ABIA STATE UNIVERSITY, UTURU

FACULTY OF HEALTH SCIENCES

DEPARTMENT OF OPTOMETRY

A PRESENTATION ON: CURRENT CHALLENGES, RECENT ADVANCES AND

POSSIBLE FUTURE OF CONTACT LENS PRACTICE

BY

GROUP NUMBER: GROUP (11)

COURSE CODE: OPT 671

COURSE TITLE: ADVANCED CONTACT LENS

LECTURER:
PROF. (MRS.) O.U. AMAECHI

10TH AUGUST , 2023.

GEOUP MEMBERS

1. OKOLI ANITA OLUCHUKWU 2017/112971/REGULAR

2. EKPENDU IKENNA CHIDUZIE 2017/113076/REGULAR

3 AZUMA JOSEPH OKORO 2017/113180/REGULAR

4. ONYESOM VICTORIA 2017/113240/REGULAR

5. MONG CHIMA ONWUKA 2017/113351/REGULAR

6. FRANCIS FAVOUR CHIAMAKA 2017/113372/REGULAR

7. EKEKWE CHISOM RUTH 2017/113379/REGULAR

8. OKAFOR HENRY EBUBECHUKWU 2017/113491/REGULAR

9. NDUKA MIRACLE CHINONYEREM 2017/113544/REGULAR

10. ALAOMA BENNETH EKELEDIRICHUKWU 2017/113547/REGULAR

11. SAM-AGU MARY-JANE OLACHI 2017/113556/REGULAR

12. UJOATUONU CHARLES 2017/113598/REGULAR

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 PREFACE

The realm of contact lens practice has undergone remarkable transformations over the years,
revolutionizing the way we perceive and address visual correction. This preface serves as a
gateway into the exploration of the multifaceted landscape encompassing the current challenges,
recent advances, and the intriguing potential that lies ahead within the realm of contact lens
practice. As we navigate through the intricacies of this dynamic field, we delve into the obstacles
that practitioners and wearers alike encounter in our contemporary setting. Simultaneously, we
unravel the tapestry of innovation that has unfolded, propelling contact lens technology to new
heights and redefining the boundaries of visual correction. In this evolving narrative, we also cast
our gaze towards the horizon, envisioning the potential trajectories that contact lens practice may
take in the future. The synthesis of these elements invites us to embark on a journey that
traverses the present challenges, celebrates the recent triumphs, and anticipates the exciting
prospects that await us in the captivating domain of contact lens practice.

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 CERTIFICATION

This is to certify that the following document titled “Current Challenges, Recent Advances, and
Possible Future of Contact Lens Practice” has been thoroughly reviewed and examined. The
document provides a comprehensive exploration of the intricacies and developments within the
field of contact lens practice, encompassing both the present landscape and the potential
directions for future advancement.

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 DEDICATION

Prof. (Mrs.) O.U. Amaechi, Dr. Anonaba, Prof. O.C. Ahuama, ,Prof. Chris Timothy,Dr Andrew
Omaka, Dr Udo Ubani, Dr Andy Ebere, Dr Amarachi Ezeigbo, Dr Benjamin Izuchukwu, Dr
Anonaba, Dr Chijioke, Dr Nwakuche and Dr Onyekwere. Your pioneering spirit and expertise
have propelled the evolution of contact lens practice. With deep appreciation, we dedicate this
exploration of "Current Challenges, Recent Advances, and Possible Future of Contact Lens
Practice" to your invaluable contributions. Your impact on the field continues to inspire and
shape its promising horizons, and in the lens of your wisdom, the future of contact lens practice
comes into focus. With gratitude for your illuminating guidance, this exploration of “Current
Challenges, Recent Advances, and Possible Future of Contact Lens Practice” is dedicated to you.
Your insights have reshaped clarity and brought innovation to sight.

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 ACKNOWLEDGMENT

I extend my sincere appreciation to Prof. (Mrs.) O.U. Amaechi and Dr. Anonaba for their
remarkable contribution in delving into the intricate realm of "Current Challenges, Recent
Advances, and Possible Future of Contact Lens Practice." Their diligent research and insightful
analysis have illuminated the multifaceted landscape of contact lens practice, encapsulating the
hurdles faced in the present, the strides made through recent advancements, and the intriguing
potential that lies ahead. This acknowledgement is a tribute to their dedication and expertise in
exploring a subject of paramount importance, thereby enriching our understanding of this
dynamic field.

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 TABLE OF CONTENTS

1. CURRENT CHALLENGES IN CONTACT LENS PRACTICE

A. EMPIRICAL VERSUS DIAGNOSTIC FITTING IN A COVID WORLD

B. OVERNIGHT ORTHOKERATOLOGY VERSUS SOFT MULTIFOCAL CONTACT LENS

WEAR FOR MYOPIA MANAGEMENT

C. PRESBYOPIA-CORRECTING PHARMACEUTICALS AND CONTACT LENS WEAR

2. RECENT ADVANCES IN CONTACT LENS PRACTICE

A. . Advances in GP Sclerals

B. Advances in Myopia Treatment

C. Advances in Presbyopia Management

D. Advances in Flexible Contact Lenses

E. Advances in Dry Eye

F. Advances in Inflammation Treatment

3. POSSIBLE FUTURE OF CONTACT LENS PRACTICE

A. Disease monitoring lenses

B. Enhancing vision

C. Myopia management with contact lenses

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 CURRENT CHALLENGES IN CONTACT LENS PRACTICE

Introduction

In 2021, members of the American Optometric Association (AOA) Contact Lens & Cornea

Section (CLCS) were asked to identify challenges (controversies)in contact lens practice. Based

on their input, this 2022 “Clinical Controversies” article encompasses both current and future

considerations.

The COVID-19 pandemic has emphasized not only the importance of eyecare providers, it also

has emphasized that contact lenses are safe to wear when appropriate safety standards are

observed. The focus on the current myopia pandemic continues to intensify along with increasing

education on this topic. Recently, the first U.S. Food and Drug Administration (FDA)-approved

pharmaceutical option for correcting presbyopia was introduced. Such options will change the

future of eye care. Read on for a potpourri of controversies from the AOA CLCS.

1: Empirical Versus Diagnostic Fitting in a Covid World

Empirical Fitting The 2018 International Organization for Standardization (ISO) guidelines for

multiuse disinfection, coupled with the recent SARS-CoV-2 pandemic, underscore the need for

alternatives to reusable lenses and to diagnostic fitting.1 Advancing technologies have answered

the call.

In the mid-2010s, videokeratographers began to showcase advanced contact lens fitting

algorithms based on elevation maps.2-4 These algorithms have continued to improve, and they can

provide an excellent initial design for many corneal GP lenses. Such empirically designed lenses

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can offer an outstanding first-lens experience for patients, and often they are the only lenses that

patients need.

Today, scleral profilometers are expanding the options for empirical fitting. Multiple instruments

now provide initial recommendations for scleral lenses.5 These instruments scan the scleral

profile, select a lens design, and recommend initial lens parameters. Once the initial lens is

chosen, the calculations can be exported to the manufacturer’s site for further customization.

Usually, the recommendation is to apply a diagnostic lens that is similar, then over-refract to

finalize the power. While slightly less accurate, an initial lens power can be calculated based on a

patient’s habitual lens or based on central keratometry readings, refraction, and the

recommended lens base curve.

In addition to standard scleral lens designs, fully scan-designed initial lenses can be created. A

lens that is designed based on scleral shape can help prevent lens rotation and improve the fitting

relationship, which can streamline examination time, reduce lens reorders, and improve a

practice’s bottom line.6

The latest advance in profilometry is software for designing custom orthokeratology (ortho-k)

lenses. After a patient’s ocular surface is scanned and the prescription is entered, the software

calculates the first lens. When follow-up data is input, the software can make recommendations

for parameter adjustments.

One of the advantages of empirical fitting is that it minimizes the risks associated with

concurrent infections. Hepatitis C, adenovirus, prions, and human T lymphotropic virus, in

addition to a variety of others, have all been identified in tears.7-10 When patients are infected

with one of these viruses, diagnostic lenses used on them should be discarded. Unfortunately, it
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is not always known when our patients have these infections. The level of disinfection required

to meet ISO guidelines can put a burden on a practice.1 The parameters must be logged, and

while the lenses soak for three hours, practitioners must keep track of the original cases for those

lenses. Ordering a lens directly from testing eliminates all of this inconvenience.

By using the latest technologies available, we can create loyalty among our patients, many of

whom recognize the level of expertise and the advanced techniques provided. Patients also

appreciate being fit with lenses that are applied to their eyes only. With the challenges associated

with COVID-19 and its virus (SARS-CoV-2), which also has been identified in the tears of some

patients (albeit at very low levels),11 having an alternative that eliminates the need for a reusable

lens is appealing.

Diagnostic Fitting During the height of the COVID-19 pandemic, there were serious concerns

about office protocols and a need to limit patient contact. While the literature supported the use

of contact lenses,12 there was a legitimate concern about the safety of reusable in-office

diagnostic lenses. As practices return to normal, a question remains: Is it acceptable to reuse

contact lenses for fitting purposes?

This discussion does not typically apply when fitting most standard soft lenses; manufacturers

supply practitioners with single-use lenses that can be discarded after every patient. There are

greater concerns about other lens designs, specifically specialty soft lenses, GP lenses (including

scleral lenses), and hybrid lenses. To address these concerns, a contact lens disinfection protocol

was developed in cooperation with the AOA CLCS and the American Academy of Optometry

Section on Cornea, Contact Lenses and Refractive Technologies.1 This report, which was based

on the 2018 recommendations from the ISO, describes a detailed cleaning process to be

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performed after every use of in-office diagnostic lenses and every 28 days for lenses that have

been opened and not reused. This report explains what should be done with reusable GP, hybrid,

and soft contact lenses. Putting this evidence-based research into practice can help practitioners

feel more comfortable fitting reusable lenses.

Fitting patients with diagnostic lenses can result in fewer lens modifications and remakes.

Placing a lens on the eye enables practitioners to accurately assess fitting factors such as

movement and centration. A diagnostic fitting approach is the only way to evaluate this in all

positions of gaze in addition to evaluating the exact relation between the lens material, design,

and its interaction with the ocular surface and tear film. Empirical fitting could miss other

aspects of a contact lens fitting such as lid-lens interaction and ocular surface issues. Although

the first lens placed on the eye may not completely correct vision, an over-refraction can

demonstrate the real visual potential. In addition, patients and practitioners may have a greater

appreciation for diagnostic fitting, as there is more to the examination.

We also cannot overlook the patients’ perspective. Yes, chair time is a consideration, and the

fitting should be as efficient as possible; but, it is much easier to justify a fitting fee when the

examination has more components and extensively involves patients. Allowing patients to

experience the fitting process can make a positive impression on their opinion of your expertise.

In the past, designing empirical lenses was challenging with certain irregular corneas, but that

reality is changing. Anterior segment imaging technology has come a long way,13 but the cost of

such diagnostic equipment makes these options unrealistic for some practitioners. Diagnostic

contact lens fitting sets are less costly and are more accessible to many more practitioners.

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2: Overnight Orthokeratology Versus Soft Multifocal Contact Lens wear for Myopia

Management

Overnight Orthokeratology One of the more common concerns that parents have about ortho-k

is its safety. Practitioners go to great lengths in their practices and as a profession to educate

patients and parents on the risks of sleeping in their contact lenses. When using overnight ortho-k,

we tell parents that we want to prescribe a therapy to help manage their child’s myopia by having

them sleep in their contact lenses. It’s a common concern, but the research is clear that ortho-k is

a safe and effective way to manage myopia.14,15,17

With any contact lens modality, the major safety concern is microbial keratitis (MK), a rare but

serious adverse event. One study was comprised of 667 children who wore either ortho-k lenses

or single-vision spectacles (control).14Researchers found no occurrences of MK, and although

they found a higher incidence of nonsignificant adverse events, the dropout rate was similar to

that of the controls wearing single-vision spectacles. The overall incidence of MK has been

estimated at 7.7 per 10,000 years of ortho-k wear.15This estimate puts the risk of MK for patients

wearing ortho-k somewhere between daily-wear soft lenses and extended-wear soft lenses.16

A tempting conclusion could be that because daily-wear soft lenses have a slightly lower risk of

MK, they should be preferred in all situations. This is simply not true, as many risky contact lens

behaviors can be avoided with ortho-k use. For example, many children and parents tend to

forget that soft contact lenses should not be worn while swimming, or they simply ignore the

risks in favor of convenience. Convenience can become a motivating factor for other risky

contact lens behaviors. Children wearing daily-wear soft lenses may find it inconvenient to wash

their hands or to use proper cleaning solutions while away from home during the day; conversely,

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children wearing ortho-k apply their lenses at night before they go to bed and remove them in the

morning upon waking, so they are almost always near their solutions, hand soap, and assistance

from parents while wearing their lenses.17

Along with a good safety profile, current research suggests that axial length progression can be

slowed by about 50% with ortho-k wear.18-20 Significant reductions in axial length and in dioptric

progression have been demonstrated in comparison to controls over various population groups

and various time frames.21,22 Over many decades of use, research, and improvement, ortho-k has

secured its place as a safe and effective option for myopia management.

Soft Multifocal Lenses Originally prescribed for presbyopia, both aspheric (center-distance) and

concentric-ring-design multifocal lenses have been prescribed for myopia management. In

addition to axial length and refractive error, factors such as add power and pupil size need to be

considered when prescribing lenses to manage myopia. With this background in mind, two

arguments that favor the use of soft multifocal lenses for myopia management can be considered.

 Argument #1: By its very nature, ortho-k precludes knowing whether myopia

management with respect to refractive error is effective. Cycloplegic refraction and axial

length measurements are the standard of care for monitoring the effectiveness of myopia

management with daytime-use contact lenses.23 Because ortho-k corrects refractive error

by reshaping the cornea, refractive error cannot be used as an effective treatment

indicator. If the goal is to decrease refractive progression, it cannot be determined

whether the progression of refractive error is being effectively controlled in patients who

are being treated with ortho-k.

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  Argument #2: The peripheral defocus cue responsible for reducing myopia progression is

easier to control with soft multifocal lenses than with ortho-k lenses. Myopia

management using contact lenses depends on creating peripheral defocus, and it makes

sense to infer that higher add powers will provide better efficacy.24 To examine this

hypothesis, the Bifocal Lenses In Nearsighted Kids (BLINK) study randomly assigned

children to wear either commercially available single-vision contact lenses or medium-

(+1.50D) or high- (+2.50D) add-power soft multifocal contact lenses for three

years.25 This study demonstrated that treatment with high-add-power multifocal lenses

reduced the rate of myopia progression more effectively compared with either the

medium-add-power multifocal or the single-vision contact lenses. With custom soft lens

designs, much higher add powers (e.g., +3.00D or greater) can be easily incorporated and

prescribed for myopia management.

By contrast, to create greater defocus for more effective myopia management with ortho-k lenses,

aspheric curves must be employed. This requires special computer software that integrates with

topography to generate the requisite aspheric curves. Used correctly, this approach can be

effective; however, the software, hardware, and/or training to use these may not be available to

every practitioner.

3: PRESBYOPIA-CORRECTING PHARMACEUTICALS AND CONTACT LENS

WEAR

Presbyopia is an age-related vision condition that causes difficulty in focusing on close-up

objects due to the natural aging of the eye's lens. As the global population ages, the
demand for effective solutions to address presbyopia has led to significant advancements
in both pharmaceuticals and contact lenses.

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Presbyopia-Correcting Pharmaceuticals:

Eye Drops: Recent research has explored the use of eye drops containing miotic agents or
other compounds that temporarily improve the eye's ability to focus on near objects.
These drops aim to relax the eye's ciliary muscle, enhancing the depth of focus for reading
or other close tasks.

Oral Medications: Some pharmaceutical companies are investigating oral medications

that can influence the eye's ability to accommodate. These medications work by affecting
the ciliary muscle's contraction and relaxing mechanisms, allowing for improved near
vision.

Challenges:

Maintaining appropriate dosage and effectiveness of eye drops.

Potential side effects and long-term safety of oral medications.

Presbyopia-Correcting Contact Lenses:

Multifocal Lenses: These lenses have multiple zones with varying prescriptions, allowing
wearers to see clearly at different distances simultaneously. They provide a seamless
transition between near, intermediate, and distant vision.

Monovision Lenses: Monovision involves wearing a contact lens with distance correction
in one eye and a lens with near correction in the other eye. The brain learns to rely on the
appropriate eye for different tasks, providing functional vision for both distances.

Hybrid Lenses: These lenses combine features of both rigid gas-permeable and soft
contact lenses, offering comfort and improved vision for presbyopic individuals.

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Advantages:

Non-invasive and reversible options for vision correction.

Customizable solutions to cater to individual preferences and needs.
Challenges:

Adaptation period for wearers adjusting to multifocal or monovision lenses.

Selecting the optimal lens design for each individual's visual requirements.
Conclusion:
The rapid advancements in presbyopia-correcting pharmaceuticals and contact lenses are
providing viable options for individuals seeking improved near vision as they age. Both
avenues offer unique advantages and challenges, emphasizing the importance of
personalized recommendations by eye care professionals. As technology continues to
evolve, the landscape of presbyopia correction is likely to expand, enhancing the quality
of life for those affected by this common vision impairment.

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 RECENT ADVANCES IN CONTACT LENS PRACTICE

Introduction

Contact lens practice has evolved dramatically over this clinician's active career of four decades.

It has developed from a purely commercial enterprise, with lenses manufactured in garages and

sold to naïve patients by almost equally naïve clinicians who understood some optics and some

mechanics but little of physiology, immunology, or microbiology, to a set of sciences driven by

evidence-based medicine.

Advances in the pipeline should in the next few decades produce devices that will correct vision,

perhaps some that will decrease or reverse myopia, while having little impact if any on the

tissues over which they ride.

Advances in GP Sclerals

Although we have had notable improvements in GP lens materials and lens design over the past

few decades, arguably the most important advance is in the resurgence of GP sclerals.

The original practical contact lenses, introduced in Europe more than a century ago, were large

glass shells covering the entire front of the eye. Eventually called “sclerals” or “haptics”—as

opposed to the later and smaller corneal rigid or semi-scleral hydrogels—because they do not

touch the cornea but rather align with, and rest upon, the less sensitive sclera, this lens design has

undergone a recent resurgence. Led by “pioneers” Drs. Don Ezekiel, Perry Rosenthal, and Rob

Breece, scleral lenses, now made from high-tech oxygen permeable plastics, have shown an

ability to serve a previously underserved—but admittedly small in numbers—group of desperate

patients who suffer from various eye disease states. These include patients who have severe

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corneal irregularity (Figure 1) due to advanced keratoconus, trauma, and post-corneal graft

(patients for whom more normal corneal designs fail for a variety of causes), but primarily those

who have severe dry eye due to diseases such as ocular cicatricial pemphigoid, Stevens-Johnson

syndrome, and graft versus host disease (secondary to treated lymphoma, etc.).

Scleral lenses were first made from glass and then, after World War II, from

polymethylmethacrylate (PMMA). They were abandoned for the most part in the 1950s in favor

of corneal PMMA lenses and then later in favor of GPs and the popular hydrogels invented by

Professor Otto Wichterle. These newer designs offered good vision correction and enhanced

ocular tolerance, the former through tear exchange, the latter through size and flexibility, for the

cosmetically driven, primarily mildly and modestly myopic populations.

The gradual enhancement of contact lens plastic oxygen permeability (Dk) over the succeeding

decades, in both rigid and flexible formats, eventually resulted in our pantheon of modern GP

and soft materials, all but eliminating hypoxia during daily wear as a clinical issue. Parallel

advances in understanding lens design and optics extended the prescriptions addressable to

patients who have significant astigmatism, presbyopia, and those suffering the extremes of

optical correction, both myopic and hypermetropic/aphakic.

The anecdotal story is that about a decade ago, Donald Ezekiel of Perth, Australia, was the first

to have the epiphany that the time had come to revisit the scleral lens, now made in a high-Dk

material. He petitioned for the availability of large-diameter rigid lens buttons, and this led to the

development of several clinical centers providing such lenses in Boston, London, and Perth. A

cadre of devoted clinicians developed by experience the rules that we are now learning to help

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these patients (van der Worp, 2010), followed by the development of several manufacturing

laboratories providing these large-overall-diameter (16mm to 25mm) high quality lenses.

The primary clinical goal of current GP scleral lens application is to arrive at a lens that totally

vaults the patient's corneal surface, limbus to limbus. Any significant corneal touch will likely

result in corneal irritation and erosion as well as other secondary concerns such as intolerance.

The secondary clinical goal is to provide a scleral portion (or haptic) that neither overly

compresses the conjunctiva (resulting in large areas of conjunctival vascular blanching) nor is so

loose as to allow free enough exchange of fluids to generate bubbles under the lens corneal vault.

Such bubbles, if immobile, will likely desiccate the underlying corneal epithelium, again leading

to corneal erosion with its secondary consequences.

The third clinical goal is to provide the necessary optics for each patient. Hundreds if not

thousands of patients who cannot otherwise see, and/or to avoid intolerable photophobia and

ocular suffering or corneal surgery, have benefited. With the growth of various lens designs and

increase in clinicians who can provide such lenses, distribution and costs should be enhanced.

We must recognize, however, that the numbers of such lens fits will remain limited as we have

so many other, easier to fit, and less costly devices to serve most of the contact lens-wearing

population.

Gas permeable (GP) contact lenses, also known as rigid gas permeable (RGP) lenses, are hard

contact lenses made of silicone-containing compounds that allow oxygen to pass through the lens

material to the eye. They are much bigger than most GP lenses, so they arch over the cornea and

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rest on the white part of the eye (sclera). That helps the lenses fit underneath the eyelid, making

them comfortable to wear.

Advances in Myopia Treatment

Another area of slow, incremental progress has been in the linked—but not precisely the same—

endeavors of myopia prevention and treatment. Undoubtedly stimulated by both the

developments in refractive surgeries and parents eager to offer their children options to avoid

both the cosmetic/optical as well as ophthalmic disease consequences of myopia progression,

research has slowly begun to understand both myopia development and appropriate preventive

and therapeutic interventions.

Both “traditional” and newer paradigms of orthokeratology were directed at the use of GP lenses

to reshape the anterior corneal surface. Orthokeratology was limited in effect, and may have

suffered from cost effectiveness. Also, some potential hazard continues with extended wear of

orthokeratology lenses (Lu et al, 2001).

Now with science being led by such visionaries as Dr. Earl Smith, we are learning that peripheral

retinal myopic defocus may be the driving mechanism leading to progressive myopia; so

peripheral hyperopic defocus (caused by ortho-k lens designs and those similar to concentric

bifocals) could be effective in reducing the stimulus to myopic progression. As evidence gathers,

confirmation of this paradigm should allow the development of treatment designs, both in

spectacles and, more likely, in contact lens formats, that will be both better accepted and more

cost effective.

Recent advances in myopia treatment within contact lens practice have brought about exciting

developments that address the increasing prevalence of myopia worldwide. Myopia, or

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nearsightedness, has become a significant concern due to its association with sight-threatening

conditions like retinal detachment, glaucoma, and myopic maculopathy. Here are some

noteworthy advancements in myopia treatment using contact lenses:

1. Multifocal Contact Lenses: Multifocal contact lenses are designed to correct both distance

and near vision simultaneously. Recent advancements have improved the design and fitting of

these lenses, making them a viable option for myopia control. They work by creating a myopic

defocus on the peripheral retina, which has been shown to slow down the progression of myopia

in children.

2. Orthokeratology (Ortho-K): Ortho-K lenses are specially designed gas-permeable lenses

that are worn overnight to reshape the cornea temporarily. They correct myopia and also induce

peripheral myopic defocus during waking hours, which has been linked to myopia control effects.

Recent lens designs and materials have enhanced comfort and efficacy, making ortho-K a

popular choice for myopia management.

3. Peripheral Defocus Contact Lenses: These lenses are designed to alter the peripheral optics

of the eye in a way that slows the progression of myopia. By creating myopic defocus in the

peripheral retina, these lenses aim to reduce the stimulus for axial elongation of the eye.

4. Soft Bifocal Contact Lenses: These lenses incorporate different prescriptions for distance and

near vision. Similar to multifocal lenses, they induce myopic defocus on the retina and show

promise in managing myopia progression.

5. Customized Contact Lenses: Advancements in technology have enabled the creation of

personalized contact lenses based on an individual's corneal shape and visual needs. Customized

21
designs optimize the optical properties of the lens for each wearer, potentially leading to

improved outcomes in myopia control.

6. Atropine-Infused Contact Lenses: Atropine eye drops have been used for myopia control,

but recent innovation involves incorporating low-dose atropine within contact lenses. This allows

for controlled delivery of the medication, minimizing side effects while providing myopia

control benefits.

7. Dual-Focus Contact Lenses: These lenses have a central zone for clear vision and a

peripheral zone designed to create myopic defocus. This dual-focus design aims to slow down

the elongation of the eye and reduce myopia progression.

8. Combination Therapies: Some practitioners are exploring the benefits of combining different

myopia control methods, such as wearing multifocal contact lenses during the day and ortho-K

lenses at night. This approach aims to leverage the strengths of each method for enhanced

myopia management.

These advancements demonstrate the growing focus on myopia control and the role that contact

lenses can play in managing its progression. As research continues and technology evolves, the

field of contact lens practice is likely to see even more innovative approaches to address the

global rise in myopia.

Advances in Presbyopia Management

As a clinician, I am aware that over the past decade, there has been another slowly but definitely

incrementally improving area of subspecialization: that of presbyopic contact lens correction.

The people to whom we clinicians, and our patients, owe thanks for this development are mostly

22
unknown (at least not known to me) optical engineers and designers at large and small contact

lens manufacturers who have developed relatively successful presbyopic lens designs for

(primarily) simultaneous vision through a slow iterative process.

Contact lens options for presbyopia include single vision distance contact lens correction with

reading spectacles providing the required near addition, monovision correction, or a bi-

/multifocal correction based on alternating or simultaneous image principles(Charman,

2014).Here are some notable developments in the field of contact lens practice and application

for presbyopia.

1.Monovision and enhanced monovision correction involves correcting one eye for optimal

distance viewing and the alternate eye with a single vision near or bi-/multifocal contact

lens(Benneth, 2008).Although typically less expensive and perceived as easier to fit compared to

multifocal lens designs, a major limitation with monovision is a reduction in stereopsis and

contrast sensitivity,both important for critical visual tasks such as driving(Collins, Brown, &

Bowman, 1989).

2.Multifocal contact lenses accommodate multiple refractive prescriptions. Contact lens selection

and a comprehensive pre-fitting evaluation are important in multifocal lens wear, due to patient

satisfaction relying strongly on lens centration, pupil size, ocular optics, and neural

adaptation.The success of multifocal contact lenses can vary substantially across individuals due

to differences to blur tolerance, ocular aberrations and neural adaptation.According to Remón et

al. (2020), bifocal and multifocal contact lenses have been investigated for their potential use in

managing presbyopia and controlling myopia.

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3.Hybrid Lenses: These lenses combine features of both soft and rigid gas permeable lenses.

They provide the comfort of soft lenses with the visual clarity of rigid gas permeable lenses,

making them suitable for presbyopic patients.

4.Scleral Lenses: Scleral lenses are large-diameter lenses that vault over the cornea and rest on

the sclera (white part of the eye). They can be designed with multifocal optics to address

presbyopia while also correcting other vision issues like astigmatism and irregular corneas.

5.Extended Depth of Focus (EDOF) Lenses: These lenses enhance a continuous range of vision

by manipulating the depth of focus, allowing patients to see well across multiple distances

without distinct zones.

6.Customized Lenses: Advances in manufacturing technology allow for highly personalized

contact lenses. Custom designs can account for individual eye anatomy and visual needs,

optimizing comfort and vision quality.

7.Simultaneous Vision Lenses: These lenses provide simultaneous vision correction for distance

and near vision by splitting light entering the eye between two focal points. While there might be

an initial adaptation period, many users find success with this approach.

8.Aspheric Designs: Modern aspheric multifocal contact lenses optimize optical quality,

minimizing visual disturbances like halos and glare that were common with earlier multifocal

designs.

9.Daily Disposable Options: The convenience of daily disposable lenses has extended to

multifocal designs as well. This eliminates the need for cleaning and maintenance while

providing a fresh lens every day.

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10.Toric Multifocal Lenses: These lenses address both presbyopia and astigmatism, offering

clear vision at varying distances for patients with astigmatism.

11.Advanced Materials: New materials with improved oxygen permeability enhance comfort and

overall eye health for extended contact lens wear.

Although the extent to which multifocal and monovision lenses are prescribed for presbyopia

varies considerably by country, an international survey report in 2011 revealed the rate of

multifocal soft contact lens prescribing was over 3 times greater than that for monovision soft

contact lenses (25% compared to 7%), with survey results revealing an overall low rate of

presbyopic contact lenses prescribing.However, in more recent years the multifocal market share

has grown due to technological advances in lens design, materials and manufacturing methods,

as well as the availability of various lens replacement options and the increased practitioner

confidence.Although such technological advances may attempt to satisfy the complexity of

presbyopic treatment requirements, the development of age-related conditions such as dry eye

may hinder patients’ lens-wearing experience in terms of vision and comfort.

Females are more likely than males to wear contact lenses for presbyopia, owing in part to

cosmetic reasons.In a survey of 14,690 patients in the UK, women were twice as likely to have a

presbyopic contact lens correction,and an Irish study found that 65% of the patients (N=97)

undergoing surgical compensation of presbyopia and additional ametropia were female.

25
Advances in contact lens practice and application have revolutionized the management of

presbyopia, catering to various patient needs and preferences. Here are some in-depth insights

into these advancements:

1. Precision Design: Modern presbyopic contact lenses are designed using advanced computer

modeling and simulation techniques. This precision design allows for better control of the optics,

minimizing visual disturbances and maximizing visual clarity at all distances.

2. Diffractive and Simultaneous Vision Designs: Diffractive contact lenses split light into

different focal points, enabling clear vision at varying distances. Simultaneous vision designs

provide multiple prescriptions in different parts of the lens, allowing the brain to automatically

choose the appropriate focal point.

3. Center-Near and Center-Distance Designs: These designs have a central area optimized for

either near or distance vision, while the peripheral areas provide the opposite prescription.

Wearers can look through the center for their desired distance, providing a natural transition

between visual tasks.

4. Neuroadaptation Training: With advanced multifocal lens designs, optometrists now offer

neuroadaptation training to help patients adjust to the lenses more quickly. This training involves

specific exercises to improve the brain’s ability to switch between different prescriptions

seamlessly.

5. Customized Fitting Process: Optometrists use advanced corneal mapping and measurement

technologies to create customized contact lens designs tailored to each patient’s unique eye

shape, size, and visual requirements.

26
6. Hybrid Lens Technology: Hybrid lenses combine the benefits of rigid gas permeable and soft

contact lenses. The rigid center provides crisp vision, while the soft skirt enhances comfort.

These lenses are particularly beneficial for presbyopic patients who need both distance and near

corrections.

Advances in Flexible Contact Lenses

There have been many advances in flexible contact lenses in recent years,
making them more comfortable, versatile, and capable of providing a wider range
of benefits. Some of the most notable advances include:

The development of new materials that are more flexible and biocompatible:This
has made it possible to create contact lenses that are more comfortable to wear
and less likely to cause eye irritation.
The miniaturization of electronic components: This has allowed researchers to
integrate sensors, microprocessors, and other electronic devices into contact
lenses, making them capable of monitoring eye health, delivering medication,
and even displaying information.
Advances in manufacturing technique:. These advances have made it possible to
produce flexible contact lenses that are more precise and consistent in their
quality.
As a result of these advances, flexible contact lenses are now being developed
for a wide range of applications, including:

Vision correction: Flexible contact lenses can be used to correct nearsightedness,

farsightedness, and astigmatism.
Eye health monitoring: Flexible contact lenses can be used to monitor eye
pressure, glucose levels, and other important health indicators.
Medication delivery: Flexible contact lenses can be used to deliver medication
directly to the eye, which can be helpful for treating conditions such as glaucoma
and dry eye.
Information display: Flexible contact lenses can be used to display information
such as the time, date, and weather conditions.
27
The future of flexible contact lenses is very promising. As research and
development continues, we can expect to see even more advances in the years
to come. Flexible contact lenses have the potential to revolutionize the way we
treat eye diseases, manage our health, and interact with the world around us.

Here are some additional examples of recent advances in flexible contact lenses:

In 2022, researchers at the University of California, Berkeley developed a flexible

contact lens that can deliver medication to the eye for the treatment of glaucoma.
In 2021, researchers at the University of Illinois at Urbana-Champaign developed
a flexible contact lens that can monitor glucose levels in tears for the early
detection of diabetes.
In 2020, researchers at the University of Toronto developed a flexible contact lens
that can display information such as the time, date, and weather conditions.
These are just a few examples of the many advances that are being made in
flexible contact lenses. As research and development continues, we can expect
to see even more innovative and life-changing applications for this technology in
the years to come. Smart Contact Lenses: Looking into the Future" by
I'MNOVATION #Hub (2022) link: https://www.imnovation-hub.com/science-and-
technology/smart-contact-lenses/

Advances in Contact Lens Practice" by Contact Lens Spectrum (2012) link:

https://www.clspectrum.com/issues/2012/may-2012/advances-in-contact-lens-
practice

Advances in Inflammation Treatment

When I graduated optometry school in 1972, most clinicians thought that extending contact lens

wear through one or more overnight (sleep) cycles could be physiologically dangerous, but we

all saw the occasional patient who, over our objections, would tell us of such experiences

without much effect. In my experience, I recall patients who suffered substantial corneal

28
vascularization following noncompliant PMMA contact lens wear—or use of thick edged e.g.

toric soft lenses but I recall no corneal infections from such contact lens use.

When soft lens extended wear became a popular modality a decade later, however, it did not take

long before emergency rooms saw a dramatic increase in patients presenting with corneal

infections primarily associated with extended wear. I know, because I was there (Weissman et al,

1984). This experience continues today (Lee et al, 2011)

At first manufacturers thought that lens disposability would solve this problem by eliminating

exposure to potentially contaminated and/or toxic solutions. Then, when this first paradigm

failed, enhanced oxygen permeability (silicone hydrogels) became the proposed “Holy Grail”

answer. Unfortunately, while both advances resulted in improved lens tolerance and much

improved corneal physiology, neither has changed the rate at which microbial corneal infection

occurs during extended wear (Schein et al, 2005).

We are making progress in understanding the pathophysiology of several types of corneal

infection thanks to researchers such as Drs. Suzanne Fleiszig (2010), Charlotte Joslin (2010), and

Mark Willcox (2011). However, for an obscure reason or reasons, it is clear that lens wear

extended through one or more sleep cycles increases bacterial corneal infection risk, especially

with the gram negative bacteria Pseudomonas sp. Fleiszig has proposed that the in-vivo corneal

surface has many interacting anti-bacterial defenses only surmounted by multiple failures and

microbes “educated” by exposure of some time length to our cells. Such advances in our

understanding may soon change the way we manage patients to preclude such events as well as

the way we treat patients suffering such disease.

29
Acanthamoeba sp. (not a bacteria, but a protozoa) keratitis infections (AK) are more associated

with poor lens care, especially exposure of the lenses and/or cases to non-sterile waters, than

with extended wear. Although it is clear that AK is a very rare event, it is catastrophic for

patients: horribly painful and often blinding. Well-known failures of two multipurpose lens care

solutions since withdrawn from the contact lens marketplace have added to our understanding of

how to protect patients from such risks.

In addition to our enhanced understanding of both avoidance and treatment strategies, research

suggests that pre-immunization may be a most successful management strategy for AK in

particular (Alizedeh, 1995).

Gell and Coombs (1963) organized our understanding of non-infection driven inflammation into

four types, the first of which is classic allergy, a mast cell-IgE mediated response. Other distinct

and different forms of hypersensitivity commonly encountered during contact lens practice

include contact derma-titis. Toxicity is distinguished by being a non-immunological mediated

broad spectrum reaction to a universally noxious substance. Allansmith et al (1977) recognized

the initial Gell Combs type 1 ocular complication of contact lens wear (giant papillary

conjunctivitis), but as the era of hypoxia fades, the era of immune response surfaces.

The understanding of this collection of responses that lead to similar types of suffering in the

eyes and adnexa (conjunctival injection, discharge, itching, burning, etc.) is complicated by the

interwoven and still poorly understood role of tear insufficiency (dry eye) and by the danger of

possible clinical confusion with direct microbial infection. We are slowly learning more and un-

teasing more parts of this puzzle.

30
The clinician's role is to first distinguish non-infectious immune response from infection. Ocular

infection must be treated aggressively and appropriately to reduce the risk of vision loss through

corneal scarring/distortion and further damage to other ocular structures. If ocular infection has

been eliminated from the differential diagnosis, then reducing the signs and symptoms of often

inappropriate non-infectious driven immunological response becomes the clinician's objective.

Fortunately, we are gaining many enhanced pharmacological tools to assist us in managing non-

infectious inflammation, including mast cell stabilizers, antihistamines, and immunomodulators.

I suspect that the pharmologic industry will provide us, and our patients, with ever more finely

directed drugs as we progress into the 21st century. CLS

31
 POSSIBLE FUTURE OF CONTACT LENS PRACTICE

Introduction

The future;

As contact lenses that mediate drug release become more widely available, eye care practitioners

(ECPs) may begin to consider the clinical and commercial implications of this novel lens

category on their own practice. As yet, data on practitioner and patient views towards drug

eluting lenses remains limited and the early evidence is mixed.22-25 Further work investigating

safety, tolerability and efficacy could help in understanding the likely uptake by patients and

practitioners. The expert predicts that future lenses will be able to monitor eye pressure, look for

glaucoma (a disease that damages the optic nerve) and even produce images of the retinal

vasculature for the early detection of hypertension, stroke and diabetes. With contact lenses in

the future, glance at the passengers in a subway car is enough to see that cell phones have

changed how we communicate (and not communicate). However, it is also clear that the

evolution of these terminals has been slowing down. While a decade ago there were qualitative

leaps forward, today manufacturers announce a larger number of cameras or megapixels. Could

we be on the verge of a technological breakthrough? Augmented and mixed reality and the

development of new contact lenses and smart glasses suggest we are.

There are several lens subcategories that fall under the umbrella of the ‘smart lens’, a brief

overview is provided below

Disease monitoring lenses;

32
 DISEASE MONITORING CONTACT LENSES

Disease monitoring contact lenses, also known as Smart Contact Lenses, are a

type of wearable technology designed to monitor various health parameters through

the eye. They can be equipped with sensors to measure things like glucose levels for

diabetes management or intraocular pressure for glaucoma monitoring. These lenses

could provide real-time data to users and healthcare professionals, helping in early

disease detection and management.

Glucose Monitoring: Some companies were working on contact lenses that could

measure glucose levels in tears, offering a non-invasive way for diabetes patients to

monitor their blood sugar levels without pricking their fingers. These lenses could

transmit data to a mobile device for real-time monitoring.

Intraocular Pressure Monitoring: Glaucoma patients could benefit from contact

lenses that measure intraocular pressure, a key factor in glaucoma management. These

lenses could help individuals and their doctors track pressure changes and adjust

treatments as needed.

Augmented Reality: While not strictly for disease monitoring, there were

developments in creating contact lenses with augmented reality capabilities. These

lenses could overlay digital information onto the user's field of vision, opening up

possibilities for enhanced visual experiences and applications.

Ocular Surface Health Monitoring: Some smart contact lenses were being designed

to monitor the health of the ocular surface. These lenses could detect early signs of
33
conditions like dry eye disease or corneal infections by analyzing tear composition

and other factors.

ADVANTAGES:

Non-Invasive Monitoring: Disease monitoring contact lenses offer a non-invasive

way to collect real-time data about various health parameters. This can be particularly

beneficial for individuals who dislike or struggle with traditional monitoring methods,

such as frequent blood tests.

Continuous Monitoring: These lenses can provide continuous monitoring of health

parameters, allowing for more accurate tracking of fluctuations and trends over time.

This is especially valuable for conditions that require constant management, like

diabetes or glaucoma.

Early Detection: The real-time data provided by these lenses can help in the early

detection of changes or abnormalities, allowing for timely medical intervention and

better disease management.

Convenience: Wearing a contact lens is often more convenient than carrying around

monitoring devices or having to visit a medical facility for tests. Users can go about

their daily activities while still benefiting from continuous monitoring.

DISADVANTAGES:

Limited Availability: These lenses are still in the development and research stages.

This means that they might not be widely available to the general public yet.
34
Cost: The initial cost of these advanced contact lenses might be higher than

traditional contact lenses, making them less accessible to some individuals.

Additionally, the costs associated with maintenance, calibration, and data transmission

could add up.

Comfort and Fit: Some users might find it uncomfortable to wear these specialized

lenses for extended periods. Ensuring a proper fit and comfort level could be a

challenge, particularly if the lenses incorporate sensors or electronics.

Data Security and Privacy: The data collected by these lenses, especially if

transmitted to external devices, raises concerns about data security and privacy.

Safeguarding sensitive health information is crucial, and any vulnerability could have

serious consequences.

Reliability: Like any technology, there could be issues with the reliability and

accuracy of the sensors and data collected by these lenses. Calibration, maintenance,

and calibration drift could impact the accuracy of the monitoring.

It's important to note that these advantages and disadvantages might evolve as the

technology matures and becomes more widely available.

To overcome the need for home finger-prick blood tests, companies such as Microsoft and

Google have tried developing contact lenses for monitoring tear glucose levels.

35
Several approaches have been proposed including use of graphene sensors;302 and boronic acid

based attempts to develop lenses that fluoresce in the presence of raised glucose.36-37 Thus far,

there seems to be little in the way of commercially available products.

Intraocular pressure (IOP);

The Sensimed Triggerfish contact lens is a FDA approved and CE marked device for measuring

diurnal intraocular pressure fluctuations for periods of up to 24 hours, intended for use in

individuals at risk of glaucoma.38 A strain gauge sensor, embedded within the soft disposable

contact lens, detects changes in corneoscleral shape. Information is then sent wirelessly to an

adhesive external antenna, attached near the eye, before being passed onto a wearable portable

recorder.39 At the end of the recording period, the recorder data can be transferred to the

practitioner. The intention is to monitor fluctuations in IOP; these are recorded in millivolts,

unlike conventional IOP measurements which are recorded in millimetres of mercury, thus

making it difficult to draw direct comparisons with conventional tonometry readings.

Other novel proposals to measure IOP, using contact lenses, have included development of

materials that change colour in response to pressure and moisture changes.

Dry eye;

Dry eye related conditions are linked to the presence of various biomarkers within the tears.42-

43
There is potential to both detect and treat dry eye conditions using smart contact lenses.

There have also been reports that biomarkers for Parkinson’s disease, multiple sclerosis and

possibly for some types of cancers may be present in the tears,45-58thereby extending the

diagnostic potential of smart contact lenses to beyond ocular conditions.

36
  Enhancing vision;

Accommodative

In addition to disease detection, smart contact lenses have been used to enhance vision, including

proposals to develop accommodating contact lenses for presbyopes

While several approaches have been put forth one which is supported by growing research

interest is the use of liquid crystal (LC) cells. A small change in voltage brings about large

changes in refractive index and thus lens power. Activation could potentially be via an external

device, eg a smartwatch, or possibly through deliberate blinking.

Digital smart lenses

Augmented reality, mixed reality and virtual reality, are terms found more often among tech

blogs than the optical press (see figure 2), but this has gradually been changing over the past

decade. Frequent reports of smart glasses and contact lenses detail prospective features that

include displaying of digital alerts such as text messages, weather information and the potential

to capture images and video recording. Several tech giants such as Sony and Samsung have been

granted patents relating to smart contact lenses with the most recent press releases reporting on a

collaboration between Menicon and Mojo Vision

37
In addition to the entertainment and novelty aspects, smart lenses also possess the potential to

help aid navigation, object detection and to magnify aspects of the visual environment; all

potentially useful applications for individuals with visual impairment.

The delays in these, sometimes theoretical, products reaching the market are a likely mix of

technical and regulatory challenges. The microelectronics need to be small and lightweight

enough to not impede oxygen permeability, positioned to avoid negative impact on vision, while

retaining lens dynamics and comfort. An added challenge is displaying the digital images in such

a way that is both visible, but not obstructive.

The future

Most smart contact lenses remain in a developmental stage. While newer materials and

technological advances may overcome any technical hurdles,31 wider discussions about privacy,

safety, and the role ECPs might play, will all need to take place.

Myopia management with contact lenses

It is reported that almost half the world’s population will be myopic by the year 2050;63 but a

statistic of greater significance to practitioners in the UK and Ireland is that Western Europe is

expected to reach this unfortunate milestone around a decade earlier. In fact, by the year 2030, an

estimated ~45% of the population in Western Europe will have already become myopic 43.

Axial myopia is attributed to a discord between increasing axial length and the refractive

capabilities of the cornea and crystalline lens.64 Typically, a 1mm increase in axial length equates

to approximately ~2.5 to 3DS of axial myopia,65-66 but differences can exist between different

demographics.

38
Earlier onset is often linked to greater risk of progression to higher levels of myopia.67 For most

individuals, progression will stabilise by the late teens,68-69 however, an unlucky minority may

continue to progress beyond this point.68-69 As myopia and axial length increase, so too does the

risk of developing sight threatening disorders.70 Hence, inhibiting the onset of myopia, or at least

minimising the risk of high myopia, could yield significant benefits.

The reasons underlying escalating myopia prevalence are believed to be multifactorial. Exposure

to a myopigenic environment (a lack of time outdoors, near work, pursuit of higher education),71-

73
may increase an individual’s risk of developing myopia, elements of which may be further

compounded by an existing genetic predisposition 74.

Theories of myopia development and progression are wide-ranging, but the design of many

myopia inhibiting contact lenses relies, in some way, on the concepts of relative peripheral

hyperopia (see figure 3) and/or accommodative lag.

Methods of myopia management using contact lenses

While time outdoors may deter the onset of myopia, for individuals who are already myopic

various myopia inhibiting solutions are gradually making their way to market. Current solutions

include spectacle lenses, contact lenses and on the horizon is the potential for myopia specific

pharmaceutical preparations.

Rigid gas permeable corneal lenses

Some older texts advocated the use of rigid corneal lenses to manage myopia, while this practice

has now largely fallen out of favour it still persists in some parts of the world.75 There is,

39
however, limited evidence of a genuine treatment effect.76 Any positive impact is thought to be

linked to a mechanical flattening of the cornea rather than a slowing of axial elongation.

Orthokeratology in myopia

Orthokeratology (OK) has long been used as a reversible non-surgical alternative to refractive

surgery. Lenses are worn at night to temporarily reshape the cornea providing temporary relief

from refractive error during the day.77-78 While in this article OK is referred to in the context of

correcting myopic refractive error, the technique has also been used to correct hyperopic,

presbyopic and astigmatic errors.

OK affords freedom from spectacles and contact lenses during most waking hours, however,

towards the end of the day corneal shape may begin to recover, causing a regression effect76-77 of

around ~0.50-0.75D. To counter this, a small amount of overtreatment is often incorporated.

OK (or reverse geometry) lenses are unlike the rigid corneal lens designs intended for daily wear.

There is a greater need for high oxygen transmissibility; stability, to ensure the same part of the

cornea is treated consistently and, of course, a requirement to temporarily reshape corneal

geometry.79 The latter is achieved through use of a flat central base curve and the incorporation

of a secondary lens curve that is relatively steeper than both the central and peripheral curves.

This arrangement creates a tear reservoir or ‘reverse zone’ that facilitates lens stability while

permitting rapid changes to corneal shape.

During lens fitting and aftercare appointments the cornea is closely monitored. Corneal staining

and lens binding are common complications associated with OK,79,82 but among the most serious

potential complications is microbial keratitis; the risk of which increases due to overnight lens

wear.
40
It is now well established that use of OK can inhibit axial length increase and therefore impede

myopia progression.76,81 While the mechanisms underlying this inhibitory effect are unclear,

some researchers have attributed it to a redistribution of corneal cells, in which there is central

corneal flattening, compared to relative steepening more peripherally.82 In line with the theories

of peripheral hyperopia; changes to corneal morphology could, therefore, both reduce central

myopia and induce peripheral myopic defocus.83 Others suggest an increase in higher order

aberrations84 or changes to accommodative response may also play a role.

The introduction of OK lenses specifically for myopia management may signify the growing

interest of manufacturers in this area of practice. Yet questions remain, including a need for

further clarity and consensus around a potential rebound effect, the underlying mechanisms for

the myopia inhibition effect and a need for longer-term data in some population groups.

Soft contact lenses for myopia management

Until recently a lack of licensed soft lens products, for myopia management, led some ECPs to

off-label prescribing of multifocal lenses intended for presbyopia. While these lenses generated

pockets of impressive data, a published review of myopia management, that was limited to

randomised controlled trials (RCTs), concluded bifocal soft contact lenses were of little

benefit. Nevertheless, since this landmark review was undertaken, several key RCTs of soft

lenses for myopia management have now been published, demonstrating an impressive slowing

of both axial elongation and myopia using dual focus and extended depth of focus lenses.

Evidence is still emerging and recent work has shown how manipulation of the lens add can lead

to further improvements in outcomes.76 Future developments may give rise to a broader range of

myopia management options including greater soft lens provisions for myopic astigmats.

41
42
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45