Epidemiology of Refractive Errors An interplay among corneal power, lens power, anterior chamber depth, and axial length

determ ines an individual's refractive status. A1l 4 elements change continuously as the eye grows. On average, babies are born with about 3.0 D of hyperopia. In the first few months of life, this hyperopia may increase slightly, but it then declines to an average of about 1.0 D of hyperopia by age I, because of marked changes in corneal and lenticular powers, as well as axial length growth. By the end of the second year, the anterior segment attains adult proportions; however, the curvatures of the refracting surfaces continue to change measu ra bly. One study found that average corneal power decreased O. I - 0.2 D, and lens power decreased about 1.8 D, between ages 3 and 14 years. From birth to age 6 years, the axial length of the eye grows by approximately 5 mm, and one might expect from this a high prevalence of myopia in infants. However, most children are actually emmetropic, with only a 2% incidence of myopia at 6 years. This phenomenonis due to a still undetermined mechanism called emmetropization. During the first 6 years of life, as the eye grows by 5 mm, a compensatory loss of 4 D of corneal power and 2 D of lens power keeps most eyes close to emmetropia. It appears that the immature human eye develops so as to reduce refractive errors.

Prevention of Refractive Errors Over the years, many treatments have been proposed to prevent or slow the progression of myopia. Optical correction in the form of bifocal spectacles, multifocal spectacles, or removal of distance spectacles when performing close work has been recommended to reduce accommodation, because accommodation is a postulated mechanism for the progression of myopia. Administration of atropine eyedrops has long been proposed to prevent progression of myopia because it inhibits accommodation, which may exert forces on the eye that result in axial elongation. Use of an agent that lowers intraocular pressure has been suggested as an alternative pharmacologic intervention; this agent works presumably by reducing internal pressure on the eye wall. It has also been postulated that use of rigid contact lenses could slow the progression of myopia in child ren. Visual training purported to reduce myopia includes exercises such as near-far focus ing change activities and convergence exercises. Evidence reported in the peer-reviewed literature, including from randomized clinical trials, is currently insufficient to support a recommendation for intervention using any of these proposed treatments.

Treatment of Refractive Errors The need to correct refractive errors depends on the patient's symptoms and visual needs . Patients with low refractive errors may not require correction, and small changes in refract ive corrections in asymptomatic patients are not generally recommended. Correction

options include spectacles, contact lenses, or surgery. Various occupational and recreational requirements as well as personal preferences affect the specific choices for any individual patient.

VAUGHAN

Lensa Kontak Contact lenses are now widely used. There are basically two types of contact lenses hard and soft. Hard contact lenses have been available for about 30 years. However, they are not as comfortable to wear and require careful fitting. For this reason, soft lenses have become more popular, being easy to fit and well-tolerated. Optically, contact lenses function in the same way as glasses. They help to focus the image sharply on the retina. There are several reasons why contact lenses are used. The most common one is cosmetic. The lenses are very popular with young female myopic patients who are willing to tolerate any discomfort or inconvenience in order to improve their appearance. Contact lenses are also used by sportsmen who find that glasses fog with perspiration and by stage or television personalities who find it less attractive to wear glasses. They may be contraindicated in dusty or industrial conditions. Soft contact lenses are sometimes used therapeutically to bandage a corneal ulcer which fails to heal or to prevent discomfort from chronic corneal epithelial disturbance. Complications A common complication, especially with hard lenses, is overwear. This leads to corneal oedema. The patient gives a history of having used the lenses longer than usual. He complains of pain, watering, photophobia and eyelid spasm (blepharospasms). Because of complications, any contact lens wearer who complains of persistent pain or discomfort should have the cornea assessed by an ophthalmologist. The main problem with soft contact lenses, however, is the risk of corneal infection which may lead to corneal ulcers and blindness. Another problem with soft lenses is the development of giant papillary conjunctivitis due to a hypersensitivity reaction. The patient complains of redness, itching, irritation and mucoid discharge. Eversion of the upperlid will reveal characteristic giant papillae. If severe, the patient should stop wearing the contact lenses.

Contact lenses have changed dramatically since their basic optical concept was described first by Leonardo da Vinci in the sixteenth century and later by Ren Descartes in the seventeenth century. [1] [2] Many large textbooks are devoted exclusively to the subject of contact lenses; in this chapter an overview is presented. About 35 million people in the United States wear contact lenses, constituting about 20% of those who use refractive correction.[3] The major use of contacts is to correct myopia, but contact lenses are also used to correct hyperopia, astigmatism, presbyopia, and aphakia. Rigid contact lenses are often the best type to correct for irregular corneal surfaces, as found in keratoconus, corneal trauma, and penetrating keratoplasty, and, sometimes, after radial keratotomy. Soft contact lenses may be used as a therapeutic bandage for some conditions, such as bullous keratopathy and recurring corneal erosion, and also to improve comfort, vision, and wound healing in the immediate postoperative period after photorefractive keratectomy. LENS TYPES AND USAGE Types of lenses available include rigid lenses, typically gas permeable (GP) lenses, conventional soft lenses (hydrogels), and silicone hydrogels. Daily wear (DW) contact lenses are worn during the day; after removal, they are cleaned and disinfected. The first extended wear (EW) contact lenses were designed to be worn day and night for periods of 17 days, which was the maximum continuous wearing period approved by the Food and Drug Administration (FDA). They must then be removed, cleaned, and disinfected.[5] In 2001, the FDA approved a lens made from a silicone hydrogel material for continuous wear of up to 30 days and nights. Since then, other silicone hydrogel materials and a GP material have also been approved for continuous wear of up to 30 days and nights. Mandatory postmarketing surveillance is required as part of the approval in order to determine the true level of safety and efficacy under real-life conditions and for more patients than were involved in the research required for approval. For example, 5000 subject years are required to assess the incidence of microbial keratitis. Conventional soft DW and EW lens materials are basically the same, and so too are their oxygen permeability (Dk) values. Although these values are generally sufficient for DW, they are about one third of those required for EW.[6] The resultant EW hypoxia and insufficient soft lens hydration and cleanliness during sleep increase significantly the probability of infectious and inflammatory tissue reactions in relation to the continuous duration of wear. For example, microbial keratitis is 1015 times more common with conventional EW lenses than with DW.[7] The vast majority of contact lens clinical researchers advise most patients against conventional soft lens EW, except for occasional periods of short duration. Some GP materials have a high

enough oxygen transmissibility (Dk/t) value to satisfy the corneas oxygen needs with EW; however, owing to problems such as binding and increased corneal distortion, only a small percentage of patients are fitted for GP EW. The Dk/t values of silicone hydrogel materials seem to be adequate for EW and researchers believe that it is safer for many patients to use them for EW. The lenses are treated in gas plasma-reactive chambers to transform the hydrophobic surfaces to a hydrophilic state, which is necessary for adequate in vivo wetting and resistance to formation of deposits. Contact lenses with a GP central portion attached to a hydrogel skirt have been developed. Current versions have been improved by use of a higher Dk/t GP portion and an enhanced attachment of the hydrogel skirt. Disposable Contact Lenses The use of disposable and programmed replacement soft contact lenses has grown enormously since their introduction in 1986.[8] When made from the same basic materials as conventional DW and EW soft lenses, their Dk/t values are insufficient for EW but silicone hydrogel lenses are available for that programmed replacement regimen. The uniqueness of disposable programmed replacement lenses lies in the manufacturing techniques that produce lenses inexpensively and with relatively good reproducibility; this reduces the per lens cost to patients. Should patients replace their lenses daily, weekly, monthly, quarterly, semiannually, or annually? The answer is different for each patient and is determined by safety, efficacy, economic, and convenience factors. Colored Lenses Soft and rigid lenses can have very light tints to improve their visibility when off the eye and to aid the patient in handling them. Soft and rigid lenses that alter the apparent eye color are available in cosmetic enhancement tints for people who have lighter eyes and opaque tints for people who have darker eyes. Such soft lenses typically have a clear central area of about 4 mm for visual purposes and a clear annular peripheral area of about 1 mm that overlies the sclera.

INITIAL FITTING Two general methods exist to fit contact lenses. First, in the measurement and standard procedures used to determine the parameters, readings are taken of the corneal curvature using keratometry or videokeratography and measurements are made of the horizontal iris diameter, vertical palpebral aperture, and pupil diameter. These findings then are related to nomograms to determine the contact lens parameters to be ordered. Second, in the diagnostic lens procedure, the preceding measurements are made first. Next, the appropriate lens is selected from the

practitioners contact lens trial set, inserted on the patients eye, and allowed to settle for 1520 minutes. With corneal lenses this is necessary so that the initial lacrimation decreases; with soft lenses it is necessary because the temperature on the eye is greater than the ambient temperature, which forces fluid out of the lens (i.e., the lens must equilibrate).[14] Then the position, movement, and relationship between the back surface of the contact lens and the front surface of the eye are evaluated in relation to criteria for a good fit. Corneal lenses are fitted for either superior positioning or intrapalpebral aperture positioning. For either of these (with primary fixation) the lens should be centered horizontally and its lower edge should be at least 12 mm above the lower eyelid. The upper edge with a superior positioning lens should be under the upper eyelid, but not over the superior limbus, and with intrapalpebral positioning the upper edge should be just below the upper eyelid. With blinking, the lens should move 12 mm, return to its original resting point, and remain there during the interphase between blinks. The relationship between the back surface of the lens and the front surface of the cornea is evaluated after sodium fluorescein has been applied.[15] Fluorescein mixes with the preocular film between the lens and the cornea and, when activated with a black light, it fluoresces with specific patterns. When the curves of the lens are very different from those of the cornea, the precorneal fluid is deeper and the fluorescence is a brighter yellowish green. Conversely, closer alignment of lens and corneal curves produces a shallow precorneal fluid, less fluorescence, and a bluish black appearance. For corneas that have less than 1.5 D of astigmatism, the desired optic zone pattern is blueblack or a very mild, uniform yellowgreen and the desired secondary zone pattern is a moderately bright yellowgreen