investigation, even i not the measurement, o the
contact-lens-wearing eye.
ACKNO WLEDGEMENTS
We would like to thank Luigina Sorbara and Alex Muntz at the Uni-
versity o Waterloo or their assistance with several o the images used
in this chapter.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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37
Pre liminary Examinat io n
ADRIAN S BRUCE

Int ro d uct io n O b je ct ive and Sub je ct ive Re fract io n

T e preliminary examination includes the taking o a ull
history and initial patient assessment (see Chapter 35), ocu-
lar measurements, re raction, slit-lamp biomicroscopy and
additional tests. T e examination enables the practitioner to
advise patients on their suitability or contact lens wear and,
i it is decided to go ahead with lens tting, o appropriate
lens choices. T e in ormation obtained rom the preliminary
examination is vital in the selection o the most suitable lens
type (so , corneal or scleral), replacement requency, wear
modality (daily or extended wear), care system and wearing
time.
T e preliminary examination also orms a baseline or the
monitoring o the patient’s eye condition. Possible clinical ques-
tions include:
1. Whether keratoconus is present and i cross-linking is
necessary.
2. I a corneal gra is showing signs o rejection or whether
the intraocular pressure is increased by steroid treatment.
3. In high myopia, whether there are peripheral retinal
changes or signs o glaucoma.
T is chapter provides an overview o the typical ull routine o
the preliminary contact lens examination, ollowing case his-
tory, and comments on the interpretation o the in ormation
obtained. T e sequence o examination described is shown in
Fig. 37.1. Details o the instrumentation re erred to in this chap-
ter can be ound in Chapter 36.
T e rst phase o the re raction is to undertake preliminary
objective assessment. Digital autore ractors are now being
used more commonly; these devices are combined in a single
instrument that can also per orm tonometry and / or corneal
curvature assessment. A ully objective digital assessment o the
optical quality o the eye requires a wave ront re raction (see
later in this chapter).
T e long-established, skilled art o retinoscopy still has util-
ity in contact lens practice; as well as allowing objective deter-
mination o re ractive status, it also enables the quality o optics
o the eye to be assessed. Possible indications or retinoscopy
include:
• vision with spectacle re raction o less than 6 / 6 (20 / 20)
• astigmatism o higher levels, or changing magnitude or
direction o astigmatism, where keratoconus may be sus-
pected

Me asure me nt o f Visio n
A er the case history, vision is usually the rst measurement
in the preliminary examination. T e initial measurement gives
the habitual vision o the patient, una ected by later test pro-
cedures that use lights or ocular manipulations. An additional
bene t o the baseline measure o vision is or medicolegal
reasons.
T e computer-presented visual acuity chart has advantages
over other types o vision chart or contact lens practice, but
in particular computer-generated optotypes can be random-
ized to prevent the contact lens patient rom learning the letter
sequences at successive visits.
Vision should be measured with and without the habitual
distance spectacles o the patient at both distance and near. T e
level o vision will be use ul in ormation to relate to the history, Fig . 37.1 Flow o the p re liminary e xamination or contact le nse s.
re raction and the binocular vision examination. T e unaided Stand ard p roce d ure s are locate d at the top o the chart and p roce e d
clockwise . More ad vance d te sts such as corne al top og rap hy, wave ront
vision is o interest because patients who are commonly or re raction or corne al tomog rap hy are cond ucte d on ind ication (e .g . p re -
intermittently uncorrected will compare that with the level o vious d iag nostic history, loss o b e st corre cte d visual acuity, scissors re -
acuity they achieve with contact lenses. e x on re tinoscop y or ke y slit-lamp sig ns o corne al irre g ularity).
346
 37 Pre liminary Examinat io n 347

• looking or clues o corneal irregularity, such as a scissors residual astigmatism in rigid lens wear. I the keratometry mires
re ex (Goebels et al., 2015) appear distorted, then irregular astigmatism may be present, i.e.
• pseudomyopia, whereby less minus may be revealed. where the principal axes are not orthogonal.
T e subjective re raction may be best per ormed in a trial rame, Keratometry is a simple, rapid and non-invasive test, but it
since many contact lens patients are young and the trial rame does have some limitations. It measures only central corneal
may be less likely to induce accommodation than the phoropter. radius, it assumes a spherical cornea with regular astigmatism
Even i 6 / 6 (20 / 20) vision is achieved with the patient’s cur- and it has a limited range o powers (36.00–53.00 D). Extreme
rent spectacles or contact lenses, it is use ul to check the subjec- corneal powers can be measured by interposing a −1.00 D lens
tive re raction in each eye or excess minus power that could ( or low corneal powers, i.e. very at corneas) or a +1.25 D lens
account or symptoms unrelated to visual acuity (such as asthe- ( or high corneal powers, i.e. very steep corneas) in ront o the
nopia or binocular vision problems). keratometer. T e keratometer reading is converted to the actual
It is necessary with non-presbyopic patients to adopt a tech- corneal power using tables (Appendix E).
nique with the re raction so as to relax their accommodation. As well as the keratometer, K-readings may also be obtained
Measuring a blur unction is one such method, whereby the rom many autore ractors, as well as with corneal topography
addition o +0.50 D or +0.75 D lenses is expected to almost and tomography (see later in this chapter).
completely blur the 6 / 6 (20 / 20) line.
Slit -lamp Bio micro sco p y
Anat o mical Me asure me nt s In the preliminary examination, biomicroscopy is used to assess
Measurements o the dimensions o anatomical structures o the the health o the anterior eye, and to identi y conditions or ea-
anterior eye should be routinely made or contact lens tting. tures that may be relevant to contact lens wear. It is also important
Because o the di erences in tting characteristics between so to record baseline appearance o the eyes or medicolegal reasons.
and rigid lenses, di erent sets o measurements may be required. Six areas o the anterior eye should be assessed in the pre-
Horizontal corneal diameter is usually between 10 and 13 liminary examination, and any signs should be reconciled with
mm (average about 11.5 mm) (Al onso et al., 2010). A cornea o symptoms and assessment o the corneal curvature (Fig. 37.2).
less than 10 mm may be de ned as microcornea and one greater
than 13 mm as megalocornea. T e cornea reaches adult dimen-
sions by about 2 years o age.
T e pupil diameter is usually between 3 and 6.5 mm under
photopic conditions, and about 5–8 mm under mesopic con-
ditions. Patients with large pupils are usually more sensitive to
re ractive error and even small amounts o corneal irregularity.
For these patients, contact lenses with larger optical zones may
be bene cial.
For rigid lens tting, it is use ul to record the upper and
lower eyelid positions in relation to the cornea. Assessment o
lid geometry assists in the selection o lens diameter and design
or the optimization o lens com ort. Most o en, the upper eye-
lid covers the superior limbus by 1–2 mm, and the lower eye-
lid is very near the in erior limbus (Bruce, 2006). An unusually
high or lower eyelid positions should be noted.
Protocols or anatomical measurement when tting so and
rigid lenses are given in Chapters 7 and 14, respectively.

Ke rat o me t ry
Assessment o corneal shape is a standard part o the contact lens
preliminary examination. Digital topographers that provide a
detailed map o the shape o the cornea are rapidly becoming the
norm in contact lens practice (see below); however, the optical
keratometer can measure the curvature o the principal merid-
ians o the central 3 mm o the cornea, known as K-readings,
which are use ul measures or many aspects o contact lens tting.
For so lens tting, particularly disposable lenses, which
might, or example, be available in only two back optic zone
radii (BOZR), the assessment is o en used simply to iden-
ti y steeper corneas, which require the lens with the steeper
(smaller) BOZR.
In rigid lens tting the K-readings are used directly to select Fig . 37.2 Consid e ratio ns in the asse ssme nt o the ante rior e ye . The re
are six p rimary are as to e xamine with the slit lamp , as we ll as consid e ring
the BOZR o the initial trial lens. T e amount o keratometric corne al shap e and symp toms. (Ad ap te d from Bruce , A. S. & Bre nnan,
astigmatism should be compared with the ocular astigmatism. N. A. (2000). A Guid e to Clinical Contact Le ns Manag e me nt, 3rd e d .
T is identi es lenticular astigmatism, which may be the cause o Duluth, GA: CIBA Vision.)
348 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 37.3 (A) Di use illumination slit-lamp te chniq ue . (B) Di use illu-
mination vie w o the corne a. ((A) Ad ap te d from Jone s, L. W. & Jone s,
D. A. (2001). Slit lamp b iomicro scop y. In N. Efron (e d .) The Co rne a: its
Examination in Contact Le ns Practice (p p . 1–49). O xford : Butte rworth-
He ine mann.)
Characteristics o the normal anterior eye, and the severity
o any abnormalities that are detected, can be recorded with the
assistance o grading scales (see Chapter 39). E ron and McCub-
bin (2007) have demonstrated that e ective grading can be
undertaken in a ew seconds, which means that this important
clinical practice will not consume undue amounts o valuable
chair time.
A normal technique is to use a variety o illumination meth-
ods – such as those described below (Jones and Jones, 2001) –
and cobalt blue light or uorescein staining.
DIFFUSE WIDE BEAM
A di use wide beam is generally used to provide low-magni ca-
tion views o the opaque tissues o the anterior segment, includ-
ing the bulbar conjunctiva, sclera, iris, eyelid margins and the
tarsal conjunctiva o the everted eyelids (Fig. 37.3).
A broad, even illumination over the entire eld o view may
be produced in a variety o ways. Some slit lamps may have a
ground-glass lter placed to di use the ocused light beam o the
slit lamp, others may have a separate bre optic or background
illumination, otherwise the slit-beam intensity is reduced and
opened to ull width.
Unusual clinical signs could involve the bulbar conjunctiva
vasculature, pigmented lesions in the conjunctiva or eyelids,
roughness or opacity o the conjunctiva and abnormal eyelash
position or orientation. Such signs could be indicative o condi-
tions such as trichiasis, bulbar injection, pterygium or papillary
conjunctivitis.
In assessing the eyelid margins, consider the apposition o
the lids and puncta against the globe. Also look or clear glands
near the base o the lashes, and aking or scaling o the eyelid
skin. T ese may indicate the presence o ectropion, blepharitis
or epiphora.
DIRECT FO CAL ILLUMINATIO N
T is describes any illumination technique where the slit beam
and viewing system are ocused at the same location. T e illu-
mination beam is placed at an angle o 30–50° on the side o
the microscope corresponding to the section o the cornea to
be viewed. T is technique is most commonly used or assessing
the transparent tissues o the eye (i.e. the cornea and crystal-
line lens) because the oblique illumination o the tissue creates
a dark background or maximum contrast. ypically a beam
width o 2–3 mm is chosen initially and this may be reduced so
as to bring more contrast (due to less light scatter) to an area o
interest.
Several speci c types o direct illumination are possible,
including parallelepiped, optic section and specular re ection.
Paralle le p ip e d
Using the set-up described above, a 0.1–1.0 mm wide illuminat-
ing beam is swept smoothly over the ocular sur ace (Fig. 37.4),
particularly to assess the ocular media (i.e. the cornea and crystal-
line lens). T e parallelepiped is the most commonly used direct
illumination technique and is employed, or example, to assess
corneal scarring, in ltrates and corneal staining. T e corneal
pro le may show signs o ectasia, thinning or asymmetry. Whilst
scanning the external ocular sur ace, a low-to-medium magni -
cation is initially chosen and the magni cation is increased i any
area o interest needs to be examined more closely.
O p tic Se ction
Once an area or object o interest is located the beam width is
narrowed to approximately 0.02–0.1 mm to take a cross-section
o the corneal tissue. T is provides the ability to assess accu-
rately the location and depth o a lesion within the transparent
tissue layers (Fig. 37.5). ypical uses include assessment o the
depth o a oreign body, location o a corneal scar and determin-
ing whether tissue within an area o staining is excavated, at
or raised.
Sp e cular Re fle ction
T is is a speci c case o a parallelepiped set-up, where the angle
o the incident slit beam is equal to the angle o the observation
axis through one o the oculars. At this angle (typically 30–50°)
the illumination beam is re ected rom the smooth optical sur-
aces o the anterior segment and provides a mirror-like re ec-
tion (Fig. 37.6).
Such specular images occur at every inter ace between tis-
sues o di erent re ractive index. At the corneal endothelium,
the technique may reveal changes such as endothelial blebs,
 37 Pre liminary Examinat io n 349

Fig . 37.4 (A) Paralle le p ip e d slit-lamp te chniq ue . (B) Paralle le p ip e d illumination vie w o the corne a. ((A) Ad ap te d from Jone s, L. W. & Jone s, D. A.
(2001). Slit lamp b iomicroscop y. In N. Efron (e d .) The Corne a: its Examination in Contact Le ns Practice (p p . 1–49). O xford : Butte rworth-He ine mann.)

Fig . 37.5 (A) O p tic se ction slit-lamp te chniq ue . (B) O p tic se ction vie w o a corne al ore ig n-b od y injury. ((A) Ad ap te d from Jone s, L. W. & Jone s,
D. A. (2001). Slit lamp b iomicroscop y. In N. Efron (e d .) The Corne a: its Examinatio n in Contact Le ns Practice (p p . 1–49). Butte rworth-He ine mann. (B)
Courte sy of Pab lo Gili Manzanaro, Bausch & Lomb Slid e Lib rary.)

guttae and polymegethism. T e tear lm lipid layer and the in e-
rior tear meniscus can also be readily examined, as well as the
anterior sur ace o the crystalline lens. I a contact lens is being
worn, ront-sur ace wetting break-up time can be assessed and
the post-lens tear lm status may be evaluated (Little and Bruce,
1994; Hom and Bruce, 2009).
INDIRECT ILLUMINATIO N
T is re ers to any technique where the ocus o the illuminat-
ing beam is lateral or adjacent to the ocal point o the observa-
tion system, although in the same plane. Indirect illumination
techniques are required because light back-scattered rom the
ocular media (such as observed with direct illumination) o en
di ers rom the light orward-scattered or side-scattered by the
same tissues. Evaluation o the ocular media using indirect illu-
mination is more likely to provide in ormation on the visual
e ect or the patient (Pinero et al., 2010).
wo speci c types o indirect illumination are possible: ret-
roillumination and sclerotic scatter.
Re troillumination
T is re ers to the technique o directing light onto the iris,
anterior lens sur ace or undus, in order to back-illuminate the
cornea or crystalline lens. T e angle o the incident slit beam
to the observation axis through one o the oculars is usually
small (10–20°) i the undus is being used, but the angle may be
greater i the iris is used. By lateral movement o the slit beam
in the same ocal plane, the lesion or area o transparent tissue
may be examined.
T e area o interest may be seen against a light background
(direct retroillumination; Fig. 37.7) or a dark background (indi-
rect retroillumination; Fig. 37.8), depending on whether or not
the illumination and viewing systems are coincident. Direct ret-
roillumination is used most o en, whereby corneal or lenticular
opacities will appear dark against a bright eld. T is technique
350 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 37.6 (A) Sp e cular re e ction slit-lamp te chniq ue . (B) Sp e cular re -
e ction vie w o the corne al e nd othe lium. i = ang le o incid e nce ; r = ang le
o re e ction. ((A) Ad ap te d from Jone s, L. W. & Jone s, D. A. (2001). Slit
lamp b iomicroscop y. In N. Efron (e d .) The Corne a: its Examination in
Contact Le ns Practice (p p . 1–49). O xford : Butte rworth-He ine mann.)
is particularly use ul or examining epithelial microcysts, neo-
vascularization, scars, corneal degenerations, iridectomy, pig-
mentary dispersion and cataract.
Scle rotic Scatte r
T is technique is used to investigate any subtle changes in cor-
neal clarity occurring over a large area, such as central corneal
oedema. T e slit lamp is set up or a wide-angle parallelepiped
(45–60°) and the viewing system is ocused centrally. T e beam
is manually o set (‘uncoupled’) and ocused on the limbus. T e
slit beam is totally internally re ected across the cornea and a
bright limbal glow is seen around the entire cornea (Fig. 37.9).
Any speci c area o abnormality, such as a corneal scar, will
interrupt the beam in its passage and produce a light re ection
in the otherwise-dark cornea.
FLUO RESCEIN STAINING
Slit-lamp examination using the vital stain uorescein,
observed in cobalt blue light and a yellow Wratten or Bos-
ton observation lter, allows the assessment o ocular sur ace
de ects and irregularities. T e cornea, bulbar conjunctiva and
tarsal conjunctiva may be assessed. arsal papillae and rough-
ness, as well as a wide variety o corneal changes, such as desic-
cation, may be detected.
Te ar Film Evaluat io n
T ere are six clinical categories o technique or diagnosis o
tear lm impairment (the six Ss) (Mainstone et al., 1996):
1. Symptoms and history – quanti y with the dry-eye survey,
such as that shown in Appendix J.
2. Slit-lamp biomicroscopy – including tear meniscus height
assessment and lipid layer inter erometry in specular re-
ection.
3. ear stability tests – most notably uorescein or non-inva-
sive break-up time. I contact lenses are being worn, tear
stability may be assessed using the specular re ection o
the slit-lamp beam, or using the mires o the keratometer
or topographer (Bruce et al., 2001; Hom and Bruce, 2009).
4. Ocular staining evaluation – in particular using uores-
cein or lissamine green.
5. Lid surfacing assessment – including blink rate and com-
pleteness.
6. ests o tear secretion or quantity – such as the Schirmer
and more recently the cotton thread tests (Zone Quick,
Menicon).
A thorough analysis o symptoms and related history is perhaps
the most important o the above tests, ollowed by di erentia-
tion o the type o dry eye – it o en being an aqueous de ciency
(with reduced tear secretion) or a meibomian gland dys unc-
tion (with coloured lipid layer patterns in specular re ection).
Wave fro nt Re fract io n
I a patient does not achieve 6 / 6 (20 / 20) visual acuity with the
subjective re raction in the preliminary examination, then an
assessment o the wave ront re raction may be help ul. A wave-
ront re ractor (aberrometer) applies a orm o high-resolution
autore raction across the entire area o the patient’s pupil, giving
the wave ront error (WFE) in terms o micrometres o devia-
tion (root mean square [RMS]) rom the ideal wave ront plane.
T e irregular portion o the WFE is termed higher-order wave-
ront error (HO-WFE) – that is, not correctable with a standard
sphero-cylindrical re raction. In the normal eye, the HO-WFE
is usually less than 0.5µm (Bruce and Catania, 2014). T e HO-
WFE is clearly abnormal i in excess o 1.0 µm, such as in ocular
pathologies a ecting the cornea or crystalline lens, or ollowing
eye surgery. Abnormal ocular conditions such as keratoconus
can induce a large HO-WFE, o en in excess o 3.0 µm, which is
particularly attributed to coma (Fig. 37.10). Wave ront re raction
enables a more complete measurement o the patient’s vision.
Co rne al To p o g rap hy
Corneal topography projects a set o illuminated concentric
rings (Placido disc) onto the cornea, enabling most o the cor-
neal sur ace to be measured. Especially in the assessment o
Fig . 37.7 (A) Dire ct re troillumination slit-lamp te chniq ue . (B) Ve sse ls vie we d b y d ire ct re troillumination ag ainst the b rig ht iris in the b ackg round . ((A)
Ad ap te d from Jone s, L. W. & Jone s, D. A. (2001). Slit lamp b iomicroscop y. In N. Efron (e d .) The Corne a: its Examination in Contact Le ns Practice (p p .
1–49). O xford : Butte rworth-He ine mann. (B) Courte sy of Patrick Caroline , Bausch & Lomb Slid e Lib rary.)

Fig . 37.8 (A) Ind ire ct re troillumination slit-lamp te chniq ue . (B) Dimp le ve iling vie we d b y ind ire ct re troillumination ag ainst the d ark p up il in the b ack-
ground . ((A) Ad ap te d from Jone s, L. W. & Jone s, D. A. (2001). Slit lamp b iomicroscop y. In N. Efron (e d .) The Corne a: its Examination in Contact Le ns
Practice (p p . 1–49). O xford : Butte rworth-He ine mann. (B) Courte sy of Sylvie Sulaiman, Bausch & Lomb Slid e Lib rary.)

Fig . 37.9 (A) Scle rotic scatte r slit-lamp te chniq ue . (B) Ce ntral corne al oe d e ma vie we d using scle rotic scatte r. ((A) Ad ap te d from Jo ne s, L. W. &
Jone s, D. A. (2001). Slit lamp b iomicroscop y. In N. Efron (e d .) The Corne a: its Examination in Contact Le ns Practice (p p . 1–49). O xford : Butte rworth-
He ine mann. (B) Courte sy of Patrick Caroline , Bausch & Lo mb Slid e Lib rary.)
352 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 37.10 Ke ratoconus in the rig ht e ye o a 20-ye ar-old man. (A) Corne al top og rap hy map sho wing an ap ical p owe r o 65 D. (B) HO -WFE map or
a 6 mm p up il, with total hig he r ord e r o 2.928 µm; total coma 2.087 µm; (Ad ap te d from Bruce , A. S. & Catania, L. J. (2014). Clinical ap p lications of
wave front re fraction. O p tom Vis Sci., 91, 1278–1286.)
conditions such as keratoconus or a er surgery, it is pre erable
to use corneal topography in order to gain a comprehensive
appreciation o the shape o the cornea (see Chapter 36).
With corneal topography, keratoconus is indicated i one or
more o the ollowing observations are ound:
• a di erence in corneal power o ≥1.50 D at locations 3 mm
above and below the visual axis
• an apical corneal power ≥47.00 D
• interocular asymmetry in apical corneal power ≥1.00 D
(Bruce and Bohl, 1992).
Corneal topography maps may be displayed in a number o
ways. T e most common ormat is known as the axial (sagit-
tal) map, where all curvatures are calculated in re erence to the
visual axis o the patient. Axial maps are use ul in the diagnosis
o a range o corneal conditions (Fig. 37.11).
A tangential (instantaneous) map provides a more accurate
guide to corneal topography. angential maps are based on local
curvature at each corneal point and more sensitive or detecting
localized changes (e.g. keratoconus, postsurgical). In addition,
tangential maps show the true position o the corneal apex and
will correspond to a rigid lens uorescein pattern.
Co rne al To mo g rap hy and Pachyme t ric
Map p ing
Corneal tomography is a three-dimensional reconstruction o
the cornea, including anterior and posterior sur ace elevation
analysis, pachymetric mapping and anterior corneal topogra-
phy. Corneal tomography gives the most comprehensive assess-
ment or ocular pathologies a ecting the cornea or ollowing
eye surgery. Most instruments also allow anterior chamber
assessment or glaucoma and the Scheimp ug-based instru-
ments can image the crystalline lens.
Corneal tomography results are typically presented in a
‘Quad-map’ ormat, with a particular emphasis on the elevation
and pachymetry data, but also including an axial (sagittal) or
re ractive curvature map or re erence (Fig. 37.12). By show-
ing the di erent analyses together, it is possible to understand
the entire three-dimensional reconstruction o the cornea. In
order to make it easier or the clinician to understand corneal
elevation data, both the anterior and posterior corneal sur ace
elevation data are presented in comparison to a re erence shape,
usually a best- t sphere (Belin and Khachikian, 2010). T e ante-
rior elevation map and the best- t sphere data are also available
on many Placido topographers and can be used as a guide or
rigid lens tting.
O p ht halmo sco p y
An ocular undus exam is a routine part o an initial patient
examination or screening ocular disease. Examination o the
ocular media in retroillumination with a +10.00 D lens addi-
tion to the ophthalmoscope also shows cataract or corneal
abnormalities.
A mydriatic undus examination is o en bene cial, enabling
assessment o the optic disc with stereopsis and visualization
o the retinal periphery. Mydriasis may also be used i there is
a reduction in visual acuity, or symptoms o ashes or oaters,
among other indications.
Bino cular Visio n Asse ssme nt
Contact lens wear may exacerbate the e ect o a pre-existing
accommodation or convergence insuf ciency; the optical basis
or this is explained in Chapter 3. In essence, there may be di -
erences in vergence and accommodation demand between
contact lenses and spectacles. In higher degrees o myopia, the
contact lenses can require greater accommodation and conver-
gence by the wearer or near activities. Depending upon age,
the patient may also need to be advised that a near correction is
required at an earlier age.
I the patient has pre-existing symptoms o dif culty with
near vision, then accommodation and vergence per ormance
should be assessed. Measures should be compared with age
norms or accommodative amplitude, near point o conver-
gence, distance and near heterophoria, relative near accommo-
dation and vergence reserves at near.
 37 Pre liminary Examinat io n 353

Fig . 37.11 Examp le s o corne al top og rap hy using the Unive rsal Stand ard Scale (Smole k e t al., 2002). The scale hig hlig hts ab normally ste e p curva-
ture s using the colour cod ing o re d or white . Instantane ous (tang e ntial) corne al top og rap hy map s in the rig ht column show imp rove d d e f nition o
are as o ste e p e ning , p articularly or cond itions urthe r rom the ce ntral axis such as the p e llucid marg inal d e g e ne ration.
354 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 37.12 Corne al tomog rap hy q uad -map re p ort or a p atie nt with mild –mod e rate ke ratoconus (me an-K o 50.7 D). The e ctasia is e vid e nt in all our
map s, b ut p e rhap s most in the p oste rior corne al e le vation map (up p e r rig ht) and corne al p achyme try map (lowe r rig ht).
Sup p le me nt ary Te st s
T ere are a number o tests that will not be routinely conducted
on all contact lens patients, but may be per ormed on indication.
CO RNEAL SENSITIVITY
I there is reason to suspect that the patient may have anaesthetic
corneas, then corneal sensitivity should be assessed. Possible indi-
cations could be a history o ocular surgery or corneal in ection.
Sensitivity may be simply checked clinically, using a wisp o ster-
ile cotton wool touched to the cornea. Approach rom the side,
so that the patient does not see it coming, and avoid touching
the lashes. A normal blink re ex should result rom touching the
cotton wool to either the corneal apex or limbus. A more sophis-
ticated technique – the Cochet-Bonnet aesthesiometer – can be
used to quanti y the extent o the de cit o corneal sensitivity.
VISUAL FIELDS
esting o visual elds should be conducted i the patient has
peripheral vision symptoms, i there are questionable undus
signs or i there is an unexplained reduction in acuity. Contact
lenses can improve or restrict the visual eld, depending upon
the type. For example, contact lenses can remove the mid-
peripheral scotoma associated with spectacles in hyperopia.
TO NO METRY
Whether the measurement o intraocular pressure is carried out
routinely on patients under 40 years o age, or only on indica-
tion, will vary between di erent clinical situations. Although
the onset o glaucoma typically occurs in patients over 40 years
o age, the clinical examination o a younger patient that reveals
extensive optic disc cupping in relation to overall optic disc size,
or asymmetry o cupping (di erence 0.2), may be an indication
or per orming tonometry.
STEREO PSIS
Measurement o stereopsis is indicated when binocularity is
particularly important to contact lens wear. A good example is
contact lens monovision correction or presbyopia, where the
monocular near-vision correction can disrupt binocularity. A
test o stereopsis can quanti y the extent o this disruption (Col-
lins and Bruce, 1994).

CO LO UR VISIO N TESTING
Red–green colour de ciencies occur in an estimated 8% o male
and 0.5% o emale patients. It may be worthwhile assessing
colour vision at least once in all contact lens patients.
Co nclusio n
T e preliminary examination o a prospective contact lens
patient is in many respects similar to that which would be
conducted on any healthy patient seeking a general eye exami-
nation. Perhaps the key distinction is that, in the case o a con-
tact lens patient, consideration is being given to prescribing a
37 Pre liminary Examinat io n 355
device that will come into direct contact with the ocular tis-
sues. In this regard, a thorough examination with the slit-lamp
biomicroscope is perhaps the cornerstone o the preliminary
examination. More advanced assessments may be indicated i
the visual acuity is abnormal, or i there is a history or signs
o conditions such as corneal ectasia or surgery. Certainly,
the in ormation obtained at this initial visit is o paramount
importance because it will provide the baseline ndings
against which all uture observations o the e ects o lens wear
will be assessed.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
REFERENCES
Al onso, J. F., Ferrer-Blasco, ., González-Méijome,
J. M., et al. (2010). Pupil size, white-to-white cor-
neal diameter, and anterior chamber depth in pa-
tients with myopia. J. Refract. Surg., 26, 891–898.
Belin, M. W., & Khachikian, S. S. (2009). An intro-
duction to understanding elevation-based topog-
raphy: how elevation data are displayed – a review.
Clin. Exp. Ophthalmol., 37, 14–29.
Bruce, A. S. (2006). Gas-permeable lens tting and
eyelid geometry [CD-ROM]. In M. Hom, & A. S.
Bruce (Eds.), Manual of Contact Lens Fitting and
Prescribing with CD-ROM (3rd ed.). Boston, MA:
Butterworth-Heinemann Elsevier, pp159-165.
Bruce, A. S., & Bohl, G. N. (1992). opographic
modelling system in assessment o keratoco-
nus. Clin. Exp. Optom., 75, 149–152.
Bruce, A. S., & Brennan, N. A. (2000). A Guide to
Clinical Contact Lens Management (3rd ed.).
Duluth, GA: CIBA Vision.
Bruce, A. S., & Catania, L. J. (2014). Clinical applica-
tions o wave ront re raction. Optom. Vis. Sci., 91,
1278–1286.
Bruce, A. S., Golding, . R., & Mainstone, J. C.
(2001). Analysis o tear lm breakup on eta lcon
A hydrogel lenses. Biomaterials, 22, 3249–3256.
Collins, M. J., & Bruce, A. S. (1994). Factors in u-
encing per ormance in monovision. J. Br. Contact
Lens Assoc., 17, 83–89.
E ron, N., & McCubbin, S. (2007). Grading contact
lens complications under time constraints. Op-
tom. Vis. Sci., 84, 1082–1086.
Goebels, S., Käsmann-Kellner, B., imo Eppig, ., et al.
(2015). Can retinoscopy keep up in keratoconus di-
agnosis? Cont. Lens Anterior Eye, 38, 234–239.
Hom, M. M., & Bruce, A. S. (2009). Prelens tear sta-
bility: relationship to symptoms o dryness. Op-
tometry, 80, 181–184.
Jones, L. W., & Jones, D. A. (2001). Slit lamp bio-
microscopy. In N. E ron (Ed.), T e Cornea: its
Examination in Contact Lens Practice (pp. 1–49).
Ox ord: Butterworth-Heinemann.
Little, S. A., & Bruce, A. S. (1994). Hydrogel (Acu-
vue) lens movement is in uenced by the postlens
tear lm. Optom. Vis. Sci., 71, 364–370.
Mainstone, J. C., Golding, . R., & Bruce, A. S.
(1996). ear meniscus measurement in the diag-
nosis o dry eye. Curr. Eye Res., 15, 653–661.
Pinero, D. P., Dolores Ortiz, D., & Alio, J. L. (2010).
Ocular scattering. Optom. Vis. Sci., 87, E682–
E696.
Smolek, M. K., Klyce, S. D., & Hovis, J. K. (2002). T e
universal standard scale. Proposed improvements
to the American national standards institute (ANSI)
scale or corneal topography. Ophthalmology,
109, 361–369.
355.e 1
38
Pat ie nt Ed ucat io n
SARAH L MO RGAN

Int ro d uct io n he delegation o this role requires care ul selection o per-

T e quality o instruction and advice given to a patient contrib-
utes to the success or ailure o the new wearer (Ettinger, 1993).
T ere ore, the importance o the dispensing visit should not be
underestimated, and this chapter covers some o the key aspects
o this activity.
O BJ ECTIVES
Proper and care ul tuition o a patient at a dispensing visit will
acilitate con dent lens handling by the patient and will help to
nurture a sound appreciation o how lenses should per orm and
how to manage various situations that can arise in contact lens
wear. Certainly, poor patient education can result in premature
discontinuation rom lens wear and increase the likelihood o
unscheduled visits to the practice.
T e dispensing visit seeks to:
• teach the patient the correct methods o lens application
and removal
• explain the methods that optimize lens com ort, such as
understanding when a lens is inside out or the removal o
post-lens debris
• in orm the patient about the likely adaptation issues that
may be encountered
• outline the correct use o the prescribed care regimen.
sonnel who can be relied upon to provide accurate in orma-
tion to the patient and re er back to the practitioner when
necessary (Morgan, 2008).
THE TEACHING AREA
Patients who have elected to wear contact lenses are o en
apprehensive about the process o lens application and removal.
For this reason, the teaching room should be o a com ortable
temperature and well ventilated, as many patients become quite
anxious in their rustrations i they do not apply the lens on the
rst attempt. T e area should be reasonably private – perhaps
screened o rom the rest o the practice – and it is essential that
the instructor and the patient are ree rom incidental interrup-
tions. Patients require care ul attention when they rst handle
lenses, and the instructor must not be taken away or distracted
rom this supervisory task.
Good lighting is important, along with suitable seating or
both the patient and the instructor, as exibility to be able to sit
on each side o the patient is needed (Fig. 38.1).
T e patient’s chair should be set at a desk such that the
patient’s knees can t com ortably under the desk. T is is help-
ul i the patient accidentally drops the lens during handling.
ACCO UTREMENTS

TIMING An illuminated, double-sided (with one side that magni es),

height-adjustable and tilting mirror is ideal. T e teaching area
T e availability o diagnostic lens banks has negated the need must be prepared in advance o the lesson, so that all the ollow-
or individual lens ordering (with the exception o more spe- ing necessary items are to hand:
cialized lenses such as so toric lenses and the majority o rigid
lenses) and has made both the tting and dispensing appoint-
ment possible on the same day. Some patients are so motivated
ollowing their rst experience o contact lens wear that the dis-
pensing can take place immediately a er the initial trial tting.
On the other hand, rescheduling the dispensing visit or another
day has the bene ts o giving the patient a break a er the tting
visit, and allows the patient to read through some preliminary
literature about the contact lenses.

Cre at ing t he O p t imum Te aching

Enviro nme nt
A trained member o support sta rather than the practi-
tioner commonly adopts the teaching role; this person is
sometimes re erred to as the contact lens hygienist. Having
a trained member o the support sta undertaking this task
can have several advantages. Some patients eel pressured to Fig . 38.1 The te aching are a should b e we ll illuminate d , with se ating
have to ‘per orm’ in ront o the practitioner whereas they for b oth p atie nt and instructor and with all ne ce ssary accoutre me nts im-
may eel more relaxed with a member o the support sta . me d iate ly to hand .
356
 38 Pat ie nt Ed ucat io n 357

• contact lenses – cross-checked with the record card and
spectacle prescription
• lens case – which may be supplied with the solutions
• trial pack o solutions* – suf cient or the needs o the pa-
tient until the rst scheduled a ercare visit (*check expiry
date)
• additional solution – or rinsing during the lesson
• com ort drops – to help alleviate any ocular discom ort
• box o tissues – with a spare box available
• handwashing acilities – soap (in pump dispenser) and
lint- ree paper towels
• mirror as described above – cleaned and ree rom nger-
prints
• appropriately sized bag – or the patient to carry away
lenses, solutions and accompanying literature.
Pat ie nt Inst ruct io n
Contact lens handling can be a very rustrating experience or
the novice patient. Accordingly, patience and communication
skills are the most critical personality traits o the member o sta
chosen to instruct contact lens patients. T e instruction session
should not be rushed, and the patient should eel com ortable
asking questions. A good technique is to alternate the practical
side o lens application and removal with verbal advice on the
wear and care o the lenses (e.g. care, product use, and do’s and
don’ts). When suitable, coloured or iris-enhancing disposable
so contact lenses should be considered or use during the tuition
appointment, and perhaps the rst ew days o wear, as they pro-
vide additional visibility and reassurance o on-eye lens location.
In order to take control o your right upper lid, look down-
wards so that the whole o the upper lid is exposed. Next,
bringing your le hand vertically over your orehead, place
the f ngertip o your middle f nger on your lid margin close
to the eyelashes and gently draw the lid upwards and hold it
against your brow bone (Fig. 38.2).
Now look straight into the mirror, and place the middle f nger
o your right hand on the middle o your lower lid and gen-
tly retract the lower lid (Fig. 38.3). (T is urther increases
the palpebral aperture and helps to stabilize the hand ap-
plying the lens.) T e oref nger o your right hand is then
ree to apply the lens directly onto your eye.
Once the patient has mastered lid manipulation, lens han-
dling can be taught.
LENS INSPECTIO N
Practitioners routinely inspect lenses prior to application or
evidence o lens damage, debris and whether a so lens is inside
out or not. Patients need this basic level o instruction, even to
the level o detail o explaining how to remove the lens rom the
lens packaging and also how to replace and remove a lens care-
ully rom the lens case to avoid lens damage; this is particularly
relevant to basket-style cases or so lenses, which clip shut, and

HAND GRO O MING AND HYGIENE

T e nails o all ngers that are likely to be involved in lens manip-
ulation should be cut short and led smooth to avoid both lens
damage and the potential or corneal insult. It is imperative that
the importance o handwashing (and drying) prior to lens han-
dling is rein orced throughout the instruction phase. T e best
way o achieving this without appearing to be patronizing to the
patient is or the instructor to wash his / her hands prior to lens
handling, in ull view o the patient. A very brie explanation as
to why this is so important – the prevention o lens contamina-
tion and reducing the risks o in ection – can be given to the Fig . 38.2 Taking control of the up p e r lid .
patient. T e patient can then be invited to wash his / her hands.
At all uture instruction or a ercare visits, patients should be
prompted to wash their hands i they orget to do this be ore
proceeding to handle lenses.

LID MANIPULATIO N
ouching the eye area can be awkward or many patients. T e
patient must rst practise how to overcome the natural blink
re ex, and this can be achieved by way o a ‘dry run’, in that the
patient is not handling the lens at rst. It is usual or the instructor
to per orm each part o the handling process be ore the patient
tries. E ective upper-lid control is crucial to lens application.
Most patients will pre er to apply lenses onto each eye using
the same hand, whereas some will use the right hand to apply
the right lens and the le hand to apply the le lens. Consider,
by way o example, a ‘dry run’ or lens application onto the
right eye with the right hand. T e patient is given the ollowing Fig . 38.3 With b oth lid s re tracte d the p atie nt is re ad y to ap p ly the
instructions: le ns.
358 PART 6 Pat ie nt Examinat io n and Manag e me nt

barrel cases with lens supports or rigid lenses. Patients need

reassurance that a so contact lens applied inside-out is not
harm ul, but such a lens may be slightly uncom ortable and may
be prone to move excessively, which in turn can a ect vision
per ormance and in some cases cause the lens to be blinked out.
For the experienced contact lens practitioner, care ul passive
inspection o the lens on the tip o the nger will reveal whether
the lens is inside out or not. However, or the novice, assessing
so lens inversion can be dif cult. An active approach can be
more enlightening; the lens is allowed to dehydrate or a ew
seconds, and then, with the lens placed in the crease o the palm
o the hand, the lens edges are moved together by cupping the
hand as i intending to old it in hal – this is called the ‘taco test’,
as a lens that is the right way around curls up rather like a taco
shell. I the lens edges appear to curl towards each other, the
lens is the right way around (Fig. 38.4A), and i the edges appear
to curl outwards, the lens is probably inside out (Fig. 38.4B).
ypically, a practitioner would utilize this technique by placing
the lens on the tip o the nger; however, by de nition, a new
wearer nds lens manipulation a challenge so the hand tech-
nique is both easier to teach and more practical or the patient.
It may be necessary to invert the lens repeatedly in order to
con rm this; the drier the lens becomes, the more apparent the
inversion status o the lens will be. For the novice wearer, the
instructor may deliberately ask the patient to rst apply one
lens the correct way around, and then the other lens inside out,
asking the patient to comment on the di erence. T is serves
as a good demonstration o the di erence in sensation rom
an inside-out lens to a lens placed the correct way round – the
direct comparison may be needed or the patient to appreci-
ate the di erence. New wearers may consider themselves to be
‘unsuitable’ or contact lenses i they intermittently apply one or Fig . 38.4 A simp le te chniq ue for che cking whe the r a soft le ns is in-
ve rte d . (A) Rig ht way; (B) wrong way.
both lenses inside out during their rst ew days o lens wear.
Attention to teaching lens inversion, as well as proactively dem-
onstrating the sensation o an inverted lens, may help to reduce
drop-out rates at this early stage. to the lens being ejected owing to air trapped behind the lens.
Some manu acturers mark their lenses with an inversion T e instructor should sit beside the patient rather than across
indicator. When viewed rom a designated aspect, letters or a the desk because, rst, this is less con rontational, and second,
number sequence can be observed in the correct orientation. a better view o the actions o the patient is possible. When the
I the lens is inverted, the letters or number sequence will be right lens is applied and removed, the instructor should sit on
reversed (incorrect) when viewed rom the same aspect. Patients the right side o the patient and vice versa. T e patient should be
should be advised o any other markings on the lenses, and their directed to apply the lower edge o a so contact lens to the area
purpose i known (such as toric lens scribe marks) so that they 1–2 mm below the limbus at an angle o 45°, having vaulted the
are aware that these eatures are meant to be present on the lens lower lid (Fig. 38.5).
and are not a hair or de ect. Once contact with the tear lm has been made, the contact
When handling lenses, the ore nger applying the lens needs lens is attracted to the cornea. I there are any air bubbles under-
to be as dry as possible. On removing the lens rom the case or neath the lens, these can be overcome by the patient looking
packaging, it should be placed in the palm o the opposite hand downwards and slowly releasing the upper lid whilst still look-
to help drain o excess solution. T e lens can then be ‘scooped ing down and then closing the eye tight so as to squeeze out the
up’ rom the palm by the side o the ngertip o the ore nger remaining air.
with some aid rom the ore nger and thumb o the opposite A rigid lens, being o smaller diameter, is easier to apply,
hand. issues on the desk – pre erably lint ree – can be used and its shape remains consistent throughout handling. Rigid
to dab the ore nger dry during this process. In the case o so lenses should be placed directly onto the central cornea as
lenses, the lens may need to be li ed o the ore nger to dry the ailure to do so can lead to the lens being displaced onto the
ngertip so as to prevent the lens rom sagging back over a wet conjunctiva.
ngertip owing to sur ace tension. T e complete circum erence Some patients have exibility problems with their arms
o the lens should be sitting proud o the nger. and / or hands, so common-sense adaptations to the usual rec-
ommended approach will need to be made. For example, one-
LENS APPLICATIO N handed application can be achieved with the patient dipping
the chin towards the chest and looking upwards into the mirror.
So lens application requires a slow-motion approach. T e T is serves to provide a larger area in erior to the limbus on
patient must not release the upper lid too soon, as this can lead which to apply a so lens, and the lens, once applied, can be

Fig . 38.5 The le ns is b e st ap p lie d at an ang le of 45° to the corne a.
Fig . 38.6 O ne -hand e d le ns ap p lication.
manipulated into place. A rigid lens can be applied directly onto
the cornea using this method (Fig. 38.6).
Having applied the lens, the patient can check that it is in
position by covering the other eye and checking that vision is as
clear as expected. For patients wearing monovision correction,
the near lens should be applied rst so that application o the
distance lens is easier. In other cases, developing a habit o han-
dling the right lens rst or both application and removal helps
to avoid mixing up the two lenses.
TIPS O N CO MFO RT AND LENS RECENTRING
Contact lenses can attract debris during lens preparation prior
to application and wearers can experience some mild lens
awareness. In the case o so lenses, sliding the lens temporally
onto the conjunctiva can relieve this (Fig. 38.7).
38 Pat ie nt Ed ucat io n 359
Fig . 38.7 Disp lacing a soft co ntact le ns late rally is a use ful te chniq ue
for re moving d e b ris from b e hind the le ns.
For the right eye, the patient looks directly into the mirror and
turns the head to the right whilst maintaining a straight-ahead
gaze. T is helps to expose a large area o temporal conjunctiva
onto which the lens can be displaced. Using the right hand, the
patient displaces the in erior lid slightly with the middle nger
and slides the lens completely o the cornea and onto the tem-
poral conjunctiva using the ore nger. T e patient will usually
experience instant relie rom any previous oreign-body sensa-
tion. At this point, the patient blinks three to ve times, which
washes the tear lm over the cornea, thereby displacing any
unwanted debris. T e lens can be manually repositioned onto
the cornea, or alternatively the patient can look temporally with
a couple o blinks, which will achieve the same result. I this type
o discom ort is experienced on application o a rigid lens, the
lens should be removed, rinsed and reapplied. With so lenses,
i a oreign-body sensation persists a er this technique has been
tried, the lens should be removed, rinsed and inspected or any
signs o damage; the lens can then be reapplied i all looks well
(or replaced i damaged).
I a rigid lens is decentred rom the cornea onto the con-
junctiva, the patient must attempt to manoeuvre the lens onto
the cornea by holding the upper and lower edges o the lens
through the lids and gently li ing the lens edges to allow tears
to ow underneath the lens, which in turn helps to release the
lens and allows manipulation back onto the cornea. Locating
the lens in the rst instance may require care ul observation
using the mirror as well as li ing the upper lid to investi-
gate whether the lens has been displaced vertically. T is is a
good moment to in orm the new wearer that contact lenses
can never ‘disappear behind the eyes’ and ‘ oat into the brain’,
which is a commonly held misconception requiring reassur-
ance, anatomical in ormation and education. T e instructor
should explain that a lens can move only under the upper lid
(the most common place or a lens to ‘disappear’) or perhaps
behind the lower lid. Most rigid lenses can be elt through the
lid because o their rigidity, whereas so lenses can be more
dif cult to locate, especially i they have olded in hal be ore
being swept up under the upper lid. T e instillation o com-
ort drops may suf ce, or saline solution (via an eye bath) can
be help ul in releasing lenses in this situation. Comparing the
ront aspect o the eye to a ‘pocket’ is a good analogy to use,
which serves to convince the patient o the very limited range
o displacement o the lens.
360 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 38.8 A soft le ns should b e d isp lace d d ownward s p rior to re moval.
Fig . 38.9 Soft le ns re moval.
LENS REMO VAL
Whilst so lenses are more dif cult to apply than rigid lenses,
they can be easier to remove. So lens removal must be achiev-
able in any situation, so it is recommended that patients learn
how to remove lenses without the aid o a mirror. T e chance
o causing a corneal abrasion on lens removal must be given
consideration; thus, removal o so lenses rom the more resil-
ient conjunctiva is pre erable. T e back sur ace o a so lens is
designed to align closely with the cornea, so displacing the lens
onto the conjunctiva helps to loosen the attachment o the lens,
thereby aiding removal.
o remove a so lens rom the right eye, the patient rests the
middle nger o the pre erred hand on the lower-lid margin,
displacing it away rom the globe slightly, looks upwards and
then slides the lens downwards onto the in erior conjunctiva
using the ore nger (Fig. 38.8).
Whilst still touching the lens with the ore nger, the thumb
o the same hand can be brought in to pinch the lens o the con-
junctiva, thereby completing lens removal (Fig. 38.9).
Sometimes a ew attempts are necessary with instructor
guidance until the patient becomes aware o the sensation o
Fig . 38.10 The b link te chniq ue for rig id le ns re moval.
Fig . 38.11 The two-hand e d te chniq ue for rig id le ns re moval.
lens displacement and o gripping the lens between the thumb
and ore nger.
T e technique or rigid lens removal is patient dependent.
Some patients can more easily spring the lens out using their
lids; others, however, need to employ a di erent method.
The Blink Te chniq ue
T is technique utilizes the natural narrowing o the palpebral
aperture and lid margin tension to get behind the lens to ‘ ip’ it
out (Fig. 38.10).
With this technique, the patient rst stares very wide to
ensure the lid margins are beyond and not over the lens edge.
T e eye o the patient needs to be as central as possible in the
palpebral aperture to achieve this. T e patient then places the
ore nger only on the outer canthus whilst pulling temporally
to make the lids taut. Once the patient eels the edge o the lens,
a orce ul blink may ip the lens out. Sometimes it is necessary
or the patient to look slightly nasally in order to position the
cornea and lens in an area o narrower aperture.
The Two-hand e d Te chniq ue
T is method involves manually tensioning the lids against the
lens edge (Fig. 38.11).

For the right eye, the patient positions the ore nger o the
le hand on the middle edge o the upper lid and the ore nger
o the right hand on the middle edge o the lower lid. T e lids
are rst moved apart to ensure that the lens is ree to move, and
they are then moved into the globe to tighten against the lens
edge. Slightly more pressure is applied to the upper lid in order
to ip the lens out over the lower lid with the top o the lens
being released rst. Care must be taken that the lens edge is not
orced into the cornea itsel .
Suction Hold e rs
Special rigid lens suction holders are available, although these
have three key disadvantages:
1. I patients are able to remove the lens only with the aid o
this device, they will be unable to remove the lens in an
emergency without it
2. An inexperienced wearer may ail to attach the suction
holder to the lens and bring the holder in contact with
either the cornea or conjunctiva
3. Proper hygiene o the suction cup is required: it may be an
additional source o contamination o the contact lenses
(Boost and Cho, 2005).
In these respects, the use o suction holders is not advocated.
Patients must be able to remove their contact lenses sa ely
be ore taking them away. For new wearers, per orming this rou-
tine three times is recommended. For existing wearers new to
the practice or having been tted with a new lens with subtly
di erent handling characteristics, demonstrating the estab-
lished technique once usually suf ces. Some practitioners,
when re tting patients who are new to the practice, assume
that they ollow a good routine with respect to lens wear and
care. It may be prudent in an age o litigation that all patients
undergo some degree o in-practice training as well as signing
an in ormed consent orm so that there is a written record that
the patient understands the correct protocols or lens wear and
care. Periodically, all established lens wearers may be updated
in this way to ensure they are aware o current advice and the
recommended practice protocols.
CARE PRO DUCTS
T e ull care regimen should be demonstrated rom start to
nish, explaining why each step is necessary as well as what
could happen i the routine is not strictly adhered to. T e
patient should be handed written in ormation about the care
products being dispensed; this may be in ormation that is sup-
plied by the manu acturer and / or material prepared by the
practitioner.
Having applied and removed lenses a couple o times,
the patient may appreciate a com ort drop in each eye. T is
serves to demonstrate the bene t o ocular lubricants as well
as teaching the patient how to instill com ort drops when
wearing lenses. Instances in which com ort drops provide
symptomatic relie – such as during prolonged near work
when blink rates are reduced, and in dry atmospheres (e.g.
during ights) – can be discussed. T e dangers o using tap
water and saliva as rewetting agents can be outlined (Shovlin,
1990), as well as the appropriateness or otherwise o using
prescribed and over-the-counter eye drops when wearing
lenses. Patients should be aware that persistent lens discom-
ort should not be ignored, and that lens removal is indicated
in this instance.
38 Pat ie nt Ed ucat io n 361
CO SMETICS
For contact lens wearers using cosmetics, advice rom the prac-
titioner about their sa e use should be given. Contact lenses can
readily become soiled or damaged as a result o contamination
rom various cosmetic products ( lachac, 1994). Also, some
make-up removers and waterproo mascaras can change the
shape and optical per ormance o some silicone hydrogel lenses
(Luensmann et al., 2015) and some mascaras can deposit on the
sur ace o silicone hydrogel lenses and reduce lens sur ace wet-
tability (Srinivasan et al., 2015), which could have an impact on
various aspects o in vivo lens per ormance.
Some tips or cosmetic use by lens wearers (Association o
Contact Lens Manu acturers, 2009):
• Always wash your hands be ore handling your lenses;
avoid per umed or medicated soaps.
• Apply your contact lenses be ore applying make-up. T is
will help you to see what you are doing while applying
your cosmetics.
• Close your eyes when applying loose powder, to keep it
rom getting in your eyes.
• Stay away rom make-up and cleansers that can leave a
greasy lm on lenses. T e same goes or hand creams and
lotions; put these on a er handling your lenses.
• Avoid using ‘lash extender’ mascaras, as they contain -
bres that can ake o and get into your eyes, causing pos-
sible irritation.
• Cream or liquid blushers, eyeshadows and eyeliners are
pre erable since they do not contain gritty substances that
can irritate your eyes. I you use powdered eyeshadow,
make sure to apply it with a wet applicator. Do not use
rosted shadows, as they contain tinsel, an ingredient that
will stain your lenses.
• Never apply your eyeliner on the inside part o your lid. It
could get on your contact lenses, blurring vision and ir-
ritating your eyes.
• Look out or cosmetics designed especially or contact lens
wearers.
• It is best not to use hairsprays and other aerosol products
a er applying your lenses. I you nd it necessary to apply
hairspray when you are wearing lenses, close your eyes.
• Store your make-up properly, making sure lids are tightly
sealed. Replace mascara and applicators at least every 3
months to avoid bacteria build-up.
WEARING SCHEDULES
In the past, all patients were advised to adopt a wearing schedule,
which means progressively increasing lens wearing time when
wearing lenses or the rst time, or a er not having worn lenses
or a prolonged period. T e said purpose o advising adherence
to a wearing schedule was to allow patients to adapt to lenses.
Failure to adapt to early-generation, low-oxygen-per ormance
polymethyl methacrylate (PMMA) and thick so lenses – by
exceeding the adaptation wearing schedule – resulted in wors-
ening discom ort and red and watery eyes towards the end o
the wearing period. T e physiological basis o this adaptation
process remains unclear, but it appears to be related to the
e ects o lens-induced hypoxia.
Soft Le nse s
T e introduction o 1-day disposable so lenses in the mid
1990s has meant that a number o patients wear their lenses on
362 PART 6 Pat ie nt Examinat io n and Manag e me nt
a part-time basis. So contact lens wearers used to be advised to
wear their lenses or no more than 4 hours on the rst day and
increase the next consecutive wearing days by no more than 2
hours each day up to a maximum o 12 hours wear per day. New
modalities and improvements in so lens materials and designs
have now largely rendered this approach redundant.
Some gradual adaptation may be advised i the patient is
working towards ull-time wear or when a patient is partic-
ularly sensitive to lens wear. Inevitably, the more requently
lenses are worn, the greater is the level o adaptation. Patients
should be warned not to overwear daily-wear non-silicone
hydrogel so contact lenses in spite o how com ortable they
may eel.
For new lens wearers embarking on continuous wear o
lenses, a week o daily wear is advised prior to sleeping in them
(Maldonado-Codina et al., 2005). T is serves two purposes: (1)
ensuring the patient is adapted to lens wear; and (2) ensuring
the patient is pro cient in lens handling.
Rig id Le nse s
Rigid lenses require a longer adaptation period. opical anaes-
thetics have been advocated by some practitioners to alleviate
discom ort during the tting appointment and the dispensing
visit (Bennett et al., 1998). Nominally, patients are instructed
to wear lenses on the rst day or about 2 hours, and build-
ing up by an extra 2 hours per day. Some practitioners accel-
erate this process by advising patients to wear lenses in the
morning, ollowed by a break during the a ernoon, and then
to recommence wear in the evening. T e adaptation process is
patient dependent, and the patient’s own level o com ort can
act as a guide.
It sometimes takes a ew days or the sur ace o rigid lenses
to attain an optimal level o wettability and com ort or a
variety o reasons. First, some hydrophobic polishing com-
pounds may not have been completely removed rom the lens
sur ace prior to delivery (thorough lens cleaning prior to dis-
pensing the lens to the patient can alleviate such problems).
Second, until becoming coated with natural constituents o
the tears, rigid lenses may remain slightly hydrophobic on
the rst day o wear, especially i they have been delivered in
a dry state (storing rigid lenses in solution or about 24 hours
prior to dispensing will minimize this e ect) (Bourassa and
Benjamin, 1992).
RECO GNIZING AN EMERGENCY
Patients need to know how to identi y an emergency situation
when wearing lenses, in the same way that ight attendants
go through the routine emergency procedure at the start o all
ights. In addition to this, new wearers need to be aware o nor-
mal adaptation symptoms such as mild oreign-body sensation
and intermittent blurring o vision. I a contact lens wearer is
concerned that there is a problem, he / she can be advised to
check that the eyes ‘look good, eel good and see good (well)’.
T is easy-to-remember adage re ers to the ollowing:
• ‘look good’ – there is no more ocular redness than normal
• ‘ eel good’ – their eyes eel com ortable prior to and a er
lens application
• ‘see good (well)’ – their vision is what they would usually
expect (each eye checked monocularly).
Any signi cant redness when accompanied by pain needs
urgent practitioner attention, which may also require medical
treatment, especially i the redness and pain do not ease ol-
lowing lens removal. Visual losses should not automatically be
put down to contact lens wear, as there may be some orm o
ocular pathology present that is unrelated to lens wear. T e cur-
rent spectacles can be used by the patient as another method o
checking the vision in each eye monocularly.
PATIENT DISCHARGE
A use ul strategy to instil con dence in patients who have never
worn lenses previously is to have the patient apply the lenses at
the conclusion o the training session, and to leave the practice
wearing the lenses. T e patient will then be orced to con ront
the challenge o lens handling (at least lens removal in the rst
instance), rather than, as might occur, putting the lenses aside
until enough courage can be mustered to wear lenses at a later
date.
An a ercare appointment should be made be ore the patient
leaves the practice with the new contact lenses. Practice sta
must be vigilant about the attendance o new wearers to their
rst ollow-up appointment. Any no-shows or cancellations
should be contacted by a member o sta (ideally the person
who conducted the instruction appointment) to enquire about
the progress with lens wear. A new wearer may be too embar-
rassed to return with minor handling dif culties or perhaps the
simple loss o , or damage to, one o their trial lenses. Signi cant
time is spent tting and teaching the patient, so a new wearer
does not ail at this nal hurdle when a ew more minutes o
instruction (or perhaps one replacement lens) would lead to a
li etime o success ul lens wear. T e patient must appreciate that
ongoing success with contact lenses is dependent upon several
actors, such as adaptation to the lenses, compliance with the
instructions given and attendance or regular a ercare visits.
It should be impressed upon the patient that, although good
vision and com ort are indicators o success, this does not auto-
matically prove optimum product choice and individual com-
patibility. All wearers must be made aware o the importance
o regular biomicroscopic examination. T e standard strategy
or encouraging compliance with the requirement to return or
regular a ercare visits is to restrict the supply o lenses issued to
the patient to correspond with the desired time period between
a ercare appointments. Patients should also be made aware
o the regularity o contact lens types and ancillary products
becoming available, so attendance or a ercare visits ensures
that they are advised about the most up-to-date product choices
or their individual needs.
Info rme d Co nse nt
In ormed consent means that a patient embarking on contact
lens wear should be made aware o both the risks and bene ts o
contact lens wear as well as having the opportunity to ask ques-
tions (Rosenwasser, 1991; Roberts et al., 2005). T e in ormation
provided verbally should be rein orced with written material.
As well as providing the patient with in ormation about the rec-
ommended lenses and / or solution system o choice, the practi-
tioner must also have discussed the possible alternatives.
A comprehensive list o every possible contact lens com-
plication does not need to be discussed, but a practitioner is
required to discuss those that a reasonable person or members
o the pro ession would expect to be told. A practitioner would
be expected to mention the more common non-serious aspects

o lens wear, such as the normal adaptation symptoms, in addi-
tion to the less common risks that could lead to a serious com-
plication such as visual loss rom corneal in ection.
Prospective wearers should also be made aware o the con-
sequences o not ollowing the recommended instructions.
T is may be perceived by some practitioners as a negative
approach, as it does not present contact lenses in a positive
light. However, discussing such possible scenarios will pre-
clude patients rom claiming lack o in ormed consent i they
are non-compliant with advice. T ere is no legal stipulation
regarding the provision o in ormation when prescribing a
contact lens; however, providing in ormation and obtaining
in ormed consent orm part o good clinical practice. Although
written consent is not evidence that in ormed discussion has
taken place, written agreements can be used to provide a basis
or the process.
A standard orm can be used, which the patient signs to
acknowledge that he / she has been given the necessary advice
and instructions (Rosenwasser, 1991). T e patient should be
38 Pat ie nt Ed ucat io n 363
given a copy o this with the other copy retained in the records.
In the case o minors, the orm should be signed by both the
child (where possible) and the parent or guardian.
Co nclusio n
T e success o the dispensing visit is undamental to the uture
wel are o the contact lens patient. Care ul preparation and skil-
ul instruction are involved in setting the patient on the road
to success. Although this unction is commonly and appropri-
ately delegated to support sta , the practitioner must eel con-
dent in the training and instruction routine so that all aspects
o contact lens wear and care are covered. Written in ormation
in addition to booklets provided by manu acturers are essential
accompaniments or this visit as well as a requirement o sign-
ing the statement o in ormed consent.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
REFERENCES
Association o Contact Lens Manu acturers
(ACLM). (2009). Lens and Makeup Care. [On-
line]. [Accessed 8 July 2016.].
Bennett, E. S., Smythe, J., Henry, V. A., et al. (1998).
E ect o topical anesthetic use on initial patient sat-
is action and overall success with rigid gas perme-
able contact lenses. Optom. Vis. Sci., 75, 800–805.
Boost, M. V., & Cho, P. (2005). Microbial ora o
tears o orthokeratology patients, and microbial
contamination o contact lenses and contact lens
accessories. Optom. Vis. Sci., 82, 451–458.
Bourassa, S., & Benjamin, W. J. (1992). RGP wet-
tability: the rst day could be the worst day. Int.
Contact Lens Clin., 19, 25–34.
Ettinger, E. R. (1993). Pro essional Communications
in Eye Care. Boston, MA: Butterworth-Heine-
mann.
Luensmann, D., Yu, M., Yang, J., et al. (2015). Im-
pact o cosmetics on the physical dimension and
optical per ormance o silicone hydrogel contact
lenses. Eye Contact Lens, 41, 218–227.
Maldonado-Codina, C., Morgan, P. B., E ron, N.,
et al. (2005). Comparative clinical per ormance
o rigid versus so hyper Dk contact lenses used
or continuous wear. Optom. Vis. Sci., 82, 536–
548.
Morgan, S. (2008). T e Complete Optometric Assis-
tant. Edinburgh: Butterworth-Heinemann.
Roberts, A., Kaye, A. E., Kaye, R. A., et al. (2005).
In ormed consent and medical devices: the case o
the contact lens. Br. J. Ophthalmol., 89, 782–783.
Rosenwasser, H. M. (1991). Malpractice and Contact
Lenses. Boston: Butterworth-Heinemann.
Shovlin, J. P. (1990). Acanthamoeba keratitis in rigid
lens wearers: the issue o tap water rinses. Int.
Contact Lens Clin., 17, 47–49.
Srinivasan, S., Otchere, H., Yu, M., et al. (2015).
Impact o cosmetics on the sur ace properties o
silicone hydrogel contact lenses. Eye Contact Lens,
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lachac, C. A. (1994). Cosmetics and contact lenses.
Optom. Clin., 4, 35–45.
363.e 1
39
Aft e rcare
LO RETTA B SZCZO TKA-FLYNN | NATHAN EFRO N
Int ro d uct io n
Contact lenses are generally very well tolerated by the majority
o patients; however, appropriate a ercare o the contact lens
patient is essential to ensure that long-term success is main-
tained. A ercare procedures are equally as important as the
original lens tting because the lenses that were tted initially
may develop unanticipated complications, which require cor-
rection at any time during post tting patient care. In act, it is
commonly held that contact lens a ercare represents a contin-
uum and as such can never be considered to be complete.
Post tting care can be considered as ‘early’ or ‘late’ a ercare.
Early a ercare usually encompasses the rst 3 months a er lens
dispensing and is generally considered part o the initial lens
tting, during which parameters are o en modi ed, early toxic
or allergic reactions are identi ed and patients are adapting to
lens wear. Late a ercare includes 6-month and annual progress
evaluations, which assess contact lens e ects on corneal shape
and physiology. Lenses are reordered or replaced as needed. T e
late-a ercare visits are critical to evaluate the patient or signs o
lens-induced pathology, such as papillary conjunctivitis, bleph-
aroptosis, neovascularization, polymegethism, corneal warpage
and re ractive error change. All a ercare visits should assess the
patient or compliance as well. Routine ophthalmic examina-
tions also should be per ormed as necessary during the a ercare
visit or conditions unrelated to lens wear.
T is chapter will o er a measure o the standard o care
required o an a ercare visit by highlighting the procedures
and strategies that can be employed at every a ercare visit in
order to investigate e ciently and accurately the contact-lens-
wearing eye and arrive at the precise diagnosis i there are any
problems. Occasionally, patients will present with complaints o
poor vision, discom ort or red eyes. Ocular changes associated
with such symptoms may or may not be detected by examin-
ing the eye and vision with standard clinical instruments such
as the phoropter, slit-lamp biomicroscope and keratometer. I
subclinical ocular changes are responsible or such lens-related
complaints, they may be detected only using speci c problem-
solving strategies, and o en with the use o advanced equip-
ment. T ere ore, strategies and advanced procedures used in
the investigation o symptomatic as well as preclinical ocular
changes associated with contact lens wear are also highlighted.
Some instruments are ound only in research and teaching insti-
tutions, but others are a ordable enough to become part o the
key devices that contact lens practitioners can add to their prac-
tices or routine pre- and post tting care.
Re co mme nd e d Visit Sche d ule s
A ercare schedules will vary based on lens type, mode o wear
and underlying corneal physiology. For example, patients
364
wearing rigid lenses should be examined more requently dur-
ing the rst ew months o lens wear. Patients using lenses or
extended wear must be monitored more requently; with the
initial visits in the early morning – especially or rigid lens over-
night wear – to assess lens adherence (Fig. 39.1), excessive over-
night corneal swelling or in ltrative responses.
Additionally, patients with corneal pathology such as kera-
toconus or corneal dystrophy, postkeratoplasty, post-re ractive
surgery or those using contact lenses or other therapeutic
applications such as aphakia or high ametropia, and paediat-
ric patients, generally require more requent a ercare as part
o their management compared with uncomplicated cosmetic
lens wearers.
able 39.1 lists the recommended schedule o visits based
on lens type, modality or therapeutic requirement or contact
lens wear. I lens replacements and modi ed parameters are
provided within this time period, the clock starts over again or
each lens dispensed.
T ese recommendations are based on a survey o the litera-
ture and common clinical practice, and are listed in re erence to
the suggested mode o lens wear.
Pre p aring o r t he A t e rcare Visit
Certain preparations need to be made be ore the a ercare
appointment. T e previous record o the patient should be
reviewed be orehand so that the practitioner can become amil-
iar with the case history, anticipate any potential problems and
devise an appropriate history-taking strategy. It is common
practice that contact lens records or contact lens a ercare
examinations are separate rom the comprehensive examination
encounter orm, even within electronic medical record systems.
E cient electronic medical records or contact lens practices
will include separate orms or entry o contact lens parameters
tried during the tting as well visual and tting results o trial
and historical lenses. For example, e cient electronic records
will allow the entry o comprehensive trial lens parameters with
resulting vision, overre raction, and tting data stored, with the
option o a carry- orward o the dispensed trial lens parameters
at the ollow-up visits. Data rom a contact lens tting or ol-
low-up appointment may be retained separate or merged with
typical encounter orms. All a ercare evaluations should record
the recommended post tting procedures including care solu-
tions dispensed, whether on paper or within electronic medical
records. Electronic systems may be preprogrammed with mac-
ros o common lens wear and care instructions or ease o selec-
tion and entry into the signed encounter note.
Be ore acquiring any patient-abstracted in ormation, it is
critical to include some patient demographics and appoint-
ment in ormation. Along with patient names and identi cation
numbers, age is an important variable to document, as this will

assist in identi ying presbyopic symptoms. T e appointment
date as well as time should be recorded on paper records; this
data will probably be automatically recorded within electronic
medical record systems. Date and time entry allow more accu-
rate postexamination reviews i adverse reactions are noted at
a certain time o day. For example, orthokeratology or rigid
lens extended-wear patients typically are required to have ini-
tial extended-wear progress checks within 2 hours o awaken-
ing to monitor or lens adherence. Silicone hydrogel wearers
should have initial progress checks within the rst 2–4 hours
o lens insertion to document any asymptomatic corneal stain-
ing induced rom unanticipated lens–solution interactions
(Andrasko and Ryen, 2008). Daily-wear rigid lens patients
are usually examined later in the day because lens-induced
pathology is likely to become more evident the longer the lens
is worn.
Expected parameters o contact lenses worn to the a ercare
visit should be at hand; these are typically carried over rom
the previous visit. T is strategy is not always accurate because
patients can present wearing a previous pair o lenses, or lenses
that have become switched between the eyes; however, it a ords
an important point o re erence during case history and compli-
ance review.
A recent survey o eye-care practitioners around the world
was per ormed to gather current practices or anterior eye
health recording within examination records, and secondarily
to provide the contact lens practitioner with guidelines on best
practice (Wol sohn et al., 2015). T e guidelines recommend:
record which grading scale is used; always grade to one deci-
mal place; record what you see live rather than based on how
Fig . 39.1 Fluore sce in re ve als b ind ing o a rig id le ns to the corne a. This
was ob se rve d in the morning ollowing ove rnig ht le ns we ar. (Courte sy of
Rolf Hab e re r, Bausch & Lomb Slid e Lib rary.)
TABLE
39.1 Sug g e st e d A t e rcare Sche d ule s
Le ns Typ e Examine Aft e r:
1 we e k 1 months
So t d aily we ar
Rig id d aily we ar
So t and rig id e xte nd e d we ar
Scle ral
The rap e utic
39 Aft e rcare 365
you intend to manage a condition; grade bulbar and limbal
hyperaemia, limbal neovascularization, conjunctival papillary
redness and roughness (in white light to assess coloration with
f uorescein instilled to aid visualization o papillae / ollicles),
blepharitis, meibomian gland dys unction, and sketch staining
(both corneal and conjunctival) at every visit (Wol sohn et al.,
2015). T ey suggest that other anterior eye eatures be recorded
or sketched only i they are remarkable, although one should
always indicate the tissue that has been examined, even i there
are negative ndings.
A t e rcare Pro ce d ure s w hile Le nse s
are Wo rn
T e general strategy adopted or a ercare visits is to consider
the procedures in two phases: those conducted with the patient
wearing lenses (assuming that the patient presents wearing
lenses) and those conducted ollowing lens removal. Certainly,
patients should present to all a ercare visits while wearing
lenses, unless a complication warrants lens discontinuation. It
is also desirable that patients present towards the end o their
lens replacement cycle (e.g. a er having worn a pair o lenses
or 2 weeks i on a 2-week lens replacement schedule). T is will
allow proper evaluation o the lenses and ocular response to the
period o non-replaced lens wear.
It is rarely necessary to conduct all possible a ercare pro-
cedures at every ollow-up visit. Essential procedures (such as
those outlined below) generally should be per ormed; these
can be supplemented with ancillary testing to solve speci c
problems. T e a ercare visit may on occasions be very brie ;
or example, i a patient presents with a minor problem soon
a er having been given a ull a ercare examination and the
solution is straight orward, it may only be necessary to see
the patient or a ew minutes. T e only caveat here is that,
or medico-legal reasons, vision should always be measured
i the patient enters the consulting room, no matter how brie
the visit.
HISTO RY TAKING
T e case history is crucial to assess patient compliance and to
begin to ormulate an opinion about the cause o any possible
contact-lens-related complications that have developed. T e
in ormation obtained should include, at minimum, a subjec-
tive assessment o vision (including extent and duration o any
morning or post-lens removal blur), com ort, wearing time and
care regimen. Additionally, it is important to elicit symptoms
such as redness, tearing, photophobia or discharge i they are
present. In the early a ercare phase, these series o questions are
imperative to establish whether there is an incompatibility with
the solutions or lenses.
Examine Eve ry: Rat io nale
6 months 12 months
Intrinsically sa e
Incre ase d risk o ad ve rse e ve nts
Incre ase d risk o ad ve rse e ve nts
Incre ase d risk o ad ve rse e ve nts
Comp romise d e ye s
366 PART 6 Pat ie nt Examinat io n and Manag e me nt
During the late a ercare phases – in addition to the above
case history – it is good practice to review medications used
by the patient and to ascertain whether any general allergic
responses have been encountered, so as to ensure that these
circumstances have not changed since the last visit. Addition-
ally, patients can be invited to describe their chie complaint
(i any) and review the overall lens-wearing history. A more
detailed account o contact lens history taking can be ound
in Chapter 35.
VISUAL ACUITY
Presenting distance and near visual acuity with contact lenses
should be recorded monocularly and binocularly with the con-
sulting room lights on. T is should be undertaken at each visit
and the results compared with those expected rom the dispens-
ing visit or previous progress check. Visual acuity should be
recorded prior to the utilization o any bright lights or disclo-
sure dyes, which can induce lacrimation or lens misalignment.
O VERREFRACTIO N
As with any subjective re raction, initial objective assessment o
re ractive status using an autore ractor or retinoscope provides
the starting point or the subjective overre raction. Retinoscopy
can also provide invaluable in ormation when qualitatively
viewing the red ref ex over the lenses. Features such as optical
zone edges or bi ocal segments within the entrance pupil can be
observed and correlated with patient complaints. Distortions or
small visual obstructions induced rom lens deposits, scratches,
warped lenses or lens li -o rom the corneal sur ace may also
be detected during overretinoscopy. Lastly, ocular pathology o
new onset since the last visit, such as a posterior subcapsular
cataract, can be easily detected by viewing the red ref ex.
A subjective sphero-cylindrical re raction over the contact
lenses is an important measure that should be recorded at every
visit. At any a ercare visit, overre raction can reveal required
power changes due to unanticipated lacrimal lens ormations,
lens rotation, changes in re ractive error, patient-induced lens
power changes, lens warpage or lens f exure. T e duochrome
test is especially use ul in determining the re ractive end-point
o an eye wearing a contact lens.
A use ul clinical technique during subjective re raction is
to obtain both spherical and sphero-cylindrical end-points
independently (rather than merely calculating the best-sphere
re raction rom the sphero-cylindrical end-point). In cases o
spherical lens tting, spherical power modi cations can be
demonstrated to the patient and the resultant visual acuity mea-
sured. I vision is inadequate ollowing a spherical overre rac-
tion, a sphero-cylindrical overre raction should be per ormed
and a toric lens t initiated i warranted. In so toric or rigid
ront-sur ace toric lens tting, a sphero-cylindrical overre rac-
tion can assist in determining the magnitude and direction o
any cylinder mislocation (Lindsay et al., 1997).
A repeatable cylindrical overre raction obtained over a
spherical rigid lens suggests lens f exure. T in rigid lenses can
f ex approximately one-third o the corneal toricity. T e proba-
bility o f exure increases with steeper and larger lenses. Flexure
has been thought to increase with materials o higher oxygen
permeability (Dk), but a study o rigid materials across a range
o Dk values ( rom 15 to 151 Barrer) ailed to nd a di erence
in f exure when measured by overre raction (Lin and Snyder,
1999). Flexure can be con rmed by manual or automated kera-
tometry over the lenses. A cylindrical overre raction over a
back toric rigid lens results rom a crossed-cylinder e ect and
care ul review o the measured cylindrical power and axis sug-
gests either over- or undercorrected cylindrical correction, mis-
aligned cylinder axes or residual lenticular cylinder.
O VERKERATO METRY
Corneal topography or keratometry per ormed while the lenses
are worn will provide an index o lens f exure over a spherical
rigid lens. As the anterior lens sur ace is being measured, the
absolute instrument readings will not correlate with the base-
line corneal measurements. T e degree and location o detected
cylinder should correlate with the overre raction i lens f exure
is the suspected cause o residual astigmatism over a spherical
lens on a toric cornea.
Assessing lens sur ace topography is believed by some prac-
titioners to be a use ul aid in determining the lens–cornea rela-
tionship in so lens tting. When using keratometry, the clarity,
consistency and shape o the mires that are ref ected o the
anterior so lens sur ace can be use ul or problem solving. For
example, overkeratometry can help detect a steep or f at- tting
so lens even though the lens t may be judged to be clinically
acceptable upon biomicroscopic examination. In a steep- tting
relationship, sustained overkeratometry observation can reveal
distorted mires that become more irregular as the eye is le open
between blinks. Additionally, the mire quality improves imme-
diately a er the blink when the lens has temporarily improved
drapage over the cornea. In a f at t, the opposite occurs: the
mires blur immediately a er blinking owing to excessive lens
movement and the mire quality improves as the eye remains
open and the lens stabilizes (Fig. 39.2).
EXTERNAL EXAMINATIO N
General inspection o the eye under an angle-poise lamp will
reveal the presence o any general ocular pathology, such as red
eye, conjunctival oedema or indeed almost any orm o pathol-
ogy, i severe enough. Also, evaluation o head posture, blink
habits and palpebral aperture o the patient can provide impor-
tant in ormation on lens adaptation and lid e ects. New rigid
lens wearers o en present with partial blinks or a narrowing o
their palpebral aperture in an attempt to decrease lid sensations.
Rigid contact lens wear has also been shown to induce true
acquired non-senile blepharoptosis rom mechanical manipula-
tion o the eyelids, or mild contact-lens-induced lid inf amma-
tion (see Chapter 40).
SLIT-LAMP BIO MICRO SCO PY
During the biomicroscopy evaluation while contact lenses are
worn, the lens sur ace is rst examined, ollowed by an evalua-
tion o the lens tting characteristics, and nally an assessment
is made o possible interactions between the lens and eye.
Le ns Surface Asse ssme nt
Both rigid and so lenses should be inspected or sur ace qual-
ity, deposit ormation, tear lm interactions, and gross sur ace
or edge de ects. Clinically, it is very use ul to observe the charac-
teristics o the tear lm and anterior lens sur ace between blinks.
All so lenses orm mucoprotein deposits, which begin to orm

Fig . 39.2 Ap p e arance o ke ratome te r mire s re e cting o the sur ace o g ood , ste e p - and at-f tting le nse s, ob se rve d imme d iate ly b e ore a b link,
and imme d iate ly, 5 se cond s and 10 se cond s a te r a b link.
as soon as the lens is inserted. ear lm constituent deposition
and coating is also expected; however, the analysis at this stage
is aimed at determining whether the speci c lens–cornea inter-
action in the patient being examined has resulted in the orma-
tion o a biocompatible coating and, i it has, whether there has
been any adverse reaction as a result. A decision can then be
made as to whether the lens replacement requency needs to be
increased. Deposit ormations have been discussed in Chapter
19, and usually indicate that more- requent lens replacement, or
a change o lens material, is necessary.
Although the majority o deposits on hydrogel lenses are
mucoprotein, silicone hydrogel lenses may develop an incom-
patible lipid deposition. It is estimated that there are more than
45 individual lipids within the tear lm and the chemistry o
the relatively hydrophobic silicone hydrogel materials has
resulted in clinicians needing to understand the deposition o
lipids onto contact lenses and how they may best manage these
interactions (Lorentz and Jones, 2007; Heynan et al., 2011).
T us, silicone hydrogel lenses should be closely observed or
deposition even in the early re tting phase. Although these
lenses deposit minimal amounts o protein (Suwala et al.,
2007), about 13% o patients wearing silicone hydrogel lenses
exhibit clinically signi cant lipid deposition on new lenses,
even though they may not have had this problem with previ-
ous hydrogel materials (Nichols, 2006, 2013). Although some
care products are speci cally ormulated or use with silicone
hydrogel lenses, there are conf icting ndings (depending
on the care product ormulation, lens substrate and research
methods) with respect to care products that have the abil-
ity to alter lipid sorption appreciably (Zhao et al., 2009; am
et al., 2014); however, adding a rubbing step removes a small
amount o sorbed lipids ( am et al., 2014).
39 Aft e rcare 367
Although it is clinically di cult to assess lens and tear lm
interactions, a biomicroscopy method or assessing tear break-
up time using white light has been suggested. It is assumed that
an intact and smooth tear lm coating on the anterior sur ace
o a lens (indicated by longer tear break-up times) enhances the
biocompatibility o the lens and thus promotes com ort and tol-
erance. T e patient is instructed to re rain rom blinking and
the examiner records the time to observe disruption o the tear
lm as evidenced by a disruption o the white-light specular
ref ex rom the anterior lens sur ace. Generally, break-up times
o greater than 5 seconds should be observed on clean or mildly
coated lenses. Break-up times o 4 seconds or less are usually
associated with visible deposits and may indicate that the lens
should be replaced more regularly or that the lens material is
incompatible with the ocular sur ace o the patient (Hart, 1987).
Obvious non-wetting o rigid lenses is easily detectable dur-
ing the biomicroscopy evaluation and should correlate with
patient symptoms o discom ort, hazy vision and the requent
need or lens removal and cleaning (Fig. 39.3). Non-wetting o
rigid lenses is common in patients with meibomian gland dys-
unction (MGD). Patients may have worn rigid lenses success-
ully or years, and used the same material and care products,
yet nd themselves with poor wetting lenses and di culty man-
aging com ort i the patient develops signi cant meibomian
gland dys unction. T e international workshop on meibomian
gland dys unction (MGD) presented data suggesting that dis-
com ort and dryness symptoms in contact lens wear are asso-
ciated with MGD, and management o the MGD can improve
the symptoms (Schaumberg et al., 2011). Managing MGD
and non-wetting in rigid lens wearers with lid hygiene, care
solutions and material selection is achievable but can be chal-
lenging; o en patients have to switch to hydrogels or suspend
368 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 39.3 De p osition on the sur ace o a rig id le ns, p re sume d to b e
d e nature d p rote in. (Courte sy of Kathy Dumb le ton, Bausch & Lomb Slid e
Lib rary.)
lens wear i the deposition cannot be managed. Other cases o
non-wetting detected in late a ercare visits may be secondary
to organic compounds such as cosmetics or moisturizers, inap-
propriate lens care or adverse chemical interactions between
incompatible solutions.
Rigid lens non-wetting is also occasionally noticed dur-
ing lens dispensing; this immediate non-wetting is usually not
related to MGD but may be due rather to improper prepara-
tion o the lens by the manu acturing laboratory that supplied
the lens. Causes o manu acturing-related non-wetting include
residual pitch and improper polishing.
Another lens sur ace change that should be assessed includes
sur ace hazing. Symptoms caused by rigid lens sur ace hazing
include lens dryness and variable vision; this problem is thought
to be due to excess tear lm evaporation rom the anterior lens
sur ace, resulting in sur ace drying. Sur ace hazing on rigid
lenses in the early a ercare phases may be an indication to
change the lens material. In general, silicone acrylate and f uo-
rosilicone acrylate materials behave di erently, with the latter
exhibiting greater tear lm retention. Lastly, sur ace scratches
and calci ed deposits are common on aged lenses. As lens pol-
ishing is not routinely practised in o ces anymore, these nd-
ings typically dictate lens replacement.
Le ns Fitting Characte ristics
Lens movement and centration should be evaluated as described
in Chapters 8 and 15 or so and rigid lenses, respectively.
Deviations rom the initially desired tting approach should be
assessed and changes made to lens parameters as needed. How-
ever, practitioners should anticipate the possibility o a slight
alteration o in-eye hydrogel lens per ormance towards the end
o each day, as the lens dehydrates (E ron et al., 1987). Lens t-
ting may also alter towards the end o the wearing cycle o reus-
able so lenses. T is is due to an ‘ageing e ect’, whereby there
is a gradual loss o water over the li e o the lens (Morgan and
E ron, 2000). T is water loss can possibly alter the lens dimen-
sions and have an impact on lens movement and com ort.
Fig . 39.4 (A) Rig id le ns uore sce in p atte rn at initial le ns d isp e nsing ,
showing ap ical cle arance . (B) Same p atie nt and le ns as in (A), se e n at an
a te rcare visit 2 we e ks late r, a te r ad ap ting some what to le ns we ar. Note
that mild corne al touch is now e vid e nt; this may have b e e n maske d b y
e xce ssive te aring d uring le ns f tting .
For rigid lenses, a f uorescein pattern evaluation should
always be per ormed, with either the Burton lamp or the slit-
lamp biomicroscope, or both. It should be noted that with the
Burton lamp it is not possible to observe the f uorescein pat-
terns o rigid lenses made rom materials that deliberately or
inadvertently absorb ultraviolet light. When the slit-lamp bio-
microscope is used, the appearance o the f uorescein pattern
can be enhanced by introducing a cobalt blue lter into the illu-
mination system and a yellow barrier lter (Wratten number 12
yellow) into the observation system.
T e f uorescein pattern should be assessed at every rou-
tine rigid lens a ercare visit to establish whether the lens t
has changed. In the early a ercare phase, f uorescein pattern
interpretations can vary as patients adapt to their lenses and
ref ex tearing subsides. It is not uncommon or a lens to be
judged to be t with apical clearance at a dispensing visit, yet
be observed to be t with apical touch at a progress evaluation
(Fig. 39.4).
Scleral lenses should be assessed without f uorescein rst to
check or conjunctival blanching and post-tear lens thickness.

Fig . 39.5 Ep ithe lial ind e ntation ring imme d iate ly ollowing le ns re -
moval, re ve ale d with the aid o uore sce in, ind icating an e xtre me ly
ste e p -f tting le ns and / or a strong ly ad he re nt le ns.
T e tear layer thickness can be assessed with a parallelopiped
slit-lamp beam; the gap between the posterior lens sur ace and
the anterior cornea can be judged in relation to the known
corneal or lens thickness using white light. Fluorescein can
then be added to assess tear exchange and f ow beneath the
lens sur ace.
Because corneal shape and posterior lens tear lm thick-
ness may change as the patient adapts to new lenses (which will
inf uence the interpretation o the lens t), it is wise not to alter
lens parameters until the tting has stabilized, typically about 2
weeks a er lens tting. Scleral lens settling is known to change
the posterior tear lm thickness dramatically once the patient
has adapted (Kau man et al., 2014). Over an 8-hour time span,
lenses can settle by about 100 µm; there ore, lens changes made
or tear clearance on the initial dispensing day may not be accu-
rate. T e lenses should be su ciently settled a er a ew weeks,
and then patients should present at least 2 hours a er lens inser-
tion or the a ercare visits.
Le ns–e ye Inte ractions
With the lens in the eye, there is an opportunity to look or
any adverse interactions between the lens and ocular sur ace.
In the case o 3 and 9 o’clock corneal staining, the tissue com-
promise would be expected to be aligned with the position
o the lateral edges o a rigid lens. In the context o lens t-
ting, the peripheral pro le o a rigid lens may appear steeper
at a ollow-up visit than was initially documented once ref ex
tearing has subsided; this can be detected by insu cient edge
clearance, peripheral seal-o or even an epithelial indentation
ring (Fig. 39.5).
A conjunctival indentation ring induced by a tight- tting
so lens would be expected to coincide with the position o the
lens circum erence. Higher-modulus silicone hydrogel lenses
may also create asymptomatic conjunctival imprints, circum-
erential conjunctival staining, or conjunctival f aps at the edge
o the lens. Corneal staining induced by a lens de ect is likely to
be observed in the proximity o that de ect. It would be di cult
39 Aft e rcare 369
to reconcile many o the adverse reactions described above
with lens per ormance and location i these reactions were rst
detected a er the lens had been removed.
A t e rcare Pro ce d ure s Fo llo w ing Le ns
Re mo val
At this juncture, the lenses need to be removed rom the eyes o
the patient. Patients should be invited to remove their lenses so
as to demonstrate what they would normally do in their habitual
lens maintenance environment. T is provides an opportunity to
observe and evaluate attention to hygiene (e.g. handwashing
prior to lens handling), lens-handling skills, appropriate solu-
tion usage and general compliance. Any improper or irregular
procedures should be either raised at this point or noted or
later discussion with the patient. A series o tests that parallel
those per ormed with the patient wearing lenses can now be
undertaken with the lenses removed.
UNCO RRECTED VISIO N
An initial measure o uncorrected vision can be reconciled
against the presenting visual acuity, the magnitude and
nature o the re ractive error and the subsequent subjective
re raction. It should be noted that vision may be signi cantly
degraded – beyond that attributable to uncorrected re ractive
error – during the rst 15 minutes ollowing lens removal. T is
is due to the act that the tear layer is disrupted ollowing lens
removal, which can take about 15 minutes to recover (Faber
et al., 1991).
REFRACTIO N
Contact-lens-induced alterations in corneal curvature can
signi icantly alter the re ractive error with associated changes
in visual acuity. An autore ractor or retinoscope should be
used initially to determine re ractive status prior to under-
taking a subjective re raction. Retinoscopy has the added
advantage o acilitating direct observation o the optical
quality o the eye, the detection o ocular aberrations or dis-
tortions induced by the contact lens. he re ractive error
should be expected to remain constant or to progress slowly
over time, and should be una ected by lens wear. Also, visual
acuity should remain correctable to pre itting levels. Reduced
visual acuity may signal the presence o ocular pathology or
lens-induced warpage i it correlates with corneal curvature
changes, as described later in this chapter. An average o a
one-line decrease in best corrected visual acuity attributable
to contact-lens-induced topographic abnormalities has been
reported (Ruiz-Montenegro et al., 1993).
Speci c re ractive error changes have been documented with
certain lens types and wearing schedules. Myopic progression
associated with daily wear o hydrogel lenses with low oxygen
permeability was reported in early clinical trials (Barnett and
Rengstor , 1977). An average o 0.30 D increase in myopia
has been reported a er 9 months o extended wear o low-Dk
so lenses, which is presumably due to hypoxia-driven corneal
oedema (Binder, 1983; Dumbleton et al., 1999). Conversely,
extended wear with high-modulus silicone hydrogel materials
has no impact on re ractive error, and may even be associated
with a hyperopic shi rom central corneal f attening in some
patients (Dumbleton et al., 1999). In act, orthokeratology-like
370 PART 6 Pat ie nt Examinat io n and Manag e me nt
induced topographic changes have been documented with
high-modulus silicone hydrogel lenses that are typically o high
powers and / or being worn inside out (Szczotka-Flynn, 2004;
Caroline and Andre, 2005).
Re ractive error changes have been reported in adult patients
who have monocular blur intentionally induced with mono-
vision contact lens correction. Speci cally, studies show that
approximately one-third o patients can expect changes in
anisometropia between 0.50 and 1.25 D a er wearing monovi-
sion contact lenses (Wick and Westin, 1999).
KERATO METRY AND CO RNEAL TO PO GRAPHY
Corneal shape changes and / or warpage may appear with any
type o contact lens secondary to mechanical stress or lens
inter erence with corneal metabolism (Holden et al., 1985a;
Wilson et al., 1990; Ruiz-Montenegro et al., 1993; Smolek et al.,
1994; Sarzynski et al., 1997). It is important to be able to identi y
these corneal changes correctly be ore they create severe visual
consequences. Also, care ul corneal curvature assessment is a
good predictor o lens t and physiology. Corneal topography
or keratometry may reveal numerical changes rom the pre t-
ting values, or an increase or decrease in corneal astigmatism. A
general consensus is that, in normal eyes, changes greater than
±1.00 D rom baseline are clinically signi cant, and in such
cases the t should be investigated or potential alteration to
prevent potentially long-term corneal moulding. In eyes with
pathology such as keratoconus or post-corneal transplanta-
tion, large changes in keratometry readings are not uncommon.
Increased corneal astigmatism or curvature changes in kerato-
conus indicate progression o the disease, and in post-corneal
transplant patients indicate continued wound healing, recurrent
disease (i the transplant was per ormed or keratoconus), or
instability o the host cornea. Large changes in corneal astig-
matism can be detected in keratoconus patients post-transplant,
Fig . 39.6 O b late corne al shap e ind uce d uninte ntionally in a lotraf lcon A e xte nd e d -we ar contact le ns use r.
beginning about a decade a er surgery (Szczotka-Flynn et al.,
2004); there ore, continued measurement o keratometry or
topography is prudent in these patients. Keratometry can detect
sur ace irregularity by assessment o mire distortion. In act, the
quality o the mires should be graded at every progress check
(see Appendix K).
A better technique to assess changes in corneal curvature is
corneal topography. One o the most valuable applications o
this technology is to monitor the stability o the cornea a er
both short- and long-term lens wear. Subtle corneal steepening
or sphericalization that is undetectable with keratometry may
characterize early corneal changes due to contact lens wear.
Serial topography and topographic di erence maps may reveal
slight changes over time.
Occasionally, contact lenses can distort the corneal sur ace,
resulting in transient or permanent corneal warpage. Most
orms o distortion can be traced back to the t and / or mate-
rial o the lens. Di erent orms o corneal distortion can be
detected, and o en can be classi ed into one o three categories:
(1) a shi rom a prolate to an oblate shape, (2) in erior corneal
steepening, or (3) ‘smile’ impression arcs.
O b late Shap e
T e normal cornea is a prolate shape: it is steeper in the cen-
tre and f attens aspherically in the periphery. Long-term f at-
tting lenses can permanently shi the cornea to an oblate
shape by f attening the central cornea and secondarily steep-
ening the periphery. T is type o warpage may not be detected
with keratometry or mani est re raction i the astigmatism is
regular and the patient remains correctable to 6 / 6. Only cor-
neal topography can reveal the oblate shape, which can create
di culty in rigid lens tting and problem solving. As men-
tioned previously, silicone hydrogel lenses can induce a tran-
sient oblate corneal shape and a related decrease o myopia.
Fig. 39.6 shows an example o this phenomenon where a high

myope wore a high-modulus silicone hydrogel lens or 30-day
continuous wear, and 3 months a er entering this mode o
wear, central corneal f attening and 1 D o decreased myopia
were detected.
Infe rior Ste e p e ning
Long-term wear o polymethyl methacrylate (PMMA), low-Dk
rigid lenses or superiorly decentred rigid lenses can cause in e-
rior corneal steeping and give the appearance o keratoconus
(Fig. 39.7).
Lebow and Grohe (1999) compared the topography ndings
o 100 eyes with either keratoconus or contact-lens-induced
warpage. T ey concluded that keratoconic eyes have high shape
actors, extremely high corneal irregularity measures and steep
toric mean re erence curvatures, whereas contact-lens-induced
warpage is characterized by almost-spherical shape actors,
elevated corneal irregularity measures and normal toric mean
re erence curvatures.
Even so t lenses can cause severe shape changes, which are
o ten due to corneal hypoxia with secondary tissue swelling,
Fig . 39.7 In e rior corne al ste e p e ning se cond ary to corne al warp ag e
rom long -te rm rig id le ns we ar. (Courte sy of Le on David s, Bausch &
Lomb Slid e Lib rary.)
Fig . 39.8 (A) Pse ud o ke ratoconus p atte rn d ue to so t le ns-ind uce d hyp oxia. (B) Same e ye as re p re se nte d in (A) a te r 3 we e ks without le ns we ar; note
the re solution o corne al d istortion.
39 Aft e rcare 371
and which can also give the appearance o in erior corneal
steepening and pseudokeratoconus. Fig. 39.8A shows the
topography o a patient a ter sleeping in group 4 hydrogel
lenses on a weekly basis or 6 months. Note the in erior
steepening, which mimics keratoconus. A ter discontinuing
all lens wear, topography returned to normal in 3 weeks (Fig.
39.8B).
Imp re ssion Arcs
Rigid lens-induced arcuate corneal shape changes are most
o en located in the in erior third o the cornea and are com-
monly encountered i topography is routinely per ormed.
T ese changes are re erred to as ‘smile’ patterns because the
resultant topographic plot gives the impression o a smiling
ace. In traditional rigid lens tting, a f attened arcuate com-
pression ring usually signi es unintended corneal moulding
rom the in erior edge o a superiorly decentred rigid lens. Just
outside the lens edge, an arcuate zone o steepening appears
(Fig. 39.9).
I the patient reports spectacle blur, this may suggest inter-
mittent lens adhesion, and an attempt should be made to f atten
the posterior curves or improved corneal stability. Di erence
maps are help ul in quanti ying the amount o such lens-
induced corneal changes (Fig. 39.10).
Once corneal warpage or clinically signi cant shape changes
have been detected, the a ercare strategy should ocus on
adjusting the lens t and monitoring the cornea or resolution.
So lens-induced corneal curvature changes have been shown
to stabilize between 6 and 18 weeks a er discontinuing lens use
(Sarzynski et al., 1997). In rigid lens-induced corneal warpage,
up to 6 months may be required or a return to stable corneal
topography (Calossi et al., 1996). I re tting a long-term PMMA
contact lens wearer into rigid lenses, improved corneal health is
be expected and spectacle-corrected acuity may improve, but
the general topographic patterns o corneal warpage may not
improve signi cantly (Novo et al., 1995).
Poste rior Corne al Ele vation
Corneal topography is widely recognized as the gold-standard
method o measuring and ollowing the cornea during contact
lens tting, especially with rigid lenses. Both Placido-based
372 PART 6 Pat ie nt Examinat io n and Manag e me nt
and Schiempf ug systems that image the posterior corneal
sur ace are routinely ound in contact lens practices. Devices
that can image the posterior corneal sur ace are e cient in
their ability to screen or abnormally high posterior-sur ace
elevation that would not have been detected with anterior-
sur ace topography and provide corneal thickness across the
measured image. Contact lenses can rarely alter the posterior
corneal sur ace elevation; however, having access to posterior
corneal curvature and elevations can help di erentiate to early
Fig . 39.9 In e rior arcuate ‘smile ’ corne al d istortion cause d b y a d e -
ce ntre d rig id le ns.
Fig . 39.10 Top og rap hy d i e re nce map d e noting the amount o corne al curvature chang e at an a te rcare visit, which took p lace 3 we e ks a te r
d isp e nsing a ne w rig id le ns.
keratoconus, posterior keratoconus (Fig. 39.11) and postsurgi-
cal ectasia rom other conditions causing decreased acuity that
could not be detected with anterior-sur ace topography alone.
T us, in a ercare procedures, the best patients to utilize this
instrumentation on are re ractive surgery patients who have
resumed contact lens wear and have a decrease in visual acu-
ity (to screen or posterior corneal ectasia), and other patients
who have decreased visual acuity that cannot be accounted or
by any other pathology a er a complete dilated exam has been
per ormed.
Using the Orbscan instrument, the average amount o maxi-
mum posterior elevation is about 21–28 µm in non-diseased
eyes. In a series o 140 normal eyes examined by Wei et al.
(2006), the maximum posterior elevation was never greater than
46 µm. T ere ore, i using the Orbscan instrument, a posterior
elevation greater than 50 µm is clearly outside the normal range.
Some eel that a posterior elevation greater than 40 µm, when
coupled with positive ndings on other topographic screening
programmes, is a cause or concern (Rao et al., 2002). T e Pen-
tacam instrument di ers rom Orbscan and generally provides
much lower values or posterior corneal elevation. I using this
instrument, suggested cut-o points to delineate forme fruste
KC range rom 15.5 to 32.0 µm.
PACHYMETRY
Ultrasonic pachymetry is a common and quick method o
obtaining the corneal thickness on a single point on the cornea.
Ultrasonic pachymetry has the advantage o ease o use, allow-
ing ancillary sta to operate the apparatus pro ciently with only
modest training. T e small size o an ultrasonic pachymeter

makes it portable and convenient. It is an applanation device that
requires anaesthetic prior to use, there ore this test should be
per ormed a er the slit-lamp examination has been completed.
In the pre-silicone hydrogel lens era, one common applica-
tion o the ultrasound pachymeter was to assess corneal swell-
ing in extended-wear patients. It is a well-established nding
that, with no lens wear, the cornea swells by an average o 2–4%
overnight during sleep (eye closure). In extended wear with
traditional hydrogel lenses, an average o about 10% corneal
swelling has been documented. T is instrument was there ore
very bene cial in monitoring extended-wear patients wearing
low-Dk lenses and, in act, some practitioners used the corneal
swelling response as an indicator o success ul extended-wear
candidates (Solomon, 1996). However, with the almost-exclu-
sive use o silicone hydrogel lenses or extended wear currently,
where very little corneal swelling has been documented, the use
o pachymetry to monitor extended-wear patients has signi -
cantly diminished.
In specialty contact lens practices, monitoring corneal
thickness is important and necessary or keratoconus and
corneal transplant patients. In keratoconus, knowing the
corneal thickness assists in determining which patients may
be candidates or corneal collagen cross-linking. I the cor-
nea is too thin, cross-linking may be contraindicated. Moni-
toring corneal thickness also assists in knowledge o the
corneal thinning and progression o the disease over time.
Fig . 39.11 Ab normal p oste rior corne al e le vation in an othe rwise asymp tomatic myop ic co ntact le ns we are r. The hig h p oste rior e le vation re sults in
ce ntral corne al thinning .
39 Aft e rcare 373
For corneal transplant patients, increased corneal thickness
over time is an indication o either rejection (Larkin, 1994)
or gra t ailure (Sugar, 2015). Global corneal thickness is
easily provided rom the Sheimp lug or slit-scanning-based
elevation topography or anterior-segment optical coher-
ence tomography (Fig. 39.12). However, clinicians should be
aware that corneal thickness measurements are in luenced by
the method o measurement and that, although highly cor-
related, instruments such as ultrasound pachymetry, ante-
rior-segment optical coherence tomography and topography
should not be used interchangeably or the assessment o
corneal thickness (Li et al., 2007).
SLIT-LAMP BIO MICRO SCO PY
Biomicroscopy with f uorescein instillation and upper-lid ever-
sion is essential at each a ercare visit. T e clinical technique
o slit-lamp biomicroscopy as it speci cally applies to contact
lens wear has been described in Chapter 37. T e various ocular
complications associated with contact lens wear are described
in Chapter 40.
During each a ercare visit, a general anterior-segment
examination should be per ormed and any signi cant nd-
ings care ully noted on the record card. T e general anterior-
segment examination includes an assessment o the lids and
adnexa, conjunctiva, cornea, tear lm, anterior chamber, iris
374 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 39.12 Pe ntacam corne al thickne ss map in b ottom le t corne r in p atie nt with p ost-LASIK e ctasia.
and lens. Additionally, the progress evaluation orm should
contain a clinical grade o the severity o any observed tissue
change under evaluation (see section on Grading scales, below).
With silicone hydrogel lenses encompassing the majority o
the contact lens market, it is important at this stage to screen
or lens–solution incompatibility. T is can be detected by the
presence o corneal staining, as seen in Fig. 39.13. T is so-called
‘solution-induced corneal staining’ (SICS) is most evident 2
hours a er lens insertion in silicone hydrogel wearers who uti-
lize a multipurpose solution (Jones et al., 2002; Garo alo et al.,
2005; Andrasko and Ryen, 2008).
LENS INSPECTIO N AND VERIFICATIO N
Lens inspection and veri cation is an important nal step o
the a ercare visit. Lenses can be inspected using a 10× hand
loupe or a binocular microscope. Alternatively, the lens can
be retained using rubber-tipped tweezers and held in position
adjacent to the brow rest o a slit-lamp biomicroscope. A broad
beam is used to illuminate the lens, which is best viewed against
a dark background.
T e techniques o so and rigid lens veri cation are
described in Chapters 7 and 14, respectively. Rigid lens veri -
cation is important because these lenses can steepen or f atten
with time and may be susceptible to warpage. An assess-
ment made on a patient who – unknown to the practitioner
– is wearing a distorted lens, may result in that practitioner
reordering a lens o inappropriate parameters. Additionally,
rigid lens power changes have been shown to be induced as
a result o overzealous lens cleaning by patients. For example,
increased minus power in rigid lenses can result rom aggres-
sive digital cleaning with abrasive cleaners on silicone acrylate
lenses (O’Donnell, 1994; Woods and E ron, 1999). So lenses
can also be veri ed in cases o suspected lens mix-up or to

Fig . 39.13 Corne al staining in a silicone hyd rog e l le ns we are r using
a multip urp ose cle aning and storag e solution. (Courte sy of Suzanne
Efron.)
characterize the key eatures o the lens o a patient who may
be new to the practice.
ADDITIO NAL PRO CEDURES
Additional procedures, which may not be readily available
to all contact lens clinicians, include endothelial specular
microscopy, con ocal microscopy, and anterior-segment opti-
cal coherence tomography (OC ). I available, these tech-
niques a ord valuable in ormation that can have an impact
on the management o contact lens patients at early and late
a ercare visits. Digital slit-lamp imaging is a valuable method
o recording clinical in ormation; this technique is described
in Chapter 41.
Corne al End othe lial Analysis
Specular microscopy is an in vivo technique o viewing the
corneal endothelium. It is a standard method or determining
cell loss or changes in cell size (polymegethism) or cell shape
(pleomorphism) with ageing (Laing et al., 1976) and ollowing
contact lens wear (Carlson et al., 1988). In the contact lens prac-
tice, the major unction o this device is to evaluate the short-
term endothelial response (‘blebs’) (Holden et al., 1985b) and,
more importantly, the long-term endothelial response to con-
tact lens wear (polymegethism and pleomorphism, re erenced
to age-matched normals) (Carlson et al., 1988) during the a er-
care visits. T ese endothelial responses to contact lens wear are
described in Chapter 40.
Analysis o the endothelium is especially important in
the corneal transplant patient. In penetrating keratoplasty
patients, the mean endothelial cell density decreases 7.8%
per year rom 3 to 5 years a ter keratoplasty, compared with
approximately 0.5% per year in unoperated normal corneas.
Five years a ter surgery, the mean cell loss is about 60% o
preoperative baseline donor values (Bourne et al., 1994).
he analysis o endothelial cell densities a ter transplant,
and during contact lens itting o these patients, is important
because low endothelial cell densities are signi icantly asso-
ciated with increased corneal thickness and an increased risk
o subsequent ailure (Bourne et al., 1994). Low endothelial
39 Aft e rcare 375
Fig . 39.14 Corne al e nd othe lium as imag e d on a Nid e k con ocal
microscop e .
cell densities will also dictate using contact lenses with
higher Dk / t values.
T e corneal endothelium can be viewed with specular or
con ocal microscopy. In vivo con ocal microscopy is a non-
invasive way o examining the cornea. T e basic principle o
a con ocal microscope is that a single point o tissue can be
illuminated by a point light source and simultaneously imaged
by a camera in the same plane. T is produces an image with a
very high resolution but virtually no eld o view, owing to a
single point o illumination and detection. o solve this prob-
lem, the instrument instantaneously illuminates and synchro-
nously images a small region o tissue with thousands o tiny
spots o light, which are reconstructed to create a usable eld o
view with high resolution and magni cation. T e result is that
con ocal microscopes provide an en face view o the structure
being analysed (Masters and Bohnke, 2002; E ron, 2007; Patel
and McGhee, 2007; Gutho et al., 2009) Con ocal microscopy
is commonly used or analysing all the layers o the cornea, but
provides an exceptional view o the endothelium compared
with specular microscopy, especially on eyes that are di cult
to image (Fig. 39.14). T e con ocal microscope can be used to
measure corneal endothelial density and morphology, epithelial
structure and ref ectivity, subbasal nerve plexus morphology
and stromal ref ectivity and thickness. In other aspects o con-
tact lens practice, con ocal microscopy is beginning to be used
to assess subclinical inf ammatory cells in the cornea (Sindt
et al., 2012; Villani et al., 2014; Alzahrani et al., 2016a), bulbar
conjunctiva (Alzahrani et al., 2016a) and lid wiper (Alzahrani
et al., 2016b) as an indication o preclinical inf ammatory events.
Ante rior-se g me nt O p tical Cohe re nce Tomog rap hy
(O CT)
In contact lens practice, anterior-segment optical coherence
tomography (OC ) is use ul or corneal pachymetry as men-
tioned above, but also to achieve cross-sectional analysis o
the anterior segment. OC is a non-invasive, high-resolution
and high-speed imaging modality that has experienced rapid
clinical growth. Modern anterior-segment OC is capable o
generating three-dimensional ocular sur ace maps o the cor-
nea and sclera with potential application in contact lens tting
376 PART 6 Pat ie nt Examinat io n and Manag e me nt

Fig . 39.15 Ante rior-se g me nt O CT o scle ral le ns on the corne a. Variab le te ar f lm thickne ss can b e o b se rve d in the ve rtical and horizontal cross-
se ction.

Fig . 39.16 Ante rior-se g me nt O CT imag e o p e rip he ral scle ral le ns land ing and conjunctival comp re ssion (on rig ht).

(Luo and Jacobs, 2012). T e most use ul application is in the
analysis o scleral lens conjunctival landing, as well as corneal
and limbal clearance (Fig. 39.15). It allows precise calculations
o the tear layer thickness, which may or may not be easily
visible on slit-lamp examination. Peripheral landing and con-
junctival compression can be easily assessed minutes a er lens
insertion, which may not be detectable clinically until hours
a er wear (Fig. 39.16).
O the r Te sts as Re q uire d
Although the patient may be presenting or an eye exami-
nation relating to contact lens wear, practitioners have an
obligation to be cognizant o all possible causes o reported
signs and symptoms, which on occasion may be unrelated to
lens wear. I time is available, and / or the signs and symptoms
are marked, it may be necessary to undertake a procedure
that normally relates to a primary eye-care examination, such
as visual elds, ophthalmoscopy, tonometry, gonioscopy,
binocular vision assessment, corneal sensitivity, earscope
evaluation and colour vision assessment. I , or whatever
reason, these techniques cannot be undertaken at the time
o the a ercare visit, another appointment should be made,
or the patient should be re erred or specialist attention, as
appropriate.
 39 Aft e rcare 377

Discussio n w it h Pat ie nt TABLE Mag nif cat io n o Co mp licat io ns sho w n in t he

39.2 E ro n Grad ing Scale s
A critical aspect o the a ercare visit is the nal discussion with
the patient concerning the outcome o the consultation. T e Co mp licat io n Mag nificat io n* Imag e
patient should be given reassurances as appropriate – or exam-
Corne al staining 1× A
ple, that the cause o the signs / symptoms has been identi ed Corne al ulce r 1× B
(assuming this to be the case) and that the remedial action rec- Corne al inf ltrate s 1× C
ommended should solve the problem. An explanation should Corne al ne ovascularization 1× D
be given to the patient as to why changes are being made – or Pap illary conjunctivitis 1× E
example, that lenses are being changed because the patient has Me ib omian g land d ys unction 1× F
Ble p haritis 1× G
become more myopic through natural progression. T e patient Superior limbic keratoconjunctivitis 2× H
should be invited to ask any questions. Potential or actual Limb al re d ne ss 2× I
aspects o non-compliance detected during the examination Conjunctival staining 2× J
can be raised with the patient, and good practice rein orced. Conjunctival re d ne ss 2× K
Corne al d istortion 2× L
T e essence o this discussion should be noted in the medical Corne al oe d e ma 40× M
record (Veys et al., 2001). Finally, patients should be instructed Ep ithe lial microcysts 100× N
o the date and time o their next a ercare appointment, and End othe lial b le b s 200× O
they should be advised to wear their lenses to the next a ercare End othe lial p olyme g e thism 600× P
visit and to bring their lens case, solutions and any other para- *Re lative to a whole corne a b e ing ×1.
phernalia associated with lens wear.

Grad ing Scale s IMAGE SIZE

As an aid to accurate record keeping, health-care practitioners
o all disciplines o en resort to the use o standardized grad-
ing scales o various conditions. Presented in Appendix K are
the E ron grading scales or contact lens complications (E ron,
2000); these provide a simple, convenient and accurate means
by which clinicians can record and communicate the severity
o complications o contact lens wear. T e E ron grading scales
were painted by an ophthalmic artist; the advantage o using
painted (versus photographic) grading scales is that greater
clarity can be achieved because the precise level o severity can
be depicted, all other actors can be kept constant, potentially
con ounding arte acts can be avoided and artistic licence can
be adopted. Practitioner surveys have revealed that painted
grading scales are pre erred to photographic scales (E ron et al.,
2011).
T e grading assigned to a particular condition can serve
as a re erence against which any uture tissue change may be
assessed, and can there ore inf uence clinical decision making.
T ese grading scales may act as a standard clinical re erence or
describing the severity o contact lens complications.
Each complication has been painted to an equivalent level o
magni ication that addresses the compromise between being
high enough to depict the key eatures o the tissue changes,
and being low enough to relate to what practitioners can
observe with available clinical techniques. he approximate
magni ication o each complication (relative to a whole cor-
nea depicted as 1×) is given in able 39.2. Fig. 39.17 shows
the 16 complications at grade 4 severity (each o which is
identi ied by a letter code in able 39.2) and indicates the
approximate magni ication o the images with a series o size
boxes.
A consequence o these magni cation levels is that, although
epithelial microcysts and endothelial blebs can be detected and
graded at 40× magni cation on a slit-lamp biomicroscope,
they will not be viewed at the resolution depicted. Further-
more, endothelial polymegethism can be assessed only with the
aid o an endothelial microscope. All other complications can
be viewed at the resolution depicted and are capable o being
graded by direct observation and / or using a slit-lamp biomi-
croscope at up to 40× magni cation.

GRADING SCALE DESIGN HO W TO GRADE

T e primary design criteria upon which the E ron grading
scales are based are simplicity, convenience and ease o use
by clinicians. Sixteen sets o grading images are depicted in
two panels, each comprising eight complications. T ese 16
grading scales cover the key anterior ocular complications
o contact lens wear. T ose shown on the panel beginning
with ‘conjunctival redness’ are requently encountered; those
in the other panel are less common and thus less likely to be
graded routinely. On each panel, complications are depicted
in the approximate order that they would be encountered in
the course o a typical slit-lamp examination o the eye. Each
complication is illustrated in ve stages o increasing severity,
rom 0 to 4, with ‘tra c light’ colour banding rom green (nor-
mal) to red (severe). T e severity o the complications is based
on an appraisal o accumulated evidence in the literature and
clinical experience.
Grading is a simple procedure that can be undertaken with little
additional chair time (E ron and McCubbin, 2007). T e tissue
change o interest should be observed directly or with the aid
o a slit-lamp biomicroscope, under low and / or high magni-
cation as required, and the grade o severity should be esti-
mated to the nearest 0.1 scale unit. For example, a tissue change
that is judged to be considerably more severe than grade 2,
but not quite as severe as grade 3, may be assigned a grade o
2.8 or 2.9. Although this procedure can sometimes be di cult
(E ron and Chaudry, 2007), grading to the nearest 0.1 scale unit
(rather than simply assigning a whole-digit grade o 0, 1, 2, 3
or 4) a ords much greater precision and increases the sensitiv-
ity o the grading scale or detecting real changes or di erences
in severity. Objective, automated grading is also possible using
digital image capture and analysis (Peterson and Wol sohn,
2009).
378 PART 6 Pat ie nt Examinat io n and Manag e me nt

Fig . 39.17 The 16 comp lications re p re se nte d in the E ron g rad ing scale s (p re se nte d in ull in Ap p e nd ix K), d e p icte d he re at g rad e 4 se ve rity. The
ap p roximate mag nif cation o e ach comp lication (re lative to the whole corne a b e ing 1× mag nif cation) is ind icate d b y coloure d b oxe s inte rp ose d ove r
the imag e o the e ye . The 16 comp lications are lab e lle d with a le tte r cod e and are id e ntif e d in Tab le 39.2.

HO W TO RECO RD GRADING
De sig nat io n and Int e rp re t at io n o t he
TABLE
Various grading scales are available, so it is important to des- 39.3 Vario us Le ve ls o Se ve rit y sho w n in t he
ignate clearly the grading system used and the speci c tissue E ro n Grad ing Scale s
change being graded. A more expedient approach would be to Grad e Se ve rit y Co lo ur Band Clinical Int e rp re t at io n
record the 16 tissue changes in a computerized or paper medi-
cal record, each with an accompanying box, or entering the 0 Normal Gre e n Clinical action not
re q uire d
assigned grade. It may be necessary to make additional annota- 1 Trace Lime Clinical action rare ly
tions to describe the condition more ully – or example, to indi- re q uire d
cate the location o the pathology. Specially designed electronic 2 Mild Ye llow Clinical action p ossib ly
medical records could include either the picture-based grading re q uire d
scales or computer morphs o the images. T e latter have been 3 Mod e rate O rang e Clinical action usually
re q uire d
shown to o er considerable utility in terms o recording grad- 4 Se ve re Re d Clinical action ce rtainly
ings (E ron et al., 2002). re q uire d

INTERPRETATIO N O F GRADING
T e ve-stage 0–4 grading scale is based on a universally
accepted concept whereby a higher numeric grade denotes
greater clinical severity. T is schema can be applied to any tis-
sue change. T e designation and general interpretation o each
grading step are shown in able 39.3; it must be recognized that
these are only very general guidelines, and are not intended to
replace sound pro essional judgement.
T ere are two exceptions with respect to the above inter-
pretation. Corneal ulceration may require urgent action when
detected or even suspected at any level o severity. Endothelial
blebs require no clinical action, even at grade 4.
When using grading scales or the rst time, a con dence
range o about 1.2 is to be expected (E ron et al., 2001); how-
ever, with experience, this con dence range may reduce to 0.7
grading scale units. In general, a change or di erence o more
than about 1.0 grading scale unit, or a level o severity o more
than grade 2, is considered to be clinically signi cant. Practitio-
ners can determine their own grading precision using a grading
tutor (E ron and Morgan, 2001).

DETERMINANTS O F GRADING PERFO RMANCE
Reliable and accurate grading o contact lens complications is
thought to be a unction o three attributes, which collectively
constitute the ‘clinical skills set’ (E ron et al., 2003a):
1. knowledge – the broad knowledge base that underpins
the clinical task, e.g. that attribute gained a er optometric
training
2. training – the pedagogic experience o teaching and guid-
ed learning, e.g. gained through lectures, tutorials, work-
shops and directed learning
3. experience – the repeated use o a grading scale over time,
e.g. that attribute gained with unguided learning by ‘trial
and error’.
E ron et al. (2003a) ound that those without ophthalmic
training (engineering students) were able to grade as accurately
as optometrists, although less reliably and with less con dence.
T ey concluded that the possession o a relevant clinical skills
set ensures that one is more reliable and con dent when grading
contact lens complications. Further studies revealed that grad-
ing reliability is not enhanced by training, but does improve
with experience (E ron et al., 2003b).
Ge ne ral Ap p ro ache s t o So lving
Pro b le ms
Patient-reported symptoms generally all into three broad cat-
egories, relating to the ollowing:
1. appearance o the eyes – or example, ‘my eyes have been
quite red lately’
2. ocular discom ort – or example, ‘the lenses are irritating
my eyes’
3. poor visual quality – or example, ‘everything seems a
little blurry’.
Indeed, it was probably the realization that this is the classi-
cal pattern o symptomatology in contact lens practice that led
to the adoption o the catchphrase advice that is o en related
to patients – to check periodically that one’s eyes ‘look good,
eel good and see good (well)’ (see Chapter 38). It is pertinent,
there ore, to consider strategies or solving problems relating to
these categories o symptoms.
EYE REDNESS
Conjunctival and / or limbal redness is so obvious and easily
recognizable that it is perhaps the only sign o contact lens
wear that is also reported as a symptom by patients. Indeed,
excessive eye redness is cosmetically unsightly and is gener-
ally perceived as a potential disadvantage o wearing contact
lenses. It is recognized in eye care generally that the clinical
presentation o a ‘red eye’ can be one o the most di cult
cases to solve owing to the numerous possible causes that are
known. T is problem may be even more complex in a contact
lens wearer because there are many additional contact-lens-
related causes o red eye.
Characte rizing Eye Re d ne ss
T roughout the literature, the terms hyperaemia, injection, vas-
cularity and redness are used synonymously. T ese terms are
de ned as ollows:
• hyperaemia – increased blood in a part, resulting in dis-
tension o the blood vessels (Osol, 1973)
• injection – a state o hyperaemia (Osol, 1973)
39 Aft e rcare 379
Fig . 39.18 Conjunctival hae mo rrhag e in the e ye o a so t le ns we are r
who was struck in the e ye b y a sq uash b all. Note the cle ar avascular zone
around the limb us.
• vascularity – the quality o vessels (Osol, 1973)
• redness – o or approaching the colour seen at the least-
re racted end o the spectrum, o shades varying rom
crimson to bright brown and orange (Sykes, 1976).
In strict terms, ‘hyperaemia’ or ‘injection’ is the cause and
‘redness’ is the e ect. T at is, an increased volume o blood in
the conjunctival vessels (hyperaemia or injection) causes an
increased appearance o redness. T e term ‘vascularity’ is some-
what ambiguous and could represent both the cause and e ect.
Strate g ie s for Diag nosing and Solving Eye Re d ne ss
When a contact-lens-wearing patient presents with a red eye as
a primary complaint, the initial diagnostic step is to determine
whether or not the problem is related to lens wear. T is can o en
be simply solved by removing the lens; eye redness should dissi-
pate quickly i the problem is purely lens related. I , ollowing lens
removal, the redness has not dissipated by the end o the o ce visit
– and all other possible causes o redness have been ruled out – the
patient should be given instructions to monitor or dissipation o
redness and to report back i it remains red a er a ew hours. T e
possibility that the lens was somehow exacerbating a complication
unrelated to lens wear itsel should not be discounted.
Another di erential diagnosis that may be necessary when
presented with an extremely red eye is to determine to what
extent the redness is due to conjunctival injection or ciliary f ush.
wo simple tests can be applied. A sterile cotton bud can be held
lightly against the bulbar conjunctiva in the region o redness
and gently moved rom side to side. T e conjunctival vessels
will move but the ciliary vessels will remain in a xed position.
It can then be determined whether the redness relates primarily
to the ‘moving’ vessels (indicating conjunctival involvement) or
the ‘static’ vessels (indicating ciliary involvement).
An alternative test is to instil a decongestant into the eye
(Jose et al., 1984). T e e ect o a decongestant is limited to the
super cial conjunctival vessels; these drugs have no e ect on
the deeper ciliary vessels. T us, i the instillation o a deconges-
tant alleviates eye redness, the condition is primarily conjuncti-
val. I the decongestant has no impact on the appearance o the
eye, then the redness can be attributed to excessive ciliary f ush.
A subconjunctival haemorrhage can be easily di erentiated
rom conjunctival and / or ciliary hyperaemia because o the
stark appearance o an intensely ‘blood-red’ eye and the lack o
hyperaemia around the limbus (Fig. 39.18).
380 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 39.19 Small conjunctival hae morrhag e s ob se rve d in a p atie nt
we aring so t le nse s. (Courte sy of Hilmar Bussake r, Bausch & Lo mb Slid e
Lib rary.)
Fig . 39.20 Limb al re d ne ss sug g e stive o corne al p atholog y.
Small haemorrhages o individual conjunctival vessels
can also increase conjunctival redness (Fig. 39.19), but again
these are sel -evident and di erential diagnosis rom vascular
engorgement is clear.
Assuming that a given case o eye redness is lens related, it
is necessary to determine whether the source o the problem is
the cornea or the conjunctiva. Conjunctival redness associated
with a quiet limbus and absence o pain indicates a primary
conjunctival problem. Conjunctival redness associated with
an injected limbus and severe pain indicates corneal involve-
ment, or indeed a problem that is related exclusively to the
cornea (Fig. 39.20).
Redness o both the limbus and bulbar conjunctiva may
indicate a coexistence o corneal and conjunctival pathology
(Fig. 39.21).
Care ul examination o the anterior ocular structures with
a slit-lamp biomicroscope, and inspection o the lens at high
magni cation, will generally reveal the cause o the problem.
It may also be necessary to prescribe di erent care systems and
di erentially diagnose the e ects o various solutions over time.
Fig . 39.21 Comb ination o limb al and b ulb ar conjunctival re d ne ss in a
rig id le ns we are r, p ossib ly d ue to 3 and 9 o’clock staining (i.e . corne al in-
volve me nt) and conjunctival d e siccation (i.e . conjunctival involve me nt).
I the red eye is deemed to be unrelated to lens wear, then
other possible causes must be investigated. T is may involve a
ull ocular examination involving the use o direct and indirect
ophthalmoscopy and tonometry.
DISCO MFO RT
T e most common patient symptom that will con ront a con-
tact lens practitioner is that o discom ort, and in particular,
‘dryness’ (Brennan and E ron, 1989; Begley et al., 2000). Rec-
onciliation o patient symptoms with clinical signs is a constant
challenge to all health-care practitioners (Nichols et al., 2013).
T ere is always the potential to devote undue attention to a
complaint that bears little signi cance to the well-being o the
patient, or conversely to give token consideration to a symp-
tom arising rom a potentially serious condition. Furthermore,
there are many signs that the clinician detects that also have a
major inf uence upon patient management but or which the
patient shows no or minimal symptoms. Conditions that may
be asymptomatic, such as corneal neovascularization, micro-
cystic oedema and endothelial polymegethism, are important
pathophysiological signs that require some orm o treatment
– however, the most rewarding management plans, rom the
perspective o the patient, are those that alleviate discom ort.
During adaptation to contact lens wear, so lenses o er a
greater level o com ort than do rigid lenses. Indeed, a study that
assessed com ort o hydrogel lenses over short wearing periods
ound that more than hal o lens wearers were unaware o the
presence o the lens in their eyes at any given moment (E ron
et al., 1986). Both so and rigid lenses are very com ortable once
the patient has adapted to the lenses. Nonetheless, occasions
will arise when lenses become less com ortable. Because o the
subjective nature o discom ort symptoms, most reports in the
literature concerning this topic have been anecdotal. Here, a sys-
tematic approach or quanti cation o discom ort is outlined, and
management strategies or solving this problem are advanced.
T e neural mechanisms by which the conjunctiva and cornea
produce ocular sensibilities during contact lens wear have yet to
be elucidated. Certainly, these mechanisms are somewhat impre-
cise. For example, ocular sensibilities are o en poorly di erentiated
such that the description and localization o an abnormal event in
the eye by a patient are o en inaccurate. It is there ore not surpris-
ing that patient reports o ocular sensations can be con using to

Fig . 39.22 Ve rtical analog ue scale use d to q uanti y sub je ctive com-
ort, whe re b y a hig he r numb e r ind icate s g re ate r com ort.
the practitioner. In the absence o major anomalies o the lens or
eye, the com ort o the lens appears to depend upon the interaction
between the lid – especially the lid wiper – and lens.
T e exact nature o the stimulus that gives rise to the sen-
sation o dryness is also unclear and the reasons or the high
requency o this symptom in contact lens wearers are a mat-
ter or speculation, given that it is the least requently reported
symptom o non-lens wearers (McMonnies and Ho, 1986). As
there are no speci c ‘dryness receptors’ in human tissue, the
ocular sensation o ‘dryness’ must be a response to speci c cod-
ing o a erent neural inputs. One may hypothesize that ‘dryness’
results rom an inter erence with tear physiology and structure
by the contact lens – the speci c mechanism being an increased
tear evaporation and aster break-up o the tear lm. T e sensa-
tion may also arise rom the neural misinterpretation o stim-
uli seemingly unrelated to dryness, such as direct mechanical
interaction o the lens with the ocular tissues, lens dehydration
or vasodilation and the subsequent rise in local temperature
(E ron and Brennan, 1996).
Characte rizing Symp toms of Discomfort
Patients can employ one or more o a myriad o descriptions
to describe symptoms o discom ort during contact lens wear.
erms that may be used include:
• scratchy • hot • uncom ortable
• dry • cold • sore
• watery • burning • hurting
• itchy • tired • aching
• gritty • irritated • pain ul.
A systematic approach can be applied or quanti ying the level
o subjective discom ort experienced during lens wear. Speci -
cally, the severity o discom ort can be described in three ways:
1. Nominal – purely descriptive terms are used, such as mild
or severe.
2. Ordinal – the level o severity is ranked on a scale o dis-
crete steps, e.g. grades 0, 1, 2, 3 or 4. Descriptors may be
employed or the extreme grades as a guide, e.g. grade 0
means ‘no sensation’ and grade 4 means ‘extreme pain’.
3. Analogue – where the level o com ort is indicated on a
continuous scale. A popular technique employed in con-
tact lens research is the vertical analogue com ort scale
(Fig. 39.22). T e patient is invited to mark the position
on a vertical scale corresponding to the level o com ort.
(T e reason why the scale is oriented vertically is to avoid
potential bias that may invalidate the use o a horizontal
scale, as a result o ‘handedness’.) T e distance along the
scale rom the zero position is measured and taken as an
index o the degree o com ort (so the higher the score,
the more com ortable is the lens).
39 Aft e rcare 381
Strate g ie s for Solving Symp toms Re lating to
Discomfort
T e ollowing strategies can be employed to determine whether
the discom ort is eye or lens related:
• Always be on the lookout or concurrent ocular pathology
that may be unrelated to lens wear (e.g. glaucoma).
• Consider the laterality o the discom ort – or example,
discom ort caused by a toxic reaction to a contact lens so-
lution would be expected to be bilateral, whereas discom-
ort caused by damaged contact lens would be expected to
be unilateral.
• Remove the lenses – persistent discom ort ollowing
lens removal suggests an ocular problem, whereas re-
lie o discom ort ollowing lens removal suggests a lens
problem.
• Swap the lenses between the eyes – an ocular problem is
indicated i unilateral discom ort remains in the same eye
a er the lenses have been swapped; a lens-related problem
is indicated i unilateral discom ort trans ers to the other
eye a er the lenses have been swapped.
• Prescribe ocular lubricants – relie a er an ocular lubricant
has been instilled into the sore eye suggests a mechanical
or abrasive source o the discom ort.
T ere are many possible causes o lens-related discom ort.
T ese causes, and strategies or alleviating the problem, include:
• Poor- tting lenses – change to a better- tting lens; speci -
cally, a lens o larger diameter and / or steeper base curve
may move less and there ore be more com ortable.
• Physical de ects in lenses – replace the lens and / or change
to a superior product.
• Particulate matter partially embedded in lenses – replace
the lens.
• Foreign bodies beneath lenses – rinse the lens.
• End-o -day dryness in hydrogel lens wear – use a silicone
hydrogel lens to enable longer wearing times (Dumbleton
et al., 2008).
• A toric so lens might be slightly less com ortable than its
spherical equivalent because o thick stabilization zones –
employ a toric design with a thinner pro le.
• Dehydration o hyperthin hydrogel lenses can lead to epi-
thelial drying and discom ort (Fig. 39.23) – re t the pa-
tient with a thicker lens.
• Older lenses tend to eel drier – replace lenses more re-
quently.
• Lenses with sur ace deposits can be uncom ortable – re-
place the lens and increase the replacement requency.
I a patient complains o lens discom ort, and there is no appar-
ent cause a er having care ully examined the lens and eye, the
lens should be replaced.
Various orms o contact-lens-related ocular pathology can
cause discom ort; it should be noted that the apparent severity
o the tissue pathology does not necessarily correlate with the
degree o discom ort su ered by the patient. Such conditions
include the ollowing:
• Corneal epithelial microcysts – may cause slight discom-
ort.
• Corneal stromal oedema – moderate oedema (5% swell-
ing) can cause mild discom ort but severe oedema (20%
swelling) can be very pain ul, although the pain may be at-
tributed to associated pathology such as an anterior uveal
reaction. Oedema associated with the corneal exhaustion
syndrome may be very uncom ortable.
382 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 39.23 Ep ithe lial d e siccation cause d b y a hyp e rthin e xp e rime ntal
so t le ns. (Courte sy of Brie n Hold e n, Bausch & Lomb Slid e Lib rary.)
Fig . 39.24 Se ve re toxicity re actio n d ue to the p atie nt inad ve rte ntly
intro d ucing a so t le ns cle aning so lutio n d ire ctly into the e ye (having
mistake n this o r a we tting so lutio n). Se ve re co rne al staining is re -
ve ale d with uo re sce in. (Courte sy of W. Vre ug d e nhil, Bausch & Lo mb
Imag e Lib rary.)
• Contact-lens-associated acute red eye (CLARE) – occurs
in extended-wear patients, and can be very pain ul; lens
removal o en gives immediate relie .
• Superior limbic keratoconjunctivitis – causes increased
lens awareness and itching; symptoms are alleviated by
ceasing lens wear.
• In ectious keratitis – can be extremely pain ul, especially
Acanthamoeba keratitis, where patients can be suicidal.
• ear lm dys unction – discom ort is due to lens sur ace
drying (Versura et al., 2000); ocular lubricants can provide
short-term relie .
Ocular discom ort during contact lens wear may be due to
the use o associated lens care products. Speci cally, the dis-
com ort may be related to:
• solution pH and tonicity
• solution toxicity (Fig. 39.24)
Fig . 39.25 Hig h-contrast (le tte rs on the le t) and low-contrast (le tte rs
on the rig ht) log MAR visual acuity chart.
• solution allergy
• solution-induced corneal staining
• residual unneutralized hydrogen peroxide
• hydrogen peroxide burn.
PO O R VISIO N
T e causes o vision loss during contact lens wear are not always
obvious, and a de nitive diagnosis may be di cult owing to the
transient or inconsistent nature o the problem (Brennan and
E ron, 1996). A wide variety o actors may lead to vision prob-
lems during contact lens wear; in this section, consideration will
be given to ways in which vision loss can be denoted, and sug-
gestions will be o ered or strategies to determine the cause o
suboptimal vision during contact lens wear.
Characte rizing Symp toms of Poor Vision
In addition to measuring vision with and without contact
lenses, additional descriptive in ormation relating to symp-
toms o poor vision should be obtained rom the patient,
such as:
• severity – mild or severe
• consistency – constant or f uctuating
• onset – immediate or delayed
• proximity – di culty at distance or near
• persistence – whether the problem persists throughout the
period o lens wear and / or ollowing lens removal
• description – whether the problem is best described as
blur, haze, glare or some other descriptor.
Other techniques or assessing vision may help characterize the
problem. T ese include the ollowing:
• Contrast sensitivity unction – this may be suppressed
during adaptation, but otherwise should be no di erent
rom that obtained with the best corrected spectacle pre-
scription.
• High- and low-contrast acuity charts (Fig. 39.25) – re-
duced acuity with a high-contrast chart suggests a re-
ractive problem, whereas reduced acuity with a low-
contrast chart indicates a ‘non-re ractive’ problem,
such as poor lens it, ocular pathology or excess lens
deposition.
• Glare sensitivity test – a bright light is positioned next
to a low-contrast eye chart acing the patient; reduced
vision under this condition indicates glare sensitivity,

Fig . 39.26 An unusual case o vision loss with rig id le nse s. (A) A f ne
stip p le d ap p e arance is e vid e nt using the slit lamp with g e ne ral d i use
illumination. (B) A hig h-mag nif cation p hotog rap h take n throug h the
slit-lamp e ye p ie ce conf rms a case o e xte nsive d imp le ve iling , d ue to
b ub b le ormations b e ne ath the le ns. O n q ue stioning , it was d iscove re d
that the le ns was sp raye d with ‘f zzy’ ae rosol saline p rior to le ns inse r-
tion. Vision re cove re d a te r a e w hours. (Courte sy of Sylvie Sulaiman,
Bausch & Lomb Slid e Lib rary.)
which can be due to conditions that scatter light, such
as epithelial oedema, epithelial microcysts and anterior-
chamber lare.
Strate g ie s for Solving Symp toms Re lating to Poor
Vision
A er the symptoms o poor vision with contact lenses have
been ully characterized, the ollowing general strategies can be
employed to help resolve the problem:
• Restoration o vision immediately a er lens removal (with
a corrective trial lens be ore the eye) suggests a lens-related
problem.
• Sustained vision loss a er lens removal (with a corrective
trial lens be ore the eye) suggests an ocular problem (which
may or may not be related to lens wear) (Fig. 39.26).
39 Aft e rcare 383
• Unilateral vision loss may be due to the lens or uniocular
pathology.
• Bilateral vision loss may be due to a re ractive cause or to
general ocular pathology (e.g. toxic or allergic solution re-
action) or systemic disease (e.g. diabetes).
• Worse vision immediately a ter a blink may signal ex-
cessive lens movement and either a lat it (corrected
by itting the lens more steeply) or inappropriate lens
rotation in the case o a so t toric lens (corrected by em-
ploying better lens stabilization techniques). his indi-
cator is correlated with the appearance o keratometer
mires be ore and a ter the blink (discussed above; see
Fig. 39.2).
• Improved vision immediately a er a blink may signal a
tight t (corrected by tting the lens more loosely).
T e ollowing causes o vision loss with contact lenses relate to
spherical re ractive error:
• Patients may be unaware that the lens has become dis-
placed rom the cornea onto the sclera, or even lost rom
the eye, leaving vision uncorrected – veri y the presence or
absence o the lens.
• Shi s in re ractive error can reduce vision – check the re-
raction.
• Lens power may have been incorrectly ordered and sup-
plied – check the record card against the power speci ed
on the lens packaging.
• Lens power may have been ordered correctly but supplied
incorrectly – check the record card against the power spec-
i ed on the lens packaging.
• Lens power may be incorrect (manu acturing / packag-
ing error) – measure the power o the lens and check this
against the power speci ed on the lens packaging.
• T e tear layer beneath a rigid lens can have signi cant op-
tical power – reconcile ocular re raction, overre raction,
corneal topographic assessment, lens parameters and ob-
served f uorescein pattern.
• Flexure o thick so lenses can induce power shi s – t
lenses that are thinner and / or made o a material o lower
modulus.
An uncorrected astigmatic component o a re raction with con-
tact lenses can be due to:
• an astigmatic shi in re raction
• residual uncorrected astigmatism
• mislocation o toric lens cylinder axis
• lens power may have been incorrectly ordered and sup-
plied – check the record card against the power speci ed
on the lens packaging
• lens power may have been ordered correctly but supplied
incorrectly – check the record card against the power spec-
i ed on the lens packaging
• lens power may be incorrect (manu acturing / packag-
ing error) – measure the power o the lens and check this
against the power speci ed on the lens packaging
• corneal warpage.
Contact lens correction o presbyopia entails a variety o visual
compromises, such as:
• Monovision correction – degrades stereopsis at near.
• Alternating-vision bi ocal lenses – incomplete or improp-
er lens translation will compromise vision.
• Simultaneous-vision bi ocal lenses – the visual system may
have di culty in processing clear and blurred images on
384 PART 6 Pat ie nt Examinat io n and Manag e me nt
the same region o retina; non-optimal pupil size will de-
grade vision.
Most non-optical causes o vision loss relate to problems o poor
lens tting, such as the ollowing:
• Flat- tting lenses will decentre away rom the pupil.
• Excessive lens movement can degrade vision.
• Steep- tting lenses may buckle in the centre and degrade
vision.
• Hyperthin hydrogel lenses can dehydrate the epithelium,
leading to vision loss.
• Lenses o low oxygen transmissibility can induce gross oe-
dema, leading to vision loss.
• Poor lens sur ace quality – due to manu acturing prob-
lems, lens deposits or excessive sur ace drying – can de-
grade vision ( utt et al., 2000).
A variety o pathological and non-pathological ocular problems
relating to lens wear can cause vision loss, including:
• corneal in ection
• tear lm dys unction
• corneal epithelial desiccation
• corneal epithelial oedema
• corneal stromal oedema
• corneal stromal in ltrates
• corneal neovascularization
• corneal warpage
• binocular vision problems.
Co nclusio n
A ercare examinations should be undertaken routinely on all
contact lens wearers, on the basis that ‘prevention is better than
cure’. A thought ul approach to these visits should, in most cases,
result in the early detection o subclinical problems. Remedial
action can o en be undertaken without the patient being aware
that a problem exists.
Patients can present or unscheduled visits complaining
o one or more o a large number o possible problems – or
reasons that are not necessarily the ault o the patient or prac-
titioner. A strategic approach can be adopted, whereby patient-
reported problems are considered in the context o three broad
categories – eye appearance (redness), discom ort and poor
vision. T is approach should acilitate an e cient determina-
tion o a likely cause and appropriate remedial action can be
put into e ect. T e outcome would hope ully be a happy patient
who is motivated to continue to derive the undoubted bene ts
o contact lenses.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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Alzahrani, Y., Colorado, L. H., Pritchard, N., et al.
(2016b). Inf ammatory cell upregulation o the lid
wiper in contact lens induced dry eye. Optom. Vis.
Sci., 93, 917–924.
Andrasko, G., & Ryen, K. (2008). Corneal staining
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40
Co mp licat io ns
NATHAN EFRO N
Int ro d uct io n
Just as contact lenses have become easier to t over the past cen-
tury, our knowledge base o the ocular response to lens wear has
expanded exponentially over the same period. T us, there has
been a commensurate shi in emphasis in contact lens prac-
tice away rom the technical skills o lens tting (although these
are certainly still required) and more towards the theoretical
knowledge and clinical diagnostic skills required or a ercare
management and problem solving.
Contact lenses can adversely a ect most o the anterior
ocular structures, and the conditions described in this chap-
ter are categorized in terms o these anatomical structures.
T is schema re ects the natural approach to clinical decision
making, whereby the initial observation and consideration o a
problem begin with an examination o the a ected ocular tissue.
T is chapter reviews the key ocular responses to contact lens
wear, some o which can have serious consequences (e.g. micro-
bial keratitis), and some o which are benign (e.g. endothelial
blebs). Each o these conditions can present at various levels
o severity so, to assist the reader in gaining an appreciation o
this, attention is drawn to the E ron grading scales or contact
lens complications in Appendix K. T roughout this chapter, re -
erences will be made to various grades o severity re erenced
against a ve-point scale that extends rom 0 (normal) to 4
(severe). More details on the application o the use o grading
scales in practice are given in Chapter 39.
Eye lid s
T e eyelids can impact upon, and be a ected by, a contact-lens-
wearing eye by way o their pattern o movement (e.g. blinking),
their physical state (e.g. ptosis), their general state o health and
the condition o the eyelashes. Each o these actors will be con-
sidered in turn.
BLINKING
Contact lenses elicit re ex blinking during lens insertion,
removal and other instances o manual manipulation. Also, as a
result o a re ex blink, contact lenses may mislocate or become
dislodged rom the eye. Both so and rigid lens wear cause the
spontaneous blink rate to increase (Carney and Hill, 1984; Hill
and Carney, 1984). In rigid lens wear, this change may be more
related to re ex blinking rather than spontaneous blinking; that
is, the increased blink rate may be a result o continual irritation
caused by the lens edge bu eting against the lid margin. Such
alterations to blink rate are not thought to be permanent.
Contact lenses can a ect the pattern o blinking. A decrease
in the requency o occurrence o long-duration interblink
periods occurs in association with rigid lens wear, but not so
lens wear. Neither rigid nor so lens wear alters the proportion
o complete, incomplete, twitch and orced blinks. In requent
or incomplete blinking with contact lenses (Fig. 40.1) can
cause a number o problems, including lens sur ace drying and
deposition, epithelial desiccation, post-lens tear stagnation,
hypoxia and hypercapnia, and 3 and 9 o’clock staining. Faults
in lens design and tting can inter ere with proper blink-
mediated lid–lens interaction. Fewer complete eyeblinks,
more incomplete eyeblinks and more eye-blink attempts were
observed in rigid lens wearers with 3- and 9-o’clock staining
compared with those with minimal staining and non-wearers
(van der Worp et al., 2008).
T ere are essentially two options when aced with a clini-
cal problem relating to non-pathological disorders o sponta-
neous blinking activity associated with contact lens wear, such
as in requent and / or in requent blinking. T ese options are to
train patients to modi y their blinking activity (Collins et al.,
1987), and / or to alter the lens type or lens t.
Practitioners should always be alert to the possibility that
apparent anomalies in the type or pattern or blinking activity
in a contact lens wearer may be attributable to unrelated dis-
ease states. Interruptions to the neural input and / or muscular
systems o the eyelids can adversely a ect normal spontaneous
blinking activity. For example, patients with Parkinson’s dis-
ease exhibit a low blink rate. Increased mechanical resistance
to eyelid movement, as in Graves’ disease, can also reduce blink
requency. Local pathology o the eyelids, such as ptosis, cha-
lazia and carcinomas, can alter eyelid unction and movement,
and hence inter ere with normal blinking activity. It is there-
ore essential to rule out the possibility o unrelated pathology
be ore ascribing blinking dys unction to contact lens wear.
PTO SIS
T e classical appearance o ptosis is o a narrowing o the pal-
pebral ssure and a relatively large gap between the upper-lid
margin and the skin old at the top o the eyelid (Fig. 40.2).
Fonn et al. (1996) measured the palpebral aperture size to be
10.10 ± 1.11 mm in non-wearers and 9.76 ± 0.99 mm in rigid
lens wearers; it was unaltered in so lens wearers. According
to van den Bosch and Lemij (1992), clinically signi cant ptosis
occurs when the distance between the centre o the pupil and
the lower margin o the upper lid is less than 2.8 mm. Using this
criterion, contact-lens-induced ptosis (CLIP) occurs in about
10% o rigid lens wearers (van den Bosch and Lemij, 1992). T e
ptosis takes 4–6 weeks to develop ully, and is generally noticed
by patients in advanced cases. T ere are no associated signs or
symptoms.
A number o mechanisms have been advanced as possible
causes o CLIP. T ose involving some orm o dys unction o the
aponeurosis include orced-lid repeated squeezing and lateral
385
386 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 40.1 Incomp le te b link in a so t le ns we are r. (Courte sy of Hilmar
Bussake r, Bausch & Lomb Slid e Lib rary.)
Fig . 40.2 Unilate ral rig ht-e ye p tosis ind uce d b y the we aring o a rig id
le ns in the rig ht e ye or 4 we e ks on an e xte nd e d -we ar b asis; the le t e ye
wore a so t le ns. Note that the g ap b e twe e n the skin old (just b e ne ath
the e ye b rows) and the up p e r-lid marg in is g re ate r in the rig ht e ye than
the le t. (Courte sy of De smond Fonn, Bausch & Lomb Slid e Lib rary.)
eyelid stretching during lens removal, rigid lens displacement o
the tarsus and blink-induced eye rubbing (Fujiwara et al., 2001).
Non-aponeurogenic causes o CLIP include lens-induced lid
oedema, blepharospasm and papillary conjunctivitis. Watanabe
et al. (2006) suggest that CLIP is o en attributable to brosis in
Müller muscle.
o di erentiate between these possible causes, patients dem-
onstrating CLIP should be required to cease lens wear or at
least 1 month (to detect any trends towards recovery) and per-
haps as long as 3 months (to demonstrate complete resolution).
I the CLIP partially or completely resolves a er ceasing lens
wear or 1 month, then the cause is lid oedema and / or invol-
untary blepharospasm, and the patient may need to be re tted
with so lenses (which do not induce ptosis). T e eyelids should
also be inverted to determine whether papillary conjunctivitis is
involved and, i so, whether appropriate action should be taken
to alleviate the condition. I the ptosis persists a er resolution
o the papillary conjunctivitis, or a er ceasing lens wear or 1
month, then the cause is most likely damage to the aponeurosis
or Müller muscle, whereby surgical correction is the pre erred
option. Management strategies available to patients with severe
CLIP who do not wish to undergo lid surgery include being t-
ted with a ‘ptosis crutch’ (Fig. 40.3).
T e prognosis or recovery rom aponeurogenic CLIP is
poor; the condition can be reversed only by surgical correc-
tion or by other management options as described above. T e
Fig . 40.3 Scle ral le ns with ‘p tosis crutch’ in the orm o two lug s and a
she l . (Courte sy of Frank Pe ttig re w.)
prognosis or recovery rom non-aponeurogenic CLIP is good.
I the cause o ptosis is papillary conjunctivitis, the time course
o resolution o the ptosis will parallel the time course o recov-
ery o the papillary conjunctivitis.
I a contact lens wearer presents with ptosis, the numerous
other possible causes o this condition must be considered so
that the appropriate course o management can be adopted.
MEIBO MIAN GLAND DYSFUNCTIO N
Meibomian gland dys unction (MGD) is de ned as a chronic,
di use abnormality o the meibomian glands, commonly
characterized by terminal duct obstruction and / or qualita-
tive / quantitative changes in the glandular secretion. It may
result in alteration o the tear lm, symptoms o eye irritation,
clinically apparent in ammation, and ocular sur ace disease
(Nichols et al., 2011).
MGD is classi ed into two major categories based on mei-
bomian gland secretion: low-delivery states and high-delivery
states. Low-delivery states are urther classi ed as hyposecre-
tory or obstructive, with cicatricial and non-cicatricial sub-
categories. Hyposecretory MGD describes the condition o
decreased meibum delivery due to abnormalities in meibomian
glands without remarkable obstruction. Obstructive MGD is
due to terminal duct obstruction. In the cicatricial orm, the
duct ori ces are dragged posteriorly into the mucosa, whereas
these ori ces remain in their normal positions in non-cicatri-
cial MGD. High-delivery, hypersecretory MGD is characterized
by the release o a large volume o lipid at the lid margin that
becomes visible on application o pressure onto the tarsus dur-
ing examination. Overall, MGD can lead to alterations o the
tear lm, symptoms o eye irritation, in ammation and dry eye
(Nichols et al., 2011).
ear lm lipids are essential or ease and com ort in contact
lens wear, but also orm deposits on lenses. It is possible that
contact lens wear itsel disrupts the meibomian glands and / or
lipid layer and leads to tear lm evaporation and ocular sur ace
discom ort.
T e oily secretion rom the normal meibomian gland is
generally clear. One diagnostic eature o contact-lens-associ-
ated meibomian gland dys unction (CL-MGD) is a change in
the appearance o the clear oil expressed rom healthy meibo-
mian glands to a cloudy, creamy-yellow appearance (Fig. 40.4).

Fig . 40.4 Insp issate d me ib omian g land se cre tion in the lowe r lid o a
e male p atie nt we aring rig id le nse s. (Courte sy of Lynd on Jone s, Bausch
& Lomb Slid e Lib rary.)
Fig . 40.5 Frothing in the te ar lm d ue to me ib omian g land d ys unc-
tion. (Courte sy of Lourd e s Llob e t, Bausch & Lomb Slid e Lib rary.)
Frothing or oaming o the lower tear meniscus is sometimes
observed in CL-MGD, especially towards the outer canthus
(Fig. 40.5). T is appearance is accompanied by symptoms o
smeary vision, greasy lenses, dry eyes and reduced tolerance to
lens wear (Ong, 1996). In severe cases where the meibomian
ori ces are blocked, there may be an absence o gland secre-
tion. Long-standing cases o CL-MGD may be associated with
additional signs such as irregularity, distortion and thickening
o eyelid margins, slight distension o glands, gland drop-out,
mild to moderate papillary hypertrophy, vascular changes and
chronic chalazia. T e prevalence o CL-MGD is unrelated to
gender but increases with age.
Associated signs o CL-MGD include all those which arise
rom clinical diagnostic procedures that are designed to indicate
the integrity or otherwise o the lipid layer. Speci cally, patients
su ering rom CL-MGD may display a reduced tear break-
up time (measured either with uorescein or non-invasively).
Examination o the tear layer in specular re ection using a ear-
scope may reveal a contaminated lipid pattern, which is exacer-
bated by the use o cosmetic eye make-up. Symptoms o blurred
or greasy vision can probably be attributed to adhesion o waxy
40 Co mp licat io ns 387
dys unctional meibomian oils to the sur ace o the contact lens;
this can lead to lens sur ace drying, lens dehydration and sensa-
tions o dryness.
T ere is probably no single cause o CL-MGD; proposed
aetiological actors include excess eye rubbing causing chronic
damage to meibomian glands, and papillary conjunctivitis. From
a tissue pathology standpoint, obstructive MGD is characterized
by increased keratinization o the epithelial walls o meibomian
gland ducts. As might be expected, there ore, this condition is
o en observed in combination with seborrhoeic dermatitis and
acne rosacea. T is leads to the ormation o keratinized epithelial
plugs that create a physical blockage in meibomian ducts, which
in turn restricts or prevents the out ow o meibomian oils. Arita
et al. (2009) have shown that contact lens wear is associated with a
decrease in the number o unctional meibomian glands, and that
this decrease is proportional to the duration o lens wear.
Although it may not be possible to treat the underlying cause
o CL-MGD symptomatic relie can be provided by adopting
one or more o the ollowing procedures, all o which should be
undertaken with contact lenses removed:
• application o warm compresses
• lid scrubs
• mechanical expression
• prescription o antibiotics
• use o arti cial tears
• omega-3 dietary supplements
• use o sur actant lens cleaners.
By adopting these procedures, CL-MGD can be kept under
good control and adverse symptoms minimized (Paugh et al.,
1990; Macsai, 2008).
LID WIPER EPITHELIO PATHY
T e lid wiper is a thin strip o tissue near the lid margin that is in
contact with the ocular sur ace or anterior lens sur ace (where
contact lenses are worn). It is responsible or spreading tears
across the ocular sur ace during blinking (Korb et al., 2002). In
the upper eyelid, the lid wiper extends about 0.6 mm rom the
crest o the sharp posterior (inner) lid border (i.e. the mucocu-
taneous junction, or line o Marx) to the subtarsal old superi-
orly and rom the medial upper punctum to the lateral canthus
horizontally (E ron et al., 2016).
Histologically, the lid wiper is seen as an epithelial elevation
comprising strati ed epithelium with a conjunctival structure
o cuboidal cells, some parakeratinized cells and goblet cells
(E ron et al., 2016). Lid wiper epitheliopathy denotes staining
o the lid wiper a er instillation o dyes such as uorescein, rose
bengal or lissamine green. Although Korb et al. (2002) advocate
the use o a simultaneous combination two dyes to stain the lid
wiper, most clinicians and researchers seem to avour the use o
lissamine green alone (E ron et al., 2016).
Higher rates o lid wiper epitheliopathy have been reported
in dry-eye patients and contact lens wearers; however, published
evidence supporting these observations is sometimes con ict-
ing (E ron et al., 2016). T e primary cause o lid wiper epitheli-
opathy is thought to be increased riction between the lid wiper
and ocular or anterior contact lens sur ace due to inadequate
lubrication, which could be caused by dry eye and may be exac-
erbated by actors such as abnormal blinking patterns, poor
contact lens sur ace lubricity and adverse environmental in u-
ences (Korb et al., 2002). Lid wiper epitheliopathy may be asso-
ciated with subclinical in ammation (Alzahrani et al., 2016).
388 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 40.6 Normal ap p e arance o the mucocutane o us junctio n (line o
Marx) ob se rve d at the lid marg in as a ne g re e n line o llo wing instilla-
tio n o lissamine g re e n. (Imag e courte sy o f Maria Navascue s Co rnag o .)
Fig . 40.7 Lid wip e r e p ithe liop athy re ve ale d b y lissamine g re e n stain-
ing in the e ve rte d e ye lid . A b road b and o staining e xte nd s b e low the
cle arly visib le line o Marx. Staining is ap p are nt across the ull late ral
wid th o the lid wip e r. (Imag e courte sy of Maria Navascue s Co rnag o.)
he optimal procedure or observing lid wiper epitheli-
opathy is to use a paper strip impregnated with 1 mg lissa-
mine green. he paper strip is moistened with 50 µl o saline
and applied to the eye. his procedure is repeated 1 minute
later. he eyelid is everted 3 minutes a ter the second instil-
lation to visualize the lid wiper. It is important to di erenti-
ate between normal staining o the line o Marx – a 0.1 mm
wide strip that constitutes the region o the mucocutane-
ous junction o the upper and lower lids that is essentially
located along the distal margin o the lid wiper (Fig. 40.6)
– and lid wiper epitheliopathy (Fig. 40.7). he line o Marx
is visible with lissamine green staining in upgaze without lid
eversion, whereas observation o the lid wiper requires lid
eversion.
Management o severe lid wiper epitheliopathy is indicated
i the patient is experiencing moderate to severe discom ort.
he management strategy adopted will depend on the cause
o the condition, which is not always obvious. reatment
options that have been advocated include the ollowing:
• rebamipide – this is an amino acid derivative o 2-(1H)-
quinolinone and is used or mucosal protection, healing o
gastroduodenal ulcers and treatment o gastritis. Adminis-
tration o topical rebamipide increases secretion o mucins
rom goblet cells and improves the ocular sur ace in the
‘short break-up time’ type o dry eye
• corticosteroids
• lubricant eye drops
• basic broblast growth actor
• LipiFlow T ermal Pulsation System
• punctal plugs
• t contact lenses o high sur ace lubricity
• alter lens wearing modalities – such as reducing lens
wearing time, increasing lens replacement requency,
changing lens material properties (modulus o elasticity,
silicone / water content, sur ace-active agents or packaging
wetting agents)
• improve blinking behaviour.
EYELASH DISO RDERS
Disorders o the eyelashes (cilia), and o associated structures
at the base o the eyelashes such as the eyelash ollicles, glands
o Zeis and Moll, and skin o the lid margin, have implications
with respect to contact lens wear. An external hordeolum (stye)
presents as a discrete, tender swelling o the anterior lid margin;
speci cally, it is an in ammation o the tissue lining the lash ol-
licle and / or an associated gland o Zeis or Moll. Contact lenses
may add to the discom ort due to the mechanical e ect o the
lens, and patients may pre er to cease lens wear during the acute
phase o the ormation o a stye.
Blepharitis is classi ed as being either anterior or posterior.
Posterior blepharitis is a disorder o the meibomian glands; this
was considered earlier. Anterior blepharitis is directly related
to in ections o the base o the eyelashes and mani ests in two
orms – staphylococcal and seborrhoeic. Staphylococcal ante-
rior blepharitis is caused by a chronic staphylococcal in ection
o the eyelash ollicles. T e lid margins are covered in shiny
brittle scales (Fig. 40.8), and patients may complain o burn-
ing, dryness, itching, oreign-body sensations and mild pho-
tophobia. Management strategies include antibiotic ointment,
promoting lid hygiene (Keys, 1996), application o weak topical
steroids and arti cial tears. Seborrhoeic anterior blepharitis is
due to a disorder o the glands o Zeis and Moll. T e signs and
symptoms are similar but less severe than or staphylococcal
anterior blepharitis.
Contact lens wear is generally contraindicated during an
acute phase o anterior blepharitis, especially i the cornea is
compromised. Attention to lens cleaning is critical to prevent
continued recontamination o the eye. Daily disposable contact
lenses will eliminate the problem o recontamination by contact
lenses.
In estation o the eyelashes by mites or lice can lead to signs
and symptoms that closely resemble marginal blepharitis.
ypical symptoms include pruritus, burning, crusting, itching,
swelling o the lid margins and loss and easy removal o lashes.
T e itching o en parallels the 10-day mite reproductive cycle.
T e pubic or ‘crab’ louse (Phthirus pubis) has two pairs o
strong grasping claws on the central and hind legs, allowing it

Fig . 40.8 Stap hylococcal ante rior b le p haritis. (Courte sy of De b b ie
Jone s, Bausch & Lomb Slid e Lib rary.)
to hold on to eyelashes with considerable tenacity. Crab louse
in estation (phthiriasis) is considered to be a venereal disease
because it is passed on by sexual contact, although in estation
rom contaminated bedding and towels is another possible
mode o trans er.
Signs o phthiriasis include pruritus o the lid margins,
blepharitis, marked conjunctival injection, madarosis and the
presence o lice as well as oval, greyish-white nit shells attached
to the base o lashes (Fig. 40.9). Additional signs include preau-
ricular lymphadenopathy and secondary in ection along the lid
margins at the site o lice bites. T e most predominant symp-
tom is intense itching. T e initial course o action is to attempt
to remove as many mites and mite eggs as possible. Patients
should be advised to engage in vigorous lid scrubbing twice
daily using commercially available preparations. In general,
contact lens wearers presenting with parasitic in estation o the
eyelids should be treated in the same way as similarly in ested
non-lens-wearers (Caroline et al., 1991).
Te ar Film
T e unctions o the tear lm during contact lens wear can be
categorized as ollows:
• Optical – the tear lm maintains an optically uni orm in-
ter ace between the air and the anterior sur ace o the lens.
• Mechanical – the tear lm acts as a vehicle or the continu-
al blink-mediated removal o intrinsic and extrinsic debris
and particulate matter rom the ront o the lens and rom
beneath the lens.
• Lubricant – the tear lm ensures a smooth movement o
the eyelids over the ront sur ace o the lens, and o the lens
over the globe, during blinking.
• Bactericidal – the tear lm contains de ence mechanisms
in the orm o proteins, antibodies, phagocytotic cells and
other immunode ence mechanisms that prevent contact-
lens-induced in ection.
• Nutritional – the tear lm supplies the corneal epithelium
with necessary supplies o oxygen, glucose, amino acids and
vitamins beneath contact lenses via the lid–lens tear pump.
40 Co mp licat io ns 389
Fig . 40.9 A ne arly transp are nt crab louse can b e se e n at the root o
the lashe s, surround e d b y nits e ncap sulate d in she lls, and some e mp ty
she lls. (Courte sy of Patrick Caroline , Bausch & Lomb Slid e Lib rary.)
• Waste removal – the tear lm acts as an intermediate res-
ervoir or the removal o corneal metabolic byproducts,
such as carbon dioxide and lactate, rom beneath the lens
via the lid–lens tear pump.
T is section will outline how these unctions can be compro-
mised during lens wear, leading to the primary problem o
dryness and the secondary problem o mucus ball ormation.
echniques or detecting and resolving these problems are also
considered.
DRY EYE
O all the symptoms experienced by contact lens wearers, that
o ‘dryness’ is reported most requently (Brennan and E ron,
1989); about hal o all wearers have symptoms o dryness and
discom ort (Fonn, 2007). A major di culty in assessing the
symptom o ‘dryness’ is that there may be many stimuli that
elicit this sensation – that is, it cannot be assumed that the cause
o a patient symptom o ‘dryness’ is necessarily due to the eye
being dry. Because there are no speci c ‘dryness receptors’ in
human tissue, ocular dryness must be a response to speci c
coding o a erent neural inputs. Aside rom an actual dry eye,
reports o ‘dryness’ may arise rom the neural misinterpretation
o stimuli that are unrelated to dry eye, such as vasodilation
induced by mechanical irritation o ocular tissues by depos-
its on the lens sur ace. T us, the condition o ‘dry eye’ may be
related to a broad spectrum o tear lm abnormalities in addi-
tion to a reduced tear volume.
A prudent initial approach in dealing with a tentative diag-
nosis o contact-lens-induced dry eye is to apply a comprehen-
sive questionnaire that draws in other systemic correlates o
dryness, such as dryness o other mucous membranes o the
body, use o medications, e ect o di erent challenging envi-
ronments and times when dryness is noted. Such questionnaires
can help identi y a true dry-eye situation in prospective or cur-
rent contact lens wearers and thus orm a clinical rationale or
more detailed assessment.
he most undamental test that a clinician can apply
when investigating dry eye is to observe the tear ilm and
adjacent ocular structures using the slit-lamp biomicro-
scope. he overall integrity o the tears during lens wear
can be assessed by observing the general low o tears over
390 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 40.10 In e rior d e siccation staining in a p atie nt we aring so t le nse s
and su e ring rom d ry-e ye symp toms. (Courte sy of Michae l Hare .)
the lens sur ace ollowing a blink, as indicated by the move-
ment o tear debris. A sluggish movement may indicate an
aqueous-de icient, mucus-rich and / or lipid-rich tear ilm,
and the amount o debris provides an indication o the level
o contamination o the tears – or example, rom overuse
o cosmetics. A sluggish and / or contaminated tear ilm is
potentially problematic, and could result in increased deposit
ormation, intermittent blurred vision and symptoms o dry-
ness. Incomplete blinking in so t lens wearers can lead to lens
dehydration and consequent epithelial staining o the in e-
rior cornea, corresponding to the position o the palpebral
aperture (Fig. 40.10).
T e volume o tears in prospective and current contact lens
wearers can be assessed by observing the height o the lower
lacrimal tear prism. Mainstone et al. (1996) ound that mea-
surements o tear meniscus radius o curvature and height (Fig.
40.11) correlated well with results o the cotton thread test, non-
invasive tear break-up time and ocular-sur ace-staining scores,
demonstrating the value o such an assessment in diagnosing
contact-lens-associated dry eye. ear volumes in dry-eye symp-
tomatic wearers are lower than in asymptomatic wearers, result-
ing in the sensation o dryness (Chen et al., 2009). A wide- eld,
cold cathode light source, which is available as a hand-held
instrument known as a earscope, can be used to assess tear
quality during lens wear.
Most o the strategies that are applied to alleviating signs and
symptoms o dry eye o the non-lens-wearing eye can also be
applied to the eye during contact lens wear. In the rst instance,
attention should be directed to managing the underlying cause
i this is known. For example, alleviating CL-MGD, lid wiper
epitheliopathy or papillary conjunctivitis (all o which are dealt
with elsewhere in this chapter) may lead to a diminution o dry-
eye symptoms.
T e characteristics o a contact lens that is most suited or a
patient experiencing dry-eye problems are as ollows:
• a so lens – with a highly lubricious (low riction) sur ace
and providing ull corneal coverage (although some pa-
tients report relie rom dry-eye symptoms a er changing
rom a so to a rigid lens)
• a lens that displays minimal in-eye dehydration – to pre-
vent ocular sur ace desiccation
• a lens that is replaced requently – or optimal, deposit-
ree sur ace characteristics.
Numerous other strategies have been advocated or alleviating
dry eye, including avoidance o preservatives in care solutions,
avoidance o solutions altogether via the use o 1-day disposable
lenses, use o rewetting drops, periodic lens rehydration, use o
nutritional supplements, control o evaporation, prevention o
excess tear drainage (with punctal plugs), use o tear stimulants,
reducing wearing time and ceasing lens wear.
MUCIN BALLS
Approximately 50% o patients who wear silicone hydrogel
lenses on an extended-wear basis display a peculiar phenome-
non known as mucin balls. T ese ormations can be observed in
the post-lens tear lm as small discrete particles, or ‘plugs’, and
are similar in appearance to tear lm debris. In some patients,
as many as 200 mucin balls can be observed. At high magni ca-
tion (×40), mucin balls can be seen to be o variable size and to
take on a characteristic ‘ attened doughnut’ shape, with a thin
circular annulus and broad central depression (Fig. 40.12). T ey
are observed in greater numbers in patients who sleep in sili-
cone hydrogel lenses. Mucin balls are immovable beneath the
lens and appear to be stuck to the epithelium. A higher number
o mucin balls are associated with a looser lens t (Dumbleton,
2003). Mucin balls generally increase in number over the rst
months o lens wear and remain constant therea er.
Mucin balls cause no discom ort or loss o vision, and
appear to be o no immediate consequence with respect to
ocular health (Pritchard et al., 2000). However, there may be
cause or concern in the long term. Con ocal microscopy, with
magni cation o up to 650×, has shown mucin balls can pen-
etrate the ull thickness o the epithelium, leading to activation
o keratocytes in the underlying anterior stroma (E ron, 2007).
T e precorneal mucin layer is also known to be an important
de ence mechanism against in ection, by way o preventing
attachment o microorganisms to the corneal sur ace and acili-
tating the entrapment and removal o microorganisms in the
course o the natural turnover o mucus, whereby the mucus is
constantly being aggregated, rolled up and ushed rom the eye
(Fleiszig et al., 1994). Lens-induced mucin ball production may
there ore represent a compromise to this important protective
mechanism.
Mucin balls are composed primarily o collapsed mucin, as well
as some lipid and tear proteins (Millar et al., 2003). T e mecha-
nism by which mucin balls orm beneath the lens may in part be
related to a physicochemical phenomenon caused by the plasma-
treated sur ace o some types o silicone hydrogel lenses. Speci -
cally, the lipophilic sur ace o these lenses establishes a complex
inter acial relationship with the tear lm, which creates a shearing
orce that has the e ect o rolling up tear mucus into small spheres.
T e mechanical vehicles acilitating such events may be rapid
eye movements during sleep and blink-induced lens movement
upon awakening. T e relatively high modulus o silicone hydrogel

Fig . 40.11 He althy lowe r lacrimal te ar p rism, staine d with f uore sce in.
(Courte sy of Rolf Hab e re r, Bausch & Lo mb Slid e Lib rary.)
Fig . 40.12 Mucin b alls d isp laying characte ristic ‘d oug hnut’ ap p e ar-
ance . (Courte sy of Brian Tomp kins.)
lenses (compared to hydrogel lenses) may also contribute to the
above mechanism ( an et al., 2003). In addition, the more viscous,
mucus-rich nature o the closed-eye post-lens tear lm is probably
o aetiological signi cance in the ormation o mucin balls.
Following lens removal, some mucin balls remain ‘stuck’ to
the epithelium and some are washed away with blinking but
leave behind pits in the epithelial sur ace, which ll with tear
aqueous. Both the remaining mucin balls and the sur ace uid-
lled pits stain with uorescein (Fig. 40.13). When viewed at
×40 magni cation, the uid- lled pits give rise to the optical
phenomenon o unreversed illumination, which is due to the
act that they are composed o a material (tear aqueous) o
lower re ractive index than the surrounding epithelial tissue
(Fig. 40.14). T is appearance is almost identical to dimple veil-
ing caused by air bubbles trapped beneath rigid lenses. Mucin
ball-induced uid- lled pits can there ore be di erentiated
40 Co mp licat io ns 391
Fig . 40.13 Mucin b alls and f uid - lle d p its staining with f uore sce in.
(Courte sy of Kathy Dumb le ton, Bausch & Lomb Slid e Lib rary.)
Fig . 40.14 Fluid - lle d e p ithe lial p its cause d b y mucin b alls d isp laying
unre ve rse d illumination. (Courte sy of Brian Tomp kins.)
rom epithelial microcysts, which display reversed illumination.
Mucin-ball-induced uid- lled pits will stain heavily with uo-
rescein and give the appearance o an extensive punctate kera-
titis, whereas epithelial microcysts do not stain except or a ew
small spots caused by some microcysts breaking through the
epithelial sur ace.
Co njunct iva
As a tissue that is in direct apposition with a contact lens, the
conjunctiva has an important role to play in the maintenance o
success ul lens wear. Unlike the cornea, it is a vascularized tis-
sue and is thus capable o mobilizing rapid and o en dramatic
de ence mechanisms, which will in turn serve to resolve the
problem and at the same time send a strong signal (e.g. red eye)
to the lens wearer and clinician o the existence o a physiologi-
cal disturbance that requires attention.
CO NJ UNCTIVAL STAINING
Lakkis and Brennan (1996) evaluated 50 hydrogel lens wear-
ers and 50 non-lens-wearing control subjects or conjunctival
392 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 40.15 Fluore sce in lls natural old s in the conjunctiva. (Courte sy
of Bausch & Lomb Slid e Lib rary.)
staining and symptoms. T ey disregarded parallel line patterns,
which are attributed to pooling o uorescein in natural con-
junctival olds (Fig. 40.15). It was observed that 98% o all sub-
jects displayed some degree o clinically signi cant conjunctival
staining, but only 12% o the non-wearers versus 62% o the lens
wearers exhibited staining greater than grade 1. T e symptom
o dryness was associated with increased conjunctival staining.
Brautaset et al. (2008) reported observing conjunctival staining
in 33% o 338 adapted hydrogel contact lens wearers.
An imprint can be created on the conjunctiva as a result o
cha ng or physical compression by the edge o a so lens. Cha -
ing may be due to a lens edge design that causes the edge to ‘dig
in’ to the conjunctiva. De ects in the lens edge have also been
demonstrated to cause increased conjunctival staining (E ron
and Veys, 1992). Fitting a lens with a di erent edge design and a
‘de ect- ree’ edge will alleviate this problem.
Compression staining will usually be accompanied by a tight-
tting and / or a decentred lens. T is mani ests as a broad ring
o heavy conjunctival staining corresponding to the lens edge,
which is clearly evident ollowing lens removal (Fig. 40.16).
Conjunctival vessels distal to the lens edge may be engorged.
T e patient is usually asymptomatic. T is condition can be
solved by re tting the patient with a lens o greater back optic
zone radius.
Instillation o uorescein in a dry-eye patient may reveal
the presence o desiccation staining on the conjunctiva, which
mani ests as a series o di use punctate lesions within the
interpalpebral zone. T e condition will return to normal soon
a er removing the lens, but long-term resolution may require
a combination o treating the underlying cause o the dry eye
and re tting the patient with lenses that will acilitate complete
conjunctival wetting.
A conjunctival epithelial ap may be seen in patients wearing
silicone hydrogel contact lenses. T ese arcuate ormations on
the conjunctiva are composed o sheets o cells detached rom
the underlying conjunctiva, which probably orm as a result o
physical irritation by the edge o lenses o higher modulus (Gra-
ham et al., 2009). T ey are seen more o en in patients wearing
lenses on an extended-wear basis (Santodomingo-Rubido et al.,
Fig . 40.16 Conjunctival staining cause d b y comp re ssion rom the
e d g e o a tig ht- tting so t le ns. (Courte sy of Marc Rob b oy, Bausch &
Lomb Slid e Lib rary.)
2008). T ese aps are asymptomatic, and their clinical signi -
cance is unclear.
Compromise to the conjunctiva as revealed by uorescein
staining is o concern because o recent demonstrations o mor-
phological changes to the conjunctival epithelium associated
with lens wear. T ese changes include alterations to conjunc-
tival cell shape, nuclear morphology and chromatin condensa-
tion (Knop and Bremitt, 1992), and they are reported to be more
prevalent in symptomatic lens wearers (Aragona et al., 1998).
So lens wear is also associated with a reduction in goblet cell
density (Knop and Bremitt, 1992; Colorado et al., 2016); this
could lead to reduced mucin production, which in turn could
explain and perhaps urther exacerbate pre-existing symptoms
o dryness.
CO NJ UNCTIVAL REDNESS
T e clinical presentation o a ‘red eye’ can be one o the most di -
cult cases to solve owing to the numerous possible causes that
are known. T is problem may be even more complex in a con-
tact lens wearer because o the wide variety o causes o red eye.
Conjunctival redness in lens wearers is generally asymptomatic,
but patients may complain o itchiness, congestion, non-speci c
mild irritation or a warm or cold eeling (Fig. 40.17). T e exis-
tence o pain usually indicates corneal involvement or other tis-
sue pathology (e.g. uveitis or scleritis).
T e amount o conjunctival redness induced by contact
lenses is less with silicone hydrogel lenses than with conven-
tional hydrogel lenses. In a 4-week study o patients who had
not worn lenses previously, Maldonado-Codina et al. (2004)
observed that conventional hydrogel lenses caused an increase
in conjunctival redness o about 0.3 grading scale units (E ron
scale), whereas silicone hydrogel lenses induced no change in
redness.
T e conjunctiva has a rich plexus o arterioles, which con-
tain a thick layer o smooth muscle that is richly enervated with

Fig . 40.17 Bulb ar conjunctival hyp e rae mia.
Fig . 40.18 Ge ne ral b ulb ar conjunctival re d ne ss, limb al re d ne ss and
in e rior limb al hae morrhag e s. Ad ve rse re action to an e xp e rime ntal d is-
in e cting solution in a 22-ye ar-old e male so t le ns we are r. (Courte sy of
Charline Gauthie r, Bausch & Lomb Slid e Lib rary.)
sympathetic nerve bres. T e smooth muscle, as well as being
under central autonomic control, can be in uenced by numer-
ous local changes. Vasodilation re ers to enlargement in the cir-
cum erence o a vessel due to relaxation o its smooth-muscle
layer, which leads to decreased resistance and increased blood
ow through the vessel (active hyperaemia). As blood vessels
can be observed directly through the transparent conjunctiva,
this leads to an appearance o increased redness (less white
sclera is visible).
A contact lens can have a local mechanical e ect on the con-
junctiva, resulting in increased redness. As a device that can
inter ere with normal metabolic processes o the cornea and
conjunctiva, and is used in association with various solutions,
a contact lens can a ect the level o conjunctival redness via a
local chemical or toxic e ect (Fig. 40.18).
40 Co mp licat io ns 393
Local in ection and in ammation can cause eye redness.
Accordingly, treatment options all into our broad categories:
1. alterations to the type, design and modality o lens wear
2. alterations to care systems
3. improving ocular hygiene
4. prescription o pharmaceutical agents.
T e prognosis or recovery rom chronic contact-lens-induced
redness a er removal o lenses and cessation o wear is good.
Holden et al. (1986) ound that, ollowing approximately 5 years
o extended hydrogel lens wear, general conjunctival redness
resolved within 2 days. In general, removal o any noxious stim-
ulus, including a contact lens, will lead to a very rapid recovery
o eye redness to normal levels.
PAPILLARY CO NJ UNCTIVITIS
T is condition re ers to the appearance o localized swellings,
or papillae, on the tarsal conjunctiva. Papillae are primarily
observed in the upper eyelid, and can be viewed only by evert-
ing the lid. Rarely, papillae can be observed on the lower tarsus
by pulling the lower lid rmly down. In so lens wearers, papil-
lae are more numerous; they are located more towards the upper
tarsal plate (i.e. closer to the old o the everted lid), and the
apex o the papillae takes on a more rounded orm (Fig. 40.19).
In rigid lens wearers, papillae are atter and are located more
towards the lash margin, with ew papillae being present on the
upper tarsal plate. Papillae o en appear as round light re exes,
giving an irregular specular re ection (Allansmith et al., 1977).
In the early stages (less than grade 2) o contact-lens-induced
papillary conjunctivitis (CLPC), the tarsal conjunctiva may be
indistinguishable rom the normal tarsal conjunctiva apart
rom increased redness. In advanced cases (greater than grade
2), papillae can exceed 1 mm in diameter and o en take on a
bright-red / orange hue. T e distribution o papillae can be more
readily appreciated with the aid o uorescein (Fig. 40.20). T e
hexagonal / pentagonal shape is lost in avour o a more rounded
appearance, with a attened or even slightly depressed apex or
tip. A tu o convoluted capillary vessels is o en observed at
the apex o papillae; this vascular tu will typically stain with
uorescein. Other signs in severe CLPC (greater than grade 3)
include conjunctival oedema, excessive mucus and mild ptosis.
T e cornea may display punctate staining and superior in l-
trates. Injection o the superior limbus may also be apparent.
Skotnitsky et al. (2006) have proposed that two distinct clinical
presentations o CLPC are observed in hydrogel lens wearers: local
and general. T is classi cation is based on location and extent o
papillae, whereby CLPC is classi ed as local i papillae are present
in one to two areas o the tarsal conjunctiva and general i papillae
occur in three or more areas. CLPC is less commonly associated
with silicone hydrogel lens wear (Sorbara et al., 2009).
T ere is general concordance between the severity o signs
and symptoms. In the early stages o CLPC, patients may com-
plain o discom ort towards the end o the wearing period, slight
itching, excess mucus upon awakening, intermittent blurring or
a slight but non-variable vision loss while wearing lenses. As the
condition progresses, patients report itching, discom ort and
excessive lens movement.
Key actors implicated in the aetiology o CLPC include
lens-induced mechanical irritation, and immediate and delayed
hypersensitivity. T ere is o en a link with meibomian gland
dys unction, and atopic patients may be more susceptible to
developing the condition.
394 PART 6 Pat ie nt Examinat io n and Manag e me nt

Fig . 40.20 Distrib ution o p ap illae as re ve ale d b y f uore sce in (same

e ye as in Fig . 40.19). (Courte sy of C. D. Euwijk, Bausch & Lomb Slid e
Fig . 40.19 Eve rte d e ye lid re ve aling the p re se nce o contact-le ns-in- Lib rary.)
d uce d p ap illary conjunctivitis. (Courte sy of C. D. Euwijk, Bausch & Lomb
Slid e Lib rary.)

reatment options include:

• altering the lens material
• replacing lenses more requently (Porazinski and Donshik,
1999)
• altering or eliminating the care system
• improving ocular hygiene
• treating any associated meibomian gland dys unction
• prescribing pharmaceutical agents such as so steroids
(e.g. loteprednol etabonate), mast cell stabilizers (e.g. 4%
cromolyn sodium), combined antihistamine / mast cell
stabilizers (e.g. olopatadine hydrochloride 0.1% or ketoti-
en umarate 0.025%)
• dispensing ocular lubricants or symptomatic relie
• reducing wearing time
• suspending or ceasing lens wear.
Compared with planned-replacement hydrogel lenses, daily
disposable hydrogel lenses reduce the risk o papillary conjunc-
tivitis by 50% (Rad ord et al., 2009).
T e prognosis or recovery rom CLPC a er removal o lenses Fig . 40.21 Circumlimb al re d ne ss d ue to hyp oxia ind uce d b y a so t
and cessation o wear is good, with symptoms disappearing within le ns o low oxyg e n transmissib ility. (Courte sy of Bausch & Lomb Slid e
5 days to 2 weeks o lens removal, and redness and excess mucus Lib rary.)
resolving over a similar time course. Resolution o papillae takes
place over a much longer time course – typically many weeks and
as long as 6 months. T e more severe the condition, the longer is with a quiet limbus and absence o pain indicates a primary
the recovery period. In the longer term, however, the prognosis conjunctival problem. Conjunctival redness associated with
is less good. T e condition can recur, especially in atopic patients an injected limbus and corneal pain indicates more corneal
who appear to have a propensity or developing CLPC. involvement, or indeed a problem that is related exclusively
to the cornea. Care ul slit-lamp examination o the anterior
ocular structures, and inspection o the contact lens at high
Limb us magni ication, will generally reveal the cause o the problem.
T e limbus is o particular signi cance in contact lens wear It may also be necessary to prescribe di erent care systems
because it is a complex anatomical entity by way o it being a and di erentially diagnose the e ects o various solutions
transition zone between the cornea and conjunctiva, and it is over time.
the region o the anterior eye that is o en in close proximity to In the absence o any clinically observable ocular pathology,
the edge o both rigid and so lenses. corneal hypoxia is the likely cause o excessive limbal redness
(Fig. 40.21). Hypoxia stimulates the release o in ammatory
mediators rom the limbal vessel walls leading to vasodilatation;
LIMBAL REDNESS
this is an automatic reaction designed to acilitate a greater ow
Assuming that a given case o eye redness is lens related, it is o oxygenated blood to the distressed tissue. T is mechanism
necessary to determine whether the source o the problem is ails in the case o the limbus because limbal blood ow contrib-
the cornea or conjunctiva. Conjunctival redness associated utes little to corneal oxygenation; the cornea derives virtually all
 40 Co mp licat io ns 395

Fig . 40.23 Vascularize d limb al ke ratitis in a rig id le ns we are r. (Courte sy

of De b b ie Jone s, Bausch & Lomb Slid e Lib rary.)

Fig . 40.22 Limb al re d ne ss d ue to d ire ct p hysical irritation rom the

thick e d g e o a so t le ns that is o insu ce nt d iame te r or this p atie nt.
(Courte sy of Bausch & Lomb Slid e Lib rary.)

o its oxygen supply rom the atmosphere. T e result, there ore,

is contact-lens-induced hypoxia maintaining chronic limbal
vessel engorgement in a vain attempt to reoxygenate the cornea.
Papas (1998) has demonstrated a signi cant relationship
between the oxygen transmissibility o the peripheral region o
the lens and limbal redness. Indeed, one o the key bene ts o
high-permeability silicone hydrogel lenses is that they induce very
low levels o limbal redness (Maldonado-Codina et al., 2004).
Although hypoxia is presumed to be the key determinant o
limbal redness, practitioners should be alert to the possibility o
other causes, such as poor lens edge design (Fig. 40.22) or pathol-
ogy o the anterior ocular structures, especially the cornea.
T e prognosis or recovery rom chronic contact-lens-
induced limbal redness a er removal o lenses and cessation o
wear is good. Holden et al. (1986) ound that, ollowing approx-
imately 5 years o extended lens wear, general conjunctival
redness resolved within 2 days, whereas recovery rom limbal Fig . 40.24 Ep ithe lial mass in vascularize d limb al ke ratitis staining with
f uore sce in (same p atie nt as in Fig . 40.23). (Courte sy of De b b ie Jone s,
redness had a longer time course, taking about 7 days to resolve. Bausch & Lomb Slid e Lib rary.)

VASCULARIZED LIMBAL KERATITIS

T is condition is observed in patients wearing rigid contact
lenses on an extended-wear basis. It mani ests as a limbal
in ammation – typically at either the 3 or 9 o’clock positions –
and an encroachment o limbal vessels (Fig. 40.23). T e adjacent
conjunctiva may be oedematous and hyperaemic, and the lesion
may be surrounded by ne super cial punctate epithelial stain-
ing and mild corneal in ltration (Fig. 40.24) (Grohe and Lebow,
1989). T e patient may be only mildly symptomatic, complain-
ing o ocular dryness. T e problem may be exacerbated i the
lens sur ace is crazed or deposited (Miller, 1995).
T is condition o en occurs in regions o the limbus that have
become desiccated owing to poor wetting o the ocular sur ace.
T is problem is caused by bridging o the lids away rom the
globe, thus preventing the lids rom distributing tears over the
a ected area. In this regard, vascularized limbal keratitis may be
an advanced orm o 3 and 9 o’clock staining. In late stages o this
condition, the lesion can become slightly raised, in the orm o a
thickened mass o epithelial tissue through which blood vessels
traverse at various depths (Fig. 40.25) (Grohe and Lebow, 1989).
T is epithelial hypertrophy may be related to the act that the
limbus contains a high concentration o stem cells, creating a
greater capacity or epithelial cell mitosis and movement. Also,
the limbus hosts a vast array o immunological mechanisms
mediated via the reticuloendothelial system in limbal vessels.
Vascularized limbal keratitis is reversible, and cessation o
lens wear or a ew weeks will allow most o the pathology to
resolve. Converting the patient rom extended wear to daily
wear, and re tting with a smaller-diameter lens, may prevent
the problem rom recurring. Changing rom rigid to so lenses
will certainly eliminate the problem.
SUPERIO R LIMBIC KERATO CO NJ UNCTIVITIS
In its mild orm, contact-lens-induced superior limbic kera-
toconjunctivitis (CLSLK) is easy to overlook. T e condition is
396 PART 6 Pat ie nt Examinat io n and Manag e me nt

Fig . 40.25 Hig h-mag ni cation vie w (× 40) o e p ithe lial mass in vascu-
larize d limb al ke ratitis. (Courte sy of Rob e rt Te rry, Bausch & Lomb Slid e
Lib rary.)
Fig . 40.26 Early stag e o sup e rio r limb ic ke ratoconjunctivitis (g rad e
1.0) showing sup e rior limb al hyp e rae mia, ocal in ltrate s, incre ase d lac-
con ned to the superior limbal area and as such is hidden by rimation (ind icate d b y ull lacrimal rive r) and e p ithe lial d e comp e nsation
the upper lid in primary gaze. T e proper procedure or observ- (ind icate d b y hazy slit-lamp re f e x).
ing this condition is to li the upper lid while the patient gazes
down.
A myriad o signs are observed in the region o the superior
limbus in patients with CLSLK; these include:
• punctate epithelial uorescein staining
• epithelial rose bengal staining
• intraepithelial opacities
• subepithelial haze
• epithelial dulling
• microcysts
• in ltrates and irregularities
• stromal brovascular micropannus
• ne subepithelial linear opacities
• limbal oedema
• hypertrophy
• uorescein staining
• vascular injection
• poor wetting
• punctate staining
• hyperaemia Fig . 40.27 Fluore sce in re ve als tissue comp romise in sup e rior limb ic
• chemosis ke ratoconjunctivitis (g rad e 2.3). (Courte sy of Me e Sing Chong , Bausch
& Lomb Slid e Lib rary.)
• irregular thickening o the superior bulbar conjunctiva
• papillary and ollicular hypertrophy
• hyperaemia and petechiae o the upper tarsal conjunctiva mani est between 2 months and 2 years a ter commencement
• corneal laments o lens wear.
• corneal warpage and astigmatism T e primary aetiological actor in the development o CLSLK
• corneal pseudodendrites (Fig. 40.26) (Stenson, 1983). is thimerosal hypersensitivity (Wilson et al., 1981) – a preserva-
T e tissue compromise progresses rom the limbus to the cen- tive that is no longer used in contact lens care solutions. Pro-
tre o the cornea in a V-shaped pattern with the apex directed vocative tests in thimerosal-sensitized patients result in general
towards the pupil centre (Fig. 40.27). circumlimbal redness (not just con ned to the superior lim-
Symptoms o CLSLK include increased lens awareness, bus), meaning that contact lens wear must be having an impact
lens intolerance, oreign-body sensation, burning, itching, on the clinical presentation o CLSLK, which is con ned to the
photophobia, redness, increased lacrimation, slight mucus superior limbus. Although other actors perhaps play a minor
secretion and slight loss o vision. his condition is uncom- role by initiating, modulating or exacerbating the condition, it is
mon, and occurs mostly in so t lens wearers. It is almost unlikely that CLSLK will develop in the absence o ocular con-
always bilateral, and the speci ic signs o ten display symme- tact with thimerosal. Other actors implicated in the aetiology
try between the eyes. here is considerable variability in the o CLSLK include thimerosal toxicity, mechanical e ects, lens
time course o onset o the condition; signs usually becomes deposits and hypoxia beneath the upper lid.

Patients su ering rom CLSLK may be advised to cease
lens wear or 2–4 weeks i less than grade 2 and up to 3
months in severe cases (greater than grade 2). All previously
worn lenses should be discarded. Re itting can be under-
taken when the corneal haze has largely resolved and the
corneal sur ace is smooth (less than grade 1); however, a vas-
cular pannus may be permanent. Lens wear can be resumed
in the presence o a vascular pannus as long as the patient is
monitored closely to check or the absence o urther vas-
cular encroachment. himerosal and any other potentially
allergenic preservatives should be excluded rom the care
system. Single-use daily disposable lenses are the best option.
Ocular lubricants in the orm o drops or ointments may pro-
vide symptomatic relie during the recovery phase, urther to
a positive placebo e ect in a naturally anxious patient. Clini-
cal signs and visual acuity will resolve within about 4 months
o cessation o lens wear, although this can vary between 3
weeks and 9 months.
Co rne al Ep it he lium
T e corneal epithelium is in direct contact with a contact lens,
and is thus susceptible to physical trauma. Being highly met-
abolically active, the epithelium is also sensitive to metabolic
insult. In the case o contact lens wear, the primary metabolic
insult is an inter erence with normal tissue respiration. Many o
the complications that are observed throughout the ull depth o
the cornea are mediated by the epithelium.
EPITHELIAL STAINING
Epithelial staining is not strictly a condition in itsel – rather, it
is a general term that re ers to the appearance o tissue disrup-
tion and other pathophysiological changes in the anterior eye,
as revealed with the aid o one or more o a number o dyes,
such as uorescein, rose bengal, lissamine green, uorexon or
alcian blue (E ron, 2013). Fluorescein has by ar the greatest
utility in contact lens practice, so the terms ‘epithelial staining’
and ‘corneal staining’ are taken to mean staining with uores-
cein, unless stated otherwise.
Epithelial staining ollowing instillation o uorescein is
observed under cobalt blue light as a bright green uorescence,
which can be described as ‘punctate’ (spot-like) (Fig. 40.28),
‘di use’ (spots merging together) and ‘coalescent’ (large regions
o con uence). T e staining pattern may be described accord-
ing to the ollowing groups o type descriptors: arcuate, linear
or dimpled; superior, in erior, temporal, nasal or central; and
deep or super cial (Korb and Korb, 1970). Staining ‘syndromes’
include in erior epithelial arcuate lesion (‘smile stain’), superior
epithelial arcuate lesion (otherwise known as ‘epithelial split-
ting’) and exposure keratitis. An ‘epithelial plug’ re ers to a large
coalescent eld o ull-thickness epithelial loss.
Observed areas o uorescence are believed to indicate one
o three phenomena: (1) uorescein entering damaged cells, (2)
uorescein entering intercellular spaces, or (3) uorescein ll-
ing gaps in the epithelial sur ace that are created when epithelial
cells are displaced (Wilson et al., 1995). However, Morgan and
Maldonado-Codina (2009) point out that our clinical under-
standing and interpretation o corneal sur ace uorescence are
based upon assumption, extrapolation and clinical intuition
rather than solid evidence-based science underpinning the
basic causative mechanisms o this phenomenon.
40 Co mp licat io ns 397
Fig . 40.28 Exte nsive sup e r cial p unctate e p ithe lial staining . (Courte sy
of Gary O rsb orn, Bausch & Lomb Slid e Lib rary.)
Bandamwar et al. (2014) have demonstrated that micro-
punctate uorescein staining identi es individual cells that are
undergoing apoptosis, whereby the cells have internalized uo-
rescein and are hyper uorescent relative to neighbouring cells.
Normal, healthy cells also take up uorescein, but uoresce
less brightly than apoptotic cells. Dead cells do not uoresce
appreciably.
Severe staining (grades 3 and 4) may be accompanied by
bulbar conjunctival redness and chemosis, limbal redness,
excessive lacrimation and, in some cases, stromal in ltrates,
depending on the cause o the problem. Visual acuity is gen-
erally una ected by epithelial staining, although a slight loss
might be expected in extreme cases (grade 4). T ere is no clear
relationship between the severity o staining and the degree o
ocular discom ort.
T ere are numerous causes o epithelial staining, which can
be broadly classi ed into six aetiological categories: mechani-
cal, exposure, metabolic, toxic, allergic and in ectious. In
many cases the pattern o staining, and whether the condi-
tion presents in one or both eyes, can provide a clue to the
cause. Low-level staining (less than grade 2) does not neces-
sarily require action to be taken. Such staining is commonly
observed in contact lens wearers; it is typically transient and
in a daily lens wearer will have disappeared by the ollowing
morning. However, persistent minor staining orming a char-
acteristic pattern, as well as staining greater than grade 2, may
require intervention.
Management strategies are generally sel -evident i the cause
can be discerned. For example, mechanical trauma due to a
oreign body trapped beneath a rigid lens (Fig. 40.29) can be
resolved by removing and rinsing the lens and rinsing the eye;
exposure keratitis causing 3 and 9 o’clock staining in a rigid lens
wearer can be resolved by tting so lenses; epitheliopathy due
to metabolic disturbance can be solved by tting a lens o higher
oxygen transmissibility; staining due to toxicity or allergy can
be resolved by eliminating the toxic or allergic agent; staining
associated with an in ection is treated by applying the appro-
priate antimicrobial therapy. Recovery rom epithelial staining
generally occurs within hours or days o removal o the o end-
ing source, but will be more prolonged i lenses are worn during
the recovery period.
398 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 40.29 Fore ig n-b od y track stain in a rig id le ns we are r re ve ale d
with the aid o f uore sce in. (Courte sy of De b b ie Jone s, Bausch & Lomb
Slid e Lib rary.)
Fig . 40.30 Exte nsive ormation o e p ithe lial microcysts in a so t le ns
we are r.
MICRO CYSTS
Microcysts appear as minute scattered grey opaque dots when
viewed with the slit-lamp biomicroscope using low magni -
cation and ocal illumination (Fig. 40.30), and as transparent
re ractile inclusions with indirect retroillumination. T ey are
generally o a uni orm spherical or ovoid shape and are in
the order o 20 µm in diameter. At high magni cation (×40)
using the observation technique o marginal retroillumina-
tion, microcysts can be observed to display a characteristic
optical phenomenon known as ‘reversed illumination’ – that
is, the distribution o light within the microcyst is opposite
to the light distribution o the background (Fig. 40.31). T is
indicates that the microcyst is acting as a converging re rac-
tor; there ore, it must consist o material that is o a higher
re ractive index than the surrounding epithelium. Micro-
cysts probably represent apoptotic (dead) cells that either
become phagocytosed (ingested) by living neighbouring cells,
Fig . 40.31 Hig h-mag ni cation imag e (× 200) o two e p ithe lial micro-
cysts, d isp laying re ve rse d illumination. (Courte sy of Ste ve Zantos.)
or remain involuted in the intercellular spaces. In a process
similar to that occurring in Cogan’s microcystic dystrophy, the
epithelial basement membrane reduplicates and olds, orm-
ing intraepithelial sheets that eventually detach rom the base-
ment membrane and encapsulate the cellular debris (Holden
and Sweeney, 1991).
Microcysts primarily represent visible evidence o chronic
tissue metabolic stress and altered cellular growth patterns.
T ese changes are presumed to be caused by a combination o
the direct e ects o hypoxia, and tissue acidosis created by the
indirect e ects o hypoxia (producing lactic acid) and hypercap-
nia (producing carbonic acid). T ey may also have a mechanical
aetiology; E ron and Veys (1992) provided evidence that lens-
induced mechanical trauma can induce microcysts.
Although the presence o microcysts is not thought to be
dangerous, their existence in large numbers is worrying as
this is representative o epithelial metabolic distress. Based
on the working hypothesis that the severity o the micro-
cyst response is related to the level o hypoxia / hypercapnia
induced by lens wear, a variety o strategies can be employed
in an attempt to minimize the number o microcysts. Strat-
egies that are likely to be success ul include re itting with
high-oxygen-transmissibility silicone hydrogel lenses (Covey
et al., 2001; Keay et al., 2001; Brennan et al., 2007), decreas-
ing the requency o overnight wear, changing rom extended
wear to daily wear, changing rom so t to rigid lenses and
avoiding de ective lenses.
T e prognosis or eliminating microcysts is good, but the
time course is peculiar. Following cessation o lens wear, there is
an initial increase over a 7-day period in the number o micro-
cysts, ollowed by a subsequent decrease. T e initial increase
in microcysts is thought to be due to an initial resurgence in
epithelial metabolism and growth, resulting in an accelerated
removal o cellular debris ( ormation o microcysts) and a
rapid movement o microcysts towards the sur ace, where they
become more visible. T is is ollowed by a gradual decrease as
the existing microcysts are completely eliminated rom the cor-
nea over a period o 3–5 months (Holden et al., 1985a).
 40 Co mp licat io ns 399

Fig . 40.33 Vacuole e rup tion throug h ante rior laye rs. The p atie nt had
b e e n we aring hig h-oxyg e n-transmissib ility rig id le nse s on an e xte nd e d -
we ar b asis or 3 ye ars, and awoke one d ay with sting ing and b lurre d
vision. (Courte sy of Ruth Cornish, Bausch & Lomb Slid e Lib rary.)

Fig . 40.32 Ep ithe lial vacuole s, d isp laying unre ve rse d illumination.
(Courte sy of Ste ve Zantos.)

VACUO LES
When the cornea is severely compromised, such as in the case
o severe stromal oedema or an extensive microcyst response,
the epithelium can also become oedematous; this mani ests as
the appearance o small uid vacuoles in the epithelium. By
observing the cornea using indirect retroillumination on the
slit-lamp biomicroscope, uid vacuoles can be observed to dis-
play ‘unreversed illumination’ – that is, the distribution o light
within the microcyst is the same as the light distribution o the
background (Fig. 40.32). T is indicates that the microcyst is act-
ing as a diverging re ractor; there ore, it must consist o material
that is o a lower re ractive index ( uid) than the surrounding
epithelial tissue (Zantos, 1983).
T e aetiology o epithelial uid vacuoles is two old. Epithe-
Fig . 40.34 Se ve re corne al wrinkling . (Courte sy of Brie n Hold e n,
lial oedema ollows traumatic loss o sur ace epithelial cells. T e Bausch & Lomb Slid e Lib rary.)
uid barrier (zonula occludens) that is normally ound between
sur ace epithelial cells is breached, resulting in the movement o
uid into the deeper layers o the epithelium. Since the cells are created between cells by the oedematous state to gain entry to
tightly tted and attach snugly together, the oedema may not the cornea. T is scenario is possible in both contact lens wear-
occur instantly or be widespread. Epithelial oedema can also ers and non-lens wearers. Fluid vacuoles can break through
orm as a result o hypotonic ocular exposure, which can com- the anterior epithelial sur ace, leading to a very pain ul condi-
promise the integrity o the uid barrier. Animal studies have tion (Fig. 40.33). Practitioners should there ore take action to
demonstrated the coexistence o epithelial oedema and thin- eliminate uid vacuoles rom the epithelium by treating the
ning ollowing periods o rigid lens wear. underlying cause, which generally equates to the prescription o
T e are observed with uorescein in and around corneal highly gas-permeable contact lenses that a ord optimal corneal
abrasions is epithelial oedema. Histopathological evaluation o oxygenation.
corneas ollowing hypotonic exposure demonstrates that the
oedema is extracellular and is present throughout the ull thick-
WRINKLING
ness o the epithelium (Krutsinger and Bergmanson, 1985).
Re ex tears are o low tonicity and may also provoke epithelial Corneal wrinkling is a rare but severe ocular complication o
oedema, such as during adaptation to rigid lenses. contact lens wear, characterized by the appearance o a series
Breakdown o the corneal uid barrier, as indicated by the o deep parallel grooves, giving the impression o a ‘wrinkled’
presence o uid vacuoles, can lead to secondary problems. For cornea. In white light, the ridges o the wrinkles can be seen
example, contaminated low-tonicity water – such as that which as bright re exes (Fig. 40.34). T e case described by Lowe and
may be ound in a hot tub – has an association with contract- Brennan (1987) took the orm o two linear wave patterns o u-
ing an Acanthamoeba keratitis. T e amoeba may use the spaces orescein pooling across the cornea and intersecting at an angle
400 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 40.35 Corne al wrinkling p atte rn re ve ale d b y f uore sce in. (Cour-
te sy of Gary O rsb orn, Bausch & Lomb Slid e Lib rary.)
o 70°. Several discrete spots o uorescence were observed at
the points o intersection o the two wave patterns.
T is condition is observed in patients wearing steeply t-
ted, highly elastic, ultrathin, mid-water-content lenses. In the
two cases described in the literature (Quinn, 1982; Lowe and
Brennan, 1987), the lenses that induced corneal wrinkling
were custom made and were not standard commercial prod-
ucts. Excessive elastic orces are thought to draw corneal tissue
inwards rom the limbus, causing the cornea essentially to ‘col-
lapse’ in a concertina-like ashion, creating a wrinkled appear-
ance. T ese orces could be derived rom intrinsic elastic energy
created when a relatively steep lens is compressed against the
eye and then attempts to return to its original shape, and it is
noteworthy in this regard that the lens used by Lowe and Bren-
nan (1987) had a airly steep base curve o 8.20 mm. Corneal
wrinkling may also have an osmotic aetiology in view o the
observation that complete evaporation o the tear lm in nor-
mal humans can cause an almost identical corneal wrinkling
and vision loss to lens-induced wrinkling.
As one would expect with such a dramatic distortion o the
corneal sur ace, vision loss is substantial. Indeed, vision drops
to less than 6 / 60 within 5 minutes o lens insertion. T e con-
dition is also extremely pain ul. Clinical evaluation o corneal
wrinkling is best achieved by slit-lamp examination under
white light and with uorescein under cobalt blue light. Corneal
topography can provide use ul supplementary in ormation by
viewing both the unprocessed image o the re ected mires and
the processed, colour-coded sur ace map.
Lowe and Brennan (1987) argue that corneal wrinkling
involves the epithelium and anterior stroma. T is view is based
upon their observations o the extreme variance in intensity o
uorescence across the ridges o a wrinkled cornea (Fig. 40.35),
implying deep urrows, and the extreme distortion o photo-
keratometric mires (Fig. 40.36). T e intensity o the wrinkling
pattern increased with time ollowing a blink, indicating uo-
rescein pooling within deep troughs.
T e treatment protocol or a patient experiencing corneal
wrinkling is to cease lens wear immediately. Although the
appearance o wrinkling will indeed have disappeared within 24
hours, the patient should not wear lenses or 1 week as a precau-
tion so as to allow possible subclinical compromise to resolve.
Fig . 40.36 Photoke ratog ram o corne a showing e xtre me wrinkling .
(Courte sy of Noe l Bre nnan, Bausch & Lomb Slid e Lib rary.)
T e patient should then be re tted with a so lens that is devoid
o inherently high elastic orces. Alternatively, rigid lenses can
be tted because corneal wrinkling does not occur with such
lenses.
T e time course o recovery o corneal wrinkling has been
demonstrated to be directly related to the period o lens wear
that induced the changes. Lowe and Brennan (1987) noted that
corneal wrinkling took 3, 90 and 240 minutes to recover ollow-
ing 5, 90 and 300 minutes o lens wear, respectively.
Co rne al St ro ma
T e stroma constitutes 90% o corneal thickness and is a key
component o the structural integrity o the globe. As it is nor-
mally clear and transparent, the stroma can be directly observed
in exquisite detail with the slit-lamp biomicroscope and con-
ocal microscope, providing a privileged insight into adverse
tissue reactions (and a decided clinical decision-making advan-
tage) that is not available during the examination o other tis-
sues in the human body.
O EDEMA
Oedema re ers to an increase in the uid content o tissue. Since
the cornea is able to swell only in the anterior–posterior direc-
tion – as a result o the collagen bre network in the stroma
– the physical dimensions o the cornea can increase only in
that dimension – that is, in thickness. T e human cornea expe-
riences about 3.5% oedema during sleep. With hydrogel lenses,
daytime corneal oedema typically varies between 1 and 6%, and
the level o overnight oedema measured upon awakening gen-
erally alls in the range 5–13% (Holden et al., 1983). Silicone
hydrogel lenses induce less than 4% overnight oedema, which
is only a slightly higher rate than occurs when sleeping without
lenses (Sweeney et al., 2004; Martin et al., 2008).
Clinicians can estimate the magnitude o corneal oedema
by care ul observation with the slit-lamp biomicroscope, as a
number o structural changes can be identi ed that correlate
with various levels o oedema. Using direct ocal illumination,
striae appear as ne, wispy, white, vertically oriented lines in
the posterior stroma when the level o oedema reaches about

Fig . 40.37 Stromal old s ob se rve d using a slit-lamp b iomicroscop e
(× 30). (Courte sy of Michae l Hare .)
Fig . 40.38 Stromal olds ob se rved using a con ocal microscop e (×680).
5% (grade 2). Striae are thought to represent uid separation
o the predominantly vertically arranged collagen brils in the
posterior stroma. Folds can be observed – using specular re ec-
tion technique – in the endothelial mosaic as a combination
o depressed grooves or raised ridges, or as a general area o
apparent buckling, when the level o oedema reaches about 8%
(grade 3) (Fig. 40.37). It is thought that olds indicate a physi-
cal buckling o the posterior stromal layers in response to high
levels o oedema. Folds can also be observed with the con o-
cal microscope as a series o parallel lines crossing the stroma
orthogonally (Fig. 40.38). T e stroma takes on a hazy, milky or
granular appearance when the level o oedema reaches about
15% (grade 4); such high levels o oedema are o en associated
with other signs and symptoms o ocular distress.
Contact lenses potentially restrict corneal oxygen avail-
ability, creating a hypoxic environment at the anterior corneal
sur ace. o conserve energy, the corneal epithelium begins to
40 Co mp licat io ns 401
respire anaerobically. Lactate, a byproduct o anaerobic metabo-
lism, increases in concentration and moves posteriorly into the
corneal stroma. T is creates an osmotic load that is balanced
by an increased movement o water into the stroma. T e sud-
den in ux o water cannot be matched by the removal o water
rom the stroma by the endothelial pump, resulting in corneal
oedema (Klyce, 1981).
T e key strategy or reducing the oedema response is to
increase corneal oxygen availability during lens wear (Morgan
et al., 2010). Rigid lens oedema can be alleviated by increas-
ing lens oxygen transmissibility; or tting a lens o atter base
curve, greater edge li or smaller diameter so as to increase
lens-mediated tear exchange. Hydrogel so lens oedema can
be alleviated by hydrogel lenses o higher oxygen transmissibil-
ity, attening the base curve or reducing lens diameter. General
strategies or reducing oedema include changing rom extended
to daily wear, changing rom so to rigid lenses, tting silicone
hydrogel lenses, and reducing wearing time.
In general, the prognosis or recovery o the cornea rom
lens-induced oedema is excellent. T e oedema induced when
a patient wears a contact lens or the rst time will resolve
within 4 hours o the lens being removed. Chronic lens-induced
oedema can take up to 7 days to resolve (Holden et al., 1985a).
THINNING
Although low levels o oedema during the day may appear to
be harmless, there is a growing body o evidence indicating that
chronic oedema may compromise the physiological integrity
o the cornea in the long term. It is now clear that long-term
wear o conventional hydrogel lenses can induce thinning o
the stroma. Whereas the extent o stromal oedema varies with
the prevailing level o corneal oxygenation and dissipates upon
removal o hypoxic stress, stromal thinning is a chronic and
irreversible tissue change observed in patients who have worn
lenses or many years.
Stromal thinning was ormally de ned or the rst time by
Holden et al. (1985a), although it had been reported anecdotally
by earlier workers. Holden et al. (1985a) detected stromal thin-
ning by measuring the presenting corneal thickness o patients
who had been wearing a lens in one eye only on an extended-
wear basis or an average o 5 years, because o unilateral myopia
or amblyopia. Upon ceasing lens wear, it was noted that corneal
thickness in the lens-wearing eye decreased to a steady-state
level that was thinner than the ellow non-wearing eye. Assum-
ing that the corneas o both eyes were the same prior to lens
wear (this was validated in a non-lens-wearing control group
o unilateral myopes and amblyopes), the only assumption that
can be drawn is that contact lenses induce stromal thinning.
T e revelation o stromal thinning has acilitated interpreta-
tion o data rom earlier longitudinal lens-wearing studies that
incorrectly ascribed a progressive decrease in corneal thickness
over time as representing some orm o adaptation. Iskeleli et al.
(2006) ound that central corneal thickness was signi cantly
thinner in patients wearing long-term low-oxygen-transmis-
sibility rigid lenses compared with no contact lens wear and
so contact lenses with a water content o 55%. Central corneal
thickness was also decreased signi cantly in long-term so con-
tact lens wear, with a water content o 38% compared with 55%
in non-wearers.
Contact-lens-induced stromal thinning can be o clinical sig-
ni cance. For example, patients who have worn contact lenses
402 PART 6 Pat ie nt Examinat io n and Manag e me nt
µ
Fig . 40.39 (A) Con ocal microscop ic imag e s o the p oste rior stroma
in a contact le ns we are r. (B) An ag e - and se x-matche d non-le ns-we aring
control ind ivid ual. (× 300.) (Courte sy of Haliza Mutalib , Bausch & Lo mb
Slid e Lib rary.)
or many years may be precluded rom undergoing laser abla-
tive re ractive surgery i too much thinning has occurred.
T e phenomenon o contact-lens-induced stromal thinning
does not con ound or invalidate interpretation o the clinical
signs o oedema discussed above. Striae, olds and haze repre-
sent a given level o oedema irrespective o whether or not the
stroma has thinned.
It is presumed that stromal thinning is due to the e ects
o chronic oedema, and two mechanisms may be postulated
to explain how this might occur. First, stromal keratocytes
may lose their ability to synthesize new stromal tissue owing
to the direct e ects o tissue hypoxia, and / or the indirect
e ects o chronic lens-induced tissue acidosis due to an
accumulation o lactic acid and carbonic acid. Second, con-
stantly elevated levels o lactic acid associated with chronic
oedema may lead to some dissolution o the mucopolysac-
charide ground substance o the stroma. Recent evidence
obtained using con ocal microscopy, demonstrating loss o
stromal keratocytes ollowing hydrogel lens wear (Jalbert
and Stapleton, 1999; E ron et al., 2001; Kallinikos and E ron,
2004; Kallinikos et al., 2006), lends support to the ormer
theory (Fig. 40.39).
DEEP STRO MAL O PACITIES
A number o authors have noted apparently benign, deep stro-
mal opacities (DSOs) in the corneas o contact lens wearers
(Brooks et al., 1986; Gobbels et al., 1989; Remeijer et al., 1990;
Loveridge and Larke, 1992; Holland et al., 1995; Pimenides
et al., 1996). T e opacities have been variously described as
being white, grey, brown, blue and cyan in colour, and cloudy,
scar-like, lattice-like and stellate-like in orm. T ey are some-
times associated with olds and striae in Descemet’s layer, and
with deep stromal vascularization (Loveridge and Larke, 1992).
It is possible to distinguish DSOs rom in ltrates (which typi-
cally reside in the anterior hal o the stroma) because DSOs
are invariably located deep in the stroma (Fig. 40.40). How-
ever, DSOs can take on a similar appearance to certain orms o
posterior stromal dystrophy, and some o the reported cases o
DSO may have been con used with dystrophies. T e aetiology
o this condition is unknown but probably varied (Loveridge
and Larke, 1992).
Examination o the living human cornea at very high mag-
ni cation (680×) using a con ocal microscope has revealed
the presence o highly re ective ‘microdot deposits’ through-
out the corneal stroma (Böhnke and Masters, 1997; rittibach
et al., 2005) (Fig. 40.41); these microdots may be a subclinical
correlate o DSOs. According to Böhnke and Masters (1997),
microdots are small, discrete, brightly re ective spots or dots
scattered throughout the stroma; they are generally round or
oval in shape, and vary in diameter rom about 1 µm to 4 µm.
In patients who had worn so contact lenses or an average o
26 years, panstromal microdot deposits were observed with a
mean grade o 3.1 (range 1–4). In the control group, none o 29
patients had stromal microdot deposits. T e authors concluded
that stromal microdot degeneration may be the early stage o
a signi cant corneal disease, which eventually may a ect large
numbers o patients a er decades o contact lens wear.
Mutalib (2000) conducted an experiment in an attempt to
replicate the ndings o Böhnke and Masters (1997). T e cor-
neas o one eye o 13 patients (age 32 ± 7 years) who had worn
contact lenses or an average o 8.2 years were imaged using
the con ocal microscope, as were the corneas o one eye o 13
age- and sex-matched control individuals who had never worn
contact lenses. Microdot deposits were observed in the stroma
o all 13 lens wearers, with a mean severity o grade 2.0 ± 1.1.
In the control group, microdots were observed in 10 o the 13
subjects, with a mean severity in the 10 eyes displaying micro-
dots o 1.5 ± 0.7. T e di erence in the severity o microdots was
statistically signi cant. T e microdots had an identical appear-
ance in lens-wearing and control individuals, apart rom the di -
erence in grading. T ey were all airly similar in size (1–2 µm
diameter).
T e act that microdot deposits are observed in all individ-
uals, whether contact lenses have been worn or not, suggests
that this phenomenon cannot be properly characterized as a
disease (E ron, 2005). However, the higher grading assigned
to microdots in lens wearers indicates that contact lens wear
is exacerbating otherwise-normal corneal morphological ea-
tures. Deep corneal opacities seen with the slit-lamp biomi-
croscope may be a gross mani estation o microdot ormation
– or example, by way o a massive aggregation o microdots
in the deep stroma.
It should also be recognized that it is not possible at present
to determine whether the appearance o DSOs and o microdots
 40 Co mp licat io ns 403

Fig . 40.40 De e p stromal op acitie s in a 24-ye ar-old woman who had worn 38%-wate r-conte nt hyd roxye thyl me thacrylate (HEMA) le nse s o r 4 ye ars.
(A) Se e n as a g re y haze with a b ro ad slit-lamp b e am. (B) A slit-lamp vie w con rms that the op acitie s are d e e p in the stroma. The cond ition re solve d 2
months a te r ce asing le ns we ar. (Courte sy of F. E. Ros, Bausch & Lomb Slid e Lib rary.)

Fig . 40.41 Microd ot d e p osits (b rig ht white sp ots) ob se rve d in the
p oste rior stroma o a contact le ns we are r. (Courte sy of Haliza Mutalib ,
Bausch & Lomb Slid e Lib rary.)
is related to the contact lenses or to solutions used in conjunc-
tion with lens wear.
NEO VASCULARIZATIO N
Corneal neovascularization can be de ned as the ormation
and extension o vascular capillaries within and into previously
avascular regions o the cornea. Super cial neovasculariza-
tion is the most common o the various orms o contact-lens-
induced vascular response (Fig. 40.42). Vision loss is rare and
will only occur i vessels encroach the pupillary axis or i there
has been an extensive leakage o lipid into the stroma (grade
Fig . 40.42 Sup e r cial stromal ne ovascularizatio n.
4). Deep stromal neovascularization develops insidiously, usu-
ally in an already-compromised cornea (e.g. keratoconus), and
may also progress in the absence o acute symptoms (Shah et al.,
1998) (Fig. 40.43).
A pannus is a thick plexus o vessels typically observed at
the superior limbus. wo orms o pannus may be observed in
contact lens wearers: active (in ammatory) and brovascular
(degenerative). An active pannus is avascular and is composed
o subepithelial in ammatory cells. In the later stages it may be
associated with secondary scarring o the stroma.
In contact-lens-induced corneal neovascularization, vessel
lumina are approximately 15–80 µm in diameter and contain
erythrocytes and sometimes leukocytes. Numerous extravas-
cular leukocytes are observed around blood vessels, and the
404 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 40.43 De e p stromal ne ovascularization, p rog re ssing to the site o
a corne al ulce r. (Courte sy of Barry We issman.)
surrounding stromal lamellae are disorganized and separated
with lines o keratocytes lying between them. T e overlying
corneal epithelium is o en a ected, with general oedema, cell
loss and the presence o large uid- lled vesicles. T e underly-
ing Descemet’s layer and endothelium are apparently una ected
(Madigan et al., 1990).
Contact-lens-induced corneal neovascularization can be
explained in terms o a dual aetiology model. Chronic hypoxia
induces stromal oedema, which ‘so ens’ the stroma and renders
this tissue more susceptible to vascular penetration. Some sec-
ondary actor must act to stimulate vessel growth – or example,
this could be mechanical injury to the epithelium, resulting in a
release o enzymes. In ammatory cells migrate to this site and
release vasostimulating agents that cause vessels to grow in that
direction.
E ron (1987) reviewed the early literature and calculated
that the limits o ‘normal’ or ‘expected’ vascular ingrowth (i.e.
less than grade 1), measured rom the limit o visible iris, were
0.2, 0.4, 0.6 and 1.4 mm or no wear, daily-wear rigid, daily-
wear hydrogel and extended-wear hydrogel regimens, respec-
tively. T ere have been no reports o neovascularization being
induced by silicone hydrogel lenses since their introduction to
the market at the turn o the century (Sweeney, 2013).
I corneal neovascularization is a primary concern, the pre-
scription o lenses with design eatures known to provide mini-
mal inter erence with corneal physiology is indicated, namely:
high oxygen transmissibility (such as silicone hydrogel lenses or
high-oxygen-transmissibility rigid lenses, to minimize oedema
and metabolic acidosis), minimal mechanical e ect (as judged
by patient com ort) and good movement (to avoid venous stasis
resulting rom limbal compression in so lenses). Care systems
likely to induce toxic or allergic responses should be avoided,
and regular a ercare visits are essential. Other options to be
considered include changing rom extended wear to daily wear,
replacing lenses more requently, reducing wearing time or even
ceasing lens wear.
Cessation o lens wear will halt the progression o vessel in l-
tration into the cornea, but empty ‘ghost’ vessels may remain in
place or months or years. Resumption o lens wear in a pre-
viously vascularized cornea will result in immediate re lling
o the vessels. T us, in advanced cases o neovascularization,
Fig . 40.44 Broad b and o ste rile in ltrative ke ratitis in a so t le ns we ar-
e r attrib ute d to hyp oxia. (Courte sy of Luig ina Sorb ara, Bausch & Lomb
Slid e Lib rary.)
long-term cessation o lens wear is indicated until ghost vessels
can no longer be detected.
KERATITIS
Keratitis re ers to in ammation o the cornea. From the per-
spective o the aetiology and pathology o contact-lens-associ-
ated keratitis, it is possible to characterize a condition as being
either sterile (non-in ectious) or microbial (in ectious). How-
ever, the di culty with this approach is that, rom a clinical
perspective, it is virtually impossible to distinguish between
the two in the early stages o the disease. o complicate matters
urther, it has been suggested that sterile keratitis can be classi-
ed into our subgroups: the so-called contact lens peripheral
ulcer, contact lens-associated red eye, in ltrative keratitis and
asymptomatic in ltrative keratitis (Sweeney et al., 2003). Sub-
sequent research has shown, however, that these entities can-
not be readily di erentiated (E ron and Morgan, 2006a). T is
approach has now been largely abandoned in avour o consid-
ering all corneal in ltrative events – rom the mildest symp-
tomatic in ltrate to severe microbial keratitis – as a potential
disease continuum, and to treat less-severe events with cau-
tion, as possible precursors to microbial keratitis (E ron and
Morgan, 2006b).
From an aetiological perspective, contact lens-associated
sterile keratitis can result rom a variety o mechanisms, such as
solution toxicity, bacterial endotoxicity (as distinct rom in ec-
tivity), immunological reaction, trauma, hypoxia and metabolic
disturbance (Fig. 40.44). Other aetiological actors include
breakdown o trapped post-lens tear lm debris, lens deposits
and poor patient hygiene. T e condition may be ulcerative (Fig.
40.45) or non-ulcerative.
Histopathological analysis o human tissue rom patients su -
ering rom sterile keratitis reveals ocal areas o epithelial loss,
attenuated epithelium and stromal in ltration with polymor-
phonuclear leukocytes; Bowman’s layer is una ected (Holden
et al., 1999).
 40 Co mp licat io ns 405

Fig . 40.46 Ad vance d microb ial ke ratitis in a so t le ns we are r. The

co rne al ulce r d isp lays a ‘soup y’ ap p e arance typ ical o Gram-ne g ative
b acte rial ke ratitis; the le sion was culture -p ositive or Pse ud omonas ae -
rug inosa. (Courte sy of Barry We issman.)

Fig . 40.45 Contact le ns-associate d ste rile ulce rative ke ratitis. (Cour-
te sy of Michae l Hare .)

Contact-lens-associated microbial (in ectious) keratitis can

be ulcerative (e.g. Pseudomonas aeruginosa keratitis) or non-
ulcerative (e.g. epidemic keratoconjunctivitis); the latter orm
is not caused by contact lens wear and will not be considered
urther here. A positive culture result or bacteria, virus, un-
gus or amoeba will provide strong evidence that the keratitis
is in ectious (microbial), but a negative culture result simply
means that microbial agents could not be detected in the tissue.
In the latter case, a keratitis may still be classi ed clinically as
‘in ectious’ based upon associated signs and symptoms (Aasuri
et al., 2003).
An early symptom o keratitis is a oreign-body sensation
in the eyes associated with an increasing desire to remove the
lenses. Continuing or worsening discom ort ollowing lens
Fig . 40.47 Characte ristic p atte rn o rad ial ke ratone uritis in a so t le ns
removal should lead a clinician to suspect microbial keratitis, we are r with Acanthamoe b a ke ratitis. (Courte sy Flore nce Male t, Bausch
with associated symptoms including pain, eye redness, swollen & Lomb Slid e Lib rary.)
lids, increased lacrimation, photophobia, discharge and loss o
vision. Conversely, i the condition is sel -limiting and signs and
symptoms eventually resolve without any clinical or therapeu- keratitis is not as rapid; typical signs include corneal staining,
tic intervention, the condition can retrospectively be deemed to pseudodendrites, epithelial and anterior stromal in ltrates that
have been a case o sterile keratitis. However, a mild keratitis, in may be ocal or di use and a classic radial keratoneuritis – this
the early stages o development, should never be diagnosed as being a circular ormation o opaci cation that becomes appar-
a sterile keratitis (or one o the so-called subcategories re erred ent relatively early in the disease process (Fig. 40.47). A ully
to above). Sterile keratitis is a condition that can be diagnosed developed corneal ulcer may take weeks to orm (Moore et al.,
only retrospectively. So, i a patient presents with ocular dis- 1985).
com ort and in ltrates are evident in the cornea, no matter how T e actors leading to the development o microbial kera-
apparently mild or innocuous, the case should be considered as titis, and strategies or minimizing the risk o developing this
a potential microbial keratitis and managed accordingly (E ron condition, are essentially the same as those discussed above in
and Morgan, 2006b). relation to the aetiology o sterile keratitis, with the obvious
Bacterial keratitis (e.g. Pseudomonas) can have a rapid and additional actor o microbial invasion o corneal tissue. Other
devastating time course. Epithelial and stromal haze, lacrima- risk actors or microbial keratitis include male gender, diabetes,
tion and limbal redness adjacent to the lesion will be noticed tobacco use and travel to warm climates (Morgan et al., 2005).
initially, ollowed by anterior chamber are, iritis, hypopyon A corneal scraping is usually per ormed to determine
and a serous or mucopurulent discharge. I not properly treated, whether the condition is in ectious and possibly to identi y
the stroma can melt away, leading to corneal per oration in a the o ending microorganism. Medical therapies may include
matter o days (Fig. 40.46). T e time course o Acanthamoeba the use o antibiotics, mydriatics, collagenase inhibitors,
406 PART 6 Pat ie nt Examinat io n and Manag e me nt
non-steroidal anti-in lammatory agents, analgesics, tissue
adhesives, debridement, bandage lenses and collagen shields.
Steroids may be prescribed with extreme caution in the late
healing phase so as to dampen the host response. Surgical
interventions include penetrating gra t, which may need to
be per ormed in the case o large per orations or non-healing
deep central ulceration, or possibly lamellar gra t. he prog-
nosis or recovery rom microbial keratitis is variable, rang-
ing rom a ew weeks in the case o Pseudomonas keratitis
to many months o regression and recurrence in the case o
Acanthamoeba keratitis.
WARPAGE
Corneal topography reveals that all orms o contact lens wear
are capable o inducing small changes in corneal shape. T ese
shape changes, which are generally re erred to as ‘warpage’, are
primarily mediated by the stroma, which is the main structural
entity o the cornea (the epithelium and endothelium o er little
mechanical resistance to de orming orces).
T e degree o irregularity o corneal sur ace shape can be
expressed by various mathematical indices. For example, the
sur ace asymmetry index (SAI) provides a quantitative measure
o the radial symmetry o the our central videokeratoscope
mires surrounding the vertex o the cornea. T e higher the
degree o central corneal symmetry, the lower is the SAI. Ruiz-
Montenegro et al. (1993) reported SAI mean values (± standard
error o mean) associated with the ollowing orms o lens wear:
polymethyl methacrylate (PMMA) 0.86 ± 0.22, daily-wear rigid
0.48 ± 0.09, daily-wear hydrogel 0.48 ± 0.11, extended-wear
hydrogel 0.46 ± 0.08, and non-lens-wearing controls 0.35 ± 0.03.
T e SAI was signi cantly greater than the control group or all
orms o lens wear except daily-wear hydrogel.
T e sur ace regularity index (SRI) is a measure o central and
paracentral corneal irregularity derived rom the summation o
uctuations in corneal power that occur along semi-meridians
o the 10 central photokeratoscope mires. T e more regular the
anterior sur ace o the central cornea, the lower is the SRI. T e
SRI is highly correlated with best spectacle-corrected visual
acuity. Ruiz-Montenegro et al. (1993) reported SRI mean values
(± standard error o mean) associated with the ollowing orms
o lens wear: PMMA 1.17 ± 0.34, daily-wear rigid 0.93 ± 0.18,
daily-wear hydrogel 0.52 ± 0.08, extended-wear hydrogel
0.51 ± 0.06, and non-lens-wearing controls 0.41 ± 0.04. T e SRI
was signi cantly greater than the control group or PMMA and
daily rigid lens wear, but not or daily or extended hydrogel lens
wear.
All known orms o contact-lens-induced warpage can be
explained in terms o three underlying pathological mecha-
nisms that primarily act on the stroma. T ese mechanisms
are: (1) physical pressure on the cornea exerted either by the
lens and / or by the eyelids, (2) contact-lens-induced stromal
oedema, and (3) mucus binding beneath rigid lenses. T e rela-
tive contributions o these actors will govern the type and
extent o topographical alteration (Carney, 1975).
Rigid lenses can induce clinically signi cant warpage, which
may be especially evident in patients with higher prescriptions
requiring thicker lenses or unusual lens designs (Fig. 40.48).
Such lenses will impart greater physical and hypoxic stress on
the cornea compared with thinner lenses made o the same
material. Altering the parameters o a rigid lens can reduce the
physical impact o the lens on the cornea and thus minimize
Fig . 40.48 Fluore sce in p atte rn showing se ve re corne al warp ag e in the
orm o se ve ral conce ntric b and s o d e e p corne al ind e ntation. This d e -
ormation was e vid e nt imme d iate ly a te r re moval o an immob ile hyb rid
le ns (rig id ce ntre and hyd rop hilic surround annulus). The p atie nt was
ke ratoconic and re q uire d a p re scrip tion o − 34.00 D. The le ns cause d
e xtre me p ain. (Courte sy of Russe ll Lowe .)
corneal shape changes. O course, in any case o rigid-lens-
induced warpage, re tting into so lenses will usually provide a
cure because so lenses are known to have little or no e ect on
corneal topography.
T e prognosis or recovery o normal corneal topography is
highly variable and dependent upon the cause, magnitude and
duration o the lens-induced de ormation. T e time course o
recovery rom physical orces on the cornea is di cult to pre-
dict. Recovery rom chronic lens-induced oedema is known to
occur within 7 days o cessation o lens wear; thus, recovery
rom oedema-mediated warpage would be expected to ollow a
similar time course. Hashemi et al. (2008) suggest that a 2-week
contact lens- ree period is adequate or the cornea to stabilize;
however, they suggest that it is di cult to predict the minimum
time needed or each individual patient.
Co rne al End o t he lium
As the tissue layer responsible or corneal hydration control,
the endothelium must be kept healthy so as to avoid chronic
oedema-related problems and the added risk o compromise
during ocular surgery. It is only in the past 30 years that it has
been recognized that the endothelium can be a ected by con-
tact lens wear.
BEDEWING
Contact-lens-associated endothelial bedewing (CLEB) is char-
acterized by the appearance o small particles in or on the endo-
thelium in the region o the in erior central cornea, immediately
below the lower pupil margin (Fig. 40.49). T e area o bedew-
ing can vary in shape. For example, CLEB may appear as an
oval cluster o particles or a less discrete dispersed ormation.
T e condition is usually bilateral. T e cells invariably display
reversed illumination (see discussion on microcysts, above, or
an explanation o this phenomenon), suggesting that bedewing
represents in ammatory cells rather than intracellular endo-
thelial oedema (which would display unreversed illumination).

Fig . 40.49 End othe lial b e d e wing . (Courte sy of Michae l Hare .)
Fig . 40.50 End o the lial b e d e wing ob se rve d at hig h mag ni cation
(× 40). (Courte sy of Charle s McMonnie s.)
When viewed in direct illumination, CLEB can appear as ne
white precipitates or as an orange / brown dusting o cells. T e
colour o the particles can give a clue to the length o time they
have been present; newly deposited cells are o en whitish in
colour (Fig. 40.50), but these become pigmented over time. T e
cells can become engul ed within the endothelium over time
(Bergmanson and Weissman, 1992).
T e ollowing signs may coexist with CLEB: conjunctival
injection, epithelial erosion, epithelial oedema and reduced cor-
neal transparency. T e main associated eature o endothelial
bedewing is either total or partial intolerance to lens wear. Some
40 Co mp licat io ns 407
Fig . 40.51 End othe lial b le b s can b e se e n in sp e cular re f e ction (× 40)
imme d iate ly to the le t o the d ark b and running d own the ce ntre o the
p icture . (Courte sy of Ste ve Zantos.)
patients may present a er having recently abandoned lens wear.
Patients may also complain o ‘ ogging’ o vision or stinging.
On the assumption that CLEB represents a mild in ammatory
uveal response, the origin o the in ammatory cells is likely to
be the iris and / or ciliary body. During in ammation, vascular
permeability is increased and in ammatory cells leave vessels in
the iris and ciliary body and oat around in the aqueous until
they come to rest on the endothelial sur ace. One would there ore
expect to observe mild aqueous are occasionally in patients with
CLEB, but this does not appear to have been reported. T is mild
in ammatory status probably causes lens intolerance.
Patient management is guided by symptomatology rather
than clinical signs. Wearing time should be reduced to a level
that represents the balance between the needs o the patient to
wear lenses or a desired length o time each day and the level o
discom ort that can be tolerated (McMonnies and Zantos, 1979).
T e presence o in ammatory cells on the endothelial sur ace
should be viewed with great caution by clinicians, because the
condition may not necessarily be related to lens wear. Certainly,
all orms o uveitis should be considered and tests should be
conducted to exclude such possibilities. In all cases o CLEB,
intraocular pressures should be measured because some in am-
matory cells may have migrated into the anterior angle, creat-
ing a blockage o aqueous out ow. Gonioscopy is also indicated,
especially i intraocular pressure is elevated.
T e pattern o recovery rom CLEB is variable. In some cases
bedewing will completely disappear within 4 months, and in other
cases it may change little over a much longer time period. Lens intol-
erance may persist or many months in some patients, even a er
the bedewing has disappeared (McMonnies and Zantos, 1979).
BLEBS
T e endothelial mosaic undergoes a dramatic alteration in
appearance in all lens wearers within minutes o inserting
a contact lens. T ese changes can only just be resolved when
observed under the highest magni cation possible (×40) using
the slit-lamp biomicroscope (Fig. 40.51). When viewed at much
greater magni cation (×200), a number o black, non-re ecting
areas can be seen in the endothelial mosaic corresponding to
408 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 40.52 End othe lial b le b s vie we d at × 200 mag ni cation. (Courte sy
of Ste ve Zantos.)
the position o individual cells or groups o cells (Fig. 40.52).
T ese are called blebs. T ere is also an apparent increase in the
separation between cells (Zantos and Holden, 1977). T ere is a
large variation in the intensity o the response between patients.
Blebs can be seen within 10 minutes o lens insertion.
T e number o blebs peaks in 20–30 minutes (grade 3), then
decreases to a lower level a er about 45–60 minutes. A low-
level bleb response (grade 1–2) can be observed throughout
the remainder o the wearing period. Hydrogel lenses cause a
greater bleb response than rigid lenses, and hydrogel lenses o
greater average thickness also induce a greater response than
thinner lenses. Brennan et al. (2008) demonstrated the percent-
age area o blebs in response to overnight wear o a 38% water-
content hydrogel lens to be 8%, whereas the percentage area o
blebs in response to overnight wear o three silicone hydrogel
lenses ranged rom 1.6 to 2.0%. T e percentage area o blebs in
response to open-eye wear o silicone hydrogel lenses was 0.4%.
T e appearance o blebs can be explained as ollows. When
the endothelium is viewed using specular re ection, light rays
re ect rom the tissue plane corresponding to the inter ace
between the posterior sur ace o the endothelium and the aque-
ous humour. T is inter ace acts as the re ective sur ace because
it represents a signi cant change in tissue re ractive index. T e
light rays that are re ected rom this inter ace give rise to an
observed image o an essentially at (or slightly undulating)
and eatureless endothelial cell mosaic. Light rays that strike
‘blebbed’ endothelial cells will be de ected away rom the obser-
vation path, leaving a corresponding area o darkness. T us,
an endothelial bleb is simply an individual endothelial cell (or
group o adjacent cells) that has become swollen and bulged in
the direction o the aqueous humour, giving rise to the compel-
ling optical illusion that the cell (or cells) has disappeared.
Endothelial blebs are caused by a local acidic pH change at the
endothelium. wo separate actors induce an acidic shi in the
cornea during contact lens wear: (1) an increase in carbonic acid
owing to retardation o carbon dioxide ef ux (hypercapnia) by a
contact lens; and (2) increased levels o lactic acid as a result o
lens-induced oxygen deprivation (hypoxia) and the consequent
increase in anaerobic metabolism (Holden et al., 1985b). All
cells in the human body unction optimally when surrounded by
extracellular uid that is maintained within an acceptable range o
pH, temperature, tonicity and ion balance. T e carbonic acid and
lactic acid alter the physiological status o the environment sur-
rounding the endothelial cells by shi ing pH in the acidic direc-
tion. T is induces changes in membrane permeability and / or
membrane pump activity, resulting in a net movement o water
into certain endothelial cells when the threshold or a change in
membrane permeability is exceeded or those cells. T e resultant
cellular oedema in such cells is observed as ‘blebbing’.
Despite their stunning clinical appearance, blebs are asymp-
tomatic and are thought to be o little clinical signi cance. A er
removal o a contact lens, blebs disappear within minutes.
PO LYMEGETHISM
T e human corneal endothelium is a single-cell layer that
appears as an ordered mosaic o primarily hexagonal-shaped
cells (Fig. 40.53A). A signi cant variation in apparent size o
cells is re erred to as endothelial polymegethism (Fig. 40.53B).
(‘Polymegethism’ is derived rom the Greek word megethos
meaning ‘size’; poly means ‘many’). T e extent o polymegeth-
ism increases throughout li e; consequently, the degree o lens-
induced polymegethism should be taken to mean the degree o
change in excess o that expected or a given age.
It is di cult to assess the integrity o the endothelium using
a slit-lamp biomicroscope, because individual endothelial cells
are just beyond the limit o resolution. T us, a normal endo-
thelial mosaic can be seen only as a speckled or textured eld.
Endothelial polymegethism o a severity greater than grade
2 can sometimes be detected because some o the larger cells
can be seen (Fig. 40.54). Inspection o the endothelium is best
undertaken using instruments designed speci cally or high-
magni cation imaging, such as the specular endothelial micro-
scope or con ocal microscope.
Sweeney (1992) has drawn an anecdotal association between
endothelial polymegethism and a condition that she termed
‘corneal exhaustion syndrome’. T is is a condition in which
patients who have worn hydrogel contact lenses or many years
suddenly develop a severe intolerance to lens wear character-
ized by ocular discom ort, reduced vision, photophobia and
an excessive oedema response. T ese patients also displayed
a distorted endothelial mosaic and moderate to severe poly-
megethism. Bergmanson (1992), however, has observed that
the endothelium o contact lens wearers showed some inter-
and intracellular oedema; the cells were otherwise o a healthy
appearance containing normal, undamaged organelles. He
argues that endothelial polymegethism is a non-problematic
adaptation to chronic metabolic stress.
T e suggestion that endothelial polymegethism is a benign
tissue change has been challenged by researchers who have
demonstrated a link between endothelial polymegethism and
corneal hydration control (Nieuwendaal et al., 1994). Recovery
rom oedema is signi cantly slower in the corneas o contact
lens wearers than in matched controls who have corneas with
lower levels o polymegethism.
It is likely that the aetiology o endothelial polymegethism
– contact-lens-induced endothelial acidosis – is precisely the
same as the aetiology o endothelial blebs, whereby the ormer
represents a chronic response and the latter represents an acute
response to the same stimuli. Endothelial acidosis may induce
changes in membrane permeability and / or membrane pump

Fig . 40.53 (A) Normal e nd o the lial mosaic. (B) End othe lium d isp laying se ve re (g rad e 3.5) p olyme g e thism. (Courte sy of Ste ve Zantos.)
Fig . 40.54 Enlarged vie w o the e nd othe lium as see n with a slit-lamp
biomicroscop e, showing p olymeg ethism ind uced b y 10 years o so t con-
tact le ns wear. (Courtesy of Rolf Hab ere r, Bausch & Lomb Slid e Library.)
activity, resulting in water movement that acts to elongate endo-
thelial cell walls. A recon guration o cell shape then occurs in
order to preserve cell volume, resulting in the appearance o
polymegethism at the apical sur ace o the endothelium (Berg-
manson, 1992).
Lenses o higher oxygen per ormance will induce lower levels
o polymegethism (Holden et al., 1985a). Doughty et al. (2005)
ound no signi cant change in endothelial polymegethism a er
6 months o silicone hydrogel lens wear. From a clinical per-
spective, it is essential to take note o the presence o signi cant
40 Co mp licat io ns 409
endothelial polymegethism and to take action to minimize the
metabolic stress to the cornea known to be associated with this
change.
Strategies or alleviating contact-lens-induced hypoxia and
hypercapnia include the ollowing:
• tting lenses o higher oxygen transmissibility, such as sili-
cone hydrogel lenses
• sleeping in extended-wear lenses less requently
• changing rom extended lens wear to daily lens wear
• reducing lens-wearing time
• tting rigid lenses with more movement and edge li (to
enhance oxygen-enriching tear exchange).
T e prognosis or recovery rom endothelial polymegethism
is poor. Holden et al. (1985c) were unable to detect a recovery
rom endothelial polymegethism 6 months a er removal and
cessation o wear o high-water-content hydrogel contact lenses
that had previously been worn on an extended-wear basis or an
average o 5 years.
Co nclusio n
his chapter has provided key clinical insights into some o
the more common contact lens complications. Many other
rare conditions and interesting variations o the complica-
tions discussed above have not been considered. he reader
is there ore directed to textbooks devoted exclusively to
this subject or more detailed in ormation, and encouraged
to monitor the ophthalmic literature constantly. As more
sophisticated tools continue to be developed that can be
used to study the ocular response o the living eye to contact
lens wear – such as con ocal microscopy and optical coher-
ence tomography (see Chapter 36) – it is certain that ur-
ther tissue reactions and complications will continue to be
revealed.
Acce ss the comp le te re fe re nce s list online at
http ://www.e xp e rtconsult.com.
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van den Bosch, W. A., & Lemij, H. G. (1992). Blepha-
roptosis induced by prolonged hard contact lens
wear. Ophthalmology, 99, 1759–1765.
van der Worp, E., De Brabander, J., Swarbrick, H.,
et al. (2008). Eyeblink requency and type in rela-
tion to 3- and 9-o’ clock staining and gas perme-
able contact lens variables. Optom. Vis. Sci., 85,
857–866.
Watanabe, A., Araki, B., Noso, K., et al. (2006).
Histopathology o blepharoptosis induced by
prolonged hard contact lens wear. Am. J. Ophthal-
mol., 141, 1092–1096.
Wilson, L. A., McNatt, J., & Reitschel, R. (1981). De-
layed hypersensitivity to thiomersal in so con-
tact lens wearers. Ophthalmology, 81, 804–809.
Wilson, G., Ren, H., & Laurent, J. (1995). Corneal
epithelial uorescein staining. J. Am. Optom. As-
soc., 66, 435–439.
Zantos, S. G. (1983). Cystic ormations in the cor-
neal epithelium during extended wear o contact
lenses. Int. Contact Lens Clin., 10, 128–137.
Zantos, S. G., & Holden, B. A. (1977). ransient
endothelial changes soon a ter wearing so t
contact lenses. Am. J. Optom. Physiol. Opt., 54,
856–858.
41
Dig it al Imag ing
ADRIAN S BRUCE | MILTO N M HO M
Int ro d uct io n
Digital imaging can be a valuable component o contact lens
practice (Fig. 41.1). T e term re ers to the electronic capture and
display o an image, by using a combination o computer and
camera. In contact lens practice, digital imaging is most o en
used to document contact lens ttings and ocular pathology. As
with all orms o technology, the cameras and computer systems
continue to become better in quality, less expensive to set up
and easier to operate.
Advances in imaging or eye care are truly remarkable. T e
advances in smartphones have changed the landscape. Earlier
photo systems used 35 mm lm-based cameras and required
a slit lamp with a built-in ash tube. A video camera mounted
on a slit lamp was also used or imaging, student teaching and
patient educations (Hammack, 1995).
However, the most common method or recording contact
lens ttings or ocular changes remains the use o handwritten
(or electronic) notes and diagrams. In recent years these have
been improved with the advent o ormal grading scales (E ron
et al., 2001; Pritchard et al., 2003) (see Chapter 39 and Appendix
K).
T is chapter outlines the bene ts o digital imaging or con-
tact lens practice, shows the results that can be obtained and
illustrates a number o available systems.
Be ne fit s o f Dig it al Imag ing fo r
Co nt act Le ns Pract ice
T ere are numerous eatures and bene ts with digital imaging
(Bruce, 2012). T ese include the ollowing:
• Instant imaging – the record is simply and instantly made.
T e magni cation and lighting may be varied in real time
to improve image quality.
• Minimal image costs – once a digital imaging system is
set up, the unit cost or each image is virtually zero. With
modern computers having multigigabyte hard-disk capac-
ity, many thousands o images may be easily stored and
retrieved.
• Image manipulation and quanti ication – a ter an image
is captured, the brightness, contrast or colour may be
enhanced (see below). Furthermore, image parameters
can be quanti ied by the computer (e.g. blood vessel
length, scar dimensions and cup / disc ratio). However,
care must be taken not to alter an image that may be
legal evidence.
• Video movies – dynamic conditions such as contact lens
ttings or certain dynamic orms o pathology evaluation
can be captured as a short movie on the computer. Lens
per ormance is much easier to understand and interpret
when a moving (versus static) image is presented.
410
• Portability and accessibility– images can be easily trans-
erred and viewed on smartphones. Some patients love to
post their images on social media sites like Facebook or
Instagram.
Once the digital image has been captured in an electronic or-
mat; this opens up the ollowing possibilities:
• Better patient care – one problem with notes and diagrams is
variability between observers. Even within the same observer,
over a long interval between visits some interpretation o the
notes may be required. Photodocumentation is valuable to
evaluate progression or healing in the patient’s condition.
• Patient education – there is a bene t in the patient imme-
diately seeing his / her own condition. T e patient ‘wow’
actor is bene cial to practice growth – perhaps the biggest
pay-o rom imaging (Schwartz, 1998).
• Paperless of ce – many contact lens practices are using
electronic medical records or patient visits. Digital imag-
ing is a logical adjunct to electronic records and has great
value in cases o potential legal action (Schwartz, 1998).
With the internet, patient records can be accessed at more
than one of ce location.
• Image trans er – increasingly, clinicians are communicat-
ing by email. A digital image is already on the computer
and this makes attachment to an email easy. E-mail has
made consultations with colleagues rom all over the
world accessible.
• Presentations – images can be trans erred to computer pre-
sentation programs, which are used or presentations and
teaching purposes. Digital images can easily be dropped
into PowerPoint and Keynote presentation programs.
Fig . 41.1 Why d ig ital imag e ? Dig ital came ras are ve ry acce ssib le ,
e le ctronic re cord s have b e come a ke y d rive r, and p atie nt q uality o care
can b e e nhance d .

Fig . 41.2 Dig ital SLR came ra syste m. A Takag i SM-70N slit-lamp mi-
croscop e (Takag i-Se iko Co., Nag ano-Ke n, Jap an), with a d ig ital came ra
ad ap tor (TD-2A) and Canon EO S 500D 15 me g ap ixe l came ra (Canon
Inc., Tokyo, Jap an). The came ra d e ault se tting s are ISO 1600 sp e e d with
1 / 15th se cond e xp osure . (Courte sy of Takag i-Se iko Co. and Canon Inc.)
In summary, photodocumentation enhances communication
with patients as well as enhancing the quality o clinical records.
With the increased use o electronic medical records, hand-draw-
ing is reduced, making digital imaging more necessary (Sanders
et al., 2013). T e merits o photodocumentation are numerous.
Digital imaging has taken clinical documentation to another level.
Ho w much Re so lut io n is Re q uire d fo r
Ant e rio r Eye Dig it al Imag ing ?
T e basic principle o digital imaging is that a light-sensitive
silicon computer chip is used in a camera. T e silicon chip is
known as a charge-coupled device (CCD), and the number o
light-sensitive elements on the CCD determines the image res-
olution or video and digital cameras. T e two most common
types o camera used or digital imaging are the smartphone
and the digital SLR (Fig. 41.2). Modern smartphone cameras
can take good quality moderate-resolution images through the
eyepiece o a slit lamp with high illumination (Fig. 41.3).
Previous reviews o digital imaging have discussed the issues
o image ormats and colour depth (Peterson and Wol sohn,
2005; Wol sohn and Peterson, 2006) and these are there ore not
covered in great depth here. Some common clinical issues are
discussed below.
T e image resolution re ers to the image dimensions
(width × height) in units o the number o dots (pixels). As the
image proportions or most cameras are in a 4 : 3 aspect ratio,
the resolutions are simply re erred to as a million pixel count
(e.g. 10 megapixels).
One way to consider this question o ‘how much resolution’ is
by the unit o detail that needs to be recorded. Fig. 41.4 shows a
number o clinical signs that an ideal digital imaging system should
be able to capture. Examples are: (A) corneal punctate staining, (B)
keratic precipitates, (C) endothelial cells and (D) epicapsular stars.
41 Dig it al Imag ing 411
Fig . 41.3 Imag e o corne al staining take n throug h the e ye p ie ce o a
slit lamp , with a smartp hone . Such d ig ital imag ing is hig hly acce ssib le
and conve nie nt, althoug h the q uality may b e limite d .
T ese eatures are 20–50 µm in size and i the digital imaging sys-
tem can surpass this resolution by a actor o 10 (i.e. 2–5 µm) then
the characteristics o each eature should be discernible in the nal
image. A 15 megapixel camera on a slit lamp with 16× magni ca-
tion should give this resolution (i.e. 3 µm). Ye et al. (2013) measured
the spatial resolution o a commercial slit lamp with a single lens
re ex (SLR) camera to be near 2 µm, although they commented
that the spatial resolution apparent to the observer was higher still.
Ho w d o I g e t a Brig ht e r Imag e ?
T ere are our commonly used illumination techniques or
photodocumentation:
1. Di user – this is best or opaque tissues, such as the con-
junctiva, sclera and eyelids. It is used in conjunction with
a ull-width slit, and the brightness o the beam is varied
or optimum exposure.
2. Slit section – this is most use ul or transparent tissues.
An angled slit beam gives a dark- eld background to
highlight eatures. A slit section can also be used with ret-
roillumination so as to highlight opaque tissue changes.
3. Fluorescein staining – sur ace de ects are best shown with
the combination o a cobalt blue illumination lter and a
yellow barrier lter with a wide slit beam.
4. ear lm assessment – specular illumination with the slit
lamp or other instrument will show lipid layer patterns,
tear lm thickness and break-up (Nichols et al., 2002).
Underexposure o anterior eye digital images is a common prob-
lem. T e camera needs to have good low-light per ormance in
order to obtain high-contrast slit images or to show uorescein
staining with lters in place. Smartphone cameras are usually
ully automatic, so all you can do is have the slit lamp on a high
light level and use a low magni cation on the biomicroscope.
A low magni cation gives a larger exit pupil or the biomicro-
scope optics, so more light will enter the camera. Where possi-
ble, turn o the smartphone ash and auto ocus. For a modern
digital SLR camera, apply the manual settings (e.g. a high ISO
412 PART 6 Pat ie nt Examinat io n and Manag e me nt

200 m 200 m

200 m 200 m

Fig . 41.4 How much re solution is re q uire d or ante rio r e ye d ig ital imag ing ? Examp le s o ce llular-scale d e tail visib le with slitlamp d ig ital imag ing .
(A) corne al p unctate staining , (B) ke ratic p re cip itate s, (C) e nd othe lial ce lls and (D) e p icap sular stars. The se e ature s are 20–50 µm in size and i the
d ig ital imag ing syste m can surp ass this re solution b y a actor o 10 (i.e . 2–5 µm) the n the characte ristics o e ach e ature should b e d isce rnib le in the
f nal imag e .

speed o 1600 or more and a slower shutter speed o 1 / 15th to
1 / 25th second). Excellent results can be obtained with a digital
SLR camera. A ull- eatured digital slit lamp has a ash system
built in to the illumination path; however, such slit lamps carry
a higher cost and are more complex.
Examples o digital images or each o the illumination types
are shown in Fig. 41.5. T e corneal optic section is particularly
use ul in assessing corneal ectasia and corneal transplant (gra )
condition. T e contour o the corneal pro le and variations in
the corneal layers or lamellae are critical signs in terms o the

Fig . 41.5 Slit-lamp p hotog rap hy: illumination and mag nif cation g uid e .
patient’s vision and indications in terms o work-ups and man-
agement plans. By looking at the centre o the cornea, but hav-
ing the light beam at an oblique angle o 30–40°, the corneal
shape pro le, thickness and layers may be assessed (Fig. 41.6).
Co mme rcial Dig it al Imag ing Syst e ms
Contact lens practitioners wishing to enter the world o digital
imaging have the choice o purchasing a commercially produced
system or getting started using a smartphone. A commercially
produced digital imaging system can be de ned as a ready-to-use
41 Dig it al Imag ing 413
integrated system, sold by an ophthalmic equipment supplier. It
will typically consist o a slit-lamp biomicroscope attached to a
video camera or digital still camera, and a personal computer
with database and image manipulation so ware.
A commercial digital imaging system is probably the best
alternative or practitioners who are not so amiliar with com-
puters. T ese systems have the bene t o a relatively simple
inter ace and an easy-to-use database or managing records.
T e company supplying the equipment will have taken care o
the technical issues related to setting up image acquisition by
the computer rom the video camera.
414 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 41.5, co nt ’d (I–P)
Dig it al SLR Came ra Slit -lamp Imag ing
Syst e m
T e advantage o a digital still camera is in the high quality
and resolution o the image. Pro essional digital SLR cam-
eras a ord high resolution (15 million pixels or more), good
low-light per ormance and options or attaching to instru-
ments. For example, the akagi slit-lamp biomicroscope
( akagi-Seiko Co., Nagano-Ken, Japan) can be attached to
a Canon EOS 500D camera (Canon Inc., okyo, Japan) or
a camera o equivalent speci ication. Other eatures o the
system include the ollowing:

Fig . 41.6 Diag nostic use o corne al op tic se ction at 30–40° incid e nce . The ce ntral imag e shows corne al e ctasia with in e rior cone ; the le t imag e is
normal corne al contour and the rig ht imag e is a p oste rior lame llar corne al g ra t.
1. T e digital camera adaptor ( D-2A) includes a yellow
written lter to give high-contrast uorescein images o
staining or lens ttings.
2. T e digital camera adaptor places the camera away rom
the binocular eyepieces, to avoid inter erence with stereo
viewing by the observer.
3. T e slit lamp has an integrated trigger button included on
top o the joystick. In this way, photos are taken with the
maximum o convenience in normal slit-lamp operation.
4. An accompanying computer is connected via a USB cable,
so that the images taken are instantly viewed and saved.
T e computer may be directly inter aced with the practice
computer program, or integration o le access and con-
nection to the patient record.
5. A separate background breoptic illuminator is included
or broad illumination o the ocular and preocular tissues.
A commercial digital imaging slit lamp with a SLR camera
has the highest image spatial resolution compared with other
slit-lamp imaging methods (Ye et al., 2013). Yuan et al., (2015)
ound the spatial resolution o a Nikon FS-2 slit lamp connected
to a Canon 60D digital SLR camera (18 megapixel) was compa-
rable with ultra-high-resolution optical coherence tomography
(UHR-OC ), but or a raction o the cost.
Smart p ho ne Dig it al Imag ing
Perhaps the best reason to consider using your smartphone
or digital imaging is the ease o getting started, the low entry
cost and the portability – a raction o the price o a com-
mercial system. Assuming you already have a smartphone
(iPhone, Android, etc.), the only cost is an eyepiece adaptor,
which is available or a ew hundred dollars. You can nd out
more online about the eyepiece adaptor. I you search You ube
(www.youtube.com) or ‘smartphone slit lamp’ you will nd
many guides on how to use such adaptors and where to pur-
chase. A use ul online article demonstrating implementation is
41 Dig it al Imag ing 415
available at www.journalmtm.com/2014/diy-smartphone-slit-
lamp-adaptor/.
As with any digital imaging system, there is a learning curve
towards taking good quality images. Where possible, turn o
the smartphone ash and auto ocus. Initially the best images
will be most readily taken using a uni orm illumination o the
eye – that is, with a broad beam or di user in ront o the light
beam (see Fig. 41.5). Opaque tissues such as eyelids, conjunc-
tiva / sclera or iris should be straight orward. Lower-light imag-
ing such as with uorescein lters, narrow optic section beam
or higher magni cations may take more time. Images can be
trans erred rom the phone to the practice computer system,
usually using wireless ‘drop boxes’ online or email. T ere is also
potential or global telemedicine using a smartphone or real-
time slit-lamp eye examination (Ye et al., 2014).
Additional digital imaging applications or smartphones
are also being described. It is possible to quanti y pupillary
anisocoria using a smartphone as a macro-camera (Mojumder
et al., 2015). It is also possible to use a smartphone or imaging
through a desktop microscope (Skandarajah et al., 2014). Clini-
cal applications o microscopy include assessment o ocular
pathogens such as Demodex (Hom et al., 2013).
Vid e o Slit -lamp Imag ing Syst e m
A video slit lamp may be a relatively low-cost method to capture
an image, or display on a screen or to input into a computer. It
has the advantage over the smartphone method o being a per-
manent installation, but has a lower resolution and quality than
a digital SLR camera.
T e two key steps are to connect a video camera to the slit
lamp and to input the video signal into the computer. T e per-
manent connection o a video camera to a slit lamp requires a
beam splitter in the slit-lamp observation system.
Some slit lamps, like the Haag-Streit BD900 (Haag-Streit AG,
Koeniz, Switzerland), have a standard built-in beam splitter.
416 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 41.7 Haag -Stre it BD900 vid e o slit lamp , with comp act imag ing
syste m. (Courte sy of Haag -Stre it.)
T is is a neat design, since it is in line with the observation sys-
tem and makes it easy to connect a video (CCD) camera (Fig.
41.7). Other slit lamps, such as the Zeiss SL120 or CSO SL990,
have a modular design and the beam splitter and camera can
be readily added together. For other slit lamps, it may be neces-
sary to check with the slit-lamp supplier as to whether a suitable
beam splitter is available.
For these types o beam splitter, a video camera must be
selected. A good solution is a single- or three-CCD microcamera
with separate power supply. T ese are known as ‘lipstick’ cam-
eras, owing to their compact size, making them suitable or an
ophthalmic instrument. T e low-light per ormance, resolution
and colour rendering are acceptable or most slit-lamp applica-
tions. I a video camera with a digital (Firewire or USB) output is
selected, then it will connect directly to the computer. T e image
can then be displayed on the computer, saved or printed. T is
option has the bene ts o good low-light per ormance, live image
preview and the acility or digital movie capture.
Re co rd ing Dig it al Mo vie s
Contact lens practice is photogenic not only or still images,
but also or dynamic movies. wo important uses or movies
include recording the dynamic procedures involved in lens t-
tings, and showing corneal complications as the light source
is moved or scanned. Viewing o uorescein patterns, lens
centration and movement bene ts immensely rom the use
o digital movies. Other interesting non-contact-lens-related
pathology where motion is use ul includes anomalies o the
pupils, eye movements and vitreous. Most smartphones and
digital SLR cameras have included so ware to allow movie
recording.
File Back-up and Print ing
Whatever system is used, it is vital to have a means o back-
ing up the data stored on the slit-lamp-inter aced computer, or
example by using a recordable CD-RW or DVD-RW, a remov-
able USB hard disk or a ash memory drive. Recently, the costs
o external hard-drive systems have become very reasonable.
Attaching an external several-terabyte drive is convenient and
easy to do. Backing up to the cloud is also becoming increasingly
common; this usually requires an internet connection and ade-
quate storage space.
T ere is a wide range o printers available, each with its
unique bene ts. For contact lens private practice work, an inkjet
printer is appealing because o its compact size, low capital cost
and high-quality prints. I quarter-page (postcard) size images
are made or attachment to record cards or re erral letters, then
both the speed and cost per print are moderate.
Infrare d Imag ing
T e Oculus Keratograph 5M (www.oculus.de) is a unique mul-
ti unctional corneal topography and digital imaging instru-
ment. It includes white diode illumination or imaging tear
lm dynamics, blue diodes or uorescein images and in rared
diodes or meibography o the eyelids. Apart rom slit imaging
or optic section viewing, it can per orm most o the unctions
o a standard digital imaging camera, with the addition o Plac-
ido corneal topography, pupillometry and in rared assessment
o the tear lm (Fig. 41.8) and meibomian glands (Fig. 41.9).
Srinivasan et al. (2012) have suggested that meibomian gland
dropout visible within the upper and lower eyelids is a use ul
means o assessing meibomian gland dys unction in dry eye.
For the rst time, it is possible to measure the tear lm break-
up time under in rared illumination, avoiding re ex tearing and
using an objective computer-based analysis. As with other non-
invasive assessments o tear lm stability, the break-up time
provides longer values than clinical assessment with uores-
cein and may provide a more natural representation (Lan et al.,
2014).
O CT Ant e rio r Se g me nt
T e newest imaging technology or contact lens practice is
optical coherence tomography (OC ), which enables quantita-
tive cross-sectional imaging o the anterior eye using in rared,
low-coherence light. OC is a signi cant advance in imaging
because o the bene t o corneal tomography at very high speed
(a raction o a second), with great accuracy and the patient
com ort associated with in rared light.
Dedicated anterior OC instruments use a 1310 nm in rared
diode or imaging. T e long-wavelength light is able to penetrate
both cornea and sclera, enabling imaging o not just the cornea
but also structures inside the anterior angles and beneath the
scleral sur ace, such as ltering blebs (Bruce, 2012).
Zeiss Visante (www.zeiss.com) was the original OC instru-
ment and, although that is now discontinued, the omey Casia
SS-1000 (www.tomey.com) is a newer higher-speed alternative.
Both instruments can image a volume up to 16 × 16 × 6 mm
depth, and can present pachymetry analysis o a 10 mm diam-
eter, with the Casia also giving corneal curvature and elevation
analysis. Image examples are shown in Figs. 41.10 and 41.11.
Posterior OC instruments can potentially provide many o the
pachymetry and corneal-imaging eatures o the dedicated ante-
rior OC .
Scanning Slit -b e am Imag ing
Scanning slit-beam instruments use visible light wavelengths
to measure corneal tomography. By measuring both anterior
and posterior corneal sur aces, a three-dimensional tomo-
gram o the cornea is constructed and typically displayed
 41 Dig it al Imag ing 417

Fig . 41.8 Automatic d e te ction o te ar f lm b re ak-up using the O CULUS Ke ratog rap h 5. (Courte sy of O culus.)

Fig . 41.9 In rare d imag ing o the e ve rte d e ye lid s showing normal me ib omian g land s (le t), with contrast e nhance d imag e s on the rig ht.

as a quad-map (see Chapter 37). T ese instruments include

the Pentacam, which uses a rotating Scheimp ug camera
(www.oculususa.com) and the Orbscan II, which uses a scan-
ning slit beam or corneal and anterior-chamber assessment
(www.zyoptix.com). Scanning slit-beam instruments are
mainly targeted at measurement, although the corneal slit
images may be displayed.
Co nfo cal Micro sco p y
Con ocal microscopy is a specialized contact microscopy tech-
nique or corneal imaging. It gives magni cation up to 400×
with a small eld o view. T e technique shows the detail o
individual cells in each layer o the cornea, allowing in vivo
assessment o the e ects o contact lenses, corneal in ections,
418 PART 6 Pat ie nt Examinat io n and Manag e me nt

Fig . 41.10 Optical coherence tomography (OCT) images o contact lens-

es. (A) Horizontal line scan (10 × 3 mm) o a rigid contact lens in moderate
keratoconus. The central corneal thickness is 0.38 mm. (B) Horizontal line
scan (16 × 6 mm) o a disposable so t contact lens or moderate hyperopia.

Fig . 41.12 Imag e e nhance me nt. (A) The orig inal d ull imag e . (B) The
same imag e a te r b rig htne ss and contrast e nhance me nt.

in ammations and dystrophies (E ron and Hollingsworth, 2008;

Pritchard et al., 2014). Available instruments include the Nidek
Con oscan4 (www.nidek.com) and the Heidelberg Laser Scan-
ning Con ocal Microscope (www.heidelbergengineering.com).

Imag e Ed it ing
Digital images have the advantage o image manipulation.
T ere are many image-editing programs available on the
market today. Basic image-editing capabilities are o ered as
a so ware eature in some commercial slit-lamp packages.
Key editing applications with respect to contact lens imaging
include the ollowing:
• Brightness and contrast correction – images that are underex-
posed can be corrected easily with image editing (Fig. 41.12).
T e lightest pixel and darkest pixel in the picture speci y each
end o the spectrum. T e remaining pixels are rescaled to ll
out the rest o the spectrum (Hom and Bruce, 1998).
• Fluorescein pattern analysis – uorescein pattern images
can be analysed by colour (Costa and Franco, 1998). Ob-
jective methods can be used to determine the t o a lens
( at, steep, aligned). T e uorescein pattern is analysed
Fig . 41.11 O p tical cohe re nce tomog rap hy imag e s in ke ratoconus. by RGB colour channels. T e histograms o the blue and
(A) Ve rtical line scan sho wing the cone p rof le , corne al thinning and
incre ase d ante rior-chamb e r d e p th. (B) Map o corne al thickne ss in the green channels can be used to di erentiate between a at,
same p atie nt showing in e rior corne al thinning . steep and aligned (on-K) t (Hom and Bruce, 1998).
 41 Dig it al Imag ing 419

the thick and thin tear layers (Fig. 41.13). T e di erent

thickness areas are made even more distinct by applying
new colours. T e corneal topography underneath a rigid
lens can be interpolated with this technique (Hom and
Bruce, 1998).

Co nclusio n
Digital photography is a hugely advantageous technique
or contact lens practice. Both commercial and smartphone
imaging systems have become simpler and less expensive.
T is chapter has demonstrated the great potential and versa-
tility o digital image capture systems or enhancing clinical
care by improved recording and sharing o clinical in or-
mation relating to contact lens practice. Digital imaging
enhances patient communication and retention and supports
practice growth.
Fig . 41.13 Te ar laye r thickne ss p atte rn (se e te xt).
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
• ear layer thickness analysis – tear layer thickness under
the lens can be determined by the intensity o the uo-
rescence. T e thinner tear layers are dark. T icker tear
layers are brighter. Reducing the colour depth o a uo-
rescein pattern separates the colour di erences between
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419.e 1
42
Co mp liance
NATHAN EFRO N

Int ro d uct io n prescription. For short-term medication (e.g. a 9-day course

Patients are of en lying when they say they have regularly
taken the prescribed medicine.
Hippo rates, 400 bc
T e issue that Hippocrates was highlighting was that o com-
pliance – an important eld o medicine that has been the sub-
ject o medical research since the beginning o the 20th century.
In the contact lens eld, studies o compliance commenced only
in the mid 1980s, with the rst peer-reviewed journal article on
this topic being published in 1986 by Collins and Carney.
Although patients sometimes unwittingly, carelessly or even
recklessly contribute to their own mis ortune (Fig. 42.1), the
model o ered by Hippocrates is perhaps a little too simplistic.
Sackett and Hayes (1976) de ned compliance as ‘the extent to
which a patient’s behaviour coincides with the clinical prescrip-
tion’. T is is a more instructive de nition in that it highlights the
critical importance o the practitioner–patient relationship in
avoiding adverse events. T is chapter will review the eld o com-
pliance as it relates to contact lens wear and will conclude with
the presentation o a contact-lens-speci c compliance model.
Co nse q ue nce s o f No n-co mp liance
Although ull compliance with practitioner instructions does
not guarantee trouble- ree lens wear (Najjar et al., 2004), it is
worth considering the possible consequences o non-compli-
ance because the conclusions rom such an analysis provide the
rationale or studying this topic. In general, non-compliance will
result in the ollowing adverse e ects: reduction o treatment
e cacy, secondary problems, incorrect prescribing, wasting o
practitioner chair time, and wasting o patient time. Clearly,
health-care delivery will be enhanced i adverse consequences
o non-compliance can be minimized or eliminated.
o antibiotics) about 20–30% o patients will be non-compli-
ant. Higher rates o non-compliance are ound or long-term
regimens: 30–40% o patients are non-compliant with pre-
ventive or prophylactic measures (e.g. using sun protection
creams outdoors in patients susceptible to skin cancer) and
more than 50% o patients do not adhere to advice relating
to long-term therapy (e.g. ongoing medication or chronic
hypertension) (DiMatteo and DiNicola, 1982; Claydon and
E ron, 1994a).
he prescription o contact lenses and contact lens care
systems is akin to a long-term preventive measure; it is there-
ore not surprising that in 2011 an international survey o
4021 lens wearers ound that ull compliance with all aspects
o the lens care regimen was very rare or most lens users,
although better (15% o wearers) or daily disposable lenses
(Morgan et al., 2011). Claydon and E ron (1994b) had noted
similar levels o contact lens non-compliance 17 years ear-
lier, indicating that little has changed in this regard in the
intervening period. Levels o non-compliance with respect
to contact lens care are broadly consistent with estimates
o patient non-compliance reported in general medicine
(Claydon and E ron, 1994a).

Ext e nt and Pat t e rn o f No n-

co mp liance
It is not always possible to characterize a person simply as com-
pliant or non-compliant, because there will be variations in the
pattern o non-compliance over time, and changes in the extent o
non-compliance at a given instance in time. Because o this, non-
compliant behaviour in some people may continue undetected
or some time. T ere is a greater likelihood o detecting consistent
and / or total non-compliant behaviours at an a ercare visit.

Durat io n o f t he Pre scrip t io n

Fig . 42.1 Re ckle ss atte mp t b y a p atie nt to o b tain re sid ual solution
In the general health-care ield, the extent o non-compli- rom a can o ae rosol saline (b e cause the nozzle had ce ase d to unction)
ance has been ound to be related to the duration o the b y sawing the top o . (Courte sy of Jane Ve ys.)
420

Erro ne o us Co nt act Le ns Pro ce d ure s
A number o epidemiological studies have identi ed risk actors
that are associated with an increasing likelihood o microbial
keratitis during contact lens wear (Morgan et al., 2011). Many
o these are ‘non-modi able’ and include age, gender and socio-
economic status. Others are ‘modi able’; in turn, these can be
subdivided into actors that are or are not related to ‘compliance’.
Fig . 42.2 Prop ortion o corre ctly b e having we are rs or mod i ab le
p atie nt-comp liance -re late d b e haviours or d aily d isp osab le le nse s.
Country cod e s: AU = Australia; CA = Canad a; CN = China; DE = Ge rma-
ny; ES = Sp ain; FR = France ; IN = Ind ia; IT = Italy; JP = Jap an; KR = South
Kore a; PL= Poland ; RU = Russia, UK= Unite d King d om, US = Unite d
State s. (From Morg an, P. B., Efron, N., Toshid a, H. & Nichols, J. J. (2011).
An inte rnational analysis of contact le ns comp liance . Cont. Le ns Ante -
rior Eye , 34, 223–228.)
Fig . 42.3 Prop ortion o corre ctly-b e having we are rs or mod i ab le p atie nt comp liance –re late d b e haviours or d aily we ar re usab le le nse s. (Country
cod e s as in Fig . 42.2.) (From Morg an, P. B., Efron, N., Toshid a, H. & Nichols, J.J. (2011). An inte rnational analysis of contact le ns co mp liance . Cont.
Le ns Ante rior Eye , 34, 223–228.)
42 Co mp liance 421
Morgan et al. (2011) identi ed eight modi able, patient-com-
pliance-related behaviours that put the patient at increased risk
or microbial keratitis:
• inadequate handwashing
• non-prescribed overnight wear
• excessive duration o extended wear
• excessive lens replacement interval
• inadequate case cleaning
• ailure to use correct disin ecting solution
• ailure to rub and rinse lenses
• topping up solution.
Surveys conducted in 14 countries identi ed the proportion o
correctly-behaving wearers or modi able patient-compliance-
related behaviours (MPCRBs) or daily disposable lenses (Fig.
42.2) and daily-wear reusable lenses (Fig. 42.3) (Morgan et al.,
2011). Statistical analysis revealed that, overall, country was a
signi cant independent actor in predicting the total number
o non-compliant steps. T e key di erence here was the greater
number o non-compliant MPCRBs reported by South Korean
respondents, with a largest least mean square (LMS) value o
3.97 compared with the other countries, which ranged rom
2.93 in France to 3.45 in Japan.
T e number o non-compliant steps also di ered across the
lens types. Daily disposable lenses were associated with the
least non-compliance, ollowed by reusable extended-wear so
lenses and the remaining lens groups (reusable daily-wear so
planned replacement lenses, non-planned replacement so
lenses and rigid lenses) per orming similarly.
Gender was predictive o the number o non-compliant
MPCRBs, with better compliance or women (3.12) than or
men (3.28). Age was also demonstrated to be an important ac-
tor, with the number o non-compliant steps diminishing with
the age o the respondent. T e rate o improvement with age was
about 0.15 non-compliant MPCRBs per decade o li e.
Respondents using their lenses more requently tended to
be less compliant than did those using lenses on a part-time
422 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 42.4 Re asons or re -use o d aily d isp osab le contact le nse s. (From
Dumb le ton, K. A., Richte r, D., Wood s, C. A. e t al. (2013a). A multi-country
asse ssme nt of comp liance with d aily d isp osab le contact le ns we ar. Cont.
Le ns Ante rior Eye , 36, 304–312.)
Fig . 42.5 Me thod o storing re -use d d aily d isp osab le contact le nse s.
(From Dumb le ton, K. A., Richte r, D., Wood s, C. A. e t al. (2013a). A multi-
co untry asse ssme nt of comp liance with d aily d isp osab le contact le ns
we ar. Cont. Le ns Ante rior Eye , 36, 304–312.)
basis. Subjects using lenses on a ull-time basis typically per-
ormed 3.47 non-compliant MPCRBs compared with 2.41 non-
compliant steps or those using lenses or a single day per week.
Respondents were more compliant i they had consulted with an
eye-care practitioner more recently (Morgan et al., 2011).
Re aso ns fo r No n-co mp liance
Dumbleton et al. (2013a) surveyed 805 patients wearing daily dis-
posable contact lenses in our countries – Australia, Norway, the
United Kingdom and the United States – to determine the rate o
non-compliant behavior and the reasons or this. Although daily
disposable lenses are designed to be worn once only and dis-
carded a er each use, overall 9% o patients were non-compliant,
with the speci c rates o non-compliance in the our countries
being: Australia 18%, USA 12%, UK 7% and Norway 4%.
T e reasons patients gave or reuse o lenses is shown in Fig.
42.4. Among those who did reuse their daily disposable lenses,
various methods were used to store lenses overnight (Fig. 42.5) and
a number o di erent o solutions employed or this purpose (Fig.
42.6). Patient perceptions o the main risk involved in reusing daily
disposable lenses are shown in Fig. 42.7 (Dumbleton et al., 2013a)
Similar reasons or non-compliant behaviour in the United States
have been reported or reusable lenses (Dumbleton et al., 2013b),
with one key di erence: the main reason cited or wearing reusable
lenses longer than recommended was orget ulness – either orget-
ting which day to replace lenses or orgetting to reorder lenses.
Fig . 42.6 Solution use d to store re use d d aily d isp osab le co ntact le ns-
e s. (Fro m Dumb le ton, K. A., Richte r, D., Wood s, C. A. e t al. (2013a). A
multi-country asse ssme nt of comp liance with d aily d isp osab le contact
le ns we ar. Cont. Le ns Ante rior Eye , 36, 304–312.)
Fig . 42.7 Patie nt p e rce p tions o the main risk o re we aring d aily d is-
p osab le contact le nse s. (From Dumb le ton, K. A., Richte r, D., Wood s, C.
A. e t al. (2013a). A multi-country asse ssme nt of comp liance with d aily
d isp osab le contact le ns we ar. Cont. Le ns Ante rior Eye , 36, 304–312.)
Co mp liance w it h t he Inco rre ct
Pre scrip t io n
T e vast majority o practitioners endeavour to dispense the cor-
rect and proper prescription; it would be unethical to do oth-
erwise. However, in the past there have been well-documented
contact-lens-related cases o practitioners dispensing the incor-
rect prescription based on misin ormation or a misinterpretation
(E ron et al., 1991; Matthews et al., 1992; Dumbleton et al., 2010).
An example o this was the recommendation by 6% and 4% o
practitioners in Canada and the USA, respectively, that patients
reuse their daily disposable lenses (Dumbleton et al., 2010).
Whether inadvertent or deliberate, incorrect prescribing is a
reality that must be considered in order to provide a comprehen-
sive analysis o non-compliance. Fig. 42.8 is a f ow diagram that
reveals ve possible outcomes based upon the assumption that an
incorrect prescription (or incorrect advice) has been dispensed to
the patient. A tick indicates the likelihood o a positive outcome,
and a cross indicates the likelihood o a negative outcome.
I the patient is compliant with the incorrect prescription then
a negative outcome, such as ocular irritation, is more likely. A
patient may also be non-compliant with the incorrect prescrip-
tion. Non-compliance can be deliberate or unintentional, and a
patient can be deliberately non-compliant in a rational or irratio-
nal manner. Unintentional non-compliance can be due to orget-
ulness or a misunderstanding o the instructions. It is unlikely
 42 Co mp liance 423

Incorrect Prescription

Non-compliance

Deliberate Unintentional

Compliance Rational Irrational Forgetful Misunderstood

Fig . 42.8 Conse q ue nce s o comp liance with the incorre ct p re scrip tion (a tick ind icate s the like lihood o a p o sitive outcome and a cross ind icate s
the like lihood o a ne g ative outcome ).

Correct Prescription

Non-compliance

Deliberate Unintentional

Compliance Rational Irrational Forgetful Misunderstood

Fig . 42.9 Conse q ue nce s o comp liance with the corre ct p re scrip tion (a tick ind icate s the like lihood o a p ositive outcome and a cross ind icate s the
like lihood o a ne g ative outcome ).

that unintentional non-compliance will result in correct proce-
dures being readopted because o the plethora o random and
most likely erroneous procedures that are theoretically available.
Co mp liance w it h t he Co rre ct
Pre scrip t io n
A patient being non-compliant with the correct prescription
probably constitutes the classical view o non-compliance taken
by practitioners. Fig. 42.9 is a f ow diagram that reveals ve pos-
sible outcomes based upon the assumption that a correct pre-
scription (or correct advice) has been issued. I the patient is
compliant with the correct prescription, a positive outcome is
more likely. Conversely, a negative outcome is likely i a patient
is non-compliant with the correct prescription.
Inve st ig at io n o f St rat e g ie s fo r
Co mp liance Enhance me nt
Vincent (1971) conducted a study on a large cohort o glaucoma
patients who were speci cally told that i they did not comply
with the instruction to instill three drops o topical medication
into their eyes daily they could go blind. T e outcome o the
study was that 50% o patients did not comply o en enough,
and that there was no improvement in compliance in those who
lost sight in one eye.
In the light o such results, one may wonder whether any-
thing can be done to improve compliance among contact lens
wearers, especially in view o the act that the consequences o
non-compliance, such as the development o a corneal ulcer,
carry a very low absolute risk. A more enlightened approach
might be to assume that there will always be a certain level o
non-compliance, and that contact lenses and lens care systems
should be designed to have a su cient level o redundancy, or
sa ety margin, to account or this.
Notwithstanding the above reservations, the search or viable
compliance enhancement strategies needs to continue in view
o the known adverse consequences o non-compliance.
Because contact lens wearers typically overestimate their
level o compliance (Donshik et al., 2007), strategies in addi-
tion to the use o questionnaires must be adopted to derive an
accurate picture o the level o adherence to instruction. Such
strategies include, but are not limited to: observation and scor-
ing o patient actions and procedures in a clinical situation,
direct determination o the number o lenses used or care solu-
tion volumes remaining over xed time rames, and anonymous
surveys o contact lens behaviours and belie s.
IMPRO VING INITIAL PATIENT EDUCATIO N
Claydon et al. (1997) conducted a 12-month study on 80 patients
who were randomly divided into two groups. One group was given
424 PART 6 Pat ie nt Examinat io n and Manag e me nt
standard verbal instructions, and the other group was subjected to
a compliance enhancement strategy. Handwashing was the only
procedure that improved to an extent that was statistically veri -
able. In contrast, the intensity o initial education had no bear-
ing on the integrity o the anterior ocular structures. T us, the
compliance enhancement strategy ailed, indicating that a level o
instruction in excess o that typically being o ered at the present
time is likely to be redundant in terms o enhancing compliance.
T ere may be other bene ts o a thorough initial education,
such as: (1) raising awareness o lens types and lens care prod-
ucts, (2) rein orcing brand loyalty (i this is o interest), and (3)
enhancing the patient–practitioner relationship. Although an
enhanced initial instruction will not improve compliance, the
bene ts o reinstruction are clear. Compliance can be enhanced
by constantly reminding patients o correct procedures at a er-
care visits (Capellani and Boyce, 1999). Rad ord et al. (1993)
demonstrated that such an approach improved the rate o com-
pliance in one study group rom 44% to 90%.
PERIO DIC SELF-REVIEW
Yung et al. (2007) administered a regular sel -review exercise on
proper lens handling to a group o 60 lens wearers once every 3
months or 12 months. T e levels o compliance and contami-
nation o contact lenses and lens care accessories between the
test group and control group (the latter was not administered a
regular sel -review) were compared at the end o the 12-month
period so as to evaluate the e ect o the intervention. All showed
some degree o non-compliance in the care o their contact
lenses and lens accessories. Most (about 60%) were non-com-
pliant with at least six o a total o 15 lens care procedures. T e
most common non-compliant behaviour among contact lens
wearers was associated with the care o the lens case. By the end
o the study period, the compliance enhancement strategy did
not appear to have had any signi cant e ect on the behaviour
o the subjects, except or improvement in the care o lens cases.
REDUCING CO ST
Sheard et al. (1995) conducted a 4-month study on 59 patients
who were randomly divided into two groups. T e ‘ ull-pay’
group paid the ull retail price o lens care products, whereas
the ‘nominal-pay’ group paid a nominal ee or their lens care
products. Sheard et al. (1995) ound that reducing cost did not
a ect compliance as measured by solution usage or procedure
demonstration. Had this experiment been conducted the other
way around – by determining the level o compliance as the
cost o care products is increased – it would have been possible
to determine a threshold cost above which patients become
dangerously non-compliant. O course, such an experimental
approach is not possible.
T e ability o patients to pay or health care was studied by
de Andrade Sobrinho and Carvalho (2003), and related to the
extent o compliance with contact lens care and wear regimens.
T e authors ound no correlation, and concluded that socioeco-
nomic actors do not seem to have an impact on compliance
with contact lens care routines.
Pre d ict ing No n-co mp liance
Many o the problems relating to non-compliant patient behav-
iour could be overcome i it were possible to predict which
patients were less likely to be compliant. Un ortunately, most
attempts at identi ying such predictors have been unsuccess ul.
For example, Davidson and Akingbehin (1980) ailed to nd an
association in general ophthalmological practice between non-
compliance and the ollowing personal and sociological char-
acteristics: age, sex, race, occupation or socioeconomic status.
Interestingly, Chun and Weissman (1987) were able to iden-
ti y one potentially use ul predictor o non-compliance relating
to contact lens wear – patient age. T ey ound that patients under
the age o 30 years and over the age o 50 years were more likely
to display non-compliant behaviour. Morgan et al. (2011) also
observed higher rates o non-compliance in younger lens wearers.
Claydon (1995) investigated the possibility that measure-
ment o certain personality traits can be used to predict the
likelihood or otherwise o compliance. She conducted a study
in which the level o compliance with a simple contact lens regi-
men was measured on 48 contact lens wearers using demonstra-
tion and questionnaire techniques. T e subjects also completed
a psychological test known as the 16PF inventory (Cattell et al.,
1988) and the data were examined or possible associations. No
overall correlations linking personality with compliance were
revealed, although some interesting individual correlations
were ound. T e personality trait ‘adherence’ was ound to be
associated with the thoroughness o case cleaning and sur ac-
tant cleaning. T e personality trait ‘extroversion’ was ound
to be associated with the thoroughness o disin ecting and
handwashing. Further work in this area may eventually lead to
the ormulation o a use ul predictive test that can be applied
clinically, such as a short questionnaire that could be quickly
analysed and yield a score that could predict the likelihood o
compliance.
Cardona and Llovet (2004) used an oral and a written com-
prehension test to establish the comprehension skills typology
o contact lens wearers, thus allowing or the appropriate type
o instructions (oral or written) to be given to each patient in
accordance with their particular abilities. T ese authors sug-
gested that this approach could enhance compliance among
contact lens wearers.
T e notion that contact lens wearers who are under strict
li e-preserving medical regimens and understand the value o
general medical compliance will be more compliant with their
contact lens wear behaviours was tested by O’Donnell and E ron
(2004). Speci cally, they hypothesized that diabetic contact
lens wearers may represent a special group displaying higher
levels o compliance with their lens care regimens as a result
o learned behaviour relating to maintenance o their diabetic
condition. Although the combined population o 29 diabetic
and 29 non-diabetic contact lens wearers was generally ound
to be compliant, there were examples o non-compliance in
both groups. Neither the duration o diabetes nor the degree o
metabolic control appeared to related to compliance. T e results
suggest that associated health compliance behaviours are poor
predictors o compliance with instructions relating to contact
lens wear and care.
A Co mp liance Enhance me nt Mo d e l
Notwithstanding the di culties discussed above in devising
strategies to enhance or predict compliance, it is possible to
construct a speci c model or compliance enhancement in
a contact lens setting based upon a wealth o evidence pub-
lished in the contact lens eld, and drawing upon the extensive

literature de ning the determinants o compliance in general
health care. T is model comprises our components: (1) the
clinic and the practitioner, (2) the patient, (3) the advice that
is given, and (4) the contact lens industry. In essence, the
model amounts to a set o general principles and guidelines
or enhancing compliance. Each component o the model will
be considered in turn.
THE CLINIC AND PRACTITIO NER
T e clinic must have the ollowing qualities:
• Sta should be in ormed and aware o key issues.
• Advice given should be consistent over time and between
personnel.
• Appointment times should be individualized (as opposed
to block booking).
• Waiting times should be minimal.
• T ere should be continuity o care wherever possible.
• T e clinical environment should be warm and riendly.
Important qualities o the practitioner are as ollows:
• Project a devotion to eye care (virtually all eye-care practi-
tioners are devoted to eye care, but this is not always out-
wardly projected).
• Listen e ectively to what the patient has to say.
• Use minimum jargon.
• Emphasize key points, especially ollowing delivery o a
long and perhaps complex set o instructions.
• Set speci c and realistic goals or patients to aim at.
• Adopt strategies to motivate patients.
Strategies or optimizing the e ectiveness o the a ercare visit
include:
• Sending appointment reminders.
• Advising patients o the importance o regular check-ups.
• Providing eedback and reward to patients.
• Repeating key in ormation.
• Stimulating any interest the patient has in the eye and vi-
sion.
• Providing in-practice in ormation via leaf ets, posters and
videos.
THE PATIENT
A valuable approach to learning patient attitudes is to explore
their health belie s (Sokol et al., 1990) using a compliance deci-
sion tree. Fig. 42.10 is a diagram o such a decision tree. T e
answers to the sequence o questions posed in the decision tree
will indicate whether or not the patient is likely to be compli-
ant with instructions relating to contact lens wear. For example,
Fan et al. (1995, 2002) ound that, among contact lens wearers,
those who had previously su ered rom lens-related microbial
keratitis believed more strongly than controls who had never
su ered rom keratitis in the perceived bene t o checking ini-
tially with the optometrist or the correct method o wearing
reusable lenses.
I it is determined that the health belie s o the patient
are likely to lead to non-compliance, steps should be taken
to modi y the speci ic belie s that are erroneous. his can
be achieved via a variety o strategies, such as talking per-
suasively, supplying pertinent in ormation or utilizing a
health-care contract that emphasizes the responsibilities o
the patient or achieving sa e and com ortable ocular health
during lens wear.
42 Co mp liance 425
Susceptibility
Am I susceptible to CL problems?
no yes
Severity
How severe are the problems?
low high
Benefits perceived
Can I prevent the problems?
no yes
Barriers perceived
Am I able to overcome the barriers?
no yes
Non-compliance Compliance
Fig . 42.10 The d e cision tre e that can b e use d to e xp lore how the
he alth b e lie s o a contact le ns (CL) p atie nt may inf ue nce his / he r le ve l
o comp liance .
THE ADVICE
Care systems should be simple and easy to understand, tailored
or the individual, ritualized and not too expensive. Advice
given to patients should be verbal and written. Printed mate-
rial should be readable and well illustrated. Clearly illustrated
sequential steps with minimum wording will aid understanding
and interpretation. Written material should also contain warn-
ings; obviously, a balance must be ound whereby patients are
alerted to possible dangers but are not rightened away rom
wearing lenses.
THE CO NTACT LENS INDUSTRY
An important role is played by the contact lens industry in
compliance enhancement – a role that alls into three broad
categories:
1. Pricing policy – it is sel -evident that prohibitive pricing
will produce a general disincentive to purchase all o the
required lenses, as well as care products i wearing reus-
able lenses, and to use them as required. T e contact lens
care industry thus has an obligation to contain prices as
ar as economically possible.
2. Product support – clear and unambiguous packaging and
simple and clear instructions are thought to be important
contributing actors to compliance enhancement; such
issues are the sole responsibility o the contact lens in-
dustry. Many companies provide attractive reusable lens
starter packs that motivate patients.
3. Research and development – contact lens care systems
should be designed to be e ective, as distinct rom the usu-
al practice o designing systems that are merely e cacious.
An e cacious system is one that can be demonstrated to
work under ideal situations – that is, assuming ull patient
compliance. An e cient system is one that will work in a
‘real-world’ scenario, allowing or a certain level o non-
426 PART 6 Pat ie nt Examinat io n and Manag e me nt
compliance. T is chapter has established that ull compli-
ance does not exist. All patients will be at least partially
non-compliant in some aspect o their care regimen. I one
accepts this argument, then it behooves the contact lens
industry to develop e ective contact lens care systems.
Co nclusio n
Patient compliance with contact lens wear and care is a com-
plex issue; it is di icult to enhance and predict. As a result,
we must continue to rely on the outcome o research and
models such as those discussed in this chapter. Practitio-
ners are invited to contemplate all o the issues highlighted
in this chapter when aced with adverse ocular reactions to
contact lens wear; although the patient may well be at ault,
it is important to avoid taking the easy option o ‘blaming
the victim’!
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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426.e 1
43
Pract ice Manag e me nt
NIZAR K HIRJI
Int ro d uct io n
Contact lens practice by de nition resides within an optometric
practice embracing, amongst other products and pro essional
services, the prescribing, tting and dispensing o contact lenses
and associated products and pro essional services. T us, prac-
tice management issues that have an impact on contact lens
practice are rstly all those that have an impact on an optomet-
ric practice, and additionally, i it is possible to separate them,
those issues that are regarded as more the domain o contact
lens practice.
Practice management may be de ned as that activity
concerned with planning, organizing and controlling the
non-clinical activities o an optometric enterprise to ensure
prede ned outcomes and goals, through the e ective use o
the available physical, nancial and human resources. T e
supply o optometric goods and pro essional services ranges
rom very tangible goods (e.g. supply o a contact lens case) to
entirely intangible pro essional services such as a contact lens
consultation (e.g. a ercare).
In managing the contact lens pro essional ‘service prod-
uct’, or want o a better descriptor, it is important to appre-
ciate that what is involved is primarily the provision o
pro essional services. A detailed description o the charac-
teristics that separate a pro essional-service-oriented busi-
ness such as a contact lens practice rom a product-oriented
business is beyond the scope o this chapter and is detailed
elsewhere (Hirji, 1999). hese characteristics place spe-
cial management demands on optometric and contact lens
practices.
T e key elements that determine the management issues in
a primarily service-oriented enterprise such as a contact lens
practice can be categorized according to the ollowing six Ps:
1. Practice location and accommodation
2. Personnel at the practice
3. Products and pro essional services provided
4. Pricing – ees and charges
5. Promotional issues
6. Processes.
T ese issues have to be considered within the ramework o
the wider legal, political, economic and institutional environ-
ment within which optometry has to operate. T is chapter
will thus con ne itsel to a limited overview o these issues.
T e model adopted here will be that o a contact lens service
being provided within optometric practice. It is recognized,
o course, that contact lens practice can be e ected in a vari-
ety o settings, such as medical practices, hospitals and opti-
cal dispensing outlets. Nevertheless, the principles o ef cient
management highlighted here can be applied to all o these
situations.
Pract ice Lo cat io n and
Acco mmo d at io n
In contact lens practice, the patient participates, in person, in
the buying process. It is there ore important or the practice
to be located as conveniently and as ‘close’ to the patient as
possible. T e decision regarding the location o the practice
is crucial, not only in terms o the ease o access or potential
patients and customers, but also because a wrong or a poor
decision cannot easily be reversed – unlike decisions on pric-
ing or product choice. T e costs o a mistake include nan-
cial losses involved in acquiring and running a practice (e.g.
xtures and ttings, launch costs) and – just as important to
many businesses – the indirect cost o not keeping a competi-
tor out o a better location. T e suitability o a particular prac-
tice location is based on the estimated potential or attracting
patients and customers in a given catchment area and the loca-
tion o competitors.
Sophisticated models using a variety o in ormation,
including census data, amily expenditure surveys and
geodemographic characteristics, have been developed to
help quanti y catchment areas and the desirability o di er-
ing sites. Checklists with key considerations listed may also
be used to help the decision-making process with or with-
out computer modelling. Other good sources o in ormation
about an area include local authorities (e.g. planning depart-
ment, electoral o ice, rating o ice, clerks’ o ice), estate
agents and the local and national press. Having decided on
the location, it is important to ensure that the physical site
will be able to accommodate a contact lens practice, includ-
ing a waiting area, consulting and data collection rooms,
spectacle and contact lens dispensaries, sta room, stor-
age / stock room and washrooms.
LAYO UT
T e layout o the practice will be governed by the physical limi-
tations o the site and the sequence and order o activities that
the patient undergoes during a visit to the practice. Fig. 43.1
illustrates the principal integrated activities o an optometric
practice with contact lenses as part o the product / pro essional
service range.
RECEPTIO N AREA AND FRO NT DESK
T is is the rst person contact position or the visiting patient,
and should be a welcoming point as well as a help desk. T e
reception area will also o en be the last point o contact be ore
the patient leaves the practice.
427
428 PART 6 Pat ie nt Examinat io n and Manag e me nt
Fig . 43.1 Activity and in ormation f ow in contact le ns p ractice .
WAITING AREA
T e waiting area needs to be com ortable, with suf cient seat-
ing to accommodate potential patients and customers. A rule o
thumb worth considering is that this area should be urnished
and decorated to be just marginally ‘better’ than the ‘ ront room’
o the patients and customers attending the practice. T is is
based on the premise that is decorated and urnished below the
standards o the ‘ ront room’ o the patients attending the prac-
tice may impart a negative image, whereas a signi cantly better
décor and urnishing may give the impression that the practice
may be ‘expensive’.
CO NSULTING RO O M
Depending on the patient workload o the practice, more than
one room may be dedicated to the consultation and examina-
tion activity. Increasingly, delegation o data collection tasks
(e.g. non-contact tonometry, visual eld analysis, autore rac-
tion, digital photography, optical coherence tomography, etc.)
to trained support sta means that an area or room will be uti-
lized or this pre-exam screening or adjunct data collection.
T e consulting room will have all the equipment ound in a
modern optometric practice with an emphasis on anterior-eye
evaluation / recording. In addition to this, it will be necessary to
have some contact lens veri cation equipment, and i a special-
ity practice, possibly a corneal topographer. T e need or spe-
cialist diagnostic tting sets and materials (e.g. pre ormed rigid
scleral lenses, bi ocal lenses, eye impression materials) will be
dictated by the pro le o patients attending the practice.
SPECTACLE DISPENSARY
Every contact-lens-wearing patient is an optometric patient
who happens to be using contact lenses. All contact lens wearers
require spectacles. T e spectacle dispensary should thus be able
to provide or the unctional and aesthetic needs o the patient,
just as any optometric practice would.
CO NTACT LENS DISPENSARY
T e contact lens dispensing area is where patients will attend
or instructions and practise o placement and removal o
contact lenses onto and rom their eyes (see Chapter 38). It is
also here that patients will receive their (starter) contact lens
care systems where applicable, and advice on wear, care and
hygiene with respect to their contact lenses, and will complete
the paperwork. It should there ore have the urniture, acili-
ties, materials and equipment to allow this to happen e ec-
tively. Employing videos (including streaming videos rom the
practice website) and CD-ROMs in this area to support the
education process along with written materials is now com-
mon practice.
Pe rso nne l at t he Pract ice
Contact lens practices rely on individuals to deliver their pro es-
sional services and products to patients and customers. T us,
at a minimum level o practice activity, it will be necessary to
employ someone to provide reception and general adminis-
trative support with respect to the day-to-day activities o the
practice. At the other end o the spectrum, a busy large practice
in a shopping centre location may employ additional optom-
etrists, dispensing sta , contact lens hygienists, technicians,
optical receptionists / advisors, secretaries and cleaners. It is
important to remember that many more individuals will need
to be employed to cover the practice requirements in terms o
hours per day, particularly as part-time employment increases.
T e issues o managing the practice sta take increasingly more
prominence as the size and the activity o the practice increase
(ACAS, 1994).
RECRUITMENT AND SELECTIO N
Once a vacancy has been identi ed, and additional hours o
sta time are justi ed, it is essential to establish the duties o the
new member o sta . Having decided the quali cations, train-
ing needs and skills that are required to do the job, it is use ul
to prepare a job description or pro le and then to decide on
the type o person who would ideally be recruited to ll this
vacancy – that is, a person speci cation. wo good methods o
producing the speci cation include Roger’s seven-point plan
(Roger, 1951), taking account o :
1. physical make-up
2. attainments
3. general intelligence
4. special aptitudes
5. interests
6. disposition
7. circumstances.
Also Fraser’s ve-point grading (Fraser, 1958), which covers:
1. impact on others
2. quali cations or acquired knowledge
3. innate abilities
4. motivation
5. adjustment or emotional balance.
able 43.1 describes an example o a person speci cation or a
receptionist in a practice that wants to develop a contact lens
interest.
Selection then involves choosing the right person
by interviewing short-listed candidates with a view to
 43 Pract ice Manag e me nt 429

a case o misconduct (breach o rules that merits disciplinary

TABLE Examp le o a Pe rso n Sp e cif cat io n – Frase r’s action) arises, the rules in the handbook will be invaluable
43.1 Five o ld Grad ing as to the expected conduct. able 43.2 gives an outline disci-
Esse nt ial Q ualit ie s De sirab le Q ualit ie s plinary procedure.
1. IMPACT O N O THER PEO PLE
(ap p e arance , sp e e ch and manne r) TRAINING STAFF
Cle an and tid y p re se ntation Smart p re se ntation
Good writing and sp e e ch Ge ts on we ll with young ad ults raining embraces the identi cation and development o
employee potential or job satis action, improvement, practice
2. Q UALIFICATIO NS AND EXPERIENCE
(e d ucation, training and work e xp e rie nce ) value creation and ultimately improved patient care. It can o en
GCSE Eng lish and Exp e rie nce in me d ical re ce p tion be the driver o improvements and has the potential to bring
mathe matics or p harmacy about reduced costs, increased value and practice pro tabil-
Ab le to work on a comp ute r Exp e rie nce o d ata inp ut and ity. Ultimately, training is about getting people to do di erent
outp ut things or to do things di erently.
3. INNATE ABILITIES For training to be e ective or a contact lens practice, how-
(ap titud e for le arning ) ever, it must be:
Q uick to g rasp id e as and Ab le to p rioritize and d e cid e on • valid – relevant to contact-lens-related jobs in the practice
vie ws action • capable o solving problems – identi ed as needing
4. MO TIVATIO N resolution in practice
(consiste ncy, d e te rmination and succe ss in achie ving g o als) • ocused on objectives – either at the individual or at the
Inte re ste d in he alth care and Inte re ste d in a p ote ntial care e r job / practice level
g e ne ral cosme sis in op tics • measurable – its results can be gauged directly or indirectly.
5. ADJ USTMENT Improvements that training and development bring should
(e motional stab ility, ab ility to hand le stre ss and ab ility to g e t on hope ully result in reduced costs and increased value and pro ts
with p e op le ) through the ollowing ( or example):
Frie nd ly and ab le to work as
p art o a te am
Com ortab le with the p re s-
sure s o d ay-to-d ay p ractice
• Improved ef ciency – doing the job correctly, accurately
activitie s and the d e mand s o and with care at the outset reduces replacements,
p atie nts and p ractitione rs unplanned rescheduling and revisits to the practice
by patients. T is improves utilization o resources and
(Ad ap te d from Hirji, N. K. (1999). Busine ss Aware ne ss for O p tome trists
– a Prime r. O xford : Butte rworth-He ine mann)
practice output overall.
• Improved quality – this enhances the reputation o the
practice, and reduces complaints, costs o returns, re unds
and credits.
selecting the applicant who has the skills, abilities, apti- • Less wastage and reworking – not only is the material
tude and personal qualities to do the job. he job descrip- not wasted, but also there is a greater cost saving in sta
tion and the person speci ication will decide the major costs, time the equipment is occupied and ancillary costs
selection criteria normally considered during the interview in reworking the job by the laboratory (e.g. a complete pair
process. o spectacles, alternative set o contact lenses).
• Improved consulting room and equipment utilization –
consulting room occupancy and equipment use dictate the
CO NTRACT O F EMPLO YMENT
capacity o the practice to conduct eye exams and contact
A contract o employment is simply the legal agreement lens consultations. An unnecessarily occupied or indeed
between the employer and the employee, clari ying their unoccupied consulting room is costly.
mutual obligations. T e law in most countries provides the • Reduced time taken to do jobs – less time taken to produce
employee with a number o employment rights and imposes the same or better-quality products will translate to
some statutory obligations on the employer. Contracts do reduced sta costs relative to sales revenues.
not have to be in writing. However, employment law in the • Improved time management – translates to improved
UK has gone slightly urther: even where a verbal contract patient scheduling and sta usage, which will lead to
may exist, there is a requirement or employers to give any reduced sta costs relative to sales revenues.
employee taken on or 1 month or more a written statement • Reduced sta turnover – costs o recruitment, selection,
setting out the main employment particulars within 2 months training and reduced ef ciency are reduced.
o the starting date o employment. Covered by common and • Reduced accidents and equipment down-time – this
contract law, contracts o employment are governed by the reduces costs to the practice in terms o costs o sick
Employment Rights Act (1996). pay, down-time o equipment, compensation claims,
insurance premiums, unscheduled service costs and
replacements.
DISCIPLINE AND DISMISSAL
• Reduced sickness and absenteeism – greater job
A practice handbook that sets out basic in ormation about satis action means better sta morale and ef cient
the policies and acilities o the practice can act as a clear teamwork.
guide or all sta to providing optometric and contact lens raining alone is not the driver o these bene ts. Other actors
services. It should be an easily accessible set o ground rules that a ect these issues include economic, political and employ-
that promote a good working environment in the practice. I ment situations locally and nationally.
430 PART 6 Pat ie nt Examinat io n and Manag e me nt

TABLE
43.2 O ut line o Discip linary Pro ce d ure s
O ffe nce Act io n De t ails
Minor miscond uct Ve rb al d iscussion Counse l and he lp e mp loye e imp rove
(in ormal) Ke e p a note
Minor miscond uct Stag e 1 Ad vise o re ason or the warning
Ve rb al warning Ad vise that this is a f rst stag e o the d iscip linary p roce d ure and the rig ht o ap p e al
( ormal) Ke e p a note o the warning or, say, 6 months and the n re p e al sub je ct to satis actory
cond uct and p e r ormance
Re p e ate d minor mis- Stag e 2 Ad vise o re ason or warning
cond uct or se rious Writte n warning Give d e tails o the imp rove me nt re q uire d and the time scale
miscond uct Ad vise that this is the se cond stag e o the d iscip linary p roce d ure and the rig ht o ap p e al
Ke e p a note o the warning or, say, 6 months and the n re p e al sub je ct to satis actory
cond uct and p e r ormance
Re p e ate d minor / se rious Stag e 3 Ad vise o re ason or warning
miscond uct or g ross Final writte n Exp lain that d ismissal will occur i the re is no satis actory imp rove me nt
miscond uct – in which warning Ad vise o the rig ht o ap p e al
case susp e nsion with Ke e p a note o the warning or, say, 12 months and the n re p e al sub je ct to satis actory
p ay may b e invoke d cond uct and p e r ormance
until inve stig ation is Stag e 4 Give the re ason or d ismissal
comp le te d Dismissal Give the d ate o te rmination o e mp loyme nt
Ad vise o the rig ht o ap p e al

(Ad ap te d from Torring ton, D. & Hall, L. (1987). Pe rsonne l Manag e me nt – a Ne w Ap p ro ach. Ne w Je rse y: Pre ntice -Hall, and ACAS (1994). Emp loying
Pe op le – The ACAS Hand b o ok or Small Firms. Lond on: ACAS Pub lications.)

An important decision or the practice owner–manager is to

decide what training can be done by the practice itsel and what
external support will be required. It is not unusual or contact
lens / ophthalmic product suppliers to support their customers
in this regard.
Pro d uct s and Se rvice s Pro vid e d
Income generated in an optometric practice is derived rom
provision and sales o :
• Eye examinations and other pro essional services – the
vast majority o patients in an optometric practice attend
or eye examinations, which is the key value driver.
Only a er a complete eye exam is conducted are contact
lenses normally prescribed and dispensed. T erapeutic
privileges are now available to optometrists in many
countries (o en requiring appropriate postgraduate
training) and this service will also contribute to the
income o the practice.
• Spectacle dispensing – regardless o how much contact
lens activity a practice has, the supply o complete
spectacles will always be a necessary part o contact lens
practice.
• Contact lenses – apart rom a stock o ‘o -the-shel ’
designs, the practice may need to have to hand specialist
contact designs and products.
• Accessories – a range o appropriate contact lens care
systems and other accessories need to be available, such
as sunglasses, spectacle chains, contact lens and spectacle
cases.
• Subscription schemes – both contact lens wearers and
spectacle-wearing patients bene t rom service agreement
schemes, which enable them to obtain replacement
products and speci c pro essional services at pre erential
terms. Such schemes are now common and maintain a
degree o continuity to the practice.
Pricing – Fe e s and Charg e s
he very personal and individual nature o both services
and products involved in contact lens practice means that
mass production approaches cannot be applied without risk-
ing negative e ects to the practice. When making pricing
decisions, three elements normally need to be taken into
account: the practice cost base, the patients and customers
to the practice, and the competition. he ees and charges
o the practice will generally be a compromise between what
the business needs to cover costs, what the patients and cus-
tomers expect to pay or the services and the products, and
what the competition charges. Pricing issues are urther con-
ounded by the act that not every owner–optometrist will
seek to maximize pro its, nor is detailed in ormation about
costs, competition and the potential patient / customer easily
available to the practice.
SPECIALITY–CO MMO DITY CO NTINUUM
T e concept o the speciality–commodity continuum applies to
both contact lens products and services. At one extreme is the
service product, consisting o a speciality service that is highly
di erentiated rom the rest o the competition, whilst at the
other extreme is a commodity.
Fig. 43.2 illustrates this speciality–commodity continuum as
a conceptual map, describing some o the characteristics o the
competition, gross pro ts, price di erentiation and image di -
erentiation associated with the two extremes.
Optometric practices would be best served by ensuring
that contact lens products and services do not slide to the
extreme commodity end. It is worth noting that the eatures
o a commodity, which include: sel -determination o need,
sel -management o use, non-invasive with little (perceived)
potential or harm, non-regulated and price determined by
market orces.

Fig . 43.2 The sp e ciality–commod ity continuum.
PRO FESSIO NAL MO DEL
Developing a ees and charges schedule is never an easy task. Once
one subscribes to the need to move away rom the commodity
end o the market, where competition relies primarily on purchase
decisions based only on price, to the speciality end then the need
or a pro essional model or ees and charges becomes paramount.
One way to do this is to establish the expenses overhead per
hour or the practice (chair time). Knowing the actual chair time
required or di ering types o contact lens services (e.g. spherical
rigid lenses, so lenses, daily / monthly disposable so lenses, toric
and bi ocal lenses), allowing or potential unscheduled visits, add-
ing the contact lens material and care system costs (duly marked
up, say 20–35%), and any other handling charges, this gure can
then be used to calculate the ees and charges or any service prod-
uct provided by the practice. With the advent o mail-order con-
tact lenses, internet trading and an increasing trend or contact
lenses to be considered as a commodity, it is important to adopt a
transparent ees and charges schedule that is competitive on a like-
or-like basis without eroding the pro essional ees dimension.
Pro mo t io nal Issue s
Communicating the availability o products and services that
have been identi ed as ‘needs and wants’ by patients and cus-
tomers, at a price that creates sustained value or the practice, is
what promotions are about. A variety o options are open to the
optometrist–owner to communicate with existing and potential
contact lens patients and customers. T e mix o these will o en
be determined by which stage the practice is at in its li e cycle.
For example, a new practice with mostly new patients will rely
more on external promotions, whereas an existing mature prac-
tice will rely more on internal communications and promotions.
INTERNAL
Internal promotions embrace all aspects o communication to exist-
ing contact lens patients and include the spectrum rom personal
contact at the practice – which embraces the practice ambience
and point-o -sale literature – through to special mailings. Personal
communication is by ar the most signi cant mode o internal con-
tact with the patient, and can adopt the ollowing guises:
• T e recall letter – with care ul database management, it
is possible not only to send out recall letters or routine
43 Pract ice Manag e me nt 431
contact lens a ercare visits, but also to tailor promotions
o speci c products and services to patients by criteria
other than clinical need.
• Special mailings – some practitioners will send patients
thank you cards or re errals and cards on the arrival o a
new amily member.
• Practice newsletters – both via conventional mail and by
e-mail – are increasingly used and are indeed a good way
o educating and maintaining contact with patients, and
keeping them aware about the practice, its personnel and
its activities.
T e use o a website as an internal communication tool merits
some mention. Practice websites, and electronic mail, will increas-
ingly play a role in allowing patient education, email recall letters,
e-promotions and opportunities or patients to contact the prac-
tice to order sun wear, contact lens accessories and replacement
products, to book an appointment and even to submit medical
history. Similarly, it makes sense to consider a contact lens a er-
care appointment reminder communication via email or SMS.
EXTERNAL
T ese promotions include all activities where potential contact
lens patients might be exposed to the activities, personnel or
products at the practice. T ese include national and regional
newspapers, trade and pro essional magazines, radio and tele-
vision broadcasts, telephone directories, exhibitions and health
airs, direct mail, public relations, speaking engagements and the
worldwide web. T is last method enables practices to broaden
their catchment area, o er sun wear, contact lens accessories,
rames and spectacles along with practice in ormation and
opportunities to book appointments online.
Pro ce sse s
hese are the procedures, mechanisms and routines that
the practice adopts to provide the services and products to
patients and customers. Although in contact lens practice the
people element is critical, no amount o attention and e ort
rom sta will overcome unsatis actory process con igura-
tion. For example, no matter how well members o sta do
their job – or what equipment one uses or the data collection
– i the process o , say, booking appointments is too cumber-
some or inaccurate then patient dissatis action is inevitable,
as is ine ective clinical care. Generally, the greater the com-
plexity and divergence (variability o the steps / sequences) o
the task, the more it is usually necessary to empower the sta
to exercise their judgement in the best interest o the patient
and the practice.
A variety o processes are employed in managing patients,
products, money and personnel. T ey are too numerous to
include in ull, so a selection o key contact lens activity-ori-
ented processes is mentioned here.
MANAGING PATIENTS
Patients who attend or contact lens services have requirements
in addition to their needs as routine optometric patients, and
will thus place special demands on the processes o the practice.
T ese range rom appointment scheduling through to the trans-
er o records and clinical details.
432 PART 6 Pat ie nt Examinat io n and Manag e me nt
CO NTRACTS, SERVICE AGREEMENTS AND
INFO RMED CO NSENT
A contract is an agreement between parties (two or more) that
is en orceable by law. Four essential elements need to be present
or a contract to be legally en orceable; speci cally, there must
be:
1. the existence o both an o er and an acceptance
2. an intention by both parties to create a legally en orceable
relationship
3. clear and certain terms and conditions, or the courts to
be able to en orce them
4. consideration – that is to say, each party has agreed to
contribute to the deal – or example, the practitioner
promises to provide agreed pro essional services to the
patient, such as eye examination, contact lens tting, sup-
ply and a ercare, and the patient in turn promises to pay
the agreed ees.
In an attempt to clari y the terms and conditions, to educate the
patient and to generate documentary evidence, practitioners
have produced a variety o contact lens service / subscription
agreements and policy documents. T ese generally range rom
describing what is included in the ees and charges, to what is
included in prepaid contact lens service subscriptions ( or regu-
lar optometric and contact lens reviews and replacement o con-
tact lenses).
Contracts, such as those mentioned above, do not have to
be in writing. T ey can be verbal, as long as the above elements
are present and en orceable by the law (in theory). However, in
practice it is a real challenge without written documentation.
T e doctrine o in ormed consent is an aspect o health care
generally that is constantly evolving, and arises rom the act
that touching another person (during an optometric consulta-
tion) without consent may be regarded as o ensive or harm ul,
or which damages could be claimed and awarded. In medicine
this has o en translated to mean consent to medical proce-
dures. In reality, it is an approach to practising de ensively, and
i a claim o negligence arises, it could be shown that the patient
knew and consented to what was done, as a potential means o
de ence. Although the USA has adopted an approach whereby
the ullest possible in ormation as to the treatment / procedure
is given to the patient to make in ormed choices, the English
courts tend to look at approved practice amongst pro essionals
when deciding what the patient should be told o the risks / pro-
cedures. Nevertheless, it would be prudent to keep patients as
well in ormed as is reasonably possible, to ensure long-term
success in contact lens practice.
PATIENT SCHEDULING
T e eye examination is the key value driver in any optometric
practice, whilst sta costs are the key costs. E ective practice
resource management without compromising clinical care is
o en dependent on the use o appropriate appointment sched-
uling methods. T ere are three principal approaches commonly
ound in practice:
1. raditional – patients here are booked in at regular inter-
vals with equal times set aside or each consultation. For
example, patients are booked in every 20 minutes, start-
ing and ending at a given time. It is simple and that is why
it is used so o en. However, it does not allow or patients
who require longer consultations or patients who require
less time. It is thus possible to end up with unproductive
portions o time when less time with a patient is needed,
and long waiting queues i a patient requires a longer con-
sultation.
2. Block system – this is not o en used in optometry but
is ound in hospitals and general medical practice. T is
method involves scheduling multiple patients in the same
time slot. For example, there would be three patients
booked at 9.00 a.m. and then none until 10.00 a.m., when
there would be three more patients booked, and so on.
Individuals who have experienced this approach are o en
disgruntled to nd that they have the same appointment
slot as others.
3. Mixed – some practices nd a mixture o traditional and
block booking to be a workable combination, using the
block system or scheduling shorter 15-minute visits (e.g.
groups o children, some contact lens ollow-up visits)
and 20-minute scheduling or routine eye exam consulta-
tions.
T e challenge is to schedule patients so that the down-time
and the time taken to ‘settle in’ in the consulting room do not
curb the consultation time o the practitioner. In contact lens
practice, appointments are normally scheduled or eye exami-
nations, preliminary examination and initial tting, evaluation
a er diagnostic lens wear (return), collection / hygiene, routine
a ercare and unscheduled visits (urgent, emergency).
PATIENT EDUCATIO N
Contact lens practice has a particular responsibility to instruct
patients on the wear, care and hygiene with respect to contact
lenses. Anyone who has been in contact lens practice will con-
cur that good patient education is key to success ul contact
lens wear. It is thus not surprising that signi cant resources are
o en dedicated to this unction in contact lens practice. T is
may include a dedicated area / room, and a dedicated and appro-
priately trained individual (contact lens hygienist) to instruct
and educate one or more patients at a time on placement and
removal o lenses, wearing schedules, caring or lenses and
cases, general hygiene and lid hygiene. It is also in this area that
any service agreements and details o emergency cover are dis-
cussed and issued. Increasingly, practices provide both verbal
and written instructions, and some also lend videos and CD-
ROMs or patients to view and review the procedures in their
own home. It is logical or this in ormation to be made available
and downloadable rom practice websites or patients.
RECO RDS O N PATIENT WEB PAGES
T e internet has already signi cantly altered the way in which
one can promote contact lens practice. Practice websites car-
rying in ormation and o ering access to the supply o contact
lenses and other optical products online directly to patients are
already here. T is is an expected reaction to counter mail-order
and online supply o optical products by non-optometrists and
non-opticians. However, rom a patient perspective, it is worth
bearing in mind that the internet also o ers the possibility to
store personal medical and associated records in one easily
accessible location (‘cloud’ storage). T is would then enable any
health-care practitioner, anywhere in the world, to access these
records with the consent o the patient and protected by using an
appropriate password. It is thus not too ar- etched or patients

to ask that their contact lens / optometric data be uploaded to
their personal health web pages in the uture.
MANAGING CO NTACT LENS PRO DUCTS
T e tangible products that contact lens practices supply include
all those products normally supplied in general optometric
practice, plus contact lenses, contact lens care systems and
associated products. In view o recent concerns about the trans-
mission o new-variant Creutz eldt–Jakob disease (see Chapter
17), the use o empirically tted rigid lenses is now the pre-
erred option, and the use o stock disposable so and silicone
hydrogel lenses a practical alternative. It is thus necessary or
contact lens practices to stock a variety o lens types or tting
and possibly initial supply. However, it must be borne in mind
that this stock, i paid or by the practice, is creating value only
i sold. Similarly, the stocking o a variety o contact lens care
systems and accessories is essential in providing a complete ser-
vice. Like contact lenses, stock that is held in the practice creates
value only i it is sold or supplied to patients and customers.
Bar-coding o contact lenses and care systems will help manage
the inventory o both contact lenses and solutions; however, the
value o this process in the absence o a standardized bar-coding
scheme is somewhat limited.
MANAGING MO NEY
Income to the practice will accrue rom patients, customers and
third-party payments (national and private health insurance,
driving licence authorities, employers). It is there ore impor-
tant that records are kept o every transaction and that there
is no hindrance to receiving these payments by any method
(e.g. cash, credit cards, cheques, direct debit, standing order,
electronic trans er o unds) (Holmes and Sugden, 1986). O
these methods, the use o direct debits in prepaid subscription
schemes has proved to be a particularly use ul option. Similarly,
the practice will need to pay its suppliers (e.g. laboratories, pre-
scription houses, various orms o sales tax, telephone, printing
and stationery) and its sta .
T e provision o contact lens services, like optometric ser-
vices, is indeed a provision o pro essional time. T e supply o
products is secondary to this, and it is appropriate to adopt an
accounting method that mirrors this approach. T e Association
o Optometrists in the UK has published guidance on such an
approach and the reader is re erred to this (Hayes et al., 1999).
T e use o computers in practice management and in par-
ticular practice nances is beyond the scope o this chapter.
Suf ce it to say that many ‘o -the-shel ’ so ware options are
available and adaptable, whilst others dedicated to optometric
practice management and incorporating the special needs or
contact lens practice are also available. Fig. 43.3 illustrates prac-
tice activity where computers may be utilized.
LENS O RDERING
A majority o lenses prescribed today are obtained initially rom
in-of ce inventories o disposable lenses. Once the patient is
satis ed with the lenses tted, an order must be placed with the
manu acturer, or a third-party distributor, or an appropriate
ongoing supply (typically or 3 or 6 months). T ere is clearly a
wide assortment o technical means o placing an order, which
parallels modes o modern communication – that is, a written
43 Pract ice Manag e me nt 433
order posted in the mail (rarely used these days), telephone, ax
and the internet. T e latter two modes o communication are pre-
erred because there is less likelihood o con usion, and a clear
audit trail or checking, i the order is issued in textual orm.
Patients are o en looking to order replacement lenses online.
I patients were able to do this rom a practice website, patient
retention would be likely to be enhanced (McNelis, 2009).
Disposable so lenses are typically speci ed by manu ac-
turer, lens tradename and lens power. I the lens is available in
a variety o parameters, then the parameter o choice obviously
needs to be speci ed also. More-detailed in ormation is gener-
ally required or custom-made so lenses and rigid lenses. As a
general rule, the more details that are supplied when ordering a
custom-designed lens, the greater is the likelihood that the lens
delivered will be as required.
Pro e ssio nal Re g ulat io n
T e manner in which a practitioner ts and supplies contact
lenses may be controlled by various regulations. In the UK, the
General Optical Council (GOC), by the powers vested in it by
the Opticians Act 1985 section 31, has made rules regulating the
prescription, supply and tting o contact lenses by registered
optometrists, opticians or companies and their employees.
T e Rules on the Fitting o Contact Lenses 1985 cover the
details with respect to the circumstances in which trainee
optometrists or opticians may t contact lenses. T e Contact
Lens (Quali cations etc.) Rules 1988 provide or a minimum
level o education, training and quali cation be ore a registered
optometrist or optician can undertake the tting o contact
lenses in the UK. T e Contact Lens (Speci cation) Rules 1989
require that an optometrist or optician who ts contact lenses
shall on completion o the tting give the patient a written spec-
i cation o the lenses in suf cient detail to enable the lens to be
replicated.
T e Opticians Act 1989 (Amendment) Order 2005, made
under section 60 o the Health Act, 1999, amends the Opticians
Act 1989 and came into e ect with its supporting Rules on 30
June / 1 July 2005. T is was the rst o the series o orders that
the government made to modernize the health-care pro essions
in the UK and it signi cantly a ects the provision o optometric
and optical care and the ramework within which the optical
pro essions practise and optical businesses operate (Hirji and
Clarkson, 2006). T is order improves signi cantly the way in
which the GOC can discharge its duty o protecting the public by
bringing about the changes that a ect registration, recognition
o specialisms, pro essional indemnity insurance, continuing
education and training, and registrants’ tness to practise and
supply contact lenses, and it allows the GOC to seek additional
relevant in ormation about the registrant, including character.
It rede nes the role o the GOC as the overseer o ‘pro essional
education, conduct and per ormance among registrants’.
All contact lens tting and a ercare remain entirely the
domain o registered practitioners, including the tting o zero-
powered contact lenses (plano cosmetic lenses), which when
completed obliges the practitioner to provide a speci cation
o the contact lenses prescribed (subject to the Data Protection
Act 1988), which has to include the ollowing in ormation (SI
2005 / 1481):
• the name and address o the patient
• i the patient has not attained the age o 16 on the day the
speci cation is issued, his / her date o birth
434 PART 6 Pat ie nt Examinat io n and Manag e me nt

Fig . 43.3 Practice activity whe re comp ute rs may b e utilize d . BNF = British National Formulary; CL= contact le ns; EPO S = e le ctronic p oint o sale ;
EFTPO S; e le ctronic und s trans e r at p oint o sale ; NHS = National He alth Se rvice ; Px = p atie nt; Rx = p re scrip tion; NCT = non-contact tonome try.
(Ad ap te d from Hirji, N. K. (1999). Busine ss Aware ne ss or O p tome trists – a Prime r. O xford : Butte rworth-He ine mann.)

• the name o the practitioner and his / her registration
number in the GOC register or General Medical Council
register
• the address rom which the practitioner practises
• the name o the practice on the premises o which the
tting was done
• the date the tting was completed
• suf cient details o any lens tted to enable a person who
ts or supplies a contact lens to replicate the lens
• the date that the speci cation expires
• and such in ormation o a clinical nature as that prescribing
practitioner considers to be necessary in the particular
case.
T is closes the loophole that existed or non-registrants to t
and supply zero-powered cosmetic contact lenses prior to this
order. However, duplicate contact lenses can be purchased by
the public rom unregistered suppliers, in person, via mail order
or through internet-enabled enterprises as a result o this order,
except or:
• minors
• those registered severely visually impaired
• those who are visually impaired
in which case, supply can only be by a registrant.
T ere are, however, conditions imposed, which include the
ollowing: that the transaction is the result o :
• a valid veri ed original contact lens speci cation rom
a registered practitioner, submitted either in writing or
electronically
• or the use o the person named in the speci cation
• be ore the expiry date mentioned in the speci cation
• and that the supply is under the direction o a registered
optometric / optical practitioner or a medical practitioner.
‘General direction’ in this context was described during the
passage o the legislation through parliament as meaning that
a registered practitioner is employed in the management chain
o the supplier’s business and accountable or what goes on
between the supplier and the purchaser, ultimately answerable
to the GOC and there ore providing a measure o protection to
the public, which was hitherto absent. T e seller (whether regis-
tered or unregistered) must also make reasonable arrangements
or the person who is purchasing the contact lenses rom the
seller to receive a ercare. T e supply o zero-powered cosmetic
contact lenses is also covered, by bringing this area under the
auspices o the GOC. T e supply o contact lenses by suppliers

and manu acturers to registrants and others and not directly to
patients would not, however, be subject to such requirements. It
should also be noted that it remains a de ence to any prosecu-
tion under the relevant section to demonstrate that the lenses
were sold as an antique (except where the seller had reason
to believe that the lenses would be used to correct, remedy or
relieve a de ect o sight) (Hirji and Clarkson, 2006).
On 30 October 2006, the GOC released a statement setting
out the GOC’s view that, whereas the sale o prescription (sight-
correcting) contact lenses may be supplied under the ‘general
direction’ o a GOC registrant or a medical practitioner, a ‘super-
vised sale’ is a requirement or the sale o plano (zero-powered)
contact lenses. T e statement also af rms the GOC position that
a supervisor (a registered optometrist, dispensing optician or
medical practitioner) must be able to exercise pro essional skill
and judgement as a clinician. In the absence o any statutory de -
nition o ‘supervision’, however, the GOC will consider the issue
o whether a sale was made under ‘supervision’ on a case-by-case
basis, involving expert clinical opinion as appropriate. Also, the
GOC asked the pro essional optical bodies to provide a detailed
guideline on their interpretation o the meaning o ‘supervision’
(February 2007). Finally, in the press release o the same date,
the GOC states that only in the supply o corrective lenses will
the purchaser be required to provide a valid ‘speci cation’ or
the supply to be legal (Hirji and Clarkson, 2007). T e College o
43 Pract ice Manag e me nt 435
Optometrists and the Association o British Dispensing Opti-
cians now provide guidance on their interpretation o ‘supervi-
sion’ (essentially that the practitioner should be in a position to
exercise clinical judgement and intervene, and ensure that appro-
priate a ercare arrangements are made) and o ‘general direction’
(essentially that the practitioner should ensure and be satis ed
that procedures are in place to sa eguard the patient, that the sup-
plier [person] is appropriately trained, that the lenses supplied
meet the speci cations and that appropriate a ercare arrange-
ments are made) (College o Optometrists, 2007, 2014). T is
guidance has been accepted by the GOC.
Co nclusio n
A key aim o this book has been to describe the great clinical
and intellectual challenges involved in contact lens practice.
T is chapter has outlined the principles involved in managing
an eye-care practice that engages in contact lens tting. By pro-
viding an organized and ef cient service to patients, and paying
proper attention to sta management and support, contact lens
practice can be enjoyable and pro table as well as being clini-
cally challenging.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
This pa ge inte ntiona lly le ft bla nk
REFERENCES
ACAS. (1994). Employing People – T e ACAS Hand-
book for Small Firms. London: ACAS Publica-
tions.
College o Optometrists. (2007). Code of Ethics and
Guidance for Professional Conduct Guidance (Re-
vised Feb 2007) Section 28. London: College o
Optometrists.
College o Optometrists. (2014). T e Guidance for
Professional Practice. [Online]. http://guidance.
college-optometrists.org/ guidance-contents/
[Accessed 10 July 2016].
Fraser, J. M. (1958). A Handbook of Employment In-
terviewing. London: MacDonald & Evans.
Hayes, I., Cornwell-Kelly, M., Hunter, I., et al. (1999).
Accounting or VA . Optom. oday, 39, 1–12.
Hirji, N. K. (1999). Business Awareness for Optome-
trists – a Primer. Ox ord: Butterworth-Heinemann.
Hirji, N. K., & Clarkson, R. (2006). T e Opticians
Act 1989 (Amendment) Order 2005 – so what’s
the story? Cont. Lens Anterior Eye, 29, 217–222.
Hirji, N. K., & Clarkson, R. (2007). ‘Order o change’.
Optician, 233(6094), 28–32.
Holmes, G., & Sugden, A. (1986). Interpreting Com-
pany Reports and Accounts (3rd ed.). Cambridge:
Woodhead-Faulkner.
McNelis, K. (2009). Use technology to improve
your contact lens practice. Ophthalmol. imes,
34, 39.
Rodger, A. (1951). T e Seven-Point Plan. London:
National Institute o Industrial Psychology.
orrington, D., & Hall, L. (1987). Personnel Manage-
ment – a New Approach. New Jersey: Prentice-
Hall.
436.e 1
 Ap p e nd ice s

O UTLINE
A Contact Le ns De sig n and Sp e cif cations 438
B Contact Le ns Tole rance s 440
C Ve rte x Distance Corre ction 441
D Corne al Curvature – Corne al Powe r
Conve rsion 443
E Exte nd e d Ke ratome te r Rang e Conve rsion 445
F So t Le ns Ave rag e Thickne ss 446
G So t Le ns O xyg e n Pe r ormance 447
H Constant Ed g e Cle arance Rig id Le ns
De sig ns 449
I So t Toric Le ns Misalig nme nt
De monstrator 450
J Dry-e ye Q ue stionnaire 451
K E ron Grad ing Scale s or Contact Le ns
Comp lications 453
L Scle ral Le ns Fit Scale s 456
APPENDIX

A Co nt act Le ns De sig n and Sp e cif cat io ns

Fig ure A.1 Plan and cross-se ctional vie w o a minus-p owe re d contact le ns with a sing le curve ront sur ace and b icurve b ack sur ace .

438
 APPENDIX A Co nt act Le ns De sig n and Sp e cif cat io ns 439

Te rms, Symb o ls and Ab b re viat io ns use d t o De scrib e Co nt act Le nse s

Te rm Symb o l Ab b re viat io n
Back op tic zone rad ius r0 BO ZR
Back p e rip he ral rad ius r1 , r2 , … BPR1, BPR2, …
Front op tic zone rad ius ra0 FO ZR
Front p e rip he ral rad ius ra1 , ra2 , … FPR1, FPR2, …
Back op tic zone d iame te r Ø0 BO ZD
Back p e rip he ral zone d iame te rs Ø 1, Ø 2, … BPZD1, BPZD2, …
Total d iame te r ØT TD
Front op tic zone d iame te r Ø a0 FO ZD
Front p e rip he ral zone d iame te rs Ø a1 , Ø a2 , … FPZD1, FPZD2, …
Ge ome tric ce ntre thickne ss tc tc
Carrie r junction thickne ss t a0 tj
Pe rip he ral junction thickne ss t a1 , t a2 , … ta1, ta2, …
Rad ial e d g e thickne ss te RET
Axial e d g e thickne ss t ak AET
Rad ial e d g e li t lr REL
Axial e d g e li t la AEL
Front ve rte x p owe r Fv FVP
Back ve rte x p owe r Fv′ BVP
O xyg e n f ux j j
O xyg e n p e rme ab ility Dk Dk
O xyg e n transmissib ility Dk / t Dk / t
The te rms and symb ols outline d ab ove we re ob taine d rom the ollowing stand ard :
ISO 8320–1986 O p tics and op tical instrume nts – contact le nse s – vocab ulary and symb ols.
The ab b re viations g ive n ab ove we re mod if e d rom those sug g e ste d b y:
Houg h, T. (2000). A Guid e to Contact Le ns Stand ard s. British Contact Le ns Association.
APPENDIX

B Co nt act Le ns To le rance s

TABLE
A Dime nsio nal To le rance s fo r So ft , Po lyme t hyl Me t hacrylat e (PMMA) and Rig id Le nse s (all unit s in mm)

Dime nsio n So ft Le nse s PMMA Le nse s Rig id Le nse s

Back op tic zone rad ius ± 0.20 ± 0.025 ± 0.05
Back op tic zone rad ii o toroid al sur ace s whe re the d i e re nce in rad ii is:
< 0.20 ± 0.25 ± 0.05
0.2–0.4 ± 0.35 ± 0.06
0.4–0.6 ± 0.55 ± 0.07
> 0.6 ± 0.75 ± 0.09
Sag itta at sp e cif e d d iame te r ± 0.05
Back op tic zone d iame te r ± 0.20 ± 0.025 ± 0.05
Back p e rip he ral rad ius ± 0.10 ± 0.10
Front p e rip he ral rad ius ± 0.10 ± 0.10
Back p e rip he ral d iame te r ± 0.20 ± 0.20
Total d iame te r ± 0.20 ± 0.10 ± 0.10
Front op tic zone d iame te r ± 0.20 ± 0.20 ± 0.20
Bi ocal se g me nt he ig ht −0.10 to + 0.20 −0.10 to + 0.20
Ce ntre thickne ss ± 0.02 ± 0.02
Ce ntre thickne ss, whe re the nominal value is:
≤0.10 ± 0.010 + 10%
> 0.10 ± 0.015 + 5%

TABLE
TABLE O p t ical To le rance s fo r So ft , Po lyme t hyl C Mat e rial Pro p e rt y To le rance s fo r So ft Le nse s
B Me t hacrylat e (PMMA) and Rig id Le nse s
Mat e rial Pro p e rt y To le rance
Dime nsio n So ft Le nse s PMMA Le nse s Rig id Le nse s
Re ractive ind e x ± 0.005
Back ve rte x Wate r conte nt ± 2%
p owe r
≤5 D ± 0.12 D ± 0.12 D O xyg e n p e rme ab ility ± 20%
≤10 D ± 0.25 D ± 0.18 D ± 0.18 D
≤15 D ± 0.25 D ± 0.25 D
≤20 D ± 0.50 D ± 0.37 D ± 0.37 D •T e tolerances outlined in this appendix were obtained
>20 D ± 1.00 D ± 0.50 D ± 0.50 D rom the ollowing standards:
Cylind e r p owe r ISO 8321–1: 1991 Optics and optical instruments – con-
≤0.2 ± 0.25 D ± 0.25 D ± 0.25 D tact lenses – part 1: speci cation or rigid corneal and
2–4 ± 0.37 D ± 0.37 D ± 0.37 D scleral contact lenses.
>4 ± 0.50 D ± 0.50 D ± 0.50 D
BS EN ISO 8321–2: 2000 (BS 7208–24:2000) Ophthalmic
Cylind e r axis ± 5° ± 5° ± 5° optics – speci cations or material, optical and dimen-
Prismatic e rror (measure d at the g e ometric centre o the op tic zone) sional properties o contact lenses – part 2: single-vision
Back ve rte x p owe r hydrogel contact lenses.
≤6 D ± 0.25 cm / m ± 0.25 cm / m • PMMA tolerances are given here because trial lens tting
>6 D ± 0.50 cm / m ± 0.50 cm / m sets are of en abricated rom this material due to its resil-
Pre scrib e d p rism ± 0.25 cm / m ± 0.25 cm / m ience.
• See also: Hough, . (2000) A Guide to Contact Lens Stan-
dards. British Contact Lens Association.

440
APPENDIX

C Ve rt e x Dist ance Co rre ct io n

Effe ct ive Po w e r (D) o f Plus- and Minus-p re scrip t io n Sp e ct acle Le nse s at t he Co rne al Plane fo r Vario us Ve rt e x
Dist ance s (mm)*
PO WER (D) AT CO RNEAL PLANE FO R DIFFERENT VERTEX DISTANCES (mm)
Sp e c Rx 8 mm 10 mm 12 mm 14 mm 16 mm
Plus Minus Plus Minus Plus Minus Plus Minus Plus Minus
4.00 4.13 3.88 4.17 3.85 4.20 3.82 4.24 3.79 4.27 3.76
4.25 4.40 4.11 4.44 4.08 4.48 4.04 4.52 4.01 4.56 3.98
4.50 4.67 4.34 4.71 4.31 4.76 4.27 4.80 4.23 4.85 4.20
4.75 4.94 4.58 4.99 4.53 5.04 4.49 5.09 4.45 5.14 4.41
5.00 5.21 4.81 5.26 4.76 5.32 4.72 5.38 4.67 5.43 4.63
5.25 5.48 5.04 5.54 4.99 5.60 4.94 5.67 4.89 5.73 4.84
5.50 5.75 5.27 5.82 5.21 5.89 5.16 5.96 5.11 6.03 5.06
5.75 6.03 5.50 6.10 5.44 6.18 5.38 6.25 5.32 6.33 5.27
6.00 6.30 5.73 6.38 5.66 6.47 5.60 6.55 5.54 6.64 5.47
6.25 6.58 5.95 6.67 5.88 6.76 5.81 6.85 5.75 6.94 5.68
6.50 6.86 6.18 6.95 6.10 7.05 6.03 7.15 5.96 7.25 5.89
6.75 7.14 6.40 7.24 6.32 7.34 6.24 7.45 6.17 7.57 6.09
7.00 7.42 6.63 7.53 6.54 7.64 6.46 7.76 6.38 7.88 6.29
7.25 7.70 6.85 7.82 6.76 7.94 6.67 8.07 6.58 8.20 6.50
7.50 7.98 7.08 8.11 6.98 8.24 6.88 8.38 6.79 8.52 6.70
7.75 8.26 7.30 8.40 7.19 8.54 7.09 8.69 6.99 8.85 6.90
8.00 8.55 7.52 8.70 7.41 8.85 7.30 9.01 7.19 9.17 7.09
8.25 8.83 7.74 8.99 7.62 9.16 7.51 9.33 7.40 9.50 7.29
8.50 9.12 7.96 9.29 7.83 9.47 7.71 9.65 7.60 9.84 7.48
8.75 9.41 8.18 9.59 8.05 9.78 7.92 9.97 7.80 10.17 7.68
9.00 9.70 8.40 9.89 8.26 10.09 8.12 10.30 7.99 10.51 7.87
9.25 9.99 8.61 10.19 8.47 10.40 8.33 10.63 8.19 10.86 8.06
9.50 10.28 8.83 10.50 8.68 10.72 8.53 10.96 8.38 11.20 8.25
9.75 10.57 9.04 10.80 8.88 11.04 8.73 11.29 8.58 11.55 8.43
10.00 10.87 9.26 11.11 9.09 11.36 8.93 11.63 8.77 11.90 8.62
10.25 11.17 9.47 11.42 9.30 11.69 9.13 11.97 8.96 12.26 8.81
10.50 11.46 9.69 11.73 9.50 12.01 9.33 12.31 9.15 12.62 8.99
10.75 11.76 9.90 12.04 9.71 12.34 9.52 12.65 9.34 12.98 9.17
11.00 12.06 10.11 12.36 9.91 12.67 9.72 13.00 9.53 13.35 9.35
11.25 12.36 10.32 12.68 10.11 13.01 9.91 13.35 9.72 13.72 9.53
11.50 12.67 10.53 12.99 10.31 13.34 10.11 13.71 9.91 14.09 9.71
11.75 12.97 10.74 13.31 10.51 13.68 10.30 14.06 10.09 14.47 9.89
12.00 13.27 10.95 13.64 10.71 14.02 10.49 14.42 10.27 14.85 10.07
12.25 13.58 11.16 13.96 10.91 14.36 10.68 14.79 10.46 15.24 10.24
12.50 13.89 11.36 14.29 11.11 14.71 10.87 15.15 10.64 15.63 10.42
12.75 14.20 11.57 14.61 11.31 15.05 11.06 15.52 10.82 16.02 10.59
13.00 14.51 11.78 14.94 11.50 15.40 11.25 15.89 11.00 16.41 10.76
Continue d

441
442 APPENDIX C Ve rt e x Dist ance Co rre ct io n

Effe ct ive Po w e r (D) o f Plus- and Minus-p re scrip t io n Sp e ct acle Le nse s at t he Co rne al Plane fo r Vario us Ve rt e x
Dist ance s (mm)* (Continue d )
PO WER (D) AT CO RNEAL PLANE FO R DIFFERENT VERTEX DISTANCES (mm)
Sp e c Rx 8 mm 10 mm 12 mm 14 mm 16 mm
Plus Minus Plus Minus Plus Minus Plus Minus Plus Minus
13.25 14.82 11.98 15.27 11.70 15.76 11.43 16.27 11.18 16.81 10.93
13.50 15.13 12.18 15.61 11.89 16.11 11.62 16.65 11.35 17.22 11.10
13.75 15.45 12.39 15.94 12.09 16.47 11.80 17.03 11.53 17.63 11.27
14.00 15.77 12.59 16.28 12.28 16.83 11.99 17.41 11.71 18.04 11.44
14.25 16.08 12.79 16.62 12.47 17.19 12.17 17.80 11.88 18.46 11.60
14.50 16.40 12.99 16.96 12.66 17.55 12.35 18.19 12.05 18.88 11.77
14.75 16.72 13.19 17.30 12.85 17.92 12.53 18.59 12.23 19.31 11.93
15.00 17.05 13.39 17.65 13.04 18.29 12.71 18.99 12.40 19.74 12.10
15.25 17.37 13.59 17.99 13.23 18.67 12.89 19.39 12.57 20.17 12.26
15.50 17.69 13.79 18.34 13.42 19.04 13.07 19.80 12.74 20.61 12.42
15.75 18.02 13.99 18.69 13.61 19.42 13.25 20.21 12.90 21.06 12.58
16.00 18.35 14.18 19.05 13.79 19.80 13.42 20.62 13.07 21.51 12.74
16.25 18.68 14.38 19.40 13.98 20.19 13.60 21.04 13.24 21.96 12.90
16.50 19.01 14.58 19.76 14.16 20.57 13.77 21.46 13.40 22.42 13.05
16.75 19.34 14.77 20.12 14.35 20.96 13.95 21.88 13.57 22.88 13.21
17.00 19.68 14.96 20.48 14.53 21.36 14.12 22.31 13.73 23.35 13.36
17.25 20.01 15.16 20.85 14.71 21.75 14.29 22.74 13.89 23.83 13.52
17.50 20.35 15.35 21.21 14.89 22.15 14.46 23.18 14.06 24.31 13.67
17.75 20.69 15.54 21.58 15.07 22.55 14.63 23.62 14.22 24.79 13.82
18.00 21.03 15.73 21.95 15.25 22.96 14.80 24.06 14.38 25.28 13.98
18.25 21.37 15.92 22.32 15.43 23.37 14.97 24.51 14.54 25.78 14.13
18.50 21.71 16.11 22.70 15.61 23.78 15.14 24.97 14.69 26.28 14.27
18.75 22.06 16.30 23.08 15.79 24.19 15.31 25.42 14.85 26.79 14.42
19.00 22.41 16.49 23.46 15.97 24.61 15.47 25.89 15.01 27.30 14.57
19.25 22.75 16.68 23.84 16.14 25.03 15.64 26.35 15.16 27.82 14.72
19.50 23.10 16.87 24.22 16.32 25.46 15.80 26.82 15.32 28.34 14.86
19.75 23.46 17.06 24.61 16.49 25.88 15.97 27.30 15.47 28.87 15.01
20.00 23.81 17.24 25.00 16.67 26.32 16.13 27.78 15.63 29.41 15.15
*Base d on the e q uation: O R = SR / (1 − [d × SR]), whe re :
O R = ocular re fraction
SR = sp e ctacle re fraction
d = ve rte x d istance (m)
The le ns p owe rs e nclose d within the he avy b ord e r re late to the stand ard ve rte x d istance of 12 mm that will ap p ly in most case s.
(Courte sy of Ad rian S Bruce .)
APPENDIX

D Co rne al Curvat ure – Co rne al Po we r

Co nve rsio n

Co nve rsio n b e t w e e n Co rne al Fro nt Surface Rad ius o f Curvat ure (r; mm) and Co rne al Po w e r (K; D)*
r (mm) K (D) r (mm) K (D) r (mm) K (D) r (mm) K (D) r (mm) K (D)
6.20 54.44 6.58 51.29 6.96 48.49 7.34 45.98 7.72 43.72
6.21 54.35 6.59 51.21 6.97 48.42 7.35 45.92 7.73 43.66
6.22 54.26 6.60 51.14 6.98 48.35 7.36 45.86 7.74 43.60
6.23 54.17 6.61 51.06 6.99 48.28 7.37 45.79 7.75 43.55
6.24 54.09 6.62 50.98 7.00 48.21 7.38 45.73 7.76 43.49
6.25 54.00 6.63 50.90 7.01 48.15 7.39 45.67 7.77 43.44
6.26 53.91 6.64 50.83 7.02 48.08 7.40 45.61 7.78 43.38
6.27 53.83 6.65 50.75 7.03 48.01 7.41 45.55 7.79 43.32
6.28 53.74 6.66 50.68 7.04 47.94 7.42 45.49 7.80 43.27
6.29 53.66 6.67 50.60 7.05 47.87 7.43 45.42 7.81 43.21
6.30 53.57 6.68 50.52 7.06 47.80 7.44 45.36 7.82 43.16
6.31 53.49 6.69 50.45 7.07 47.74 7.45 45.30 7.83 43.10
6.32 53.40 6.70 50.37 7.08 47.67 7.46 45.24 7.84 43.05
6.33 53.32 6.71 50.30 7.09 47.60 7.47 45.18 7.85 42.99
6.34 53.23 6.72 50.22 7.10 47.54 7.48 45.12 7.86 42.94
6.35 53.15 6.73 50.15 7.11 47.47 7.49 45.06 7.87 42.88
6.36 53.07 6.74 50.07 7.12 47.40 7.50 45.00 7.88 42.83
6.37 52.98 6.75 50.00 7.13 47.34 7.51 44.94 7.89 42.78
6.38 52.90 6.76 49.93 7.14 47.27 7.52 44.88 7.90 42.72
6.39 52.82 6.77 49.85 7.15 47.20 7.53 44.82 7.91 42.67
6.40 52.73 6.78 49.78 7.16 47.14 7.54 44.76 7.92 42.61
6.41 52.65 6.79 49.71 7.17 47.07 7.55 44.70 7.93 42.56
6.42 52.57 6.80 49.63 7.18 47.01 7.56 44.64 7.94 42.51
6.43 52.49 6.81 49.56 7.19 46.94 7.57 44.58 7.95 42.45
6.44 52.41 6.82 49.49 7.20 46.88 7.58 44.53 7.96 42.40
6.45 52.33 6.83 49.41 7.21 46.81 7.59 44.47 7.97 42.35
6.46 52.24 6.84 49.34 7.22 46.75 7.60 44.41 7.98 42.29
6.47 52.16 6.85 49.27 7.23 46.68 7.61 44.35 7.99 42.24
6.48 52.08 6.86 49.20 7.24 46.62 7.62 44.29 8.00 42.19
6.49 52.00 6.87 49.13 7.25 46.55 7.63 44.23 8.01 42.13
6.50 51.92 6.88 49.06 7.26 46.49 7.64 44.18 8.02 42.08
6.51 51.84 6.89 48.98 7.27 46.42 7.65 44.12 8.03 42.03
6.52 51.76 6.90 48.91 7.28 46.36 7.66 44.06 8.04 41.98
6.53 51.68 6.91 48.84 7.29 46.30 7.67 44.00 8.05 41.93
6.54 51.61 6.92 48.77 7.30 46.23 7.68 43.95 8.06 41.87
6.55 51.53 6.93 48.70 7.31 46.17 7.69 43.89 8.07 41.82
6.56 51.45 6.94 48.63 7.32 46.11 7.70 43.83 8.08 41.77
6.57 51.37 6.95 48.56 7.33 46.04 7.71 43.77 8.09 41.72
Continue d

443
444 APPENDIX D Co rne al Curvat ure – Co rne al Po we r Co nve rsio n

Co nve rsio n b e t w e e n Co rne al Fro nt Surface Rad ius o f Curvat ure (r; mm) and Co rne al Po w e r (K; D)* (Continue d )
r (mm) K (D) r (mm) K (D) r (mm) K (D) r (mm) K (D) r (mm) K (D)
8.10 41.67 8.42 40.08 8.74 38.62 9.06 37.25 9.38 35.98
8.11 41.62 8.43 40.04 8.75 38.57 9.07 37.21 9.39 35.94
8.12 41.56 8.44 39.99 8.76 38.53 9.08 37.17 9.40 35.90
8.13 41.51 8.45 39.94 8.77 38.48 9.09 37.13 9.41 35.87
8.14 41.46 8.46 39.89 8.78 38.44 9.10 37.09 9.42 35.83
8.15 41.41 8.47 39.85 8.79 38.40 9.11 37.05 9.43 35.79
8.16 41.36 8.48 39.80 8.80 38.35 9.12 37.01 9.44 35.75
8.17 41.31 8.49 39.75 8.81 38.31 9.13 36.97 9.45 35.71
8.18 41.26 8.50 39.71 8.82 38.27 9.14 36.93 9.46 35.68
8.19 41.21 8.51 39.66 8.83 38.22 9.15 36.89 9.47 35.64
8.20 41.16 8.52 39.61 8.84 38.18 9.16 36.84 9.48 35.60
8.21 41.11 8.53 39.57 8.85 38.14 9.17 36.80 9.49 35.56
8.22 41.06 8.54 39.52 8.86 38.09 9.18 36.76 9.50 35.53
8.23 41.01 8.55 39.47 8.87 38.05 9.19 36.72 9.51 35.49
8.24 40.96 8.56 39.43 8.88 38.01 9.20 36.68 9.52 35.45
8.25 40.91 8.57 39.38 8.89 37.96 9.21 36.64 9.53 35.41
8.26 40.86 8.58 39.34 8.90 37.92 9.22 36.61 9.54 35.38
8.27 40.81 8.59 39.29 8.91 37.88 9.23 36.57 9.55 35.34
8.28 40.76 8.60 39.24 8.92 37.84 9.24 36.53 9.56 35.30
8.29 40.71 8.61 39.20 8.93 37.79 9.25 36.49 9.57 35.27
8.30 40.66 8.62 39.15 8.94 37.75 9.26 36.45 9.58 35.23
8.31 40.61 8.63 39.11 8.95 37.71 9.27 36.41 9.59 35.19
8.32 40.56 8.64 39.06 8.96 37.67 9.28 36.37 9.60 35.16
8.33 40.52 8.65 39.02 8.97 37.63 9.29 36.33 9.61 35.12
8.34 40.47 8.66 38.97 8.98 37.58 9.30 36.29 9.62 35.08
8.35 40.42 8.67 38.93 8.99 37.54 9.31 36.25 9.63 35.05
8.36 40.37 8.68 38.88 9.00 37.50 9.32 36.21 9.64 35.01
8.37 40.32 8.69 38.84 9.01 37.46 9.33 36.17 9.65 34.97
8.38 40.27 8.70 38.79 9.02 37.42 9.34 36.13 9.66 34.94
8.39 40.23 8.71 38.75 9.03 37.38 9.35 36.10 9.67 34.90
8.40 40.18 8.72 38.70 9.04 37.33 9.36 36.06 9.68 34.87
8.41 40.13 8.73 38.66 9.05 37.29 9.37 36.02 9.69 34.83
*Base d on the e q uation: Surface p owe r (D) = (1.3375 − 1.0) / rad ius (m)
(Courte sy of Ad rian S Bruce and Suzanne E Efron.)
APPENDIX

E Ext e nd e d Ke rat o me t e r Rang e

Co nve rsio n
Co nve rsio n o f Ke rat o me t e r Re ad ing (D) t o it s Ext e nd e d Value (D) w he n a + 1.25 D Le ns (fo r St e e p Co rne as) o r
a − 1.00 D Le ns (fo r Flat Co rne as) is He ld in Fro nt o f t he Ke rat o me t e r*
STEEP CO RNEAS (USING A +1.25 D LENS)*
Ke rat o me t e r Ext e nd e d Ke rat o me t e r Ext e nd e d Ke rat o me t e r Ext e nd e d
Re ad ing (D) Value (D) Re ad ing (D) Value (D) Re ad ing (D) Value (D)
43.00 50.13 46.13 53.78 49.25 57.42
43.13 50.28 46.25 53.92 49.38 57.57
43.25 50.42 46.38 54.07 49.50 57.71
43.38 50.57 46.50 54.21 49.63 57.86
43.50 50.72 46.63 54.36 49.75 58.00
43.63 50.86 46.75 54.51 49.88 58.15
43.75 51.01 46.88 54.65 50.00 58.30
43.88 51.15 47.00 54.80 50.13 58.44
44.00 51.30 47.13 54.94 50.25 58.59
44.13 51.44 47.25 55.09 50.38 58.73
44.25 51.59 47.38 55.23 50.50 58.88
44.38 51.74 47.50 55.38 50.63 59.02
44.50 51.88 47.63 55.53 50.75 59.17
44.63 52.03 47.75 55.67 50.88 59.32
44.75 52.17 47.88 55.82 51.00 59.46
44.88 52.32 48.00 55.96 51.13 59.61
45.00 52.47 48.13 56.11 51.25 59.75
45.13 52.61 48.25 56.25 51.38 59.90
45.25 52.76 48.38 56.40 51.50 60.04
45.38 52.90 48.50 56.55 51.63 60.19
45.50 53.05 48.63 56.69 51.75 60.34
45.63 53.19 48.75 56.84 51.88 60.48
45.75 53.34 48.88 56.98 52.00 60.63
45.88 53.49 49.00 57.13
46.00 53.63 49.13 57.27
FLAT CO RNEAS (USING A − 1.00 D LENS)†
Ke rat o me t e r Ext e nd e d Ke rat o me t e r Ext e nd e d Ke rat o me t e r Ext e nd e d
Re ad ing (D) Value (D) Re ad ing (D) Value (D) Re ad ing (D) Value (D)
36.00 30.87 38.12 32.70 40.25 34.52
36.12 30.98 38.25 32.80 40.37 34.63
36.25 31.09 38.37 32.91 40.50 34.73
36.37 31.19 38.50 33.02 40.62 34.84
36.50 31.30 38.62 33.12 40.75 34.95
36.62 31.41 38.75 33.23 40.87 35.06
36.75 31.52 38.87 33.34 41.00 35.16
36.87 31.62 39.00 33.45 41.12 35.27
37.00 31.73 39.12 33.55 41.25 35.38
37.12 31.84 39.25 33.66 41.37 35.48
37.25 31.94 39.37 33.77 41.50 35.59
37.37 32.05 39.50 33.88 41.62 35.70
37.50 32.16 39.62 33.98 41.75 35.81
37.62 32.27 39.75 34.09 41.87 35.91
37.75 32.37 39.87 34.20 42.00 36.02
37.87 32.48 40.00 34.30
38.00 32.59 40.12 34.41
*Base d on the e q uation: Exte nd e d = (1.166 × ke ratome te r) − 0.005.
†Base d on the e q uation: Exte nd e d = (1.858 × ke ratome te r) − 0.014.
(De rive d rom d ata in: Mand e ll, R. B., (1988) Diop tral and mm curve s or e xte nd e d ke ratome te r rang e . Ap p e nd ix 7. In Contact Le ns Practice
(4th e d . p p . 998–999). Sp ring f e ld , IL: Charle s C. Thomas.)
(Courte sy o Ad rian S Bruce .) 445
APPENDIX

F So ft Le ns Ave rag e Thickne ss

The Ave rag e Thickne ss (mm) o f So ft Le nse s o f Give n Ce nt re Thickne ss (mm) and Le ns Po w e r (D)*
Ce nt re AVERAGE THICKNESS (mm) FO R VARIO US LENS PO WERS (D)
Thickne ss
(mm) +8.00 +6.00 +4.00 + 2.00 − 2.00 − 4.00 −6.00 −8.00 −10.00 − 12.00 − 14.00 − 16.00
0.03 0.047 0.062 0.075 0.088 0.099 0.110 0.121 0.131
0.04 0.057 0.073 0.087 0.100 0.113 0.124 0.136 0.147
0.05 0.067 0.084 0.098 0.112 0.125 0.137 0.149 0.160
0.06 0.077 0.094 0.109 0.124 0.137 0.150 0.162 0.174
0.07 0.087 0.104 0.120 0.135 0.148 0.162 0.174 0.186
0.08 0.052 0.097 0.114 0.130 0.145 0.160 0.173 0.186 0.199
0.09 0.062 0.107 0.124 0.141 0.156 0.171 0.184 0.198 0.210
0.10 0.072 0.116 0.134 0.151 0.167 0.181 0.195 0.209 0.222
0.11 0.082 0.126 0.144 0.161 0.177 0.192 0.206 0.220 0.233
0.12 0.091 0.136 0.154 0.171 0.187 0.203 0.217 0.231 0.245
0.13 0.071 0.101 0.145 0.164 0.181 0.198 0.213 0.228 0.242 0.256
0.14 0.082 0.111 0.155 0.174 0.191 0.208 0.223 0.238 0.253 0.267
0.15 0.093 0.121 0.165 0.184 0.201 0.218 0.234 0.249 0.263 0.278
0.16 0.103 0.131 0.174 0.193 0.211 0.228 0.244 0.259 0.274 0.288
0.17 0.078 0.113 0.140 0.184 0.203 0.221 0.238 0.254 0.269 0.284 0.299
0.18 0.090 0.123 0.150 0.194 0.213 0.231 0.248 0.264 0.280 0.295 0.309
0.19 0.101 0.134 0.160 0.203 0.223 0.241 0.258 0.274 0.290 0.305 0.320
0.20 0.112 0.144 0.169 0.213 0.232 0.250 0.268 0.284 0.300 0.315 0.330
0.21 0.123 0.153 0.179 0.223 0.242 0.260 0.278 0.294 0.310 0.326 0.341
0.22 0.094 0.134 0.163 0.189 0.232 0.252 0.270 0.287 0.304 0.320 0.336 0.351
0.23 0.107 0.144 0.173 0.198 0.242 0.261 0.280 0.297 0.314 0.330 0.346 0.361
0.24 0.119 0.155 0.183 0.208 0.251 0.271 0.290 0.307 0.324 0.340 0.356 0.372
0.25 0.131 0.165 0.193 0.218 0.261 0.281 0.299 0.317 0.334 0.350 0.366 0.382

*Base d on the following assump tions:

• b ack op tic zone rad ius = 8.7 mm
• op tic zone d iame te r = 8.00 mm
• re fractive ind e x (n) = 1.48 − 0.0015 × wate r conte nt
• wate r conte nt = 55%
(Note : variations to 38% and 74% only affe ct ave rag e thickne ss b y ± 0.03 mm)
• minimum thickne ss at e d g e of op tic zone for p lus le nse s = 0.03 mm
(Base d on the the ory outline d in: Bre nnan, N. A. (1984). Ave rag e thickne ss of a hyd ro g e l le ns for g as transmissib ility calculations. Am. J. O p tom.
Physiol. O p t., 61, 627–635.)
(Courte sy of Ad rian S Bruce .)

446
APPENDIX

G So ft Le ns O xyg e n Pe rfo rmance

Co nve rsio n Be t w e e n So ft (hyd ro g e l) Le ns Wat e r Co nt e nt (%), Barre r (Fat t unit s) and ISO O xyg e n Pe rme ab ilit y (Dk)
Value s, and Fat t O xyg e n Transmissib ilit y (Dk / t ) Value s fo r Vario us Le ns Thickne sse s
Dk / t ‡ AT 35°C (BASED O N BARRER UNITS) FO R
Dk Barre r VARIO US LENS THICKNESSES (t , mm)
Wat e r Unit s* at Dk ISO Unit s †
Co nt e nt (%) 35°C at 35°C 0.03 0.04 0.05 0.06 0.07 0.08 0.09 0.10 0.12 0.15 0.20 0.25 0.30
35 6.7 5.0 22.3 16.8 13.4 11.2 9.6 8.4 7.4 6.7 5.6 4.5 3.4 2.7 2.2
36 7.0 5.2 23.2 17.4 13.9 11.6 10.0 8.7 7.7 7.0 5.8 4.6 3.5 2.8 2.3
37 7.3 5.4 24.2 18.1 14.5 12.1 10.4 9.1 8.1 7.3 6.0 4.8 3.6 2.9 2.4
38 7.5 5.7 25.2 18.9 15.1 12.6 10.8 9.4 8.4 7.5 6.3 5.0 3.8 3.0 2.5
39 7.9 5.9 19.6 15.7 13.1 11.2 9.8 8.7 7.9 6.5 5.2 3.9 3.1 2.6
40 8.2 6.1 20.4 16.3 13.6 11.7 10.2 9.1 8.2 6.8 5.4 4.1 3.3 2.7
41 8.5 6.4 21.3 17.0 14.2 12.1 10.6 9.4 8.5 7.1 5.7 4.3 3.4 2.8
42 8.8 6.6 22.1 17.7 14.7 12.6 11.1 9.8 8.8 7.4 5.9 4.4 3.5 2.9
43 9.2 6.9 23.0 18.4 15.3 13.2 11.5 10.2 9.2 7.7 6.1 4.6 3.7 3.1
44 9.6 7.2 23.9 19.2 16.0 13.7 12.0 10.6 9.6 8.0 6.4 4.8 3.8 3.2
45 10.0 7.5 24.9 19.9 16.6 14.2 12.5 11.1 10.0 8.3 6.6 5.0 4.0 3.3
46 10.4 7.8 20.7 17.3 14.8 13.0 11.5 10.4 8.6 6.9 5.2 4.1 3.5
47 10.8 8.1 21.6 18.0 15.4 13.5 12.0 10.8 9.0 7.2 5.4 4.3 3.6
48 11.2 8.4 22.5 18.7 16.0 14.0 12.5 11.2 9.4 7.5 5.6 4.5 3.7
49 11.7 8.8 23.4 19.5 16.7 14.6 13.0 11.7 9.7 7.8 5.8 4.7 3.9
50 12.2 9.1 24.3 20.3 17.4 15.2 13.5 12.2 10.1 8.1 6.1 4.9 4.1
51 12.6 9.5 21.1 18.1 15.8 14.1 12.6 10.5 8.4 6.3 5.1 4.2
52 13.2 9.9 21.9 18.8 16.5 14.6 13.2 11.0 8.8 6.6 5.3 4.4
53 13.7 10.3 22.8 19.6 17.1 15.2 13.7 11.4 9.1 6.8 5.5 4.6
54 14.2 10.7 23.7 20.4 17.8 15.8 14.2 11.9 9.5 7.1 5.7 4.7
55 14.8 11.1 24.7 21.2 18.5 16.5 14.8 12.4 9.9 7.4 5.9 4.9
56 15.4 11.6 22.0 19.3 17.1 15.4 12.9 10.3 7.7 6.2 5.1
57 16.1 12.0 22.9 20.1 17.8 16.1 13.4 10.7 8.0 6.4 5.4
58 16.7 12.5 23.9 20.9 18.6 16.7 13.9 11.1 8.4 6.7 5.6
59 17.4 13.0 24.8 21.7 19.3 17.4 14.5 11.6 8.7 7.0 5.8
60 18.1 13.6 25.8 22.6 20.1 18.1 15.1 12.1 9.0 7.2 6.0
61 18.8 14.1 23.5 20.9 18.8 15.7 12.5 9.4 7.5 6.3
62 19.6 14.7 24.5 21.7 19.6 16.3 13.0 9.8 7.8 6.5
63 20.4 15.3 22.6 20.4 17.0 13.6 10.2 8.1 6.8
64 21.2 15.9 23.5 21.2 17.7 14.1 10.6 8.5 7.1
65 22.1 16.5 24.5 22.1 18.4 14.7 11.0 8.8 7.4
66 22.9 17.2 22.9 19.1 15.3 11.5 9.2 7.6
67 23.9 17.9 23.9 19.9 15.9 11.9 9.5 8.0
68 24.8 18.6 24.8 20.7 16.6 12.4 9.9 8.3
69 25.8 19.4 25.8 21.5 17.2 12.9 10.3 8.6
70 26.9 20.2 26.9 22.4 17.9 13.4 10.8 9.0
71 28.0 21.0 23.3 18.7 14.0 11.2 9.3
Continue d
447
448 APPENDIX G So ft Le ns O xyg e n Pe rfo rmance

Co nve rsio n Be t w e e n So ft (hyd ro g e l) Le ns Wat e r Co nt e nt (%), Barre r (Fat t unit s) and ISO O xyg e n Pe rme ab ilit y (Dk)
Value s, and Fat t O xyg e n Transmissib ilit y (Dk / t ) Value s fo r Vario us Le ns Thickne sse s (Continue d )
Dk / t ‡ AT 35°C (BASED O N BARRER UNITS) FO R
Dk Barre r VARIO US LENS THICKNESSES (t , mm)
Wat e r Unit s* at Dk ISO Unit s †
Co nt e nt (%) 35°C at 35°C 0.03 0.04 0.05 0.06 0.07 0.08 0.09 0.10 0.12 0.15 0.20 0.25 0.30
72 29.1 21.8 24.3 19.4 14.6 11.6 9.7
73 30.3 22.7 25.2 20.2 15.1 12.1 10.1
74 31.5 23.6 21.0 15.8 12.6 10.5
75 32.8 24.6 21.9 16.4 13.1 10.9
76 34.1 25.6 22.7 17.1 13.6 11.4
77 35.5 26.6 23.7 17.8 14.2 11.8
78 36.9 27.7 24.6 18.5 14.8 12.3
79 38.4 28.8 19.2 15.4 12.8
80 40.0 30.0 20.0 16.0 13.3
• For le nse s ≤± 1.50 D: ave rag e thickne ss = ce ntre thickne ss.
• Dk / t value s for thickne sse s b e low a minimum manufacturab le thickne ss are not shown.
• Data in this tab le are b ase d on the Morg an–Efron e q uation, which corre cts for b ound ary and e d g e e ffe ct e rrors d uring p olarog rap hic me asure -
me nt: Dk = 1.67 × 10− 11 e xp 0.0397WC (Morg an, P. B. & E ron, N. (1998). The oxyg e n p e r ormance o conte mp orary hyd rog e l contact le nse s. Contact
Le ns Ant. Eye , 21, 3–6.)
• The shad e d ce lls re p re se nt Dk / t value s that are consid e re d to b e ad e q uate for op e n-e ye (d aily) le ns we ar; that is, Dk / t < 12 Barre r / cm (Be njamin
W. J. (1996). Downsizing o Dk and Dk / L: The d i f culty in using hPa inste ad o mmHg . Int. Contact Le ns Clin., 23, 188–189.)
• The d ata in this tab le d o not ap p ly to silicone hyd rog e l le nse s, which are d e scrib e d b y a wate r conte nt–Dk re lationship that is e sse ntially the
inve rse of that which is use d he re to d e scrib e hyd rog e l le nse s.
*Trad itional units of oxyg e n p e rme ab ility are : × 10− 11 (cm 2 × ml O 2) / (s × ml × mmHg ), or Barre r.
†ISO units of oxyg e n p e rme ab ility are : × 10–11 (cm 2 × ml O ) / (s × ml × hPa).
2
‡Trad itional units of oxyg e n transmissib ility are : × 10− 9 (cm × ml O ) / (s × ml × mmHg ), or Barre r / cm.
2
(Courte sy o Ad rian S Bruce .)
APPENDIX

H Co nst ant Ed g e Cle arance

Rig id Le ns De sig ns

The o re t ical Ed g e Cle arance s fo r a Le ns Fit t e d w it h 10 µm Ce nt ral Cle arance o n a Co rne a w it h a Shap e Fact o r o f
0.85*
8.40 m DIAMETER – 69 µm EDGE CLEARANCE
BO ZR 7.00 7.10 7.20 7.30 7.40 7.50 7.60 7.70 7.80 7.90 8.00 8.10 8.20 8.30 8.40 8.50
BO ZD 7.40 7.40 7.40 7.40 7.40 7.40 7.40 7.40 7.40 7.40 7.40 7.40 7.40 7.40 7.40 7.40
BPR1 7.80 7.90 8.05 8.20 8.30 8.45 8.60 8.75 8.90 9.00 9.15 9.25 9.40 9.50 9.65 9.80
BPZD1 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00
BPR2 9.80 10.10 10.30 10.50 10.90 11.20 11.40 11.70 12.00 12.40 12.60 13.10 13.40 13.80 14.10 14.40
TD 8.40 8.40 8.40 8.40 8.40 8.40 8.40 8.40 8.40 8.40 8.40 8.40 8.40 8.40 8.40 8.40
8.80 m DIAMETER – 73 µm EDGE CLEARANCE
BO ZR 7.00 7.10 7.20 7.30 7.40 7.50 7.60 7.70 7.80 7.90 8.00 8.10 8.20 8.30 8.40 8.50
BO ZD 7.60 7.60 7.60 7.60 7.60 7.60 7.60 7.60 7.60 7.60 7.60 7.60 7.60 7.60 7.60 7.60
BPR1 7.70 7.85 7.95 8.10 8.20 8.35 8.45 8.60 8.75 8.90 9.00 9.15 9.25 9.40 8.55 9.65
BPZD1 8.30 8.30 8.30 8.30 8.30 8.30 8.30 8.30 8.30 8.30 8.30 8.30 8.30 8.30 8.30 8.30
BPR2 8.90 9.10 9.30 9.50 9.80 10.00 10.30 10.40 10.70 10.80 11.10 11.40 11.70 11.90 12.10 12.50
TD 8.80 8.80 8.80 8.80 8.80 8.80 8.80 8.80 8.80 8.80 8.80 8.80 8.80 8.80 8.80 8.80
9.20 m DIAMETER – 80 µm EDGE CLEARANCE
BO ZR 7.00 7.10 7.20 7.30 7.40 7.50 7.60 7.70 7.80 7.90 8.00 8.10 8.20 8.30 8.40 8.50
BO ZD 7.80 7.80 7.80 7.80 7.80 7.80 7.80 7.80 7.80 7.80 7.80 7.80 7.80 7.80 7.80 7.80
BPR1 7.60 7.70 7.85 7.95 8.10 8.20 8.35 8.45 8.60 8.70 8.85 8.95 9.10 9.20 9.35 9.47
BPZD1 8.60 8.60 8.60 8.60 8.60 8.60 8.60 8.60 8.60 8.60 8.60 8.60 8.60 8.60 8.60 8.60
BPR2 8.60 8.80 9.00 9.20 9.40 9.60 9.80 10.00 10.20 10.40 10.60 10.90 11.10 11.30 11.60 11.83
TD 9.20 9.20 9.20 9.20 9.20 9.20 9.20 9.20 9.20 9.20 9.20 9.20 9.20 9.20 9.20 9.20
9.60 m DIAMETER – 90 µm EDGE CLEARANCE
BO ZR 7.00 7.10 7.20 7.30 7.40 7.50 7.60 7.70 7.80 7.90 8.00 8.10 8.20 8.30 8.40 8.50
BO ZD 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00
BPR1 7.60 7.70 7.80 7.95 8.10 8.20 8.30 8.45 8.55 8.70 8.85 8.95 9.10 9.20 9.35 9.50
BPZD1 8.90 8.90 8.90 8.90 8.90 8.90 8.90 8.90 8.90 8.90 8.90 8.90 8.90 8.90 8.90 8.90
BPR2 8.30 8.50 8.70 8.90 9.00 9.30 9.50 9.70 9.90 10.10 10.20 10.50 10.60 10.90 11.00 11.20
TD 9.60 9.60 9.60 9.60 9.60 9.60 9.60 9.60 9.60 9.60 9.60 9.60 9.60 9.60 9.60 9.60
10.00 mm DIAMETER – 105 µm EDGE CLEARANCE
BO ZR 7.00 7.10 7.20 7.30 7.40 7.50 7.60 7.70 7.80 7.90 8.00 8.10 8.20 8.30 8.40 8.50
BO ZD 8.20 8.20 8.20 8.20 8.20 8.20 8.20 8.20 8.20 8.20 8.20 8.20 8.20 8.20 8.20 8.20
BPR1 7.65 7.70 7.80 7.95 8.10 8.20 8.35 8.45 8.65 8.70 8.85 9.00 9.15 9.25 9.40 9.50
BPZD1 8.90 8.90 8.90 8.90 8.90 8.90 8.90 8.90 8.90 8.90 8.90 8.90 8.90 8.90 8.90 8.90
BPR2 8.00 8.15 8.35 8.50 8.60 8.80 8.90 9.10 9.15 9.45 9.60 9.75 9.90 10.10 10.25 10.45
BPZD2 9.50 9.50 9.50 9.50 9.50 9.50 9.50 9.50 9.50 9.50 9.50 9.50 9.50 9.50 9.50 9.50
BPR3 8.10 8.30 8.40 8.60 8.80 9.00 9.20 9.30 9.50 9.70 9.80 10.00 10.20 10.40 10.50 10.70
TD 10.00 10.00 10.00 10.00 10.00 10.00 10.00 10.00 10.00 10.00 10.00 10.00 10.00 10.00 10.00 10.00
*(Base d on the d e sig n conce p t of Guillon, M., Lyd on, D. P. M. & Sammons, W. A. (1983). De sig ning rig id g as-p e rme ab le contact le nse s using the
e d g e cle arance te chniq ue . J. Br. Contact Le ns Assoc., 6, 19–25.)
(Courte sy of Grae me Young .)

449
APPENDIX
So ft To ric Le ns Misalig nme nt
I De mo nst rat o r

Re sid ual Re fract ive Erro r Ind uce d b y Mislo cat io n o f To ric Le nse s o f Give n Cylind rical Po w e rs, Base d up o n an O cular
Re fract io n o f Plano / − cyl × 180
Example
• O cular re fraction (re q uire d re fractive corre ction) is: p lano / −1.00 × 180
• A le ns is p lace d on the e ye of b ack ve rte x p owe r: p lano / − 1.00 × 180
• An ove rre fracton yie ld s a re sid ual e rror of: + 0.34 / − 0.68 × 35
• From the tab le , a mislocation is ind icate d of: − 20°
• The le ns b ack ve rte x p owe r in situ is: p lano / −1.00 × 160
Mislocation (−)(°) −1.00 D Cylind e r −2.00 D Cylind e r −3.00 D Cylind e r
5 0.09 / − 0.17 × 42.5 0.17 / − 0.35 × 42.5 0.26 / − 0.52 × 42.5
10 0.17 / −0.35 × 40.0 0.35 / −0.69 × 40.0 0.52 / −1.04 × 40.0
15 0.26 / −0.52 × 37.5 0.52 / −1.04 × 37.5 0.78 / −1.55 × 37.5
20 0.34 / −0.68 × 35.0 0.68 / −1.37 × 35.0 1.03 / −2.05 × 35.0
25 0.42 / −0.85 × 32.5 0.85 / −1.69 × 32.5 1.27 / −2.54 × 32.5
30 0.50 / −1.00 × 30.0 1.00 / −2.00 × 30.0 1.50 / −3.00 × 30.0
35 0.57 / −1.15 × 27.5 1.15 / −2.29 × 27.5 1.72 / −3.44 × 27.5
40 0.64 / −1.29 × 25.0 1.29 / −2.57 × 25.0 1.93 / −3.86 × 25.0
45 0.71 / −1.41 × 22.5 1.41 / −2.83 × 22.5 2.12 / −4.24 × 22.5
50 0.77 / −1.53 × 20.0 1.53 / −3.06 × 20.0 2.30 / −4.60 × 20.0
55 0.82 / −1.64 × 17.5 1.64 / −3.28 × 17.5 2.46 / −4.91 × 17.5
60 0.87 / −1.73 × 15.0 1.73 / −3.46 × 15.0 2.60 / −5.20 × 15.0
65 0.91 / −1.81 × 12.5 1.81 / −3.63 × 12.5 2.72 / −5.44 × 12.5
70 0.94 / −1.88 × 10.0 1.88 / −3.76 × 10.0 2.82 / −5.64 × 10.0
75 0.97 / −1.93 × 7.5 1.93 / −3.86 × 7.5 2.90 / −5.80 × 7.5
80 0.98 / −1.97 × 5.0 1.97 / −3.94 × 5.0 2.95 / −5.91 × 5.0
85 1.00 / −1.99 × 2.5 1.99 / −3.98 × 2.5 2.99 / −5.98 × 2.5
90 1.00 / −2.00 × 0.0 2.00 / −4.00 × 0.0 3.00 / −6.00 × 0.0
Rule s of thumb for soft toric mislocation:
1. The sp he rical e q uivale nt is ze ro if the e rror is p ure ly d ue to axis misalig nme nt.
2. The d ire ction of le ns misalig nme nt is always op p osite to the axis of the ove rre fraction, re lative to the p re scrib e d cylind e r axis.
3. LARS: ‘le ft ad d , rig ht sub tract’. Whe n allowing for nasal rotation in the rig ht e ye , the amount of rotation should b e sub tracte d from the re -
q uire d cylind e r axis and vice ve rsa for the le ft e ye .
(Ge ne rate d using the formulae in: Lind say, R. G., Bruce , A. S., Bre nnan, N. A. & Pianta, M. J. (1997). De te rmining axis misalig nme nt and p owe r e r-
rors of toric soft le nse s. Int. Contact Le ns. Clin., 24, 101–107.)
(Courte sy of Ad rian S Bruce .)

450
APPENDIX

J Dry-e ye Q ue st io nnaire

A Typ ical Dry-e ye Q ue st io nnaire

Symp t o m Fre q ue ncy
Ne ve r Some time s O fte n Constantly
Sand y or g ritty e e ling
Burning
Dryne ss
Sore ne ss
Scratchine ss
Itching
Eye d iscom ort on
waking
Te aring (wate ry e ye s)
Fore ig n-b od y se nsation
Eye p ain
Re d ne ss
Mucus d ischarg e
Lig ht se nsitivity
Blurre d vision
In e ction o lid s or e ye
Hay e ve r
O the r alle rg y
Nasal cong e stion
Coug h
Bronchitis
Cold symp toms
Sinus cong e stion
Dryne ss o
throat / mouth / vag ina
Troub le swallowing ood
Asthma symp toms
Joint p ain
Muscle p ain
DO YO UR EYES SEEM O VERLY SENSITIVE TO :
Cig are tte smoke ■ Swimming ■ Smog ■ Alcohol ■
Air cond itioning ■ Sunshine ■ Heater and air blowers ■ Wind ■
Dust ■ Use o VDUs ■ Polle n ■ Eye d rop s ■

451
452 APPENDIX J Dry-e ye Q ue st io nnaire

GENERAL Q UESTIO NS RELATING Ye s No

TO DRY EYE
Do you we ar contact le nse s?
Have you p re viously trie d to we ar
contact le nse s?
Do you use artif cial te ars or d rop s?
Have you e ve r b e e n told you sle e p
with your e ye s op e n?
Have you e ve r b e e n tre ate d or d ry e ye s?
Do you take antihistamine s?
Do you take b irth control p ills?
Are you taking d iure tics (wate r p ills)?
Are you taking any othe r me d ication
(p re scrib e d or ove r the counte r)?
I ye s, g ive b rand and re ason or taking
me d ication
Have Yo u o r Any Blo o d Re lat ive
Co nd it io n Had Any o f t he Fo llo wing ?
Yourse lf Re lative Re lationship
Arthritis
Thyroid d ise ase
Lup us
Sarcoid osis
Asthma
Sjög re n’s synd rome
Skin d isord e rs
He art d ise ase
Hyp e rte nsion
Gout
Cataract
Diab e te s
Glaucoma

(Ad ap te d with p e rmission rom: Lowthe r, G. E. (1997). Examination o p atie nts and p re d icting
te ar-f lm re late d p rob le ms with hyd rog e l le ns we ar. In Dryne ss, Te ars and Contact Le ns We ar
(p p . 23–53). O x ord : Butte rworth-He ine mann)
(Courte sy o Ke ith H Ed ward s.)
APPENDIX
K Efro n Grad ing Scale s fo r Co nt act
Le ns Co mp licat io ns
T e grading scales presented on the ollowing two pages were
devised by Pro essor Nathan E ron and painted by the ophthal-
mic artist, erry R arrant.
T ese grading scales are designed to assist practitioners to
quanti y the level o severity o a variety o contact lens com-
plications. T e eight complications on the f rst page are those
that are more likely to be encountered in contact lens practice.
Many o these complications are graded routinely by some
practitioners. T e complications on the second page are less
commonly encountered in contact lens practice, and represent
pathology that is rare or unusual.
An explanation as to how to use these grading scales is given
in Chapter 39.
T e development o these grading scales was kindly spon-
sored by CooperVision.
453
454 APPENDIX K Efro n Grad ing Scale s fo r Co nt act Le ns Co mp licat io ns
APPENDIX K Efro n Grad ing Scale s fo r Co nt act Le ns Co mp licat io ns 455
APPENDIX

L Scle ral Le ns Fit Scale s

To accurately estimate the amount o vaulting (clearance) thickness (CT) o the lens itsel , which is specif ed by the man-
underneath the posterior sur ace o a scleral lens necessitates u acturer. In each o the examples below, the CT is 0.30 mm
a re erence point or comparison. Although some have sug- (300 µm). In most scleral lens designs, the ideal amount o
gested corneal thickness or the re erence, we pre er the centre clearance is about 300 µm.

Ce nt ral Vault ing

456
 APPENDIX L Scle ral Le ns Fit Scale s 457

Limb al Vault ing

None Good Moderate

Ed g e Re lat io nship

(Imag e s and te xt re p rod uce d with p e rmission from Josh Lotoczky, O D; Chad Rose n, O D; and Craig W. Norman, FCLSA.)
This pa ge inte ntiona lly le ft bla nk
 INDEX

A Against-the-rule corneal astigmatism, rigid toric bi ocal and multi ocal contact lenses, 219, 220
Abbe re ractometer, or rigid lens measurement, 141 lens and, 157 back-sur ace, 220
Abbreviations, used or describing contact lens, Age, accommodation amplitude and, 29, 30 ront-sur ace, 219–220, 220
439t Air Optix Colors, 208, 209 zonal aspheric and spherical designs, 220–221,
Aberrations Air Optix Night and Day lens, 57 221
rigid lens optics, 133–134 Air ow, and lens wear, 249 rigid, 146–147, 146t
so lens, 69–72, 70 Alignment bitoric lenses, 160 Aspheric rigid lens manu acture, 128
spherical, 70, 71 ALK. see Anterior lamellar keratoplasty (ALK) Association o British Dispensing Opticians, 435
visual optics and Alternating copolymer, so lens and, 46, 46 Association o Contact Lens Manu acturers, 361
high-order, correction o , 38 Alternating-image (translating) designs, bi ocal and Astigmatism
ocular depth o ocus, 38, 38 multi ocal contact lenses, 224–226, 225 against-the-rule corneal, 157
white light, 37, 37 . see also Chromatic general principles o lens designs, 224–225, corneal, neutralization o , by rigid lens o
aberration 225 spherical power, 132–133, 132
Aberrometer, 350 Alternating-vision bi ocal lenses, 383 high, and high-power lens designs, 265–266
Acanthamoeba keratitis, 399 Altitude, and sport, 247–248 induced, 159–160
Accelerated orthokeratology, outcomes o , 297–299 Ametropia irregular, in children, 270, 270
Accessory lacrimal glands, 24 basic optics o eye and, 28–30 residual, 159, 159
Accommodation accommodation and precision o ocular ocus, in keratoconus, 256
demand, spectacle corrections and, 40–41, 41 29–30, 30 in so toric lenses
precision o ocular ocus and, 29–30, 30 general optical characteristics o , 28–30, degree o , 95
Accumulation o mucus, o scleral lenses, 201 28 –29 irregular, 102
Acoustic neuroma, 277, 277 model eyes and, 28–29, 29t, 30 visual optics and, 29
Acuvue lens, 175, 175 high. see High ametropia Autolensometer, 74, 74
Adjustments to lenses, bi ocal and multi ocal Amorphous polymer, so lens and, 46–47, 47 Avaira lenses, 57–59
contact lenses, 223 Analogue, discom ort, 381, 381 Average thickness o so lenses, 446t
common reasons why lenses ail to, 224t Anatomical measurements, o anterior eye, 347 Axial edge li , 138, 139
Advantages o planned so lens replacement Anisometropes, spectacle magni cation and, 40 Axial edge thickness, 439t
a ercare schedules, enhanced compliance with, Anterior blepharitis, 388
181 Anterior corneal shape, assessment o , 337–340
avoidance o long-term adverse changes Anterior eye, 10–27.e2 B
in anterior eye, 178–180 avoidance o long-term adverse changes in, Babies. see Paediatric tting
in so lenses, 176–178 178–180 Back optic zone diameter (BOZD), 197, 254, 254 ,
higher-water-content hydrogel materials, use o , discom ort, 179, 179 439t
180 ocular sur ace pathology, 179–180 in rigid lens design, 145
lens parameters easy to change, 181–182 reduced vision, 179, 179 Back optic zone radius (BOZR), 83, 197, 347, 439t
ready availability o replacement lenses, 181 conjunctiva, 20–23, 314 rigid toric lens, 157
silicone hydrogel materials, use o , 180 cornea, 10–17 so lens design, 88
simple lens care regimens, 180–181, 181t digital imaging, resolution in, 411, 411 –412 Back peripheral radius, 439t
single-use trial lenses, 181 eyelids in, 17–20 Back peripheral zone diameters, 439t
trial lens tting with accurate prescription, 181, lacrimal system in, 23–25 Back scleral radius (BSR), 197
182 ocular adnexa in, 17–25 Back scleral size (BSS), 198
Advantages o regular planned rigid lens preocular tear lm in, 25 Back-sur ace aspheric designs, 220
replacement, 189–191 Anterior lamellar keratoplasty (ALK), 288 Back sur ace o lens
daily wear, 190, 190 Anterior segment imaging technologies, in generation o , 123–124, 125
extended wear, 190–191 keratoconus assessment, 251 toric, 128
lens binding, 191, 191 Anterior-segment morphology, assessment o , toroidal, 96
A ercare, 364–384.e2 337–343 Back sur ace radius, o curvature, in rigid lens
procedures ollowing lens removal, 369–376 anterior corneal shape, 337–340 measurement, 137–138
corneal topography, 370–373 posterior corneal shape, 338–340 Back-sur ace toric lenses, 160–161
keratometry, 370–373 scleral shape, corneal and, 340–343 Back vertex power (BVP), 74, 439t
lens inspection/veri cation, 374–375 Anterior-segment optical coherence tomography calculating BVP in situ, 100–101
pachymetry, 373, 374 (AS-OC ), 375–376, 376 determination o , in so toric lenses, 98
re raction, 369–370 or corneal and scleral shape, 340–343 required, di erent BOZR and, 131, 131
slit-lamp biomicroscopy, 373–374, 375 or corneal thickness, 344, 345 rigid lens, 158
vision, uncorrected, 369 Anti-myopia lenses, 7 Bacterial keratitis, 405
procedures while lenses are worn, 365–369 Aphakia Bandage lenses, 283
external examination, 366 in children, 268–269, 268 –269 Barnacle-like calcium carbonate deposits,
history taking, 365–366 and high-power lens design, 264–265 177, 177
overkeratometry, 366, 367 Apical bearing, 254, 254 Basal lamina, o cornea, 11, 11
overre raction, 366 Apical clearance, 254–255, 254 Base curve radius, in so lens design, 88
slit-lamp biomicroscopy, 366–369 Application o lens. see Insertion o lens Bausch & Lomb lens heat unit, 104, 104
visual acuity, 366 Aquatic environment, and lens wear, 248 Bedewing, corneal endothelium, 406–407, 407
schedules, enhanced compliance with, 181 AS-OC . see Anterior-segment optical coherence BHVI eye mapper, 311, 312
solving problems, in contact lens wear, 379–384 tomography (AS-OC ) BHVI scorecard, or myopia, 307, 308
visit, preparing or, 364–365 Aspheric curve, 219–220 Biconcentric designs, bi ocal and multi ocal contact
discussion with patient, 377 Aspheric lens designs, 256 lenses, 218

Pages ollowed by b, t, or f re er to boxes, tables, or gures, respectively.

459
460 Ind e x
Bi ocal and multi ocal contact lenses, 217–229
alternating-image (translating) designs, 224–226,
225
historical designs o , 218
monovision, 226–229, 227 –228
or myopia, 309
simultaneous image designs, 218–224, 219
Binding lens, planned replacement or rigid lenses
and, 191, 191
Binocular vision assessment, 352
Bio nity lenses, 57–59
Biometry, or children examination, 271–272
‘Biomimetic’ contact lenses, 54
Bitoric rigid lenses, therapeutic applications, 280
Blebs, endothelial, 239, 407–408, 407 –408
E ron grading scale or, 455
Blemish, as non-edge (body) de ects, 66
Blepharitis, 388
E ron grading scale or, 455
Blinking
contact lenses and, 385, 386
and tting high-plus lenses, 266
technique, in lens removal, 360, 360
Block copolymer, so lens and, 46, 46
Blood and lymphatic supply, to eyelids, 20
Blood vessels, o conjunctiva, 22, 22
Body contact, extreme, and lens wear, 249
Body movements, extreme, and lens wear, 249
Bowman’s layer, o cornea, 11, 11
Boxing, and lens wear, 249
BOZD. see Back optic zone diameter (BOZD)
BOZR. see Back optic zone radius (BOZR)
Branched homopolymer, or hydrogel lenses, 46, 46
BSR. see Back scleral radius (BSR)
BSS. see Back scleral size (BSS)
Bubbles, o scleral lenses, 201
Bull’s eye, orthokeratology and, 301, 302
Burton lamp, 327, 327
BVP. see Back vertex power (BVP)
C Commercial digital imaging system, 413
CAB. see Cellulose acetate butyrate (CAB)
Capillary orces, rigid lens and, 144, 145
Captive bubble technique, hydrogels and, 50
Carbamate-substituted RIS ( PVC), or silicone
hydrogel lenses, 56 , 57
Care products, or contact lenses, 361
Carrier junction thickness, 439t
Cast moulding, 63, 64 –65
Cataracts, 316
Caucasian eyes, in so lens tting, 94
CCD. see Charge-coupled device (CCD)
Cellulose acetate butyrate (CAB), 116
Central t, o rigid lens, 152–153, 152 –153
Central island, orthokeratology and, 301, 302
Central vaulting, 456, 456
Centration, in so lens tting, 91
Centre, in so lens design, 88
Centre-distance design, bi ocal and multi ocal
contact lenses, 218
Centre thickness (C ), 456
in rigid lens design, 145, 145t
in rigid lens measurement, 137
Centred cones, 251
Chain polymerization, 47–48
Charge-coupled device (CCD), 411
Chelating agent, 108–109, 109
Chemical bond tinting, o lenses, 208, 208
Chemical injuries, therapeutic applications and,
276, 276
Children. see Paediatric tting
Chinese eyes, in so lens tting, 94
Chlorhexidine-preserved system, 105
Chlorine, 105–106
Chromatic aberration, visual optics and, 37, 37
white light, overall optical per ormance o eye,
37, 37
Cicatricial conjunctivitis, therapeutic applications
and, 276
CIEs. see Corneal in ltrative events (CIEs)
CL-MGD, Contact-lens-associated meibomian
gland dys unction (CL-MGD)
CLARE. see Contact-lens-associated acute red eye
(CLARE)
Cleaning o lenses
scleral lenses, and conditioning, 201
so contact lenses, 103–104
Cleaning solutions, or rigid lens, 163–164
Clearance, in scleral lens design, 456
ClearKone lenses, or keratoconus, 261, 261
CLEB. see Contact-lens-associated endothelial
bedewing (CLEB)
CLEK study. see Collaborative Longitudinal
Evaluation o Keratoconus (CLEK) study
Clinic, compliance enhancement model, 425
Clinical data, optimum rigid lens replacement
schedule, 191
CLPC. see Contact-lens-induced papillary
conjunctivitis (CLPC)
CLR12-70 re ractometer, 80, 80
CLSLK. see Contact-lens-induced superior limbic
keratoconjunctivitis (CLSLK)
Cobalt blue lter, in illumination system, 333
Cochet-Bonnet aesthesiometer, 335, 337
Codex of the Eye, Manual D, in contact lens, 3
Coef cient o riction (CoF), hydrogels and, 51
CoF. see Coef cient o riction (CoF)
Cold environment, and sport, 247
Collaborative Longitudinal Evaluation o
Keratoconus (CLEK) study, 255
College o Optometrists, 435
Colour vision, 206
testing, 355
Com ort, in so lens tting, 91
Com ort drops, 357
Commercial rigid lens materials, properties o ,
119–122
exure, 119–121
hardness, 121
mechanical, 119–121
optical, 121–122
oxygen permeability, 119
re ractive index, 122
sur ace, 121
Compliance, 420–426.e1
with correct prescription, 423, 423
in duration o prescription, 420, 420
enhancement o , 423–424
erroneous procedures, 421–422, 421
with incorrect prescription, 422–423, 423
industry role, 425–426
patient, history taking and, 325–326
Compliance enhancement model, 424–426
Complications, in contact lenses, 385–409.e2
in conjunctiva, 391–394
in corneal epithelium, 397–400, 406–409
in corneal stroma, 400–406
E ron grading scale or, 453, 454 –455
in eyelids, 385–389
in limbus, 394–397
in tear lm, 389–391
Compression, hydrogels and, 48
Cone, morphology o , in keratoconus, 251, 252
Con ocal microscopy, 334–335, 375, 417–418
or corneal thickness, 344–345
ocusing through, 335, 336
slit-scanning, 335
tandem scanning, 334–335
Congenital cataract, surgery or, 268
Conjunctiva
anterior eye, 20–23
blood supply o , 22
and diabetes, 314
unctional considerations in, 23
gross anatomy, 20–21, 20 –21
innervation o , 22
microscopic anatomy, 21–22
blanching, o scleral lenses, 201
complications in, 391–394
displacement and thinning, o scleral lenses,
201–202, 202
epithelial ap, 392
epithelium o , 21, 21
hemorrhage, eye redness and, 379, 379 –380
indentation, in so toric lenses, 102
papillary conjunctivitis, 393–394, 393 –394
redness, 392–393, 393
E ron grading scale or, 454
limbal and bulbar, 380
staining, 391–392, 392
E ron grading scale or, 454
stroma, 22, 22
Conjunctivitis, papillary, 245
in children, 274
Constant edge clearance, rigid lens designs, 449t
Consulting room, practice, 428
Contact aesthesiometry, 335, 337
Contact angle, hydrogels and, 50, 50
Contact-lens-associated acute red eye (CLARE), 382
Contact-lens-associated endothelial bedewing
(CLEB), 406–407, 407
Contact-lens-associated meibomian gland
dys unction (CL-MGD), 386–387, 387
Contact lens dispensary, practice, 428
Contact-lens-induced corneal neovascularization,
404
Contact-lens-induced hypoxia, 394–395
Contact-lens-induced papillary conjunctivitis
(CLPC), 393–394
Contact-lens-induced superior limbic
keratoconjunctivitis (CLSLK), 395–396
Contact lens products, managing o , 433
Contact lens-related papillary conjunctivitis, 236, 236
σ contact lenses, 250
Continuous wear, de nition o , 231
Contracts, 432
Contrast sensitivity, 70, 71
unction, in poor vision, 382
Conventional so extended wear, 231–232
Convergence demand, spectacle corrections and,
41, 41
CooperVision MiSight lens, 7
Copolymer, so lens and, 46, 46
Cornea
anterior eye, 10–17
and diabetes, 314, 315t
epithelial wound healing o , 16–17
gross anatomy o , 10, 10t
microscopic anatomy o , 10–13, 10
transparency o , 15–16
asphericity, 143
collagen cross-linking (CXL), and keratoconus,
262
degenerations
involving endothelium, 276
involving epithelium, 276
distortion, 203, 370
E ron grading scale or, 455
dystrophies involving the epithelium, 276
epithelial pain, 275
exhaustion, 240
ront sur ace radius o curvature, and corneal
power, conversion between, 443t–444t

Cornea (Continued)
gra
or keratoconus, 262
rejection and ailure, 293–294. see also
Post-keratoplasty
types o , 288–289
hydration control, in anterior eye, 315–316
hypoxia, in so toric lenses, 102
in ltrates, E ron grading scale or, 455
innervation o , 13–14
unctional considerations in, 14
nerve source and distribution, 13–14, 14
metabolism o , 14–15
oxidative metabolism, 15, 15
oxygen and nutrients in, source o , 14–15, 15
neovascularization, 240–241, 403–404,
403 –404
contact-lens-induced, 404
E ron grading scale or, 454
in so toric lenses, 102
oedema, 236, 236
E ron grading scale or, 454
so toric lenses, 102
physiology, orthokeratology and, 298–299
plana, 275
scarring/thinning, 318
shape, unusual or distorted, 275, 275
staining, E ron grading scale or, 454
stroma, 11–13, 12
complications in, 400–406
deep stromal opacities, 402–403, 403
keratitis, 404–406, 404 –405
neovascularization in, 403–404, 403 –404
oedema, 381, 400–401, 401
organization, in corneal transparency,
15–16
rejection, post-keratoplasty and, 294
thinning, 401–402, 402
warpage, 406, 406
swelling o , 236–237, 237 –238
temperature, in on-eye power changes, 68
therapy. see T erapeutic applications
thickness
anterior-segment optical coherence
tomography (AS-OC ) or, 344, 345
changes in, 237–238, 238
con ocal microscopy or, 344–345
determination o , 343–345
di erences in, 238
LenStar LS 900 biometer or, 345, 345
optical pachymetry or, 343, 343
Scheimp ug scanning in, 344
slit-scanning devices or, 344
specular microscopy or, 345
ultrasonic pachymetry or, 343–344, 344
tomography, 352, 354
topography, 147–148, 147 , 350–352, 353 ,
370–373
analysis, 338, 338 –339
irregular, post-keratoplasty and, 289–290,
289
photore ractive procedures and, 282–283
radial keratotomy and, 284–285, 285
visual optics and, 30–31, 31
transparency o
hydration control in, 16, 16
in oedema, 16
stromal organization in, 15–16
ulcerations, in ectious, 234–235, 235
wrinkling, 399–400, 399 –400
Corneal curvature-corneal power conversion,
443t–444t
‘Corneal exhaustion syndrome,’ 408
Corneal in ltrative events (CIEs), 173–174, 173 ,
235–236, 244
Corneal lenses, or keratoconus, 253–257
designs or, 255–256
aspheric, 256
spherical, 255–256
toroidal, 256–257, 256 –257
tting philosophies, 254–255
Corneal plane, e ective power o plus-and minus-
prescription spectacle lenses in, 441t–442t
Corneal powers, 347
conversion between corneal ront sur ace radius
o curvature and, 443t–444t
‘Corneal tomographers,’ 337
Corneal topographers, or rigid lens measurement,
138
Corneo-scleral lenses, or keratoconus, 257, 257
Correction, principles o , 97–101
back vertex power determination, 98
eye relationship, 99
tting, 98
lid anatomy, 98–99
misalignment o lens, 100–101, 101t
rotation
allowing, 99
e ects o , 98
measurement o , 99–100
predicting, 98, 99t
thickness pro le, 99
Corrections to spectacle, 38–41
accommodation demand and, 40–41, 41
convergence demand and, 41, 41
e ectivity and, 39, 39
magni cation, 39–40, 39 –40
Cosmetic tinted lenses, 205, 205
Cosmetics, contact lens wear and, 361
Cost
to patient, practice management, 186
reducing, in compliance enhancement, 424. see
also Pricing
‘Crab’ louse, 388–389, 389
Crimping, technique o , in toric back sur ace, 128
Cross-linked system, o polymer, 46, 46
Crystalline polymer, so lens and, 46, 47
CSM Instruments, 79
C . see Centre thickness (C )
Cylinders, in so toric lenses
axis, 95
oblique, 102
Cylindrical power equivalent toric lenses, 160–161
Cylindrical powers, residual re ractive error
induced by mislocation o toric lenses o , 450t
D o so lens, measurement, 81–82, 81 . see also
da Vinci, Leonardo, 3, 3
Daily disposable so lenses, 165–174.e1, 167 , 168t,
169 –170
advantages rom perspective
o lens wearers, 171
o practitioners, 170–171
bimodal distribution o , 170
clinical per ormance o , 170
com ort enhancement strategies, 171
corneal in ltrative events and keratitis, 173–174
disadvantages o , 171
environmental impact o , 172, 173
lens application to assist ametropes in eyewear
selection, 174
limitations to more general acceptance, 172–173
manu acturing reliability, 171, 172
patterns o wear, 168–170
Daily wear, planned replacement or rigid lenses
and, 190, 190
DALK. see Deep anterior lamellar keratoplasty
(DALK)
Danalens, 7
Ind e x 461
Decentration, o rigid lens, 153, 153
Decentred lenses, prismatic e ects due to, 134
Decongestant, or eye redness, 379
Deep anterior lamellar keratoplasty (DALK), 12–13,
288
Deep stromal opacities, 402–403, 403
Deliberate non-compliance, 422–423
Deposits on lenses, 176–178, 176 –177
tinted lenses, 213
Descemet’s membrane, 315, 316
in cornea, 13, 13
Descemet’s membrane endothelial keratoplasty
(DMEK), 288
Descemet’s stripping automated endothelial
keratoplasty (DSAEK), 288
Descemet’s stripping endothelial keratoplasty
(DSEK), 288, 289
Designs o lenses
bi ocal and multi ocal. see Bi ocal and multi ocal
contact lenses
general principles o , bi ocal and multi ocal
contact lenses, 224–225
used design, 225
solid design, 224–225, 226
rigid. see Rigid lens design
so . see So lens design
and speci cation, 438 , 439t
tinted, 204–207
toric, so , 95–97, 98
toroidal, 256–257, 256 –257
Diabetes, 314–320.e1
and anterior eye, 314–317
and other systemic disease, contact lens wear, 318
cornea, 314, 315t
corneal hydration control, 315–316
corneal nerves, 315
endothelium, 315, 316
epithelium, 314–315
eyelids, 314
glucose sensing, 317–318
glucose sensing, in anterior eye, 317–318
iris, 316
lens, 316
microbial keratitis, 316
ocular response to contact lenses, 317
orbit, 314
panretinal photocoagulation (PRP), 317
pupil, 316
tear lm, 314
Diagnostic instruments, 327–345.e5
Diameter
o rigid lens, 136–137
otal diameter
Di raction, visual optics and, 32
Di use wide beam, 348, 348
Di user, 411, 413 –414
Di using lter, in illumination system, 333
Digital imaging, 410–419.e1, 410
bene ts o , in contact lens practice, 410–411
brighter image in, 411–413, 413 –415
commercial digital imaging system in, 413
con ocal microscopy in, 417–418
digital SLR camera slit-lamp imaging system in,
414–415
le back-up and printing in, 416
image editing in, 418–419, 418 –419
in rared imaging in, 416, 417
optical coherence tomography in, 416, 418
recording digital movies in, 416
resolution in, anterior eye, 411, 411 –412
smartphone, 415
video slit-lamp imaging system in, 415–416, 416
Digital SLR camera slit-lamp imaging system,
414–415
462 Ind e x
Dimensional stability, o hydrogel lenses, 52–53
Dimensional tolerance, or so , polymethyl
methacrylate (PMMA) and rigid lenses, 440t
Dimethyl itaconate, 117, 118
Dimple veiling, 241
Direct ocal illumination, 348–349
optic section, 348, 349
parallelepiped, 348, 349
specular re ection, 348–349, 350
Direct retroillumination, 349–350, 351
Dirt, and lens wear, 248
Disadvantages o planned so lens replacement,
182–183
patient non-compliance, 182
quality and reproducibility issues, 182–183
Discipline, o personnel at the practice, 429, 430t
Discom ort, 380–382
characterizing symptoms o , 381, 381 , 381b
lens care products associated with, 382, 382
rom rigid lens, 154–155
rom scleral lenses, 201
rom so lens tting, 93
solving symptoms o , 381–382, 382
rom tinted lenses, 213
Disin ection
o so contact lenses, 103
solutions, or rigid lens, 163, 163t, 164
Dislodging, so lens, 90
Dismissal, o personnel at the practice, 429
Dispersion, 80
Disposable lenses, 6–7, 175, 175
daily, 7
so lenses. see Daily disposable so lenses
so , 232–233
Dk/t, measurement o , in corneal swelling, 238,
238 –239
DMEK. see Descemet’s membrane endothelial
keratoplasty (DMEK)
Dohlman keratoprosthesis, 288
Dot-matrix printing, o lenses, 209, 210
Drug delivery, in therapeutic applications, 280–281
Dry-eye, 389–390, 390 –391
questionnaire, 451t–452t
symptoms, photore ractive procedures and, 283
Dry storage, or scleral lenses, 201
Dryness, rom tinted lenses, 213
DSAEK. see Descemet’s stripping automated
endothelial keratoplasty (DSAEK)
DSEK. see Descemet’s stripping endothelial
keratoplasty (DSEK)
‘Dual Disin ection’ MPS, 109, 109
Dust, and lens wear, 248
Dye dispersion tinting, o lenses, 208
Dynamic stabilization, 97
Dyslexia, 206
E 235–236, 236
Ebatco, 79
Eccentric gra , 290
Eccentric optic zone, as non-edge (body) de ects, 66
Edge
clearance, in rigid lens design, 145–146, 145
de ects, in so lens manu acture, 66, 66
t, o rigid lens, 153
in lens geometry, 84, 85
li , 138, 139
in rigid lens design, 145–146, 145
polishing, 124–127, 128
pro les, in rigid lens measurement, 138–139
relationship, 457, 457
thickness, in rigid lens measurement, 137
‘Edge-slicing’ method, 84
Education
and history taking, 325. see also Patient education
E ective power, o plus-and minus-prescription Eyelash disorders, 388–389, 389
spectacle lenses at corneal plane or various Eyelids, 17–20
vortex distances, 441t–442t action, e ects on lens rotation, 99
Ef cacy, o accelerated orthokeratology, 297–298, anatomy o
298 gross, 17, 17 –18
Elastomer, or high ametropia, 263 microscopic, 19, 19
Electrolytes, in preocular tear lm, 26, 26t and so toric lenses, 98–99
Electromechanical gauge, or rigid lens o anterior eye, and diabetes, 314
measurement, 137, 137 blood and lymphatic supply to, 20
ELK. see Endothelial lamellar keratoplasty (ELK) complications in, 385–389
Employment contract, o personnel at the practice, blinking, 385, 386
429 eyelash disorders, 388–389, 389
Endothelial lamellar keratoplasty (ELK), 288 lid wiper epitheliopathy, 387–388, 388
Endothelium o cornea, 13, 13 meibomian gland dys unction, 386–387, 387
analysis, 375, 375 ptosis, 385–386, 386
complications in, 406–409 orces, rigid lens and, 145
bedewing, 406–407, 407 glands o , 19–20
blebs, 407–408, 407 –408 meibomian, 19, 20
polymegethism, 408–409, 409 Zeis and Moll, 20, 20
and diabetes, 315, 316 manipulation, 357, 357
rejection, post-keratoplasty and, 294 movements o , control o , 19
Engraving, 124, 127 muscles o , 17–18
Enhanced monovision, bi ocal and multi ocal levator palpebrae superioris, 18, 19
contact lenses, 228, 229 orbicularis oculi, 17–18, 18
Environment superior and in erior tarsal, 18
constraints on sport, and lens wear, 246–249 nerves o , 20
protection rom, 277, 277 sur acing assessment, or tear lm evaluation,
Envisu S4410, 83–84 350
Epikeratoplasty, 288 Eyewear selection, lens application to assist
‘Epithelial plug,’ 397 ametropes in, 174
Epithelium o cornea, 10–11, 11
complications in, 397–400
epithelial staining, 397, 397 –398 F
microcysts, 398, 398 Fatt oxygen transmissibility (Dk/t) values, or
vacuoles, 399, 399 various lens thickness, 447t–448t
wrinkling, 399–400, 399 –400 FBU . see Fluorescein break-up time (FBU )
degenerations involving, 276 Fenestrated lenses, 199, 200
and diabetes, 314–315 Fenestration, 124, 127
microcysts, 240–241, 240 , 381 in scleral lenses, 260
E ron grading scale or, 454 Fick, Adol Eugene, 4, 4
response, 244–245 Fields o view, xation and, 41, 42
rejection, post-keratoplasty and, 293, 294 Filamentary keratitis, 276
wound healing, 16–17 Film, tear. see ear lm
Erroneous procedures, 421–422, 421 Financial management, in planned so lens
ESP. see Eye Sur ace Pro ler (ESP) replacement, 186
Eta lcon, 232 Fingertips, roughening o , 317
Ethnicity, myopia, risk actor or, 307, 308 Fit/ tting lenses
European Medical Devices Directive, 129 assessment o so lens, 91–93
Excess material, as edge de ects, 66 bi ocal and multi ocal contact lenses, 221–222,
Extended wear, 231–245.e1 222 –223
adverse e ects o , 234–242, 235t characteristics, 368–369
acute physiological e ects, 236–238, 236 –237 children. see Paediatric tting
chronic physiological changes, 239–241, at, orthokeratology and, 301
240 –241 intrastromal corneal ring segments and,
in ectious corneal ulcerations as, 234–235, 235 286
mechanical e ects, 241–242 myope, 310–313, 311t
non-in ectious in ammatory events as, optimal, orthokeratology and, 301
photore ractive procedures, 282–284
role o hypoxia in, 238–239, 239 , 239t poor, vision loss related to, 384
application o , in practice, 243–245 post-keratoplasty, 291–293, 292 –293
in clinical practice, 242–243 principles or scleral lenses, 196–199
complications in, management o , 244 non-coaxial scleral lenses, 198–199
de nition o , 231 non-ventilated pre ormed, 196
experiences with, 231–234 optic zone sagittal depth and optic zone
conventional so extended wear, 231–232 projection, 198, 198 –200
disposable so lenses, 232–233 scleral zone, 197–198, 197
non-hydrophilic materials, 232, 232 radial keratotomy, 284–286
silicone hydrogel contact lenses, 233, rigid lens. see Rigid lens tting
233 –234 so lens. see So lens tting
planned replacement or rigid lenses and, tinted lens, 211
190–191 toric lenses, so , 96 , 98
sa ety o , 242–243 trial
External promotional issues, 431 with accurate prescription, 181, 182
Eye Sur ace Pro ler (ESP), 340, 341 calculation o required sur ace radii rom,
Eyecup, 3, 3 131–132

Fit/ tting lenses (Continued)
required BVP when the lens to be ordered has
a di erent BOZR rom, 131
so , 88–90
tear lens during, 130–131
Fixation, elds o view and, 41
Flash, as edge de ects, 66
Flat- tting lens, orthokeratology and, 301
‘Flat pack,’ contact lens, 7, 8
Flexure, 366
o commercial rigid lens materials, 119–121
e ects, rigid lens, 134
rigid lens measurement and, 141
Fluid- lled tube, in contact lens, 3
Fluid permeability, o hydrogel so lenses, 52
Fluorescein
break-up time (FBU ), 328
instillation, 152
pattern
analysis, 418
in rigid lenses, 368, 368
staining, 350
in digital imaging, 411, 413 –414
Fluorescence, rigid lens tting and, 152, 152
Fluorosilicone acrylate lenses, re ractive index, 122
Focimeter, 74, 74
or rigid lens measurement, 139, 139
Focusing, con ocal microscopy through, 335, 336
Food and Drug Administration (FDA) classi cation
system, or so lens materials, 60, 60t
Forces, acting on so lens, 86
Fourier-domain OC (FD-OC ). see Spectral-
domain OC (SD-OC )
FOZD. see Front optic zone diameter (FOZD)
FOZR. see Front optic zone radius (FOZR)
Fraser’s ve-point grading, in recruitment and
selection, 428, 429t
Friction
hydrogels and, 51
rigid lens measurement and, 140, 140
Friction angle, 79
Friction coef cient, 79
Front optic zone diameter (FOZD), 439t
in rigid lens design, 145
Front optic zone radius (FOZR), 83, 439t
Front peripheral radius, 439t
Front peripheral zone diameters, 439t
Front-sur ace aspheric designs, 219–220, 220
Front sur ace o lens, generation o , 124, 126
toric, 127–128
Front sur ace radius, o curvature, in rigid lens
measurement, 137–138
Front-sur ace toric lenses, 161, 161
Front vertex power, 439t
Frothing, in CL-MGD, 386–387, 387
Fused design, bi ocal and multi ocal contact lenses,
225
lens tting and, 225–226
G silicone hydrogel, 263–264, 264t
Gas-permeable contact lenses, rigid lenses, single-
vision, or myopia control, 307–308
Gaylord patents-harnessing silicone, 116–119
General Optical Council (GOC), 433
Geometric centre thickness, 439t
Geometry o lens
rigid, 136–139
o so lens measurement, 81–84
diameter, 81–82, 81
edge, 84, 85
radius o curvature, 83–84, 84
sagittal depth, 82
thickness, 82–83, 83
Giant papillary conjunctivitis, o scleral lenses, 202
Glands
lacrimal. see Lacrimal gland
tarsal. see Meibomian glands
o Zeis and Moll, in eyelids, 20, 20
Glare sensitivity test, or poor vision, 382–383
Glass scleral lenses, 4–5
Glaucoma, in children, 274
Glucose sensing, in anterior eye, 317–318
Glyceryl methacrylate (GMA), or hydrogel lenses,
53 , 54
GMA. see Glyceryl methacrylate (GMA)
Goblet cells, o eyelids, 21–22, 22
GOC. see General Optical Council (GOC)
Gothenburg study, 6, 241
Grading scales, 377–379
design, 377
determinants o , per ormance, 379
how to grade, 377
image size and, 377, 377t, 378
interpretation o , 378, 378t
record o , 378
Gra s
corneal. see under Cornea
polymers, so lens and, 46, 47
pro les, 290
rejection and ailure, 293–294
Gravitational orces
rigid lens and, 144, 145
and sport, lens wear and, 249
Green (‘red- ree’) lter, in illumination system, 333
H structure, 324–325
Haag-Streit BD900 video slit lamp, 415–416, 416
Hand grooming/hygiene, 357
Handling o lenses
paediatric tting, 273–274, 273 , 312–313
problems, 318, 318
Handling tints, tinted lens designs and, 204–205
Handwashing acilities, 357
Hardness, o commercial rigid lens materials, 121
Hartmann-Shack technique, principle o ,
monochromatic aberrations and, 33, 34
Hartmann-Shack wave ront sensor, 74–75, 75
Hazing, rigid lens sur ace, 368
Heat disin ection, 104
Heidelberg retina tomograph (HR ) III, 335, 337
HEMA. see Hydroxyethyl methacrylate (HEMA)
Herschel, Sir John, 3–4, 4
Hexa uoroisopropyl methacrylate monomer,
117–118, 118
High ametropia, 263–267.e1
tting challenges or, 266
high-power lens designs, principles o , 264–266
and aphakia, 264–265
and high astigmatism, 265–266
high-minus, 265, 266
high-plus, 264, 264 –265
lens materials or, 263–264
elastomer, 263
and low vision, 266
High-contrast visual acuity chart, 216
or poor vision, 382, 382
High-minus rigid lenses, 265, 266
High-plus rigid lenses, 264, 264 –265
High-power lens designs, principles o , 264–266
High-powered microscopy, 334–335
con ocal microscopy, 334–335
through ocusing, 335, 336
Rostock cornea module (RCM), 335, 337
slit-scanning con ocal microscopy, 335
specular microscopy, 334
tandem scanning con ocal microscopy, 334–335
High-water-content lenses, ionic, 105
Ind e x 463
Higher-order spherical aberrations, 75–76, 76
Higher-order wave ront error (HO-WFE), 350, 352
Higher-water-content hydrogel materials, 180
History o contact lens (listed chronologically),
1–9.e1
early theories (1508-1887), 3–4, 3 –4
glass scleral lenses (1888), 4–5, 4 –5
plastic scleral lenses (1936), 5
plastic corneal lenses (1948), 5
silicone elastomer lenses (1965), 5–6
so lenses (1972), 6, 6
rigid gas-permeable lenses (1974), 6
disposable lenses (1988), 6–7
daily disposable lenses (1994), 7
silicone hydrogel lenses (1998), 7
anti-myopia lenses (2010), 7
contact lens ‘ at pack’ (2011), 7, 8
uture, 7–9
History taking, 321–326.e2
a ercare, 365–366
amily, 325
indications and contraindications or contact lens
wear, 323–324
in ormed consent and, 325
medical, 324
medication and, 324–325
ocular, 324
patient compliance and, 325–326
patient education and, 325
reason or visit and, 324
risk/bene t analysis and, 325
social, 325
HO-WFE. see Higher-order wave ront error
(HO-WFE)
Horizontal corneal diameter, 347
Horizontal visible iris diameter (HVID), 86
HR III. see Heidelberg retina tomograph (HR ) III
HVID. see Horizontal visible iris diameter (HVID)
Hybrid lenses
designs, bi ocal and multi ocal contact lenses,
221, 222
or keratoconus, 260–262, 261
Hybrid rigid gas-permeable materials, 116
Hydration
control, in corneal transparency, 16, 16
on-eye power changes, 68
Hydrogel lenses
or aphasia, speci cations in, 269t
or children, 272
so
dimensional stability o , 52–53
uid permeability o , 52
ion permeability o , 52
mechanical properties o , 48–49, 48
optical transparency o , 48
oxygen permeability o , 51–52, 52
properties o , 48–53
re ractive index o , 52
sur ace properties o , 49–51
swell actor o , 52–53
water content o , 51. see also Silicone hydrogel
lenses
Hydrogen peroxide, 106–107, 107
Hydrophilic lenses, 231
Hydrophobic sur aces, o rigid lens materials,
115–116
Hydroxyethyl methacrylate (HEMA), in so lenses, 6
Hydroxyethylcellulose, rigid lens and, 163
Hyperaemia
eye redness and, 379
scleral lenses and, 201
Hyperglycaemia, diabetes mellitus and, 314
Hyperopic orthokeratology, 299–300
Hypersecretory meibomian gland dys unction, 386
464 Ind e x
Hyperthin hydrogel lenses, dehydration o , 381,
382
Hypoxia
during closed-eye lens wear, 240–241
contact-lens-induced, 394–395
and keratoconus, 262
role o , in extended wear, 238–239, 239
and scleral lenses, 202
‘Hysteresis,’ hydrogels and, 50
I Keratoconjunctivitis
Identi cation tints, 207
IEK. see IntraLase-enabled keratoplasty (IEK)
Illumination, 411
retroillumination, 349–350, 351
system, o slit-lamp biomicroscopes, 332–333
Image editing, 418–419, 418 –419
Image resolution, 411
Imaging. see Digital imaging
Impression arcs, corneal distortion, 371–372, 372
Impression moulding, non-coaxial scleral lenses,
199
In vivo wettability, o hydrogel lenses, 49–50
Indirect illumination, 349–350
uorescein staining, 350
retroillumination, 349–350, 351
sclerotic scatter, 350, 351
Indirect retroillumination, 351
Induced astigmatism, o rigid toric lens, 159–160
In ection
risk o , hydrogel lens, 242–243, 243
o scleral lenses, 202
In ectious ulcerative keratitis, 244
In erior steepening, corneal distortion, 371, 371
In ammation, corneal, 235–236
In ormed consent, 325, 362–363, 432
In rared imaging, 416, 417
Injection, eye redness and, 379
Innervation
conjunctival, 22
corneal, 13–14
Insertion o lens, 358–359, 359
rigid, 148–149, 149
so , 89, 89
Inspection o lens, 357–358, 358 , 374–375
nal, edge polishing and, 124–127
Internal promotional issues, 431
IntraLase-enabled keratoplasty (IEK), 288
Intraocular lenses (IOLs), 269
Intrastromal corneal ring segments, contact lens
tting ollowing, 286
Inverted air bubble technique, 121
IOLs. see Intraocular lenses (IOLs)
Ion permeability, o hydrogel lenses, 52
Ionic high-water-content contact lens, 105
Iris, o anterior eye, and diabetes, 316
Iron deposits, on non-replacement basis, 177
Irreversible water loss, 178, 178
ISO 14729:3, ow chart o disin ection, 111
ISO 18369-3, conditioning according to, 73
ISO classi cation system, or so lens materials,
60, 60t
ISO oxygen permeability (Dk) values, or various
lens thickness, 447t–448t
J Large cylindrical components, o so toric lenses,
“Jelly bumps,” on non-replacement basis, 177, 177
JENVIS 0-4 scale, 331–332
K Lathe cutting, 61–62, 61 –62
K-values, 347
Kalt, Eugène, 4, 4
KC design lenses, or keratoconus, 261, 261
Keratitis, 173–174, 404–406, 404 –405
contact-lens-associated microbial (in ectious),
405
lamentary, 276
in ectious, 382
microbial, 234–235, 235
and daily wear, 243
incidence o , 235
severe exposure, 277
sterile in ammatory, 236
sicca, 318
superior limbic, 382, 395–397, 396
E ron grading scale or, 455
and so toric lenses, 102
Keratoconus, 251–262.e2, 275 , 350, 352
clinical assessment o , 251–252
anterior ocular health, 252
anterior segment imaging technologies in, 251
cone morphology in, 251, 252
progression in, monitoring o , 262
re ractive management o , 252–262, 252b
hybrid lenses, 260–262
rigid lenses, 253–260, 253t
so lenses in, 252–253
spectacle correction in, 252
Keratocytes, 12, 12
Keratoglobus, 275
Keratology. see Orthokeratology
Keratometers, 83, 84
range conversion, extended, 445t
or rigid lens measurement, 138, 138
Keratometry, 337–338, 337 , 347, 370–373
in children, examination techniques or, 271,
272
in so lens tting, 86
mires, in so lens tting, 93
Keratoplasty
anterior lamellar, 288
deep anterior lamellar, 12–13, 288
endothelial lamellar, 288
IntraLase-enabled, 288
penetrating
ull-thickness, 288
suture techniques or, 287 , 290, 290
procedures, lexicon o , 289b. see also
Post-keratoplasty
Keratoscopy, 338
Kodak Wratten number 12 (yellow) lter, in
illumination system, 333, 333
L Mass-produced lenses, reproducibility and quality
Lacrimal drainage system, 24–25, 24
Lacrimal gland
accessory, 24
anatomy o
gross, 23, 23
microscopic, 23, 23
blood and nerve supply o , 24
unctional considerations in, 24, 24
‘Lags’ o accommodation, visual optics and, 29–30,
30
Lamellae, stromal, in cornea, 11–12, 12
Lamellar corneal transplantation techniques, 12–13
Laminate constructions, o lenses, 209–210, 210
102
Laser in situ keratomileusis (LASIK), ap damage
in, 246
LASIK. see Laser in situ keratomileusis (LASIK)
Layout, practice, 427, 428
Lens edge rubbing, 242
Lens-eye interactions, 369, 369
Lens-eye relationship, in so toric lenses, 99
Lens-holding device, 138, 138
Lens-induced mucin ball, 390
Lens o anterior eye, and diabetes, 316
LenStar LS 900 biometer, 345, 345
Levator palpebrae superioris, in eyelids, 18, 19
Lid. see Eyelids
‘Lid wiper,’ 51
Lid wiper epitheliopathy, 387–388, 388
Limbal vaulting, 457, 457
Limbus/limbal complications, 394–397
hyperaemia, 239, 240
redness, 380, 380 , 394–395, 394 –395
E ron grading scale or, 454
superior limbic keratoconjunctivitis, 395–397,
396
vascularized limbal keratitis, 395, 395 –396
Linear homopolymer, so lens and, 46, 46
Lipids, in preocular tear lm, 26–27, 26t, 27
LipiView inter erometer, 327–328, 328
LOF SEA (location, onset, requency, type,
sel -treatment, e ect on patient, associated
symptoms), 324
Long-term adverse changes, in so lenses,
avoidance, 176–178
irreversible water loss, 178, 178
lens deposits, 176–178, 176 –177
storage contamination, 178, 179
sur ace damage and crazing, 178
Loose- tting lenses, in so lens tting, 91, 93
Loss o lens, rigid, 155
lotra lcon lens, 57
Low-contrast visual acuity chart, 216
or poor vision, 382, 382
Low-water-content lenses, 87
Luminance, variation o pupil size at, 217
Luminance transmittance, in rigid lens
measurement, 141
Lymphatics, o conjunctiva, 22, 22
M
MAA. see Methacrylic acid (MAA)
Magni cation o spectacle, 39–40, 39 –40
visual optics and, 39–40, 39 –40
Maintenance o tinted lenses, 211
Manu acture o lenses
rigid. see Rigid lens manu acture
so . see So lens manu acture
Manu acturer-driven systems, planned so lens
replacement, 183, 183
Marking, rigid lens manu acture, 124, 127
o , 66–67
Mastrota paddle, 331, 331
Material properties or so lens, 77–81
modulus, 77–78, 77 –78
oxygen permeability, 79–80, 80
re ractive index, 80, 80
spectral and luminous transmittance, 80–81,
81
sur ace riction, 79
tolerance, 440t
water content, 77
wettability, 78–79, 79
Materials or so lenses, 43–60, 87
classi cation o , 59
hydrogel or, 48–55, 53 , 55t
properties o , 48–53
polymers or, 45–48
silicone hydrogel or, 55–59, 56 –57 , 58t, 59
Mechanical properties, o commercial rigid lens
materials, 119–121
Medication, 324–325
 Ind e x 465

Meibomian Gland Evaluator, 331, 331 Myopia control (Continued) Ocular adnexa, in anterior eye, 17–25
Meibomian glands lenses, types o , 307–310, 308t conjunctiva, 20–23
dys unction (MGD), 367–368, 386–387, 387 bi ocal/multi ocal contact lenses, 309 eyelids, 17–20
E ron grading scale or, 455 extended depth o ocus, lenses with, 310 lacrimal system, 23–25
examination o , 331, 331 –332 peripheral hyperopic retinal de ocus, contact Ocular depth o ocus, aberrations and, 38, 38
in eyelids, 19, 20 lens management o , 309–310 Ocular ocus, precision o , accommodation and,
Menicon Z, 118 positive spherical aberration, lenses with, 29–30
Methacrylic acid (MAA), or hydrogel lenses, 53 , 54 310 Ocular history or contact lens wear, 324
Methacrylic acid monomer, 117, 117 simultaneous de ocus or dual- ocus contact Ocular motility disorders, in children, 269–270
Methyl methacrylate (MMA) lenses, 309 Ocular side-e ects o therapy, in contact lens wear,
or hydrogel lenses, 53 , 54 single-vision rigid gas-permeable contact 318, 318
polymerization o , 115, 116 lenses, 307–308 Ocular sur ace pathology, 179–180
MGD. see Meibomian glands; dys unction (MGD) single-vision so contact lenses, 308–309 Ocular topography
Michelson inter erometry, 340–341 orthokeratology and, 303–304, 304 or cornea, 143–144
Microbial keratitis, in anterior eye, 316 patient selection and, 306–307, 307 e ect o , on so lenses, 94
Microcysts, 398, 398 risk actors or, 306–307, 308 or ethnic variations, in ocular dimensions, 144
Microwave irradiation, 105 Myopic creep, 241 or lids, 144
Mid-peripheral t, o rigid lens, 153 or rigid lens design and tting, 143–144, 143t
Miniscleral lenses OCULUS Keratograph 5M
ront-sur ace toric orms, 259 N or meibomian glands, 331, 332
or keratoconus, 258 N-vinyl pyrrolidone (NVP), or hydrogel lens, or objective ocular redness assessments, 331, 332
optical coherence tomography in, or tting o , 53–54, 53 or tear break-up, 328–329, 328 –329
258 Neovascularization, 202–203, 202 or tear meniscus height, 330, 330
speci cation o , 258–259 in children, 274 Oculus keratograph 5M, 416
Mirror, 357 Nerves Oedema, corneal, 236, 236 , 400–401, 401
Misalignment o so toric lenses o conjunctiva, 22 E ron grading scale or, 454
demonstrator or, 450t corneal so toric lenses, 102
determining, 100–101, 101t alteration to structure and unction, 202 transparency in, 16
Misight®,309, 310 o anterior eye, and diabetes, 315 On-eye power changes, 68–69, 69
MMA. see Methyl methacrylate (MMA) source and distribution o , 13–14, 14 Opacities, deep stromal, 402–403, 403
Modern orthokeratology, 296, 296 o eyelids, 20 Opaque backing, 210, 210
Modi cation code, so lens materials and, 60 Neutral-density lter, in illumination system, 333 Opaque tints, 209–210
Modi ed monovision, 228–229 Neutralization, o corneal astigmatism, by rigid lens Ophthalmic disease, in children, 274
Modulus o spherical power, 132–133, 132 Ophthalmoscopy, 352
o material properties, 77–78, 77 –78 NIBU . see Non-invasive tear lm break-up time Optic section direct illumination, 348, 349
rigid lens measurement and, 141 (NIBU ) Optic zone diameter, in rigid lens measurement,
Moiré de ectometry, 74, 75 Nick, as edge de ects, 66 136–137
or rigid lens measurement, 137–138 Non-coaxial scleral lenses, 198–199 Optic zone projection, 198, 198 –200
Money management, in practice management, 433, Non-compliance Optic zone sagittal depth, 198, 198 –200
434 consequences in, 420 Optical coherence tomography (OC ), 82, 251, 330,
Monochromatic aberrations, visual optics and, extent and pattern o , 420 330 , 416, 418
33–37, 33 –34 , 35t–36t, 36 –37 history taking and, 325–326 anterior-segment, 258
Monovision predicting o , 424 Anterior-segment Optical Coherence
correction, 383 reasons or, 422, 422 omography (AS-OC ), 340–343
enhanced, 228 Non-contact aesthesiometry, 335–336 or keratoconus, 259
general tting principles, 227 Non-disposable planned replacement lens, 176 spectral-domain, 342
modi ed, 228–229 Non-edge (body) de ects, in so lens manu acture, swept-source, 342–343, 343
partial, 227–228 66–67 time-domain, 342, 342
presbyopia, 226–229, 227 –228 Non-hydrophilic materials, 232, 232 Optical distortions, 140
problem-solving approaches or tting, 229 Non-in ectious in ammatory events, 235–236, Optical pachymetry, 343, 343
Movement, in so lens tting, 91–92, 92 236 Optical parameters, o so lens, 73–77
Mucin ball-induced uid- lled pits, 391, 391 Non-invasive tear lm break-up time (NIBU ), optical quality, 76, 77
Mucins 328–329 power and power pro les, 74–76
balls, 390–391, 391 Non-ventilated pre ormed scleral lenses, 196 scattering, 76–77
in preocular tear lm, 26, 26t Nutrients, source o , in corneal metabolism, 14–15, Optical quality, 76, 77
Müller, August, 4, 5 15 o rigid lens measurement, 140
Multicurve lens, 255 NVP. see N-vinyl pyrrolidone (NVP) Optical tolerance, or so , polymethyl methacrylate
Multi ocal contact lenses. see Bi ocal and multi ocal (PMMA) and rigid lenses, 440t
contact lenses Optical transparency, o hydrogel materials, 48
Multiple pieces, as non-edge (body) de ects, 66 O Opticians Act 1989, 433
Multipurpose solutions, 107–109 Objective ocular redness assessments, 331–332 Optics, so lens, 68–72.e1
active agents, 108 Objective re raction, 346–347 aberration, 69–72, 70
constituents o , 108t Oblate shape, corneal distortion, 370–371, 370 on-eye power changes, 68–69, 69
sodium chlorite containing, 109, 109 Oblique bitoric lenses, 161 Optimal lens t, orthokeratology and, 301
Munnerlyn ormula, 282 Observation o eye, 327–335 Optimec JCF instrument, 83–84
Myope, contact lenses and, 310–313 Burton lamp or, 327, 327 Optimum lens t, 150, 151t
Myopia high-powered microscopy or, 334–335 Optimum replacement schedule, rigid lens, 191
high, in children, 269, 269 meibomian glands in, 331, 331 –332 Orbicularis oculi, in eyelids, 17–18, 18
visual optics and, 29 objective ocular redness assessments and, Orbit, o anterior eye, and diabetes, 314
Myopia control, 306–313.e2 331–332 Orbscan II, 416–417
continuing care and complications, 313 slit-lamp biomicroscopy or, 332–334, 333 Orbscan instrument, or posterior corneal
tting myope with contact lenses, 310–313, 311t tear lm in, 327–330 elevation, 372–373
handling o lenses, 312 Obstructive meibomian gland dys unction, 386 Ordering lens, 433
lens selection and tting, 312 Occupational sa ety, in lens manu acture, 67 scleral, 200–201, 200
measurements and examination, 311, 312 OC . see Optical coherence tomography (OC ) Ordinal, discom ort, 381
466 Ind e x

Orthokeratology, 296–305.e2
accelerated, outcomes o , 297–299
corneal physiology, 298–299
determinants o success, 299
ef cacy, 297–298, 298
regression, 298, 298
sa ety, 299
a ercare, 302–303
assessment o lens t, 302–303
ocular health, 303
re raction, 303
visit schedule, 302
history o , 296
hyperopic, 299–300
lens tting in, 300–302
approaches, 300–301
base curve, 300
indications and contraindications o , 300
lens delivery, 301–302
post-wear assessment, 301, 302
modern, 296, 296
myopia control, 303–304
myopia progression, mechanism or, 303–304,
304
research and, 303
overnight, 297
unwanted, 242
Osmometry, 329, 329
Oval cones, 251
Overkeratometry, 366, 367
Overre raction, in contact lenses, 366
Oxidative metabolism, in cornea, 15, 15
Oxygen
consumption, 239t
in closed-eye oxygen tensions, 239, 239
in hypoxia, 239
need or, in rigid lens materials, 115
source o , in corneal metabolism, 14–15, 15
Oxygen ux, 439t
Oxygen permeability, 79–80, 80 , 439t
o commercial rigid lens materials, 119
o hydrogel lenses, 51–52, 52
rigid lens measurement and, 141
o so lens materials, 60t
Oxygen transmissibility, 439t
lens material and, 308–309
through corneo-scleral lenses, 257
through miniscleral lens, 259
through scleral lenses, 260
tinted lenses, 211
P Periodic sel -review, in compliance enhancement,
Pachymetric mapping, 352
Pachymetry, 373, 374
Paediatric tting, 268–274.e1
common a ercare problems in, 274
elective lens wear or, 270, 271
examination techniques or, 271–272
anterior segment examination, 271,
271 –272
biometry, 271–272
keratometry, 271, 272
handling o lenses in, 273–274, 273 , 312–313
indications or, 268–270
aphakia as, 268–269, 268 –269
high myopia, 269, 269
irregular astigmatism as, 270, 270
ocular motility disorders, 269–270
pseudophakia as, 269
lens selection or, 272–273
hydrogel lenses in, 272
rigid lenses in, 273
silicone hydrogel lenses in, 273
silicone rubber lenses in, 272–273, 272
Paediatric tting (Continued) Planned replacement rigid lenses, 187–192.e1
ocular response to, 270–271 li e expectancy o rigid contact lenses, 187–188,
therapeutic lenses, 270 188 –189
tinted and prosthetic lenses, 270 optimum replacement schedule, 191
Panretinal photocoagulation (PRP), in anterior regular, 188–189, 189 –190 , 189t
eye, 317 advantages o , 189–191
Pantographic system or lens engraving, 127 schemes available, 191
Papillae, 393, 394 Planned so lens replacement
Papillary conjunctivitis, 245, 393–394, 393 –394 advantages o , 175–182
in children, 274 disadvantages o , 182–183
E ron grading scale or, 454 practice management issues relating to
Parallel bitoric lenses, 160 cost to patient, 186
Parallelepiped direct illumination, 348, 349 nancial management, 186
Partial monovision, bi ocal and multi ocal contact lenses available or planned replacement, 184,
lenses, 227–228 184 –186 , 184t
Patient manu acturer-driven systems, 183, 183
in compliance enhancement model, 425, 425 practice-driven systems, 183–184
cost to, planned so lens replacement, 186 practice logistics, 184–186
expectations, presbyopia and, 216 practice management issues relating to, 183–186
non-compliance, planned so lens replacement, supply routes, alternative, 186
182 toric, 101–102
and practice management processes, 431 Plasma coating, silicone hydrogel materials and,
scheduling, 432 118–119
selection, presbyopia and, 214 , 216 Plastic corneal lenses, 5
wearing vision correction across the age range Plastic scleral lenses, 5
versus the proportion wearing contact PMMA lenses. see Polymethyl methacrylate
lenses, 215 (PMMA) lenses
Patient education, 356–363.e1 Polarizing lter, in illumination system, 333
in compliance enhancement, 423–424 Polarographic electrode technique, 119
and history taking, 325 Poly (4-methyl pent-l-ene), 116
instruction, 357–362 Polydimethyl siloxane (PDMS), or silicone
care products and, 361 hydrogel lenses, 56, 56
cosmetics and, 361 Polyhexanide-based MPS, 107–108, 108
emergency and, recognizing, 362 Poly(hydroxyethyl methacrylate) (pHEMA),
hand grooming/hygiene as, 357 hydrogel lenses and, 53
lens inspection as, 357–358, 358 Polymegethism, endothelial, 316 , 408–409, 409
lens recentring, 359, 359 E ron grading scale or, 455
lens removal, 360 Polymerization, so lens and, 47–48
lid manipulation as, 357, 357 Polymers, or so lens, 45–48
patient discharge and, 362 structure o , 46–47
wearing schedules and, 361–362 Polymethyl methacrylate, 115
objectives o , 356 re ractive index, 122
optimum teaching environment or, 356–357 Polymethyl methacrylate (PMMA) lenses, 147, 231,
timing o , 356 260, 296
PDMS. see Polydimethyl siloxane (PDMS) dimensional tolerances in, 440t
Penetrating keratoplasty (PKP) optical tolerances or, 440t
ull-thickness, 288 Polyquaternium-1-based MPS, 108–109
suture techniques or, 287 , 290, 290 Polyvinyl alcohol (PVA)
Pentacam, 339–340, 339 –340 , 416–417 or hydrogel lenses, 55
Per lcon A, 231 rigid lens and, 163
Per ormance-enhancing tinted lenses, 206 Polyvinyl pyrrolidone (PVP), or hydrogel lenses, 55
Peri-ballast, 97 Post-keratoplasty, 287–295.e2, 287 –288
contact lens and
424 results, 294
Peripheral corneal desiccation, o rigid lens, 154, 154 wear, indications and contraindications or,
Peripheral corneal mechanical trauma, in rigid lens, 291, 291
154, 154 continuing care and complications, 293
Peripheral t, in so lens tting, 92–93, 92 corneal topography ollowing, irregular, 289–290,
Peripheral hyperopic retinal de ocus, contact lens 289
management o , 309–310, 310 general concerns in, 291
Peripheral junction thickness, 439t gra pro les, 290
Peripheral radii, o rigid toric lens, 157 gra rejection and ailure, 293–294
Permeability coef cient (Dk), 79 indications in, 287–288
Phase-shi ing Schlieren, 75 lens- tting techniques and, 291–293, 292 –293
pHEMA. see Poly(hydroxyethyl methacrylate) management issues, 294
(pHEMA) rigid lenses, 291–292
Photore ractive procedures, contact lens tting suture techniques and, 287 , 290, 290
ollowing, 282–284 types o corneal gra , 288–289
Physiological stress, extended wear and, 244–245, Post-re ractive surgery, 282–286.e1
245 contact lens tting ollowing
Piggy-back tting, 266 intrastromal corneal ring segments, 286
PKP. see Penetrating keratoplasty (PKP) photore ractive procedures, 282–284
Placido-based keratoscopes, 338, 339 radial keratotomy, 284–286
Placido disc corneal topography, 350–352 Posterior blepharitis, 388
or keratoconus, 256–257 Posterior corneal elevation, 372–373, 373

Posterior corneal shape, 338–340
Post tting care, o contact lens, 364
Power and power pro les, 74–76
Practice-driven systems, planned so lens
replacement, 183–184
Practice location and accommodation, 427–428
Practice logistics, planned so lens replacement,
184–186
Practice management, 427–436.e1
personnel at the practice in, 428–430
planned so lens replacement
cost to patient, 186
nancial management, 186
lenses available or planned replacement, 184,
184 –186 , 184t
manu acturer-driven systems, 183, 183
practice-driven systems, 183–184
practice logistics, 184–186
practice management issues relating to,
183–186
supply routes, alternative, 186
practice location and accommodation in, 427–428
pricing in, 430–431, 431
processes in, 431–433
products and services provided in, 430
pro essional regulation in, 433–435
promotional issues in, 431
Practice newsletters, in promotional issues, 431
Practitioner, in compliance enhancement model,
425
Precorneal mucin layer, 390
Pre x, or classi cation o so lens materials, 60
Preliminary examination, or contact lenses,
346–355.e1, 346
anterior eye or, areas o , 347
binocular vision assessment and, 352
corneal tomography in, 352, 354
corneal topography in, 350–352, 353
keratometry or, 347
objective re raction in, 346–347
ophthalmoscopy and, 352
pachymetric mapping in, 352
slit-lamp biomicroscopy or, 347–350, 347
subjective re raction in, 346–347
supplementary tests in, 354–355
tear lm and, evaluation o , 350
wave ront re raction, 350
Preocular tear lm, 25–27
unction and properties o , 25, 25t
sources and composition o , 25–27, 25
electrolytes, 26, 26t
lipids, 26–27, 27
mucins, 26
proteins, 26, 26t
structure o , models o , 27, 27
tear production, 25
Presbyopia, 214–230.e1
bi ocal and multi ocal contact lenses, 217–229
contact lens correction o , 383
contact lens options or, 215 , 217t
correction o , patient’s options or, 214
initial measurements o , 216–217
lens tting or
advantages and disadvantages o , 230t
approach depending on, 216b
clinical pearls or, 230t
patient selection, 214 , 216
pupil size, 217, 217 –219
Prescription
correct, compliance with, 423, 423
duration o , 420
incorrect, compliance with, 422–423, 423
Pricing
policy, in contact lens industry, 425
in practice management, 430–431, 431
Printing, o lenses, 208–209, 209
Prion, trial lens sets and, 164
Prism ballast, 161
in so toric lenses, 96–97
Prismatic e ects, due to decentred or tilted lenses,
134
‘Problem-solving’ tool, 173
Product support, in contact lens industry, 425
Products and services provided, in practice
management, 430
Pro essional model, 431
Pro essional regulation, 433–435
Pro le o lens, myopia control and, 309
Projection systems, or rigid lens measurement, 136
Promotional issues, 431
Prophylactic tints, 207
Prosthetic tinted lenses, 205, 206
Protection rom lids, therapeutic applications and,
277
Protein removal solutions, or rigid lens, 164
Proteins, in preocular tear lm, 26, 26t
Proud gra , 289–290, 289 –290
PRP. see Panretinal photocoagulation (PRP)
Pseudokeratoconus, 371, 371
Pseudophakia, in children, 269
Ptosis, 314, 385–386, 386
‘Ptosis crutch,’ 386
Pupil
o anterior eye, and diabetes, 316
diameter o , 347
visual optics and, 31–32, 32 , 32t
size o , presbyopia, 217, 217 , 219
variation o , 218
Push-up test, in so lens tting, 92, 92
PVA. see Polyvinyl alcohol (PVA)
PVP. see Polyvinyl pyrrolidone (PVP)
Q determining appropriate lens replacement
‘Quad-map’ ormat, o corneal tomography, 352,
354
Quadrant-speci c lenses, or keratoconus, 256
Questionnaire, dry-eye, 451t–452t
R 284
Radial edge li , 138, 139
Radial edge thickness, 439t
Radial keratoneuritis, 405, 405
Radial keratotomy, contact lens tting ollowing,
284–286
Radius o curvature, 83–84, 84
Radiuscope, or rigid lens measurement, 137, 137
Random copolymer, 46, 47
RCM. see Rostock cornea module (RCM)
Rebamipide, 388
Recall letter, in promotional issues, 431
Recentring lens, 359, 359
Reception area and ront desk, practice, 427
Recruitment and selection, in personnel at the
practice, 428–429
Recurrent erosion syndrome, 275–276
Red eye, 379–380
characterization o , 379
diagnosing and solving, 379–380, 379 –380
in children, 274
Re erees, ametropic, 250
Re raction, 369–370
orthokeratology and, 303
o rigid toric lens, 158–159
surgery. see Post-re ractive surgery
Re ractive end-points, 222
Re ractive error
changes in, 370
vision loss related to, 383
Ind e x 467
Re ractive index, 80, 80
o commercial rigid lens materials, 122
o hydrogel, or so lens, 52
rigid lens measurement and, 141
Re ractive surgery
types o , 282, 282t
or vision correction, and sport, 246
Re ractometer, or so contact lens, 51
Regression, o accelerated orthokeratology, 298,
298
Removal o lens, 360
rigid, 149, 150
so , 89, 90 . see also A ercare.
Research and development, in contact lens industry,
425–426
Residual astigmatism, o rigid toric lens, 159, 159
Retina, blur circles and pupil diameter, 31–32, 31
Retinopathy, 314, 315
Retinoscopy, in so lens tting, 93
Retroillumination, 349–350, 351
Reusable so lenses, 175–186.e1, 176
advantages o planned replacement, 175–182
avoidance o long-term adverse changes in
anterior eye, 178–180
avoidance o long-term adverse changes in
contact lenses, 176–178
enhanced compliance with a ercare schedules,
181
lens parameters easy to change, 181–182
ready availability o replacement lenses,
181
simple lens care regimens, 180–181, 181t
single-use trial lenses, 181
trial lens tting with accurate prescription,
181, 182
use o higher-water-content hydrogel
materials, 180
use o silicone hydrogel materials, 180, 180
requency, 183
disadvantages o planned replacement, 182–183
practice management issues relating to planned
so lens replacement, 183–186
Reverse-geometry lens manu acture, 128–129
Reverse-geometry rigid lens designs, 283–284,
Rewetting
o scleral lenses, 201
solutions, 109–110
improved dryness symptoms, 110
RGP lenses. see Rigid gas-permeable (RGP) lenses
Rigid gas-permeable (RGP) lenses, 6, 147
Rigid lens care systems, 163–164.e1
cleaning solutions, 163–164
disin ection solutions, 163, 163t, 164
protein removal solutions, 164
trial lens sets, disin ection o , 164
wetting solutions, 163, 164
Rigid lens design, 143–155.e1, 145–147
back optic zone diameter in, 145
centre thickness in, 145, 145t
constant edge clearance, 449t
edge orm in, 146, 146
edge li and edge clearance in, 145–146, 145
ront optic zone diameter in, 145
photore ractive procedures and, 283–284
PMMA versus RGP, 147
spherical versus aspheric, 146, 146t
Rigid lens tting, 143–155.e1, 347
assessment o , 150–153
characteristics o , 150
corneal topography, 147–148, 147
empirical, 147
uorescein assessment o , 152–153
lens insertion, removal and settling or, 148–150
468 Ind e x
Rigid lens tting (Continued)
optimum, 150, 151t
problem, 153–155
satis actory, 150
selection o initial lenses or, 148, 148t
trial tting options or, 147–148
trial tting set or, 147
white light assessment o , 151. see also Rigid lens
design
Rigid lens manu acture, 123–129.e1
aspheric, 128
crazing/cracking, 126
edge polishing, 124–127, 128
engraving, 124, 127
enestration, 124, 127
nal inspection, 124–127
industry regulation, 129
lens back sur ace, generating, 123–124, 125
lens ront sur ace, generating, 124
marking, 124, 127
raw materials, 123
reverse-geometry lens, 128–129
rigid lens prescribing data, 124
specialty, 127–129
toric, 127–128
Rigid lens materials, 113–122.e1, 120t
commercial, properties o , 119–122
development, essential structural, 118
Gaylord patents-harnessing silicone, 116–119
hybrid rigid gas-permeable materials, 116
search or better, 116
Rigid lens measurement, 136–142.e1
back and ront sur ace radius o curvature in,
137–138
centre and edge thickness in, 137
edge pro les in, 138–139
riction and, 140, 140
lens and optic zone diameter in, 136–137
lens geometry in, 136–139
luminance transmittance in, 141
material properties in, 140–142
modulus and exure in, 141, 141
optical properties o , 139–140
optical quality and sur ace de ects in, 140
oxygen permeability and, 141
power and power pro les in, 139–140, 139
re ractive index and, 141
sur ace hardness in, 141–142
wettability in, 140
Rigid lens optics, 130–135.e1
aberrations, 133–134
basic tear lens properties, 130
BVP, required, 131
corneal astigmatism, neutralization, 132–133,
132
exure e ects, 134
prismatic e ects due to decentred or tilted lenses,
134
sur ace radii, calculation o , 131–132
visually disturbing e ects, 134–135, 134
Rigid lenses, 187, 187 –188 , 362
buttons, 124
or children, 273
dimensional tolerances in, 440t
orces acting on, 144–145, 144 –145
high-minus, 265, 266
high-plus, 264, 264 –265
or keratoconus, 253–260, 253t
li e expectancy o , 187–188, 188 –189
non-wetting o , 367–368, 368
optical tolerance or, 440t
planned replacement, 187–192.e1
li e expectancy o rigid contact lenses,
187–188, 188 –189
optimum replacement schedule, 191
Rigid lenses (Continued)
regular, 188–189, 189 –190 , 189t
schemes available, 191
post-keratoplasty and, 291–292
radial keratotomy and, 285, 286
single-vision gas-permeable contact lenses,
307–308
therapeutic applications o , 279, 279 –280
toric. see Rigid toric lens
Rigid toric lens
alignment bitoric lenses in, 160
back-sur ace toric lenses in, 160–161
criteria or use o , 156–157, 157
cylindrical power equivalent, 160–161
design and tting, 156–162.e1
design consideration or, 157–158
e ect o lens rotation in, 161, 162
orms o , 156
ront-sur ace, 161
induced astigmatism o , 159–160
oblique bitoric lenses in, 161
optical consideration or, 158–161
re raction o , 158–159
residual astigmatism o , 159, 159
spherical power equivalent bitoric lens in, 160
Risk/bene t analysis, 325
Rockwell scale hardness test, 121
Roger’s seven-point plan, in recruitment and
selection, 428
Rostock cornea module (RCM), 335, 337
Rotation, in so toric lenses
allowing or, 99
e ects o , 98
measurement o , 99–100, 100
predicting, 98, 99t
Roughness, as edge de ects, 66
Rules on the Fitting o Contact Lenses 1985, 433
S therapeutic applications o , 278–279
Sa ety
extended wear, 242–243
tinted lenses, 212
Sagittal depth, lens geometry, 82
SAI. see Sur ace asymmetry index (SAI)
Saline solutions, 110
or lling non-ventilated RGP scleral lenses, 201
improved dryness symptoms, 110
Satis actory lens t, 150
Scanning slit-beam imaging, 416–417
Scattering, optical parameters, 76–77
Scheimp ug imaging devices
or corneal shape, 339–340, 339 –340
or corneal thickness, 344
Schlieren principle, 75, 76
Scleral GP lenses, 292–293, 293
Scleral lenses, 193–203.e1, 368–369
advantages and disadvantages o , 195
t scales, 456, 456
tting principles o , 196–199
glass, 4–5, 4
indications or, 196, 196
or keratoconus, 260
criteria or, 260
with or without enestrations, 260
lens hygiene and maintenance, 201
modi cation, 200
non-coaxial, 198–199
ordering, 200–201, 200
photore ractive procedures and, 284
plastic, 5
radial keratotomy and, 285–286
therapeutic applications o , 279–280
wear, problems and complications with, 201–203
Scleral shape, corneal and, 340–343
Scleral zone, 197–198, 197
alignment, 195
Sclerotic scatter, 350, 351
Scuba diving, and lens wear, 248, 249
SD-OC . see Spectral-domain OC (SD-OC )
SEALs. see Superior epithelial arcuate lesions
(SEALs)
Seasonal cycles, and lens wear, 250
Secretion tests, or tear lm evaluation, 350
Secretory cells, o eyelids, 21–22, 22
Semiscleral lens designs, bi ocal and multi ocal
contact lenses, 221, 222
Sensitivity, corneal, 354
measurement o , 335–336
contact aesthesiometry or, 335, 337
non-contact aesthesiometry or, 335–336
photore ractive procedures and, 283
Series suf x, or classi cation o so lens materials, 60
Service agreements, 432
Sessile drop technique, 50, 50
Settling time, or rigid lens, 150
SF. see Shape actor (SF)
Shape actor (SF), 143
SHS Ophthalmic OmniSpect, 83–84
SICS. see Solution-induced corneal staining (SICS)
Silicone acrylate material, re ractive index, 122
Silicone elastomer lenses, 5–6
poor wetting in, 232, 232
Silicone hydrogel
or high ametropia, 263–264, 264t
or so lens, 55–59, 56 –57 , 58t, 59
Silicone hydrogel lenses, 7, 87, 367, 374
or children, 270, 273
experiences with, 233, 233 –234
risk o in ection with, 242–243, 243
Gaylord patents or, 116–119
high-modulus, 369
multipurpose solutions and, 109
sport and, 249
Silicone hydrogel materials, 180, 180
Silicone hydrogel polymers, as material, 119
Silicone rubber, structure o , 116
Silicone rubber lenses, or children, 272–273, 272
Simple lens care regimens, 180–181, 181t
Simultaneous image designs, bi ocal and multi ocal
contact lenses, 218–224, 219
aspheric, 219, 220
hybrid and semiscleral lens designs, 221, 222
lens adjustments, 223, 223b
lens tting, 221–222, 222 –223
meeting expectations, 224
Simultaneous-vision bi ocal lenses, 383–384
Simultaneous-vision tting
distance vision adjustment options during, 223b
near vision adjustment options during, 223b
Single-use disposable so trial lenses, 218
Single-use trial lenses, 181
Single-vision rigid gas-permeable contact lenses, or
myopia control, 307–308
Single-vision so contact lenses, or myopia control,
308–309
Size o eye, apparent, visual optics and, 41–42
Slit-lamp biomicroscopy, 332–334, 333 , 347–350,
347
ollowing lens removal, 373–374, 375
or tear lm evaluation, 350
while lenses are worn, 366–369
Slit-scanning con ocal microscopy, 335
Slit-scanning devices
or corneal shape, 339
or corneal thickness, 344
Slit section, in digital imaging, 411, 413 –414
Smartphone digital imaging, 413 –414 , 415
‘Smile’ patterns, in impression arcs, 371, 372
 Ind e x 469

Smiley ace, orthokeratology and, 301, 302 So lens optics, 68–72.e1 Spherical lenses, power measurement, 74
SOCRA ES (site, onset, character, radiation, aberration, 69–72, 70 Spherical power equivalent bitoric lens, 160
association, time course, exacerbating/ on-eye power changes, 68–69, 69 Spin casting, 62–63, 63 –64
relieving actors and severity), 324 So lens oxygen per ormance, 447t–448t technique, in so lenses, 6, 6
Sodium uorescein tting pattern, or miniscleral So lenses, 6, 6 , 361–362 Split, as non-edge (body) de ects, 66
lens, on keratoconus, 258, 258 corneal shape changes due to, 371 Sport, 246–250.e1
So lens care systems, 103–112.e2 daily disposable, 165–174.e1, 167 , 169 –170 environmental and physical constraints in,
chlorhexidine-preserved system, 105 bimodal distribution o , 170 246–249
chlorine, 105–106 clinical per ormance o , 170 environmental conditions, 246–249
disin ection, 103 com ort enhancement strategies, 171 physical conditions, 249
evolution o , 104 corneal in ltrative events and keratitis, general considerations in, 249–250
hydrogen peroxide, 106–107 173–174 participation in, 247t
lens cleaning, 107 disadvantages o , 171 sporting per ormance in, enhancement by
e ects o , 104 environmental impact o , 172, 173 contact lenses, 246
rationale or, 103–104 lens application to assist ametropes in eyewear tinted lenses, 206
lens rinsing, e ects o , 104 selection, 174 vision correction, 246, 247t
multipurpose solutions, 107–109 lens wearers, advantages rom perspective o , re ractive surgery and, 246
silicone hydrogel lenses and, 109 171 Spot diagram, 133
physical methods, 104–105 limitations to more general acceptance, 172–173 Spring-back test, 92
relative per ormance measures, 110–111 manu acturing reliability, 171, 172 SQI ARS (site and radiation, quality, intensity,
rewetting solutions, 109–110 patterns o wear, 168–170 timing, aggravating actors, relieving actors,
saline solutions, 110 practitioners, advantages rom perspective o , secondary symptoms), 324
storage case, 111–112, 112 170–171 Squeeze pressure, 86
thiomersal-preserved system, 105 dimensional tolerances in, 440t SRI. see Sur ace regularity index (SRI)
So lens design, 87–88 disposable, 232–233 SS-OC . see Swept-source OC (SS-OC )
back optic zone radius, 88 hydrogel, therapeutic applications o , 278–279, Stabilization techniques or so toric lens, 96–97
back vertex power, 88 279 Staining
centre, 88 or keratoconus, 252–253 conjunctival, 391–392, 392
lens material and water content, 87 material property tolerances or, 440t corneal, E ron grading scale or, 454
thickness, 88 materials or. see Materials or so lenses epithelial, 397, 397 –398
total diameter, 88 optical tolerances or, 440t uorescein, 350, 411, 413 –414
So lens tting photore ractive procedures and, 283 Staphylococcal anterior blepharitis, 388, 389
assessment o , 91–93 planned replacement or, 187 Steep- tting lens, orthokeratology and, 301
basic principles o , 86–87 radial keratotomy and, 285, 285 Steep scleral zone, 197
orces acting, 86, 87 single-vision, or myopia control, 308–309 Stem, or classi cation o so lens materials, 60
ideal t, 86–87 toric. see So toric lenses Stereopsis, 354
Caucasian versus Chinese eyes, 94 water content, in various lens thickness, Sterile in ammatory keratitis, 236
characteristics o , 90–91, 91t 447t–448t Sterile keratitis, 405
actors a ecting, 90t So toric lenses, 95–102.e1 Stevens-Johnson disease, 277
introduction, 86 correction, principles o , 97–101 Sticky eye, in children, 274
ocular measurement, 86 criteria or use, 95 Storage contamination, 178, 179
optimum t, 90 design o , 95–97, 98 Stress, physiological, extended wear and, 244–245,
options, 88 limitations o , 102 245
problems, 93–94 misalignment demonstrator, 450t Stress-strain curve, hydrogel materials and, 48–49,
requirements o , well tting, 87t power measurement, 74 48
trial lens tting, 88–90 replacement o , planned, 101–102 Subaquatic environment, and sport, lens wear, 248,
So lens manu acture, 61–67.e1 So ab chlorine system, 105–106, 106 249
edge de ects in, 66, 66 So Perm (CIBA Vision) lens, or keratoconus, Subjective re raction, 346–347
methods o , 61–63, 87–88 260–261 Subscription schemes, in practice management,
cast moulding, 63, 64 –65 Solid design, bi ocal and multi ocal contact lenses, products and services provided in, 430
lathe cutting, 61–62, 61 –62 224–225, 226 Suction holders, in lens removal, 361
spin casting, 62–63, 63 –64 Solution-induced corneal staining (SICS), 374, 375 Suf x groups, or so lens materials, 60, 60t
non-edge (body) de ects in, 66–67 Special mailings, in promotional issues, 431 Sunglasses, and glare relie , 250
occupational sa ety in, 67 Speciality-commodity continuum, 430, 431 Sunken gra , 290
reproducibility and quality o , 66–67 Spectacles Sunshades, and glare relie , 250
So lens measurement, 73–85.e2 or aphakia, 268 Superior epithelial arcuate lesions (SEALs), 242,
conditioning according to ISO 18369-3, 73 corrections, 38–41 242 , 245
lens geometry, 81–84 accommodation demand and, 40–41, 41 Superior limbic keratoconjunctivitis, 382, 395–397,
diameter, 81–82, 81 convergence demand and, 41, 41 396
edge, 84, 85 e ectivity and, 39, 39 E ron grading scale or, 455
radius o curvature, 83–84, 84 or keratoconus, 252 and so toric lenses, 102
sagittal depth, 82 magni cation, 39–40, 39 –40 Superior tarsal muscles, in eyelids, 18
thickness, 82–83, 83 dispensary, practice, 428 Supply routes, alternative, 186
material properties, 77–81 Spectral-domain OC (SD-OC ), 342 Sur ace asymmetry index (SAI), 406
modulus, 77–78, 77 –78 Spectral transmittance, 80–81, 81 Sur ace de ects, o rigid lens measurement, 140
oxygen permeability, 79–80, 80 Specular microscopy, 334 Sur ace o lens
re ractive index, 80, 80 or corneal thickness, 345 assessment, 366–368, 368
spectral and luminous transmittance, 80–81, 81 Specular re ection direct illumination, 348–349, degradation o , 203
sur ace riction, 79 350 riction, 79, 242
water content, 77 Spherical aberrations, 70, 71 Sur ace optics, in so toric lenses, 96
wettability, 78–79, 79 higher-order, 75–76, 76 Sur ace properties, o commercial rigid lens
optical parameters, 73–77 Spherical components, low, in so toric lenses, 102 materials, 121
optical quality, 76, 77 Spherical designs Sur ace radii, required, rom a trial lens t,
power and power pro les, 74–76 or bi ocal and multi ocal contact lenses, 221 calculation o , 131–132
scattering, 76–77 or rigid lenses, 146, 146t, 255–256 Sur ace regularity index (SRI), 406
470 Ind e x
Sur ace tension orces, rigid lens and, 144
Surgery
re ractive. see also Post-re ractive surgery
types o , 282, 282t
or vision correction, and sport, 246
Suture techniques, post-keratoplasty and, 287 , 290,
290
Swell actor, o hydrogel lenses, 52–53
Swept-source OC (SS-OC ), 342–343, 343
Symbols, used or describing contact lens, 439t
SynergEyes hybrid lenses, 292, 292
or keratoconus, 260–261
Systemic disease, 318. see also Diabetes
T o cornea, determination o , 343–345
anaka patent, 117–118
andem scanning con ocal microscopy, 334–335
angential maps, 352
arsal gland. see Meibomian glands
D-OC . see ime-domain OC ( D-OC )
eaching area, in patient education, 356, 356
ear lm
in anterior eye, and diabetes, 314
assessment, in digital imaging, 411, 413 –414
complications in, 389–391
dry eye in, 389–390, 390 –391
mucin balls in, 390–391, 391 . see also
Dry-eye
dys unction, 382
evaluation o , 350
examination o , 327–330
osmometry, 329, 329
tear break-up, 328–329, 328 –329
tear meniscus height ( MH), 329–330, 330
tear quality and thickness, 327–328, 328
‘ ear map,’ 328
ear meniscus height ( MH), 329–330, 330
earLab osmometer, 329, 329
ears
break-up, 328–329, 328 –329
de ciency, therapeutic applications and, 277
as edge de ects, 66, 66
lm. see ear lm
layer thickness analysis, 419, 419
lens
power o , ormula, 130
properties o , 130, 130
during trial lens ts, 130–131, 131
quality and thickness, 327–328, 328
stability tests, 350
earscope, 390
earscope-plus, 327, 328 . see also Mucins
erms, symbols and abbreviations, used or
describing contact lens, 439t
etronic 1107, hydrogel lenses and, 55
T eatric tinted lenses, 207
T eatric ‘wol -eye’ lens, 207
T eoretical model, optimum rigid lens replacement
schedule, 191
T erapeutic applications, 275–281.e1
chemical injuries, 276, 276
complications, 281
conjunctivitis, cicatricial, 276
cornea
degenerations involving the endothelium, 276
degenerations involving the epithelium, 276
dystrophies involving the epithelium, 276
drug delivery in, 280–281
environment, protection rom, 277, 277
epithelial pain, relie o , 275
erosion syndrome, recurrent, 275–276
lamentary keratitis, 276
indications or, 275–278
keratitis, severe exposure, 277
T erapeutic applications (Continued) PX. see Poly (4-methyl pent-l-ene)
lens types, 278–280 raining sta , in recruitment and selection,
rigid, 279, 279 –280 429–430
scleral, 279–280 ranslucent tints, o lenses, 208–209
so hydrogel and silicone hydrogel lenses, ransmissibility, 79–80
278–279, 279 ransparency, corneal, 15–16
lids, protection rom, 277, 277 rial lens sets, disin ection o , 164
medication in, concurrent, 280 rial pack o solutions, 357
precorneal tear reservoir, maintenance o , 277–278 ri uoroethyl methacrylate monomer, 117–118,
shape, unusual or distorted, 275 118
spontaneous per oration, 278 1,1,9-trihydroper uoro-nonyl methacrylate
tear de ciency, 277 monomer, 116–117, 117
tinted, 205–206 RIS. see ris(trimethylsiloxy)-methacryloxy-
trauma or surgery, 278, 278 propylsilane ( RIS)
T ickness ris(trimethylsiloxy)-methacryloxy-propylsilane
( RIS), 116–117, 117
geometry o lens, 82–83, 83 or silicone hydrogel lenses, 56, 56
o rigid lens, 137 runcation, 97, 97
o so lens, 82–83, 88 in ront-sur ace toric lenses, 161, 161
average, 446t wo-handed technique, in lens removal, 360–361,
toric, 99 360
o tear, 327–328, 328
T iomersal-preserved system, 105
T ree-point touch, 254 , 255 U
ight lenses, in so lens tting, 90–91, 94 UltraHealth design lenses, or keratoconus, 261
ilted lenses, prismatic e ects due to, 134 Ultrasonic pachymetry, 343–344, 344 , 373
ime-domain OC ( D-OC ), 342, 342 Ultrasound, or lens disin ection, 105
ime settling, in so lens tting, 89–90 Ultrasound pachymeters, or rigid lens
int distribution, o lenses, 211, 211 measurement, 137
inted lenses, 204–213.e2 Ultraviolet light, and lens wear, 248–249
basic options o , 204 Unintentional non-compliance, 422–423
clinical considerations o , 211–213 Uninterrupted wear, risks in, 243
discom ort and dryness, 213 Unwanted orthokeratology, 242
lens deposits, 213
lens tting, 211
lens maintenance, 211 V
multiple pairs, care o , 212 V-gauge, or rigid lens measurement, 136, 136
ocular e ects, 212 Vacuoles, 399, 399
oxygen transmissibility, 211 Vascularity, eye redness and, 379
replacement requency, 212 Vascularization, 245
sa ety, 212 Vascularized limbal keratitis, 395, 395 –396
tint distribution, 211, 211 Vat dye tinting, o lenses, 208, 208
visual e ects, 211–212 Vaulting, 456, 456
designs and applications, 204–207 central, 456, 456
cosmetic, 205, 205 limbal, 457, 457
handling tints, 204–205, 204 Vertex distance correction, 441t–442t
per ormance-enhancing, 206 Vertex power, back, in so lens design, 88
prosthetic, 205, 206 Vickers Microhardness test, 121
therapeutic, 205–206 Video slit-lamp imaging system, 415–416
manu acture, 208–210 Videokeratoscopy, 147–148, 147
sporting per ormance enhancement and, 246 in so lens tting, 93
sur ace characteristics o , 210 Virtual contact-lens- tting so ware, or
theatric, 207 keratoconus, 257, 257
issue ablation, photore ractive procedures and, Vision
282–283 binocular, assessment, 352
issues, box o , 357 distance, adjustment options or improving,
MH. see ear meniscus height ( MH) during simultaneous-vision tting, 223b
olerance o lenses, 440 loss, a er lens removal, 383, 383
omey Casia SS-100, 416 low, and ametropia, 266
onometry, 354 measurement o , 346
opography. see under Cornea; Ocular topography near, adjustment options or improving, during
oric lenses, so , 95–102.e1, 381 simultaneous-vision tting, 223b
correction, principles o , 97–101 poor, 382–384
criteria or use o , 95 and rigid lens, 155
design o , 95–97, 98 in so lens tting, 93
limitations o , 102 uncorrected, 369
replacement o , planned, 101–102 unstable, and rigid lens, 155
oric rigid lens manu acture, 127–128 variable, in so lens tting, 94
oroidal back sur ace, 96 Visit schedules, based on lens type, 364, 365 ,
oroidal lenses, 198 365t
designs, 256–257, 256 –257 Visual acuity
otal diameter, 439t with contact lenses, 366
in so lens poor, in so lens tting, 94
design, 88 Visual e ects, in tinted lenses, 211–212
tting, 93 Visual elds, 354
 Ind e x 471

Visual optics, 28–42.e2 W X

aberrations and, 32–38 Waiting area, practice, 428 Xanthelasma, 314, 315
chromatic, 37, 37 Warpage, 406 Xerogel lens, 63
correction o high-order, 38 Water
monochromatic, 33–37, 33 –34 , 35t–36t, 36 –37 content
accommodation demand and, 40–41, 41 o hydrogel lenses, 51 Y
ametropia and, 28–30, 29t, 30 measurement, o so lens, 77 Young, T omas, 3, 4
apparent size o eye, 41–42 o so lens, 87
convergence demand and, 41, 41 wetting/wettability
corneal topography and, 30–31, 31 o hydrogels, 49–50 Z
di raction and, 32 poor, o silicone elastomer lenses, 232, 232 Zeiss visante, 416
eye and rigid lens measurement and, 140 Zernike aberrations, RMS wave ront errors and,
in white light, per ormance o , 37 so lens measurement, 78–79, 79 35, 36t
elds o view and, 41, 42 Wave ront error (WFE), 350 Zernike coef cients, monochromatic aberrations
xation and, 41 Wave ront re raction, 350 and, 34–35, 34 , 37
pupil diameter and retinal blur circles, Wearing schedules, in contact lens wear, 361–362 Zernike polynomials, monochromatic aberrations
31–32, 31 –32 , 32t. see also Aberrations; Wettability. see under Water and, 35, 36
Ametropia Wetting solutions, or rigid lens, 163, 164 Zonal aspheric designs, bi ocal and multi ocal
spectacle magni cation and, 39–40, 39 –40 WFE. see Wave ront error (WFE) contact lenses, 221
Vitrodyne 2000, 78, 78 White light, anterior eye, 37, 37
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