DR Agarwals Textbook On Contact Lenses

Dr Agarwals
Textbook on
Contact Lenses
Dr Agarwals
Textbook on
Contact Lenses
Editors
Sunita Agarwal MS DO
Dr Agarwals Group of Eye Hospitals
Chennai, Bangalore, Jaipur, Trichy, Salem
19 Cathedral Road, Chennai-600 086, India
and
Eye Research Centre
Athiya Agarwal
MD DO

and
Eye Research Centre
Amar Agarwal
MS FRCS FRC Ophth

and
Eye Research Centre
Associate Editors
Guillermo L Simon-Castellvi
MD
Barcelona, Spain
Michael R Spinell
OD FAAO
Pennsylvania, USA
Adrian S Bruce
PhD FAAO
Melbourne, Australia
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Textbook on Contact Lenses
2005, Editors
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or
transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise,
without the prior written permission of the editors and the publisher.
This book has been published in good faith that the material provided by contributors is original. Every
effort is made to ensure accuracy of material, but the publisher, printer and editors will not be held
responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under
Delhi jurisdiction only.
First Edition : 2005
ISBN 81-8061-452-2
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd. A-14 Sector 60, Noida
This book is dedicated to
Larry Laks
a true friend
and
a great human being
Contributors
J Agarwal FICS DOMS FORCE
Chennai, Bangalore, Jaipur, Trichy,
Salem (India)
19 Cathedral Road, Chennai-600 086
India
T Agarwal FICS DO FORCE
Salem (India)
India
Amar Agarwal MS FRCS FRC Ophth
Salem (India)
India
Sunita Agarwal MS
Salem (India)
India
Athiya Agarwal MD DO
Salem (India)
Adrian S Bruce BScOptom PhD FAAO
Senior Optometrist,
Victorian College of Optometry and
Senior Fellow,
Department of Optometry and Vision Sciences,
The University of Melbourne, Australia
Milton M Hom OD FAAO
Private Practice
Azusa, Ca, USA
Arthur B Epstein OD FAAO
North Shore Contact Lens & Vision
Consultants PC
1025 Northern Boulevard-Suite 94
Roslyn, NY 11576
United States
Guillermo L Simon-Castellvi MD
Clinica Oftalmologica Simon
Simon Eye Clinic, Barcelona, Spain
viii
Ashok Garg MS PhD

Garg Eye Hospital
235 Model Town, Hisar
Haryana, India
Suresh K Pandey MD
Intraocular Implant Unit
Sydney Eye Hospital
GPO Box 1614
Sydney, NSW 2001
Scholar, Save Sight Institute
University of Sydney
Sydney, NSW, Australia
Phone +61-2-9382 7433
Fax +61-2-9382 7401
Email : suresh.pandey@gmail.com
Venkatesh Prajna N
Aravind Eye Hospital
Madurai, India
MD
Edward M Wilson MD
Miles Center for Pediatric Ophthalmology
Charleston, USA
Andrea Izak MD
40 Bee St #323
Charleston SC 29403
United States
Soosan Jacob MS DNB FRCS
Salem (India)
David J Apple MD
Centre for Research on Ocular
Therapeutics & Biodevices
Strom Eye Institute
Charleston
USA
Liliana Werner MD
Centre for Research on Ocular
Therapeutics & Biodevices
Strom Eye Institute
Charleston, USA
Tamar A Macky
USA
MD
Rupal H Trivedi MD
India
Michael R Spinell OD FAAO
Pennsylvania College of Optometry and
The Eye Institute
Pennsylvania, USA
Christa Sipos-Ori
Australia
Yuichi Kaji MD
Department of Ophthalmology
University of Tokyo
School of Medicine
Hongo 7-3-1, Bunkyo-Ku
Tokyo, Japan
Jairo E Hoyos MD
Instituto Oftalmologico De Sabadell
Barcelona, Spain
Melania Cigales MD
Barcelona, Spain
Jorge Prades MD
Barcelona, Spain
Fernando Rodriguez-Mier MD
Barcelona, Spain
ix
Contributors
Marta Marsan MD
Barcelona, Spain
Jose Ma Simon-Castellvi
Simon Eye Clinic
Barcelona, Spain
Dra Sarabel Simon-Castellvi

Retina Vitreous Department
Simon Eye Clinic
Barcelona, Spain
MD
Jose Ma Simon-Tor
Simon Eye Clinic
Barcelona, Spain
Dra Cristina Simon-Castellvi

Simon Eye Clinic
Barcelona, Spain
MD
MD
MD
Foreword
The very act of educating our colleagues is laudatory by nature. This is the
goal of most textbooks. Specifically, in this text, Dr Amar Agarwal, known as
both an impressive educator and author, has assembled a group of experts in
field of contact lens analysis, design and fitting. With their intelligent support,
he has attempted to provide us with an in-depth analysis of the theory, science
and art, of contact lens fitting.
Expert authors, in the subjects of physiology, and pathophysiology of the
cornea and tear film, provide a basic understanding of the environment for
successful contact lens fitting.
Building upon these basic scientific principles, specific areas of contact lens applications are then
sorted out. The carefully chosen chapter subjects deal with specific problem areas, which are often
encountered, in the clinical setting. With a problem-solving methodology in mind, tactics of fitting
contact lenses are then discussed.
Each chapter is practical, instructive and, above all, valuable in a rational sense. The step by
step approach adopted by all the authors adds a unique, physician-orientated methodology,
which is easily appreciated by the reader.
The goal of providing one textbook, which can serve as a reference for practicing ophthalmologists
to perfect their ability to use contact lenses for a multitude of therapeutic applications, is skillfully
achieved.
William J Fishkind MD FACS
Fishkind and Bakewall Eye Care
Tucson, USA
Preface
Contact lenses form an integral part of practice even in this age of lasers, phakic IOLs, intrastromal
rings etc and contrary to the common view, fitting of contact lens and its complications is not out of
the preview of the practicing ophthalmologist.
For this purpose, we have tried to bring out a very comprehensive at the same time informative
book about contact lenses by a group of experts in the field. Such a book is incomplete without the
basic knowledge of physiology and pathophysiology of the cornea and tear film. The first section
covers this area, while the second section goes into the details of the various kinds of lenses and the
methodology of fitting. The chapter on contact lenses for children will be especially useful for the
ophthalmologists. The third section covers all the other msicellaneous topics.
This book will be useful for all from post graduates to leading ophthalmologists. It especially
serves as a quick reference to contact lens fittings and its associated problems by delving into how
to deal with them.
Editors
Contents
Section 1: Basics
1. Anatomy of the Cornea, Limbus and Sclera .................................................... 3
Yuichi Kaji
2. Corneal Transparency .................................................................................... 9
Sunita Agarwal, Athiya Agarwal, Amar Agarwal
3. Tear Film Physiology ................................................................................... 13
Ashok Garg
4. Contact Lenses and Ocular Lubrication ....................................................... 34
Guillermo L Simon-Castellvi, Dra Sarabel Simon-Castellvi,
Dra Cristina Simon-Castellvi, Jose Ma Simon-Castellvi, Jose Ma Simon-Tor
5. Contact Lens Materials and Properties ......................................................... 54
Soosan Jacob, Amar Agarwal, Athiya Agarwal, Sunita Agarwal
6. Topographic and Pachymetric Changes Induced by Contact Lenses ............... 57
Melania Cigales, Jairo E Hoyos, Jorge Pradas
Section 2: Contact Lens Designs

and Their Fittings
7. Advanced Orthokeratology ........................................................................... 69
Adrian S Bruce, Christa Sipos-Ori
xvi
8. Rigid Gas-Permeable Contact Lenses .......................................................... 90

Milton M Hom
9. Soft Contact Lens Fitting ........................................................................... 116
Arthur B Epstein
10. Advances in Soft Lens Fitting .................................................................... 136
Adrian S Bruce
11. Special Contact Lens Designs for Unique Problems ................................... 159
Michael R Spinell
12. Contact Lens Fitting in Refractive Surgery ................................................. 184
Ashok Garg
13. Toric Contact Lenses ................................................................................. 193
Ashok Garg
14. Therapeutic Lenses or Bandage Contact Lenses ......................................... 204
Soosan Jacob, Amar Agarwal, J Agarwal, T Agarwal
15. Contact Lenses for Children ...................................................................... 207
Rupal H Trivedi, M Edward Wilson, David J Apple, Suresh K Pandey,
Andrea Izak, Tamer A Macky, Liliana Werner
Section 3: Miscellaneous
16. Acanthamoeba Keratitis ............................................................................ 229
N Venkatesh Prajna
17. Visual Acuity with Contact Lenses versus LASIK in Myopia ........................ 236
Melania Cigales, Fernando Rodriguez-Mier, Marta Marsan, Jairo E Hoyos
18. The Use of Contact Lenses in the Athletic World ........................................ 245
Michael R Spinell
19. Therapeutics of Contact Lens Care System ................................................ 282
Ashok Garg
Appendix 1 .................................................................................................................. 293
Index ........................................................................................................................... 295
Chapter
Anatomy of the Cornea,

Limbus and Sclera
Yuichi Kaji
CORNEA
The cornea composes the outer wall of the eye.
The structure of the collagen fibrils in the corneal
stroma and Descemets membrane is important
in the relative resistant property of the cornea.
In addition, the cornea serves as the principle
refractive surface. For this purpose, the cornea
is clear and transparent with a smooth surface.
Corneal transparency is unique and essential for
good visual acuity and this condition is actively
maintained by the corneal cells especially the
corneal endothelial cells.
Epithelium
The corneal epithelium is the outermost part of
the cornea, which is composed of stratified,
squamous and non-keratinized epithelial cells.
The thickness of the corneal epithelium is 50-90
m and consists of five or six layers of corneal
epithelial cells. The deepest of these is called
basal cell layer. This layer is the germinate locus
of the corneal epithelial cells. This means that
the basal epithelial cells divide and differentiate
into the upper layer of the corneal epithelium
FIGURE 1.1: Corneal epithelium of human eye. Corneal

epithelium is composed of 4 to 5 layers of squamous epithelial
cells. There are called superficial, wing, and basal cells.
The cytoplasm of the epithelial cells become flattened as
they move to the superficial layer. bar = 5 mm
(Figure 1.1). The second layer, wing cells, consists

of polyhedral cells, is located between the most
superficial and inner layer of the corneal
epithelium. The size of the epithelial cells increases
as they move to the superficial layer and the
outermost 1 to 2 layers are called superficial cells.
The metabolism of the corneal epithelial cells
is active. The epithelial cells contain glycogen
granules in their cytoplasm, especially in the wing
Section
and superficial cells. The content of the glycogen

decreases in bacterial infection, wound healing
and soft contact lens wear. The corneal epithelial
cells contain a fine network of intermediate filament and actin filament. The cytoskeleton plays
an important role in maintain the morphology
of the corneal epithelial cells.
The most superficial cells of the epithelium
has microvilli and glycocalyx on its surface. The
structure is important in connecting and
stabilizing the tear film on the superficial corneal
epithelial cells (Figure 1.2).
FIGURE 1.2: High magnification of superficial cells of the

human corneal epithelium. There are a lot of microvilli on the
surface of the superficial cells. Glycocalyx is also observed
on the surface of the cell membrane, which helps to connect
tear film and corneal epithelium. bar = 500 nm
The corneal epithelial cells have special adhesion molecules, which are important in cell-cell
and cell-basement attachment. Adhesion of the
neighboring epithelial cells is almost maintained
by desmosomes and tight junctions. Because the
junction between the epithelial cells is so tight, it
serves as a mechanical barrier to microorganism
and foreign bodies. However, the corneal epithelium has some permeability to small molecules including glucose, sodium, O2, and CO2.
The basal cells have numerous hemidesmosomes at the basal side, which help in attachment
to basement membrane of the corneal epithelium. The mechanism of the corneal epithelium
to the basement membrane is discussed in the
next section.
Basement Membrane of Corneal
Epithelium
The basement membrane of the corneal
epithelium is located between the basal cell of
corneal epithelium and the Bowmans layer. By
observation with the electron microscope, the
basement membrane of the corneal epithelium
is divided into two layers: the superficial one is
lamina lucida and the deeper one is lamina
densa. The basement membrane contains type
IV and type VII collagens and glycoproteins such
as laminin and fibronectin.
Basal cells of the corneal epithelium adhere
to the basement membrane and the corneal
stroma using an adhesion complex. Basal cells
of the corneal epithelium have hemidesmosomes on its surface. Fine anchoring fibrils, which
consist of type VII collagen, extend from the
hemidesmosome to the anterior corneal stroma.
The above structure is important for the corneal
epithelial cells to adhere to the corneal stroma
via the basement membrane and Bowmans
layer (Figure 1.3).
The basement membrane is impaired in
diabetic patients. The basement membrane from
diabetic patients is thick and the anchoring fibrils
do not extend into corneal stroma. In addition,
glycation of the basement membrane also
reduces the attachment of corneal epithelial cells.
These changes in basement membrane are
thought to be important for the pathogenesis of
persistent corneal epithelial erosion seen in
diabetic patients.
Anatomy of the Cornea, Limbus and Sclera
Corneal Stroma
FIGURE 1.3: Basal cells of the corneal epithelium. Adhesion

molecules including hemidesmosomes are observed at the
basal side of the corneal epithelial cells. These adhesion
molecules play an important role in attachment of the corneal
epithelium and the corneal stroma via the basement
membrane and Bowmans layer. bar = 2 mm
The corneal stroma is located between the

Bowmans layer and the Descemets membrane,
comprising about 90 percent of the corneal
thickness. The corneal stroma is composed of
extracellular matrix and scattered keratocytes
(Figure 1.4). Collagen is the major structural
component of the corneal stroma, accounting
12 to 15 percent of its dry weight. In the corneal
stroma, type I, III, V, and VI collagens are
detected. Among them, type I and type VI
collagens are thought to be the major collagen
of the corneal stroma consisting of 50-55 percent
and 25-30 percent of all the corneal stromal
collagen, respectively.
Section
Bowmans Layer
Bowmans layer is a uniform layer, 8 to 14 m

in thickness, and is beneath the corneal epithelial
basement membrane. Although the Bowmans
layer was once regarded as a specialized corneal
membrane, it is now thought of as part of the
anterior stroma. Bowmans layer has numerous
pores, which transmit the epithelial branch of
the corneal nerves.
Ultrastructurally, Bowmans layer consists of
fine meshwork of fine collagen fibrils of uniform
size. Recent study revealed the existence of type
I, III, and IV collagens and proteoglycans in the
Bowmans layer.
Bowmans layer begins to appear in the fourth
month of gestation. Now the Bowmans layer is
thought to be the product of the most superficial
keratocytes and is not produced after birth. Once
destroyed by such causes as trauma or infection,
the Bowmans layer does not reproduce.
FIGURE 1.4: High magnification of human corneal stroma.

Keratocytes with flattened cytoplasm is scattered between
the collagen lamella. The arrangement of the collagen fibrils
are regular, and the interfibrillar spacings of the collagen
fibrils are small. bar = 500 nm
The arrangement of the collagen fibers is

parallel to the surface of the cornea. In addition,
the interfibrillar spacing of the collagen fibers are
very small. This regular packing and arrangement of the collagen fibers creates a lattice or
three-dimensional diffraction grating, and the
Descemets membrane is divided into two

laminated structures. The anterior third of
Descemets membrane is recognized as the fetalband (Figure 1.5). The posterior two-third of
Descemets membrane is called posterior nonbanded zone, which is secreted after birth and
gradually thickens as age advances.
Descemets Membrane
Corneal Endothelium
Descemets membrane is a homogenous layer,

running between the corneal stroma and the
corneal endothelium. Descemets membrane is
the basement membrane of the corneal endothelial cells. The major protein of Descemets
membrane is type IV collagen and laminin, which
is common in the other part of the basement
membrane.
Descemets membrane first appears in the
second month of gestation and is synthesized
throughout life. For this reason, the thickness of
Descemets membrane increases with age: only
3-4 m thick at birth and reaches a thickness of
20-30 m in old age.
Corneal endothelium is a monolayer of hexagonally shaped cells resting on the Descemets

membrane. Mitosis seldom occurs in adult
corneal endothelial cells, so the density of the
corneal endothelial cells decreases with age. As
the density decreases with age, the size of one
endothelial cell increases.
The surface and basal side of the plasma
membrane is quite flat. In contrast, there are
many interdigitations between the neighboring
endothelial cells, where gap junction and tight
junctions are observed. Microvilli are observed
in the posterior surface of the endothelial cells,
which may help to increase the area of contact
Section
ability of the cornea to scatter 98 percent of the

incoming light is thought to be the consequence
of equal spacing of the collagen fibers. This
condition is maintained by minimal hydration
of the corneal stroma created by corneal
endothelium and small and uniform size of the
ground substances such as keratan sulfate that
separates the collagen fibers with each other.
After the corneal stromal heals following
infection, trauma or surgeries, the corneal stroma
begins to reconstruct. The regenerative corneal
stroma contains inflammation cells and activated
keratocytes. The activated keratocytes secrete
many kinds of cytokines and extracellular matrix
components including type III and type IV
collagens, fibronectin, and laminin. As the interfibrillar spacing increases and the arrangement
of the collagen fibers are disordered, the
regenerative corneal stroma becomes opaque.
This corneal stromal opacity, clinically observed
as corneal haze, may be serious in photorefractive surgeries.
FIGURE 1.5: Corneal endothelium and Descemets

membrane of human cornea. Descemets membrane is
divided into anterior fetal and banded layer and the posterior
non-banded layer. One layer of the corneal endothelial cells
attaches to the Descemets membrane. bar = 2 mm
Anatomy of the Cornea, Limbus and Sclera
48 kDa keratin expressed in hyperproliferative

states.
The corneal epithelium is replaced about
once a week. It was conceived that basal cell
layer of the corneal epithelium divides into one
basal cell and one daughter cell, which then
further differentiate into more superficial layers
of the corneal epithelial cells.
The basal epithelial cells are supplied by very
slow division of stem cells (Figure 1.6). It is
reported that the stem cells of the corneal
epithelium lie at the basal cell layer of the limbal
epithelium. Histologically, the stem cell of the
corneal epithelium in the limbal zone is small
with prominent nucleoli. Ultrastructurally, they
show large nucleoli, a lot of bundles of
intermediate filaments and many desmosomes
and hemidesmosomes, which suggest the active
metabolism of the stem cells.
LIMBAL ZONE
The limbal zone is a transitional area between
the cornea and conjunctiva. The characteristic
of the limbal zone is the deficiency in Bowmans
layer or goblet cells. Clinically, the limbal zone is
observed as the circular area with palisading
tissues called palisades of Vogt.
Immunohistochemical study has revealed that
cytokeratin typical of differentiated cells (CK3)
are expressed by corneal epithelial cells and
suprabasal limbal epithelial cells, while basal
limbal cells are negative for these cytokeratins
and positive for a group of acidic cytokeratins
with the antibody AE1, which recognizes a
Section
with aqueous humor, thus facilitating the pump

activity of the corneal endothelial cells. In the
cytoplasm, large number of mitochondria, rough
and smooth endoplasmic reticulum and, Golgi
apparatus are observed. This fact shows that the
endothelial cells have active metabolism.
The corneal endothelium has two major
functions. First, by continuously pumping fluid
and ions out of the stroma into the aqueous, it
helps to maintain the low content of water in
the corneal stroma, which is most important for
corneal transparency. This pumping activity is
energy-dependent and the Na, K-ATPase pump
plays a central role.
Secondly, the corneal endothelium serves as
a physiological barrier controlling the entry of
fluid and dissolved solutes into the stroma from
the aqueous humor. This barrier is not complete,
so some of the water and dissolved solutes that
is necessary for the corneal metabolism penetrate
into the corneal stroma. For this reason, the
barrier composed of the corneal endothelial cells
is called leaky barrier.
FIGURE 1.6: Human limbal epithelium. Some of the basal

cells of the limbal epithelium are the stem cells of the corneal
epithelium. Pigment granules are observed around the nuclei
of the limbal epithelial cells, which help to protect basal cells
from irradiation of UV. bar = 5 mm
Clinically, limbal epithelium is damaged in

such conditions as alkali burn and inflammatory
diseases like pemphigoid. When it happens, the
corneal epithelium is gradually replaced by

conjunctiva and blood vessels. So it is important
to evaluate the amount of limbal epithelium,
which remains after chemical burn or inflammatory disorders of the ocular surface.
SCLERA
Section
The sclera is the main part of the outer wall of

the eye. The sclera is the white part of the
eyeball. This opacity of the sclera is attributed to
the high water content of 68 percent, the
derangement of the collagen fibers, and the
increase in the interfibrillar spacing of collagen
fibrils composing the sclera (Figure 1.7).
The major roles of the sclera are to protect
the intraocular tissue and to maintain the shape
of the eyeball. As the sclera is a relatively tough
tissue, it consists of collagen, elastic fibers,
glycoproteins, and scattering fibrocytes and
FIGURE 1.7: High magnification of human sclera. The

arrangement of the collagen fibrils is not regular with no
lamellar structure. The interfibrillar spacings of the collagen
fibrils are slightly larger than those of the corneal stroma.
bar = 2 mm
fibroblasts. It serves to maintain the shape of

the eyeball and the intraocular pressure even
when mechanical stress is added.
Chapter
Corneal Transparency
Sunita Agarwal, Athiya Agarwal,
Amar Agarwal
INTRODUCTION
The factors that maintain corneal transparency

can be divided into two main groups:
1. Anatomical factors
2. Physiological factors
Physiological factors are the factors that
maintain corneal hydration.
ANATOMICAL FACTORS
Epithelium
The normal epithelium is transparent due to the
homogeneity of the refractive index throughout.
The layer is optically empty. The precorneal
tear film also maintains corneal transparency.
Epithelial edema is more damaging on visual
acuity than that of stromal edema.
FACTORS
The cornea is avascular except for the capillary

palisades at the limbal margin. If corneal
vascularization occurs, it is pathological. There
are sensory nerves in the cornea, through the
long ciliary nerve. They lose their myelin sheath
after 1-2 mm.
Section
If one has to see clearly, the cornea has to be

transparent. This is necessary so that there is no
scattering of light. Ninety percent of light has to
be transmitted through the cornea.
Absence of Blood Vessels and

Myelinated Nerves
Stroma
The stromal collagen fibrils and the ground
substance have different refractive indices.
Ordinarily, this would result in the tissue being
opaque due to the fibrils scattering the light in
all directions. Therefore, it seems likely that
regularity of the arrangement of stromal
components is related to transparency. There
are two theories to show how this is achieved.
A. Maurices theory: According to this, the
stromal collagen fibrils are of regular diameter
and are arranged as a lattice with an
interfibrillar spacing of less than a wavelength
of light (4000-7000 ). Then the tangential
rows of fibrils acting as diffraction gratings,
10
might result in destructive interference of all

scattered rays and constructive interference
of those rays in the line of the incident light.
Hence, rays travelling in this plane would be
enhanced, while those diffracted away from
the zero order angle would cancel out, giving
the tissue its transparency (Figure 2.1).
B. Goldman and Benedeks theory: According
to this theory, the stromal fibrils are small in
relationship to light and do not interfere with
light transmission, unless they are larger than
one half a wavelength of light.
Endothelial pump
Evaporation from the corneal surface
Intraocular pressure.
Section
FIGURE 2.2: Factors controlling corneal hydration
1. Stromal Swelling Pressure
FIGURE 2.1: Cross-sectional view of fibrils

arranged as a lattice
PHYSIOLOGICAL FACTORS
(Factors that Maintain
Corneal Hydration)
Corneal hydration is a very important factor for
vision. If there is corneal edema, vision is
impaired. There are certain factors that maintain
the correct amount of fluid in the cornea. The
factors that maintain corneal hydration are
(Figure 2.2):
Stromal swelling pressure
Barrier function of the limiting layers
Swelling pressure: The cornea contains glycosaminoglycans (GAG) in the stroma (Figure 2.3).
They are the main cause of hydration of the
cornea. The GAG acts like a sponge. It has
anionic charges. As they are the same sign, there
is an electrostatic repulsion of its molecules. So
there is a separation of the GAG molecules. If
the molecules of GAG were of different signs,
i.e. cationic and anionic, they would attract each
other and there would be no separation of the
molecules. As there is a separation, the cornea
can swell and get hydrated. This is known as the
swelling pressure of the cornea. It is about 50
mm of Hg in a normal cornea.
Imbibition pressure: The GAG anionic repulsion
expands the tissue and sucks in the fluid with
equal pressure called the imbibition pressure.
11
Endothelium
The endothelium is very permeable. It prevents

excess imbibition of water from the aqueous.
The barrier function of the endothelium is
calcium dependent. The zonulae occludens are
dependent upon calcium ions for tight linkage.
In their absence, the cells are separated by wide
intercellular spaces that allow corneal swelling
owing to loss of the endothelial barrier.
3. Endothelial Pump
H2O
H2O
Normally, the swelling pressure is equal to the

imbibition pressure in vitro, but in vivo it is higher.
The imbibition pressure is a negative value and
is 30 mm.
Intraocular pressure:
Swelling Pressure + Imbibition Pressure
= Intraocular Pressure
2. Barrier Function of the Limiting Layers
The epithelium and endothelium act as semipermeable membranes.
Epithelium
This is hundred times less permeable than the
endothelium. It prevents excess imbibition of
water from the tears.
CARBONIC
ANHYDRASE
HCO3 + H+
HCO3
H2O + CO2
FIGURE 2.3: Pressure relations in the cornea
4
2
HCO3
H2O
HCO3
H2O
1. PASSIVE INGRESS OF H2O

2. PASSIVE INGRESS OF HCO3
3. CARBONIC ANHYDRASE CONVERTING H2O &
CO2 TO HCO3 & H+
4. ANION DEPENDENT ATP-ASE
5. EGGRESS OF H2O TAGGED TO TRANSPORT
OF HCO3
FGURE 2.4: Endothelial pump
Section
The endothelium has an active pump which is

very necessary for normal corneal thickness. This
pump allows the ingress and eggress of substances like water and bicarbonate ions through
the endothelium. The pump is dependent upon
12
oxygen, glucose and carbohydrate metabolism

(Figure 2.4).
SP
IP
= Swelling Pressure (50) and

= Imbibition Pressure (30)
So,
4. Evaporation from the Corneal Surface
Evaporation from the corneal surface also affects
corneal hydration. In humans, only 4 percent
thinning of the cornea occurs due to this.
5. Intraocular Pressure
Section
If the intraocular pressure increases, corneal

edema occurs. Now,
IOP = SP + IP
where,
IOP = Intraocular Pressure (20)
20 = 50 +(30)
If IOP exceeds the SP, then epithelial edema
will occur. This occurs in acute glaucoma. In a
condition like endothelial dystrophy, the IOP is
normal but the SP is low and so once again,
corneal edema will occur.
Thus, these five factors help to maintain
corneal hydration. The most important of these
is the endothelial pump mechanism of which
very little is known.
Chapter
13
Tear Film Physiology

Ashok Garg
INTRODUCTION
Section
The exposed part of the ocular globethe

cornea and the bulbar conjunctiva is covered
by a thin fluid film known as preocular tear film.
Tear film is that surface of the eye, which
remains most directly in contact with the
environment. It is critically important for
protecting the eye from external influences and
for maintaining the health of the underlying
cornea and conjunctiva. The optical stability and
normal function of the eye depend on an
adequate supply of fluid covering its surface.
The tear film is a highly specialized and wellorganized moist film which covers the bulbar and
palpebral conjunctiva and cornea. It is formed
and maintained by an elaborate systemthe
lacrimal apparatus consisting of secretory,
distributive and excretory parts. The secretory
part includes the lacrimal gland, accessory
lacrimal gland tissue, sebaceous glands of the
eyelids, goblet cells and other mucin-secreting
elements of the conjunctiva (Figure 3.1). The
elimination of the lacrimal secretions is based
on the movement of tears across the eye aided
FIGURE 3.1: Cross-section of eye showing tear film (blue)

in its natural distribution along with tear producing glands
(Courtesy Allergan India Limited)
by the act of blinking and a drainage system

consisting of lacrimal puncta, canaliculi, sac and
nasolacrimal duct (Figure 3.2).
By definition, a film is a thin layer that can
stand vertically without appreciable gravitational
flow and the tear film meets this criteria very
well. The presence of continuous tear film over
the exposed ocular surface is imperative for good
visual acuity and wellbeing of the epithelium and
facilitates blinking. Tear film serves:
14
FIGURE 3.2: Tear drainage system

Section
An optical function by maintaining an

optically uniform corneal surface
A mechanical function by flushing cellular
debris, foreign matter from the cornea and
conjunctival sac and by lubricating the surface
A corneal nutritional function
An antibacterial function.
The composition of the tear film must be kept
within rather narrow quantitative and qualitative
limits in order to maintain the wellbeing and
proper functioning of the visual system. Abnormalities of the tear film affecting its constituents
or volume lead to serious dysfunction of the
eyelids and the conjunctiva with the concomitant
loss of corneal transparency. A thin tear film is
uniformally spread over the cornea by blinking
and ocular movements. The tear film can be
arbitrarily divided into four main parts
The marginal tear film along the moist
portions of the eyelid which lie posterior to
the lipid strip secreted by the tarsal glands
Portion covering the palpebral conjunctiva
Portion covering the bulbar conjunctiva
Precorneal tear film which covers the cornea.
The marginal, palpebral and conjunctival

portions are regarded as making the preocular
tear film.
Tears refers to the fluid present as the
precorneal film and in the conjunctival sac. The
volume of tear fluid is about 5 to 10 l with
normal rate of secretion about 1 to 2 l/minute.
About 95 percent of it is produced by the
lacrimal gland and lesser amounts are produced
by goblet cells and the accessory lacrimal glands
of the conjunctiva. The total mass of the latter is
about one-tenth of the mass of the main lacrimal
gland.
The secretory part of the lacrimal apparatus
provides the aqueous tear, lipids and mucus all
the important components of the tear film and
its boundary.
The tear film is composed of three layers
(Figure 3.3).
1. SUPERFICIAL LIPID LAYER
The superficial layer at the air-tear interface is
formed over the aqueous part of the tear film
from the oily secretions of meibomian glands
and the accessory sebaceous glands of Zeis and
Moll. The meibomian gland openings are
FIGURE 3.3: Tear film layers

The intermediate layer of tear film is the aqueous

phase which is secreted by the main lacrimal
2. MIDDLE AQUEOUS LAYER
gland and the accessory glands of Krause and

Wolfring.
This layer constitutes almost the total thickness
of the tear film 6.5 to 10 mm, many times thicker
than the fine superficial oily layer. This layer
contains two phasesa more concentrated and
a highly dilute one. The interfacial tension at the
adsorbed mucin-aqueous layer is apt to be rather
small due to the intensive hydrogen bond formation across the interface. This layer contains
inorganic salts, water proteins, enzymes, glucose,
urea, metabolites, electrolytes, glycoproteins and
surface active biopolymers. Uptake of oxygen
through the tear film is essential to normal
corneal metabolism. This layer has four main
functions
Most importantly it supplies atmospheric
oxygen to the corneal epithelium.
It has antibacterial substances like lactoferrin
and lysozyme. Therefore, dry eye patients
are more susceptible to infection than a
normal eye.
It provides smooth optical surface by
removing any minute irregularities of the
cornea.
It washes away debris from the cornea and
conjunctiva.
Section
distributed along the eyelid margin immediately

behind the lash follicles.
The chemical nature of the lipid layer is
essentially waxy and consists of cholesterol esters
and some polar lipids. The thickness of this layer
varies with the width of the palpebral fissure and
is between 0.1 and 0.2 m. Being oily in nature
it forms a barrier along the lid margins that retains
the lid margin tear strip and prevents its overflow
on to skin. This layer is so thin that there are no
interference color patterns such as one normally
sees on an oily surface. However if one squints,
the oily layer thickness and distinct interference
colors may be seen.
While the bulk of tarsal gland secretions are
nonpolar lipid compounds which do not spread
over an aqueous surface alone, many surface
active components are also present. It appears
that the tarsal gland secretions which are
transported to the cornea in the tear film are
massaged into the outermost layer of corneal
epithelial cells by eyelid action and then possibly
are changed by local metabolic processes in the
epithelium combining with conjunctival mucus
to form a stable hydrophilic base for the
precorneal tear film.
This outer lipid layer has the following main
functions
It reduces the rate of evaporations of the
underlying aqueous tear layer.
It increases surface tension and assists in the
vertical stability of the tear film so that tears
do not overflow the lower lid margin.
It lubricates the eyelids as they pass over the
surface of the globe.
15
3. POSTERIOR MUCIN LAYER

The innermost layer of tear film is a thin mucoid
layer elaborated by goblet cells of the conjunctiva
and also by the crypts of Henle and glands of
Manz. It is the deepest stratum of the precorneal
tear film. This layer is even thinner than the lipid
layer and is 0.02 to 0.04 m thick. This adsorbs
on the epithelial surface of the cornea and
conjunctiva rendering them hydrophilic. It
assumes the ridged appearance of the microvilli
of superficial epithelial cells which it covers. The
16
preocular tear film is dependent upon a constant

supply of mucus which must be of proper
chemical and physical nature to maintain corneal
and conjunctival surfaces in the proper state of
hydration. The mucous threads present in the
tear film provides lubrication allowing the eyelid
margin and palpebral conjunctiva to slide
smoothly over one another with minimal energy
lost as friction during blinking and ocular rotation
movements. They also cover foreign bodies with
a slippery coating thereby protecting the cornea
and conjunctiva against the abrasive effects of
such particles as they are moved about by the
constant blinking movements of eyelids. The
mucus contributes stability to the preocular tear
film as well as furnishing an attachment for the
tear film to the conjunctiva but not to the corneal
surface. The corneal surface is covered with a
myriad of fine microvilli which provides some
support for the tear film. The mucus dissolved
in the aqueous phase facilitates spreading of the
tear film by smoothening the film over the
corneal surface to form a perfect, regular
refracting surface.
So the mucin layer which is a glycoprotein
converts a hydrophobic surface into a hydrophilic surface and enables the corneal epithelium
to be adequately wetted.
In addition to sufficient amounts of aqueous
tears and mucin three other important factors
are necessary for effective resurfacing of the
cornea by the precorneal tear film.
A normal blink reflex is essential to ensure
that the mucin is brought from the inferior
conjunctiva and rubbed into the corneal
epithelium. Patients suffering from facial palsy
and lagophthalmos therefore develop
corneal drying.
Section

Congruity between external ocular surface
and the eyelids ensures that the precorneal
tear film shall spread evenly over the entire
cornea. Patients suffering from limbal lesions
like dermoids face the problem of apposition
of the eyelids to the globe leading to local
selective areas of drying.
Normal epithelium is necessary for the
adsorption of mucin on to its surface cells.
Patients suffering from corneal scars and
keratinizations have problem of interference
with the corneal wetting.
The tear film is not visible apparently on the
surface of the eye but at the upper and lower lid
margins a 1 mm strip of tear fluid with concave
outer surface can be seen. It is here that the oily
surface prevents spillage of the tear fluid over
the lid margin. Tears forming the upper tear strip
are conducted nasally from the upper temporal
fornix. At the lateral canthus the tears fall by
gravity to form the lower strip, spreading
medially the upper and lower strips reach the
plica and caruncle where they join together. The
tear fluid does not flow over the eye by gravity
but a thin film is spread over the cornea by
blinking and eye movements.
TEAR FILM FORMATION DYNAMICS

It is interesting to know the tear film formation.
Generally during the closure of the eyelids the
superficial lipid layer of the tear film is compressed
by the eyelid edges because it is energetically
unfavorable for the lipid to penetrate under the
lids into the fornix. The thickness of lipid layer
therefore increases by a factor of 1000 resulting
in thickness of 0.1 mm which is easily contained
between the adjacent eyelid edges. The aqueous
tear layer remains uniform under the lids and
FIGURE 3.4: Impression cytology mapping

FIGURE 3.5: Mechanism of tear film break up (Courtesy Allergan India Limited)
A deficiency in the conjunctival secretions can

lead to dry eye symptoms even in the presence
of an adequate aqueous tear component
(Figure 3.4).
BUT (Break up Time) is generally determined
after the instillation of a drop of fluorescein
solution in the eye or after staining the tear
miniscus and the tear film by a wetted paper
strip containing fluorescein. Normal BUT value
ranges from 10 to 40 seconds for normal eyes
(Figure 3.5) when the BUT is determined by a
Section
acts as a lubricant between the eyelids and the

globe. In a complete blink phenomenon, the
two tear minisci join and most of their bulk is
held at their junction to fill the slight bridge
formed by the meeting eyelids and at the
canthus.
When the eyelids open, first they form an
aqueous tear surface on which the compressed
lipid rapidly spread. Monomolecular lipid layer
is the first to spread at speeds limited only by
the moving eyelid. Following the spread of lipid
monolayer, the excess lipid and associated
macromolecules shall distribute themselves over
the tear film surface at a lower speed, usually
the lipid layer ceases within 1 second after the
opening of the eye.
Under normal conditions a person blinks on
an average 15 times per minute. Some of these
blinks may not be complete (the upper eyelid
descends only half way towards the lower eyelid).
Normally the tear film break up time (BUT) is
longer than the interval between blinks and no
corneal drying occurs.
17
18
non-invasive method (e.g. by the toposcope).

BUT values of as long as 3 to 5 minutes can be
recorded.
If the BUT is shorter than the average time
interval between two consecutive blinks, tear film
rupture can cause pathological changes in the
underlying epithelium. The tear film breaks up
prematurely over the damaged epithelial surface
thereby exacerbating the injury.
Generally there is balance between the
secretion and excretion of tears and the rate of
tear drainage increases with increased tear
volume.
NORMAL TEAR DRAINAGE
Section
In the normal tear film between 10 and 25

percent of the total tears secreted are lost by
evaporation. Evaporation rate is low because of
the protective oily surface.
In the absence of the protective oily layer
the rate of evaporation is increased 10 to 20
times. Normally tear flows along the upper and
lower marginal strips and enters the upper and
lower canaliculi by capillarity and possibly by
suction also. About 70 percent of tear drainage
is via the lower canaliculus and the remaining
through the upper canaliculus. With each blink
the superficial and deep heads of pretarsal
orbicularis muscle compress the ampullae,
shorten the horizontal canaliculi and move the
puncta medially. Simultaneously the deep heads
of preseptal orbicularis muscle which are
attached to the fascia of the lacrimal sac contract
and expand the sac. This creates a negative
pressure which sucks the tears from the canaliculi
into the sac. When the eyes are opened the
muscles relax, the sac collapses and a positive
pressure is created which forces the tear down
the duct into the nose. Gravity also plays an

important role in the sac emptying. The puncta
move laterally, the canaliculi lengthen and
become filled with tears.
TEAR COMPOSITION
Tears contain 98.2 percent water and 1.8 percent
solids. The high percentage of water in tears is a
natural consequence of the need for lubrication
of the conjunctiva and corneal surface (Tables
3.1 and 3.2). The evaporation of water between
blinks may influence the concentration of the
tear film. The evaporation rate of water from
the intact precorneal tear film through the
superficial lipid layer has been shown to be
8 107 cm2.sec1. In a time interval of 10
seconds (between two consecutive blinks) the
thickness of the tear film decreases about 0.1 m
resulting in nearly 1 to 2 percent decrease in
water concentration. The solute concentration
however increases about 20 percent.
PHYSICAL PROPERTIES OF TEARS

TEAR pH
The pH of unstimulated tears is about 7.4 and it
approximates that of blood plasma. Although
wide variations are found in normal individuals
(between 5.0-8.35) the usual range is from
Table 3.1: Relative water contents of tears and other
body fluids
Fluid
Percentage water
Tear
Aqueous humor
Vitreous humor
Blood
Serum
Urine
98.2
98.9
99.0
79.5
91.0
96.5

Table 3.2: Composition of human tears and plasma
Tears
Physical properties
pH
Osmotic pressure
Refractive index
Volume
Chemical properties
1. General tear composition
Water
Solids (total)
Ash
Plasma
7.4 (7.2-7.7)
305 mOsm/kg
Equiv. 0.95% NaCl
1.357
0.50-0.67 g/16 hour
(waking)
7.39
6.64 atm
1.35
Electrolytes
Sodium
Potassium
Calcium
Magnesium
Chloride
Bicarbonate
120-170 mmol/l
26-42 mmol/l
0.3-2.0 mmol/l
0.5-1.1 mmol/l
120-135 mmol/l
26 mmol/l
140 mmol/l
4.5 mmol/l
2.5 mmol/l
0.9 mmol/l
100 mmol/l
30 mmol/l
3.
Antiproteinasis
1-Anti trypsin(1-at)
1-Anti Chymotriypsin
Inter- trypsin inhibitor
2 Macroglobulin
0.1-3.0 mg%
1.4 mg%
0.5 mg%
3-6 mg%
280 mg%
24 mg%
20 mg%
4.
Nitrogenous substances
Total protein
0.668-0.800 g/
100 ml
0.392 g/100 ml
0.2758 g/100 ml
0.005 g/100 ml
6.7 g/100 ml
4.0-4.8 g/100 ml
2.3 g/100 ml
0.047 g/100 ml
0.04 mg/100 ml
158 mg/100 ml
51 mg/100 ml
26.8 mg/100 ml
1140 mg/100 ml
15-42 mg/100 ml
2.5 (0-5.0) mg/

100 ml
80-90 mg/100 ml
2.
Albumin
Globulin
Ammonia
Uric acid
Urea
Total nitrogen
Nonprotein nitrogen
5.
Carbohydrates
Glucose
6.
Sterols
Cholesterol and
cholesterol esters
8-32 mg/100 ml
200-300 mg/
100 ml
Miscellaneous
Citric acid
0.6 mg/100 ml
Ascorbic acid
0.14 mg/100 ml
Lysozyme
Amino acid
Lactate
Prostaglandin
1-2 mg/ml
7.58 mg/100 ml
1-5 mmol/l
75 pg PF/ml
300 pg PF/ml
0.5-1.5 g/ml
1:4 dilution
(Hemolytic assay)
2.2-2.8 mg/
100 ml
0.1-0.7 mg/
100 ml
0.5-0.8 mmol/l
80-90 pg PF/ml
7.
Catecholamine
Complement
1.32 dilution
(Hemolytic
assay)
OSMOTIC PRESSURE
The osmotic pressure in tears mainly caused by
the presence of electrolytes is about 305 mOsm/
kg equivalent to 0.95 percent sodium chloride.
Individual values over the waking day may range
from 0.90 to 1.02 percent NaCl equivalents. A
decrease to an average of 285 mOsm/kg
equivalent to 0.89 percent NaCl has been
reported following prolonged lid closure which
accounts for the reduced evaporation. When the
aqueous component of tears decreases, the tears
become markedly hypertonic (0.97% NaCl
solution or more) and corneal dehydration
results. When the eyes are closed, there is no
evaporation of tears and the precorneal tear film
is in osmotic equilibrium with the cornea. When
the eyes are open evaporation takes place,
increasing the tonicity of the tear film and
producing an osmotic gradient from the aqueous
through the cornea to the tear film. This direction
of flow will continue as long as evaporation
maintains the hypertonicity of the tear film.
Osmotic pressure is sensitive to changes in tear
flow. Reflex stimulation of tears in early
adaptation to contact lenses results in a decrease
in electrolytes and in total protein leading to
98 g/100 ml
8.6 g/100 ml
0.6-1.0 g/100 ml
7.3 to 7.7. A more acidic pH of about 7.25

is found following prolonged lid closure
possibly due to carbon dioxide produced
by the cornea and trapped in the tear pool
under the eyelids. Tear pH is characteristic for
each individual and the normal buffering mechanism maintain the pH at a relatively constant
level during waking hours. The permeability of
the corneal epithelium does not seem to be
affected by wide variations in the pH of tear fluid.
Section
98.2 g/100 ml
1.8 g/100 ml
1.05 g/100 ml
19
20
hypotonicity. This relative hypotonicity may

account for the corneal edema often seen in early
stages of contact lens wearing.
tears the very low protein content and the

absence of lipoproteins is incompatible with a
cholesterol concentration of 20 mg percent.
OTHER PHYSICAL PROPERTIES OF

TEAR (Table 3.2)
PROTEINS
Refractive index1.357
Tear volume0.50-0.67 g/16 hr (waking).
CHEMICAL COMPOSITION OF
TEAR FLUID
Section
The chemical composition (Table 3.2) of tear

fluid is quite complex. The first chemical analysis
of tears was studied in 1791 by Fourcroy and
Van Que Lin Fleming (1922) and Ridley (1934)
demonstrated the detailed chemical composition
of normal tears.
Immunoelectrophoretic studies have shown
that tears contain lipids, proteins, enzymes,
metabolites, electrolytes and hydrogen ions, etc.
LIPIDS
Lipids are present in small amount in tears as
they are contained only in the very thin superficial
lipid layer of the tear film. Chromatographic
studies of meibomian lipids reveal the presence
of all possible lipid classes mainly waxy esters,
hydrocarbons, triglycerides, cholesterol esters
and in lesser amount diglycerides, monoglycerides, free fatty acids, free cholesterol and
phospholipid. However great individual
variations occur in lipid composition.
Cholesterol
Cholesterol has been reported to be present in
tear fluid in concentrations of about 200 mg
percent which is same as in the blood. Like all
lipids in biological fluids cholesterol has to be
transported by and lipoproteins. In normal
About 60 components to tear protein fraction

have been reported which form the first line of
defense against an external infection and seen
to be more effective than systemically produced
antibodies. The protein content of tears differ
from that of blood plasma in several respects.
Proteins can be divided in two groups.
Group A: Proteins which are similar to serum
proteins with a low concentration representing
less than 15 percent of all tear proteins. Some
of them are always present in tears (Table 3.3)
namely albumin, IgG, -L antitrypsin, transferrin, -L antichymotrypsin and B-2 microglobulin others which appears sporadically are
ceruloplasmin, haptoglobin and Zinc -2
glycoprotein.
Table 3.3: Amino acid composition of human tear lysozyme
Amino acids
Aspartic acid
Arginine
Glutamic acid
Tryptophane
Alanine
Leucine
Trypsin
Glycine
Lysine
Valine
Serine
Half-cysteine
Threonine
Isoleucine
Phenylalanine
Proline
Methionine
Histidine
Residues
(gm/100 g protein)
13.23
13.05
8.55
6.89
6.36
6.11
5.65
4.94
4.92
4.62
4.02
4.01
3.67
3.59
1.97
1.72
1.50
1.01

Table 3.4: Relative quantity of various protein
fractions in tears
Fractions
Normal tears
(Percentage)
Stimulated flow
(Tears) Percentage
Albumin
Globulin
Lysozyme
58.2
23.9
17.9
20.2
56.9
22.9
Table 3.5: Origin of various tear protein fractions

Protein
fraction
Lacrimal
gland proper
Accessory
lacrimal gland
Goblet
cells
+
+
+
+
+
+
+
+
+
Lysozyme
Component-I
Component-II
Component-III
Serum albumin
Tear albumin
Mucin
Tear Albumin
Albumin represents about 60 percent of the total
protein in tears as it does in plasma. Tear albumin
is a unique protein fraction. It is electrophoretically a prealbumin and migrates to a position
similar to serum prealbumin. Genetic polymorphism has been reported of the tear albumin.
Electrophoresis of tears shows several peaks
of migration. These peaks are main which correspond to proteins synthesized by the lacrimal
glandrapid migrant proteins and lactoferrin
migrating to the anode and lysozyme migrating
to the cathode.
Lysozyme
Fleming first discovered an antibacterial
substance and showed that this substance is an
enzyme which he named lysozyme because of
its capacity to lyze bacteria. In normal tears
concentration of lysozyme is much higher than
in any other body fluid. The normal level for
human tear lysozyme (HTL) is 1 to 2 mg/ml.
The enzymic activity of lysozyme is optimal at
pH 5.2 and decreases above and below this pH
value.
Lysozyme is a long chain, high molecular
weight proteolytic enzyme produced by
lysosomesa known cellular ultra structure.
Lysozyme acts upon certain bacteria and dissolves
them by cleaning the polysaccharide component
of their cell walls. As the function of cell wall in
bacteria is to confer mechanical support a
bacterium devoid of its cell wall usually bursts
because of the high osmotic pressure inside the
cell.
Lysozyme level in tears can be measured with
a diffusion method or with a spectrophotometric
assay.
In addition to lysozyme, presence of other
antibacterial factors in human tears have been
shown. The nonlysozymal bactericidal protein
beta lysin has been reported to be derived chiefly
from platelets but it exists in higher concentration
in tears than in blood plasma. The lysozyme and
beta lysin protein fractions can be separated by
Group B: Specific proteins synthesized by tear

gland are RMP (rapid migration protein) and
some other proteins (Tables 3.4 and 3.5) which
are also present in other external secretions
(lysozyme, lactoferrin and IgA).
The total tear proteins content strongly

depends upon the method of collection of tears.
Small unstimulated tears show levels of about
20 mg/ml while stimulated tears show much
lower values in the range of 3 to 7 mg/ml
reflecting the level of lacrimal gland fluid.
Section
+ Means fraction is present

Means fraction is absent
+ Means fraction is indifferently present
21
22
Section
filtering the tears. The antibacterial activity of the

filtrate results from lysozyme but in whole tears
beta lysin is responsible for three-fourth of the
bactericidal effect. Beta lysin acts primarily on
cellular membrane while lysozyme dissolves
bacterial cell walls.
The action of lysozyme depends on the pH.
The optimum pH for lysis varies with the solubility
of the bacterial proteins but in general it ranges
between 6.0 and 7.4. Low salt concentrations
favor lysis by increasing solubility.
Human tear lysozyme (HTL) levels have
been shown to be greatly decreased in tears of
patients suffering from Sjgrens syndrome and
ocular toxicity from long-term use of practolol
therapy thus making it a useful diagnostic aid.
Other disease states where HTL level is lowered
include herpes simplex virus infection and
malnutrition in children.
migration rate of tear ceruloplasmin varies from

its serum counter part.
Immunoglobulins
Tiselius (1939) for the first time separated the
plasma proteins by electrophoresis and isolated
three types of globulinsalpha, beta and
gamma. Antibody property of the immune
serum resides in the gamma globulin fraction.
Immunoglobulins are elaborated by plasma cells
following transformation of antigen stimulated
B-lymphocytes. This elaboration constitutes the
humoral immune system.
Five major classes of immunoglobulins have
been recognized (Table 3.6). These are
Immunoglobulin A (IgA)
Immunoglobulin G (IgG)
Immunoglobulin M (IgM)
Immunoglobulin E (IgE)
Immunoglobulin D (IgD)
Lactoferrin
It is an iron carrying protein and appears to be a
major tear protein in the intermediate fraction.
Its property of iron binding (Fe III) is 300 times
stronger than the other iron binding protein
(transferrin). This is probably significant for its
bacteriostatic activity in tears making essential
metal ions unavailable for microbial metabolism.
Transferrin
Transferrin has been shown to be present in
tears. Transferrin along with serum albumin and
IgG can be detected only after mild trauma to
the mucosal surface of the conjunctiva or in tears.
Ceruloplasmin
Ceruloplasmin, a copper carrying protein is
regularly found in tears. In electrophoresis the
Table 3.6: Immunoglobulin levels in tear and serum

Ig Class
Tears
Total proteins 800 mg/100 ml

IgA
14-24 mg/100 ml
IgG
17 mg/100 ml
IgM
5-7 mg/100 ml
IgE
26-250 mg/ml
Serum
6500 mg/100 ml
170-200 mg/100 ml
1000 mg/100 ml
100 mg/100 ml
2000 mg/ml
Immunoglobulin A (IgA): It is the major immunoglobulin present in tears, saliva and colostrum.
Almost all of the IgA have a secretory component
attached to them when they occur in external
secretions. It participates in the functioning of
IgA as antibody in the external environment.
The possible functions of secretory IgA include
prevention of viral and bacterial infections that
may have an access to the external secretions,
e.g. tears and participate as opsonins in the
phagocytosis process.
Immunoglobulin M (IgM): It is present in very

low concentrations in normal tears. The average
level of IgM in normal tears range from 5 to 7
mg percent. Barnett (1968) reported first the
presence of IgM in normal tears.
The serum level of IgM is about 100 mg/dl.
The IgM molecule with a molecular weight
900,000 is the largest of the immunoglobulins.
Often referred to as macroglobulin because of
its size, the IgM molecule are pentamers with a
high valency or anticombining capacity. Due to
its high valency IgM is extremely efficient
agglutinating and cytolytic agent and is the first
type of antibody which is formed after the initial
encounter with antigen. It appears early in
response to infection and is confined mainly to
the blood stream.
Even minimum trauma to conjunctiva would
cause serum proteins to leak into the tears. There
is increased concentrations of IgA, IgG and IgE
in tears. Either these immunoglobulins are
selectively excreted into the tears or they are
locally synthesized. Increased concentrations of
Immunoglobulin G (IgG): It is present in very

low concentrations in normal tears. However after
mild trauma to the mucosal surface of the
conjunctiva it can be easily detected.
IgG is the most prominent circulating (serum)
immunoglobulin present in concentrations five
times that of IgA. The average level of IgG in
normal human tears range from 17 to 20 mg/
100 ml.
The serum level of IgG is about 1000 mg/dl.
IgG molecule has a molecular weight of about
150,000. Each molecule of IgG consists of 2 L
chains and 2 H chains linked by 20-25-S-S
bonds. The antigenic analysis of IgG myelomas
show four subclasses now termed as IgG1, IgG2,
IgG3, and IgG4,. IgG1 is the predominant variant
and together with IgG3 possesses the ability to
combine with complement to bind to macrophages and to cross the placenta. IgG synthesis
in humans is about 35 mg/kg/d and its half-life
is about 23 days. IgG molecules are Y-shaped
with a hinge region near the middle of the heavy

chain connecting the 2 Fab segments to the Fc
segment.
During the secondary response, IgG is the
major immunoglobulin to be synthesized
probably because of its small size, IgG diffuses
more readily than other immunoglobulins into
the tears, therefore as the predominating
immunoglobulin it carries the major burden of
neutralizing bacterial toxins and of binding to
microorganisms (specially streptococci, pneumococci and staphylococci) to enhance their
phagocytosis. IgG is most efficient in killing and
stopping the progress of microorganisms
invasion.
Section
The average levels of IgAthe predominant

immunoglobulin in normal human tear is 14
mg/dl.
In the human lacrimal gland, IgA appears to
be synthesized by interstitial plasma cells and
after entry into the intercellular spaces it is
coupled to SC and secreted as secretory IgA (IgASC) through the blood-tear barrier involving
intracellular transport by acinar epithelial cells
into the lumens. In the conjunctiva IgA and
plasma cells are located in the substantia propria.
Only in the acinar epithelium of the accessory
lacrimal glands can SC material be present
indicating that these are the sites of synthesis of
secretory IgA of the conjunctival secretions.
Depending upon the method of tear collection
IgA values can vary from 10 to 100 mg percent.
23
24
IgA, IgG and IgM are reported in cases of blepharoconjunctivitis, herpes keratitis, vernal conjunctivitis, acute follicular conjunctivitis, phlyctenular
conjunctivitis, keratomalacia, corneal ulcer and
acute endogenous uveitis.
Immunoglobulin E (IgE): It is mostly extravascular in distribution. IgE values ranges from 26
to 144 g/ml in normal tears. Normal serum
contains only traces of IgE but greatly elevated
levels are seen in atopic conditions.
Immunoglobulin D (IgD): IgD levels are quite
low in tears as well as in serum. It is mostly
intravascular.
Complement
Section
Complement in tears has been shown in

hemolytic assays up to dilution of 1.4 whereas
serum is active in this system up to 1:32.
Glycoproteins
Glycoproteins are present in the mucoid layer
as well as in the tear fluid since they are highly
soluble in water. Glycoproteins contribute significantly to the stickiness of the material forming
the mucoid layer. N-acetyeneuraminic acid (a
sialic acid) has been indentified in normal tears.
Glycoproteins may play a critical role in the
lubrication of the corneal surface by rendering
its hydrophobic surface more hydrophilic
permitting spreading and stabilization of the tear
film. The mucus is secreted by the conjunctival
goblet cells as a solution of glycoproteins
(mucoids) and this sticky mixture adheres to the
surface of the epithelium even though the glycoproteins are water soluble.
The glycoproteins are carbohydrate-protein
complexes characterized by the presence of
hexosamines, hexoses and sialic acid. In normal
tears relative hexosamine content of the protein

which is used as indicator for glycoproteins varies
from 0.5 to 17 percent, the hexosamine
concentration from 0.05 to 3 g/l. Sialic acid
concentration of human tears has been reported
to be 114 mmol/100 ml.
Antiproteinases
Antiproteinases, inhibitors of proteinases are
present in tears at levels much lower than in
plasma (Table 3.7).
Table 3.7: Antiproteinasis concentration in
tears and plasma
Antiproteinasis
1-antitrypsin (1at)
1-antichymotrypsin
1-antichymotrypsin
Inter--trypsin inhibitor
2-macroglobulin
Plasma
280
24
20
mg percentage
Tears
0.1-0.4
1.5
3.0
1.4
0.5
3
6
These includes 1-antitrypsin, 1-antichymotrypsin, inter--trypsin inhibitor and 2macroglobulin. The source of-1 antitrypsin is
the lacrimal gland while other antiproteinases
originate from corneal and conjunctival surfaces.
In various inflammatory conditions of the eye
the levels of 1-at and 2-m in tear fluid are
increased.
In bacterial and viral infections of the
eye (Table 3.8) and in corneal ulceration
the levels of 1-at and 2-m in tear fluids
are increased. Using albumin as a marker
protein there is evidence suggesting that these
two collagenase inhibitors are derived either from
plasma by a general increase in vascular
permeability to proteins or they are produced
locally.

Table 3.8: Antimicrobial factors in tears
Compound
Evidence
Lysozyme
IgA
IgG
IgE
IgM
Complement
Lactoferrin
Transferrin
Betalysin
Antibiotic producing
Commensal organism
+
+
+
+
+
+
+
+
+
+
+present in normal tears.

+Present in tears after stimulation (mild trauma to the
conjunctiva).
METABOLITES
Glucose is present in minimal amounts of about

0.2 mmol/litre in tear fluids of normal glycemic
persons. This low concentration of glucose
appear to be insufficient for corneal nutrition.
There is no definitive evidence that cornea
metabolizes glucose emanating from the tears.
It has been shown that some glucose in tears
originates from the goblet cells of the
conjunctiva. There is corresponding rise in tear
glucose level with elevation of plasma glucose
level above 100 mg percent. However, there is
no significant rise in tear glucose levels in
diabetics with blood glucose level of more than
20 mmol/litre which demonstrates the barrier
function of the corneal and conjunctival
epithelium against loss of glucose from the tissues
Urea
Urea concentration in tear fluid and plasma have
been found to be equivalent suggesting an
unrestricted passage through the blood-tear
barrier in the lacrimal gland. Urea concentration
in tears decreases with increasing secretion
rate.
Amino Acids
Free amino acid concentration in tears is reported
to be 7.58 mg/100 ml. This value is 3 to 4 times
higher than the free amino acid concentration
in serum.
Lactate
Lactate levels of 1 to 5 mmol/l in tears are far
higher than the normal blood levels of 0.5 to
0.8 mmol/l. Pyruvate from 0.05 to 0.35 mmol/
l is about the same as is normal for blood (0.10.2 mmol/l). These levels do not show significant
alterations after mechanical irritation. The
epithelium does not possess a barrier function
for lactate and pyruvate.
Glucose
into the tear fluid. It is the tissue fluid which contributes to the tear glucose after mechanically
stimulated methods of tear collection.
Section
A number of metabolites have been reported

to be present in normal human tears. These
include organic constituents of low molecular
weight like glucose, urea, amino acids and other
metabolites like lactate, histamine, prostaglandins
and catecholamines.
25
Histamine
Histamine is present in normal tears collected
from the conjunctival sac at a level of about 10
mg/ml. In vernal conjunctivitis specifically a
variable increase up to 125 mg/ml has been
observed.
Prostaglandins
Prostaglandins are present in normal tears at the
level of 75 pg prostaglandin F/ml and it is little
26

Table 3.9: Human tear electrolytes
Concentration in mmol/l
+
Tears
Serum
Na
120-170
145
134-170
140
6-26
24
26-42
4.5
++
Mg
0.5-1.1
0.4-1.1
0.3-2.0
2.5
0.3-0.6
0.5-1.1
lower than in serum. In inflammatory conditions

of the eye significant higher values are found up
to 300 pg/ml of tears.
Catecholamines, Dopamine,
Noradrenaline and Dopa
Catecholamines, dopamine, noradrenaline and
dopa have been found in the tear fluid. The
levels vary from 0.5 to 1.5 mg/ml. Dopamine
has values as high as 280 mg/ml.
In glaucoma patients lower values have been
reported for these compounds which reflect the
diminished activity of the sympathetic innervation of the eye. The determination of catecholamines in tears has been advocated as a test in
glaucoma diagnosis.
Section
++
Ca
ELECTROLYTES AND HYDROGEN IONS

The predominant positively charged electrolytes
(cation) in tears are mainly sodium and potassium while the negative ions (anions) are chloride
and bicarbonate (Table 3.9).
Sodium
Sodium concentration in tears 120 to 170 mmol/
litre is about equal to that in plasma suggesting
a passive secretion into the tears. While potassium
with an average value of about 20 mmol/l is
much higher than the corresponding plasma
concentration of about 5 mmol/l. This indicates
0.9
Cl
118-138
106-130
120-135
100
HCO
26
30
an active secretion of potassium into the tears. It

is interesting to observe that while the main
cationic constituent of the aqueous and vitreous
humor is sodium while cornea (mainly corneal
epithelium) contains a much higher concentration of potassium than sodium. These two
cations play an essential role in the osmotic
regulation of the extracellular and intracellular
spaces and in general changes in sodium level
are the reverse of changes in potassium level.
Calcium
Calcium is independent of the tear production
and is lower than the free fraction of plasma. In
cystic fibrosis patients have much higher calcium
values. An average of 2.5 mmol/l have been
shown only at slow rates concomitant with lower
tear sodium values.
Magnesium
Magnesium in tears is little lower than corresponding serum value possibly reflecting the free
fraction of magnesium. Both calcium and
magnesium play a role in controlling membrane
permeability.
Chloride
Chloride, an anion essential to all tissues also
plays an important role in osmotic regulation
much like sodium and potassium. The chloride

concentration is slightly higher in tears than in
serum.
27
isoenzymes bound to immunoglobulin have

been found in blood and it is probable that here
an analogous binding takes place in tears.
Bicarbonate
The bicarbonate together with the carbonate ions
in tears may be involved in the regulation of
pH. This buffer system maintains the near neutral
pH of the tear film, the surface of which is
exposed to atmospheric changes.
ENZYMES
Enzymes of Energy Producing Metabolisms
Lactate dehydrogenase (LDH) is the

enzyme in the highest concentration in
tears. It can be separated electrophoretically into
its five isoenzymes showing a pattern with more
of the slower migrating muscle type isoenzymes.
This is closely related to the distribution pattern
of corneal tissue in contrast to serum LDH where
the faster migrating heart type isoenzymes
prevail.
These findings indicate that tear LDH originates from the corneal epithelium. Therefore,
in patients suffering from corneal disease, the
distribution of LDH isoenzymes in tears differs
from those found in healthy individuals. LDH
Lactate Dehydrogenase
Lysosomal enzymes include a number of

lysosomal acid hydrolases which are present in
tears in concentration of 2 to 10 times than those
in serum. The lacrimal gland is the main
source of the lysosomal enzymes but
conjunctiva may act as a second source for
lysosomal enzymes after mild trauma. The
relative high values are found in tear fluid
collection where the epithelial cells of conjunctiva
remain intact and contain very low levels of
lactate dehydrogenase or other cytoplasmic
enzymes. Lysosomal enzyme activities in tears
are used for diagnosis and identification of
carriers of several inborn errors of metabolism.
The concentration of -hexosaminidase in
tears collected on filter paper strips is an index
for the development and prognosis of diabetic
retinopathy. The tears would reflect the
decreased enzyme activity of -hexosaminidase
and of other lysosomal glycosidases in the retina
showing a negative correlation with the increased
plasma levels of these eyzmes.
Section
Glycolytic enzymes and enzymes of tricarboxylic

acid cycle can be detected in high values only in
human tear samples. These enzymes form a
blood-tear barrier against penetration from the
blood. The source of these enzymes is in the
conjunctiva where they are secreted in small
amounts. The lacrimal gland apparently does
not secrete these enzymes. These enzymes can
be obtained during mechanical irritation.
Lysosomal Enzymes
Amylase
Amylase is the enzyme present in tear fluid in
relatively moderate levels. The origin of this
enzyme is in lacrimal gland. The reported
presence of amylase in the cornea might be due
to contamination by tear fluid.
Peroxidase
Peroxidase (POD) is present in human tears
originating from the lacrimal gland and not from
28
the conjunctiva. The level of tear POD in human

tears is 103 /l. POD activity found in the
conjunctiva is probably derived from the
tears.
unbound fraction in plasma. Ampicillin is present

in tears in concentration of about 0.02 of the
corresponding serum level.
APPLIED PHYSIOLOGY
Plasminogen Activator
Plasminogen activator has been demonstrated
in tear fluid and corneal epithelium is suggested
to be the source of this urokinase-like fibrinolytic
activity.
Collagenase
Section
Collagenase has been shown to be present in

tear fluid in the presence of corneal ulceration,
due to infection, chemical burn, trauma and
desiccation. Corneal collagenase is present as an
inactive precursor latent collagenase which can
be activated with trypsin and in-vivo possibly by
plasmin resulting from plasminogen activator
activity in tears.
DRUGS EXCRETED IN TEARS
Tears represent a potentially more stable body
fluid of low protein content and with modest
variations of pH. Passage of drugs from the
plasma to the tears apparently takes place by
diffusion of the non-protein bound fraction.
However presence of tight junctions between
the acinar epithelial cells in the lacrimal gland
forming a blood-tear barrier, the lipid solubility
is expected to play a major role. The blood-tear
barrier shows the same characteristics as that of
cell membrane. Phenobarbital and carbamazepine are excreted in tears in about 0.5 percent
of corresponding plasma concentration.
Methotrexate, an antimetabolite reaches tear
levels of 5 percent of the corresponding plasma
concentrations and is in equilibrium with the
Basic secretion of tear fluid is made up of the

secretions of the lacrimal gland and accessory
lacrimal gland tissue together with the secretions
of meibomian glands and the mucous glands of
the conjunctiva. Reflex secretions of tears is
hundreds time greater than basal or resting
secretion. The stimulus to reflex secretions
appears to be derived from the superficial
corneal and conjunctival sensory stimulation as
a result of tear break up and dry spot formation.
The secretory stimulus to the lacrimal glands is
parasympathetic with reflex secretions occurring
in both eyes following superficial stimulation of
one eye. The whole mass of lacrimal tissue
responds as one unit to reflex tearing. Reflex
secretion is reduced by topical corneal and
conjunctival anesthesia.
HYPOSECRETION OF TEARS
Hyposecretion means decreased formation of
tears.
Lacrimal hyposecretion may be congenital
although not very common. Acquired lacrimal
hyposecretion may be due to
Atrophy and fibrosis of lacrimal tissue due to
a destructive infiltration by mononuclear cells
as in keratoconjunctivitis sicca and Sjgrens
syndrome.
Local inflammatory diseases of the conjunctiva commonly conjunctival scarring secondary to bacterial or viral infection.
Chronic inflammatory disease of the salivary
and lacrimal glands (Mikuliczs syndrome).

Damage or destruction of lacrimal tissue by
granulomatous (sarcoidisis), pseudotumor or
neoplastic lesions.
Absence of lacrimal gland.
Blockage of excretory ducts of the lacrimal
gland.
Neurogenic lesions.
Meibomian gland dysfunction.
29
BUT of less than 10 seconds is considered

abnormal. This test may also be abnormal in
eyes with mucin or lipid deficiency.
Schirmers Test
The rate of tear formation is estimated by
measuring the amount of wetting on a special
filter paper which is 5 mm wide and 35 mm
long (Figure 3.6).
DIAGNOSTIC TESTS FOR TEAR

HYPOSECRETIONS (Table 3.10)
Tear Film Break-up Time (BUT)
Compound
Diagnosis
Lysozyme
Usefulness
Sjogrens disease
+
Practolol induced toxicity
+
Traumatic inflammation of eye +
Lysosomal enzymes Lysosomal storage disease
+
Collagenase
Corneal ulceration
+
a -Antitrypsin
Bacterial infections
+
1
Glucose
Diabetes mellitus
+
Tear albumin
Genetic marker
+
Immunoglobulins
Iatrogenic inflammation
+
(IgA, IgG and IgM) of anterior-segment
+ Useful
+ Comparatively useful
FIGURE 3.6: Modified Schirmer test
Table 3.10: Diagnostic tests and drug assays in tears
Section
The tear film break-up time is a simple physiological test to assess the stability of the precorneal
tear film. This test is performed by instilling
fluorescein into the lower fornix, taking
precaution not to touch cornea. The patient is
asked to blink several times and then to refrain
from blinking. The tear film is scanned with a
broad beam and cobalt blue filter. After an
interval of time black spots or line indicating dry
spots appear in the tear film. BUT is the interval between the last blink and appearance
of the first randomly distributed dry spot.
Ideally average of three measurements is taken.
A normal BUT is more than 10 seconds and a
Previously Schirmers test 1 and 2 were used

in diagnostic practice but nowadays modified
Schirmer-I test is employed. This test is performed
as follows.
Schirmer strips are prepared by cutting out
Whatman filter paper No. 41 into the strips of 5
mm 35 mm dimensions. A 5 mm tab is folded
over at one end. Before use, these strips are
autoclaved.
The bent end is placed into lower conjunctival
sac at the junction of lateral one-third and medial
two-third of the lower eyelid so that a 5-mm
bent end rests on the palpebral conjunctiva and
the folding crease lies over the eyelid margin.
This test is usually performed in sitting posture
in dim light.
30
Section
The patient is asked to keep the eyelid open

and look slightly upwards at a fixation point.
Blinking is allowed while the patient gazes at the
fixation point.
After one minute, the strips are carefully
removed and moistening of the exposed portion
of the strip is measured in millimeters with the
help of a millimeter ruler.
The measurements are made from the notch
at the bend of the Schirmer strip to the distal
end of the wetting on the strip (excluding the
folded over tab). The amount of wetting of the
Schirmer strip in one minute is multiplied by
three to correspond roughly to the amount of
wetting that would have occurred in five minutes
(Jones, 1972). It is a measure of the rate of tear
secretion in a five-minute period.
A normal eye will wet between 10 mm to 25
mm during that period. Measurements between
5 mm and 10 mm are considered borderline
and values less than 5 mm is indicative of
impaired secretion.
Vital Dye Staining
Rose Bengal 1 percent has an affinity for
devitalized epithelial cells and mucus in
contrast to fluorescein which remains
extracellular and is more useful in showing
up epithelial defects. Rose Bengal is very
useful in detecting even mild cases of
keratoconjunctivitis sicca (KCS) by staining
the interpalpebral conjunctiva in the form of
two triangles with their base at the limbus.
The only disadvantage with Rose Bengal
staining is that it may cause ocular irritation
specially in eyes with severe KCS. In order
to reduce that amount of irritation only a
small drop should be instilled into the eye. A
topical anesthetic should not be used prior

to the instillation of Rose Bengal as it may
produce a false-positive result.
Alcian blue has similar properties as Rose
Bengal and is less irritant but it is not generally
available.
Lysozyme Assay
Lysozyme assay is based on the fact that in
hyposecretion of tears, there may be reduction
in the concentration of lysozyme. This test is
performed by placing the wetted filter strip into
an agar plate containing specific bacteria. The
plate is then incubated for 24 hours and the
zone of the lysis is measured. The zone will be
reduced if the concentration of lysozyme in the
tears is decreased.
Tear Globulin Assay
Tear IgA levels are measured in this test. This
test is also based on the principle that decreased
tear formation will lead to decreased IgA
(immunoglobulin A) levels in tears. This test is
performed on a specific tripartigan immunodiffusion plates containing specific agar gel in
wells (Figures 3.7 and 3.8). Twenty ml of tear
samples is put into these wells and plates are
incubated for 48 hours. The diffusion of rings
around wells are measured to the nearest 0.1
mm with a partigen ruler. The ring will be
reduced if the concentration of IgA in tears is
decreased.
This is a reliable test for measuring tear
globulins.
Tear Osmolarity
Tear osmolarity is increased in cases of
hyposecretion.
31
Biopsy of the Conjunctiva

Biopsy of the conjunctiva and an estimation of
the number of goblet cells are other tests which
can be done. In mucin deficiency states the
number of goblet cells shall be decreased.
HYPERSECRETION OF TEARS
Section
FIGURE 3.7: Tear globulin assay (diagnostic test)
In practice when patient complains of a wet eye

there are two possibilities of excessive watering
of the eye.
Lacrimation from reflex hypersecretion due
to irritation of cornea and conjunctiva.
Obstructive epiphora as a result of failure of
tear drainage or evacuation system. The main
causes are lacrimal pump failure due to lower
lid laxity or weakness of the orbicularis muscle
and more commonly due to mechanical
obstructions of the drainage system.
If the wet eye is caused by hypersecretion
the Schirmer test values (technique already
mentioned) will be increased and the Jones
Fluorescein dye test will reveal normal outflow
function.
PHYSIOLOGICAL DIAGNOSTIC TEST FOR
HYPERSECRETIONS
Jones I (Primary) Test
FIGURE 3.8: Tripartigen immunodiffusion plates (diffusion

of rings around agar wells is measured up to 0.1 mm)
This is a physiological test which differentiates

an excessive watering due to a partial obstruction
of the lacrimal passages from primary hypersecretion of tears (Figure 3.9).
In this test 1 drop of 2 percent fluorescein
solution is instilled into the conjunctival sac. After
about 5 minutes a cotton-tipped bud or applicator (moistened in coccaine 4% or proparacaine
0.75%) is inserted under the inferior turbinate
at the nasolacrimal duct opening. This is situated
about 3 cm from the external nares.
Section
32
FIGURE 3.9: Dye testing: Jones primary test (top) and

Jones secondary test (bottom) (Courtesy: Kanski Clinical
Ophthalmology Butterworth international Edition)
The results are interpreted as follows.

If the fluorescein is recovered from the nose
on the applicator and aqueous solution
passes from the conjunctival sac to the nose
in 1 minute then the excretory system is
patent and cause of watering is primary
hypersecretion. No further tests are required
then and the test is inferred as positive.
If no dye is recovered from the nose a partial
obstruction is present or there is failure of
the lacrimal pump mechanism. In this
situation secondary dye test or Jones II test is
required.
Jones II (Secondary Irrigation) Test
This test helps to identify the probable site of
partial obstruction.
In this procedure topical anesthesia (4%

Xylocaine or 0.5% proparacaine) is instilled into
the conjunctival sac and any residual fluorescein
is washed out. The nasolacrimal system is then
irrigated with normal saline. The patient is
positioned with his or her head down by about
45 so that the saline runs out of the nose into
white paper tissues and not into the pharynx.
This test is interpreted as follows.
Positiveif fluorescein-stained saline is
recovered from the nose, the dye must have
reached the lacrimal sac during the primary
dye test but was stopped from entering the
nose by a partial obstruction in the
nasolacrimal duct. However syringing of the
lacrimal system had pushed the dye past the
obstruction into the nose. A positive secondary dye test indicates a partial obstruction
to the nasolacrimal duct which can be treated
by a dacryocystorhinostomy (DCR)
procedure.
Negativeif unstained saline is recovered
from the nose it means that no dye has
entered the lacrimal sac during the primary
dye test. This means a partial obstruction in
the upper drainage system (punctum, canaliculi or common canaliculus) or a defective
lacrimal pump mechanism. In such a situation
DCR would fail and some other operative
procedure will be required.
Fluorescein Dye Disappearance Test
An accurate status of the excretory capability of
the lacrimal system can be obtained by observing
the behavior of a single drop of 2 percent
fluorescein solution instilled into the inferior
conjunctival cul-de-sac. The color intensity after
5 minutes is measured and graded on a scale of
0 to 4+. The normal excretion of the retained

fluorescein shall be 0-1+. Any greater residual
then is indicative of impaired outflow. However
by this test one cannot distinguish between
impairment of the upper and lower segments of
the system, but it may complement the Jones
tests.
Nasal examination should be performed in
order to determine the position of normal
nasal structures specially the position of the
anterior end of the middle turbinate when
surgery is contemplated. It will also detect
the presence of polyps or tumors, etc.
SPECIAL TESTS
Intubation Dacryocystography
common canalicular lesions, subtraction macrodacryocystography

may
provide
more
sophisticated details.
These specific investigations are not only
extremely valuable in depicting the exact location
of the obstruction but they are also of help in
the diagnosis of diverticula, fistulae, filling defects
due to tumors, stones and infections by
streptothrix species.
Scintillography (Radionuclide Testing)
This test involves the labeling of tears with
gamma-emitting substances such as technetium99m and monitoring their progress through the
drainage system. This is a sophisticated and
reliable test for better understanding of excretory
physiology.
Color Doppler Scanography
Color Doppler scanography is the latest

technique for evaluating the status of the
drainage system. It is a recently introduced test
with accurate results.
Section
The conventional method of dacryocystography

consists of injecting contrast medium into one
of the canaliculi followed by the taking of
posteroanterior (PA) and lateral views, radiographs. However, far superior status of the
canalicular system can be obtained by using a
technique that combines injection of lipoidol ultra
fluid through a cathetar with macrography. In
33
34
Chapter
Contact Lenses and

Ocular Lubrication
Section
Guillermo L Simon-Castellvi
Dra Sarabel Simon-Castellvi
Dra Cristina Simon-Castellvi
Jose Ma Simon-Castellvi
Jose Ma Simon-Tor
Successful and problem-free adaptation of a

patient to contact lenses, whether they are hard
or soft, depends upon adequate wetting of both
the cornea and the lens, and the ability of the
lens to allow the necessary corneal oxygenation.
Therefore, an adequate and stable tear film layer
is essential. Tears not only lubricate the cornea,
but also lubricate the opposing surfaces of the
conjunctiva (bulbar and palpebral conjunctivae).
The action of the lids is of the utmost importance,
provided that the tear film is adequate in quality
and volume.
A correct fitting procedure, covered in depth
in this book, include adequate corneal, lids, and
tear film evaluation at the slit-lamp.
In the USA contact lens marketplace, 82
percent wear soft lenses, 16 percent wear rigid
gas-permeable (RGP), and 2 percent wear hard
contact lenses. Although very few people wear
hard lenses, they are available for people who
have adapted to them and want them. Hard
lenses are not the same as RGP lenses, since

they do not allow oxygen transmission through
the lens. Whichever contacts the patient uses,
the reading of this chapter should invite every
practitioner to bear in mind that no contact
lens patient should be out of artificial tear
lubrication. Every contact lens wearer has tear
deficiencies related to the lens. Contact lenses
are like sponges, and require considerable tear
moisture to work properly: if not, they act as a
foreign body.
The purpose of contact lens fitting is to
determine the type and specifications of the most
appropriate contact lenses for each individual
patient. Proper fit includes factors such as
optimal vision correction and proper alignment
on the eye. The quality of the fit is evaluated by
the prescriber in order to ensure optimum vision
and safety with contact lens wear. The choice of
the best lubricant for each patient will change
with fitting experience. Practitioners with poor
Contact Lenses and Ocular Lubrication
35
Table 4.1: The normal tear film

LIPID LAYER
(0.1 micron thick)
AQUEOUS
LAYER (10-12
microns thick)
prevents rapid evaporation of the aqueous

component when the eye is open
prevents drying between blinks
prevents damage of the lid margin skin by tears
(prevents the overflow of tears over the skin)
forms a seal over the exposed portion of the
eye during night
prevents sebaceous lipids from entering the tears
moisturises and nourishes the ocular surface
(the surface of the cornea must be kept moist to
prevent damage to the epithelium)
MUCOUS LAYER
(0.6-1 micron thick)
CORNEAL EPITHELIUM
allows the tear to spread upon the corneal

epithelium
its microvilli anchor the mucus to the cornea
The volume and composition of tears in a contact

lens wearer is clearly affected by the contact lens
wear (Table 4.2). On lens insertion, there is an
increase in tear production rate and a decline in
CONTACT LENS INDUCED CHANGES

IN THE TEAR FILM
tear tonicity levels (reaching plasma levels). These

changes come close to previous levels after about
a week. Later, in the adapted contact lens
wearer, there is evidence for increased tear
osmolarity probably due to an increased tear
evaporation rate, as a result of the induced
disruption of the lipid layer of the tear film and
the reduced blinking rate.
In soft lens wearers (with a new or clean
lens), the lipid layer is similar to the non-lens
wearing eye. When surface deposits or defects
are present, the tear lipid layer becomes
unstable.
In hard lens wearers, the lipid layer is almost
absent over the anterior face of the contact. It is
replaced by a thicker aqueous phase drying on
the lens surface. The edge of the hard lens forms
a barrier to the spreading of the lipid layer over
the lens, which is surrounded by an evident
amount of lipid.
Section
contact lens fitting experience encounter some

fitting problems that would have been overrun
with proper ocular lubrication.
The ocular tear film is a transient and dynamic
structure (Table 4.1) Classically, and controversially, the normal tear film has three layers (or at
least it has three major components: lipids, water
and mucus). It is not perfectly stable: each blink
tends to stabilize the different layers, but this
becomes more difficult when a foreign body
called contact lens is in place. Maintenance of a
healthy ocular surface depends on the amount
and composition of the tear film. The maintenance of a normal tear film depends on the
maintenance of a normal ocular surface.
Therefore, the best way to prevent ocular
complications in contact lens wearers is proper
lubrication.
Table 4.2: The tear film in contact lens wearer

LIPID LAYER AQUEOUS LAYER MUCOUS LAYER
CONTACT LENS is bathed in mucus
MUCOUS LAYER
AQUEOUS LAYER
MUCOUS LAYER
CORNEAL EPITHELIUM
36

levels is one of the most important signs in the
diagnosis of giant papillary conjunctivitis.
Common causes of incomplete tear film
distribution:
contact lenses (any kind)
trichiasis (see Figure 4.1A)
pterygium (see Figure 4.1B)
corneal scars (see Figure 4.1C)
pingueculae (Figure 4.1D)
Table 4.3: Origin of the different components of the film layer
Other tests for dry eye evaluation:

1. Impression cytology
2. Fluorescein and Rose Bengal: Hypofluorescence is a reliable indicator of low tear
volume in the resting state. A fluorescein strip
touching the lower palpebral conjunctiva after
moistening with a drop of non-preserved
saline will instil a standard amount of
concentrated dye, which will not fluoresce
immediately when the tear volume is low.
Section
The tear film in contact lens wearer has more

layers: Figure 4.1B notice that the contact lens is
bathed in mucus, just as happens with any other
foreign body. When the tear film breaks up, and
it does so more easily in contact lens wearers due
to the contact lens, there is a loss of the mucous
barrier, and the aqueous component tends to
evaporate. In such cases, the lipid fraction and its
debris come to direct contact with the contact
lens, damaging the lens material and leading to
spots and deposits over its surface. The best
prevention is proper lubrication.
The fluid compartment between a hard (rigid)
contact lens and the cornea acts as a lens itself
which has a refractive power independent of that
of the contact lens and that of the eye.
In soft contact lenses, the power of this fluid
compartment is virtually plano (zero) since the
contact lens conforms to the exact shape of the
anterior corneal surface.
LIPID
LAYER
AQUEOUS
LAYER
MUCOUS
LAYER
meibomian glands (lid margins)

glands of Zeis (sebaceous)
glands of Moll (sweat)
lacrymal glands (primarily by the lacrymal
gland located in the superior temporal orbit,
and secondarily by the accessory glands of
Krause and Wolfring that lie in the conjunctiva)
conjunctival goblet cells (distributed
throughout the bulbar and palpebral
conjunctiva)
The different components of the film layer

have different origins (Table 4.3): pathologic
changes in the sources lead to tear film quality or
quantity loss. For instance, in giant papillary conjunctivitis, common in cases of contact lens abuse,
the conjunctival production of mucus is dramatically increased, since extra mucus is formed in
secretory vesicles of the nongoblet epithelial cells.
Clinically, the observation of increased mucus
Common methods for tear film evaluation:

1. Lacrymal lake evaluation at slit lamp
2. Corneal videokeratography (Figure 4.2)
3. Schirmers tests
4. BUT (tear break-up time) (Figures 4.3 and
4.4)
5. Tearscope (Instrument designed by Dr
Guillon and made by Keeler Instruments,
helps to evaluate the lipidic phase or the tear
film)
Roles of tear film layer and tear film substitutes

in contact lens wearers:
Provide adequate wetting of the corneal
epithelium and the contact lens surface for
as long as possible (reduce corneal swelling
to an extent)
Adhesion between lens and cornea
FIGURE 4.1B: Pterygium
FIGURE 4.1C: Corneal scars
FIGURE 4.1D: Pingueculae
Section
FIGURE 4.1A: Trichiasis
37
FIGURE 4.2: Corneal videokeratography is a useful method

for evaluation of tear film. Irregular pattern of the rings of a
Placido disk, changing between blinks, suggests a failure in
the precorneal tear film distribution.
FIGURES 4.1A to D
FIGURE 4.3: Measuring the tear break-up time (BUT) is a

useful method for evaluating the status of the precorneal
tear film. It provides a clinical estimation of the length of time
that the tear film remains stable and intact between blinks.
The normal BUT is 10 seconds or longer: Figure shows the
broken fluorescein dye distribution in a contact lens wearer
without the contact lens, showing a fluorescent dehydration
induced staining at the superior limbus (mild punctate
keratopathy).
38
Section
FIGURE 4.4: Shows the broken fluorescein dye distribution

in a myopic contact lens wearer without the contact lens, 5
seconds after the last blink, showing a fast tear break-up
time despite a good tear meniscus stained with fluorescein.
The meniscus results from excessive irritative lacrimation
due to the contact lens wear: tear film is good in quantity but
not in quality. The patient needs extra artificial corneal
lubrication to stabilize the tear film.
FIGURE 4.5: Lagophthalmos is a rare condition in which

incomplete eye closure leads to a dry eye syndrome. Rose
Bengal staining clearly shows the damaged conjunctival
and corneal epithelium. Lagophthalmos is not a
contraindication for contacts, but intense artificial moistening
of the eye should be prescribed. Eye drops are suitable
during the day, while eye gels or ointments (with special
care in contact lens users) are preferred at night time.
Optical correction of minor corneal irregularities

Allow friction-free movement of hard lenses
over the cornea
Cushioning effect
Cleaning and wetting of the lens surface
Increase hydration of gel lenses (soft contacts)

Prevention of infections (fungal, bacterial and
parasitic)
Removes metabolic byproducts from the
cornea
Removes toxic contact lens cleaning particles
Disinfecting anterior segment surface
Provide increased wearing comfort
Improve visual acuity
Avoids complications!
Safe contact lens wear involves using common sense. Knowing when not to wear contact
lenses is important. Patients should remove any
contact lens that is causing irritation and not
reinsert the lens until the eye feels comfortable
again and the patient has consulted the
ophthalmologist. The patient should never ignore
symptoms of discomfort, redness or blurred
vision. Patients should not wear their contact
lenses under any of these situations, and should
immediately consult their contact lens prescriber:
until then, proper lubrication may be helpful in
avoiding complications. Not all the reactions to
contact lens wear have an immunological basis:
bad corneal lubrication and improper care, or
mode of usage, may be at the origin of the most
common complications.
Patients need to know that a major cause of
decreased corneal sensation is contact lens wear:
sometimes, discomfort only appears when the
problem is serious.
CONTACTS AND DRY EYE

SYNDROME
Tear abnormalities may be related to a problem
like lagophthalmos (Figure 4.5) or blepharitis
(Figures 4.6 and 4.7) or with tear volume
(quantitative abnormalities like increased tear
39
FIGURES 4.6 and 4.7: Blepharitis is a common chronic condition, not related to the contact lens use, but that may have
impact on contact lens wear. There are two basic types, seborrheic and squamous. In both, staphylococcal infections are
implicated. Notice the hard crusting scales on the anterior lid margin. Keratoconjuctivitis sicca is present in more than 50%
of patients, and is responsible for the burning of the eyes, not only in contact lens wearers. Artificial lubricants will improve
comfort and help avoiding the peripheral immune corneal infiltrates, due to hypersensitivity reaction to staphylococcal
antigens (see picture), specially in contact lenses wearers.
Section
FIGURE 4.8: Minor pinguecula in a contact lens wearer is

not related to the contact lens use but may impact on contact
lens wear. Ocular lubricants are occasionally useful to avoid
mechanical trauma through lens striking the raised area.
The same applies to pterigyum.
FIGURE 4.9: Examination findings that support a diagnosis

of dry eye include occluded meibomian gland orifices and
small papillae of the upper tarsal conjunctiva. Blepharitis
and allergic conjunctivitis are also contributing causes to
red eye and to an unstable tear film, which leads to excessive
evaporation of tears and dry eye.
evaporation or excess tear volume), tear

surfacing (like pterygia or pingueculae, Figure
4.8), tear wetting (like excess of mucus in
contact lens users), tear base (like abnormal
corneal epithelium in ulcerations or chemical
burns) and tear lipids (like meibomianitis in
acne and blepharitis (Figures 4.9 to 4.11). The
classification of tear abnormalities according to
these mechanisms provides a rationale for

therapy. Dry eye is either biological or environmental. Dry eye (Figure 4.9) can make contact
lens wear more difficult since tears may be
inadequate to keep the lenses wet and lubricated.
As we get older, we tend to produce less tears
and that makes the surface of the eye dryer.
This drying effect of ageing is frequently more
40
Section
FIGURE 4.10: Conjunctival lymphatic cysts in a contact

lens wearer are not related to the contact lens use but may
have impact on contact lens wear. Ocular lubricants are
occasionally useful to avoid mechanical trauma through
lens striking the raised area. Notice the positive fluorescein
staining over the cyst due to improper lubrication.
FIGURE 4.11: Large yellowish densified (or solidified)

secretions in a contact lens wearer plug the meibomian
gland orifices. They are not related to the contact lens use
but may impact on contact lens wear by modifying the tear
film composition. Ocular lubricants are useful to stabilize
the precorneal film
pronounced in women than in men, primarily

due to hormonal factors. While dry eye occurs
in both women and men, it occurs more frequently in women than in men. Now, environmental factors can influence the symptoms of
dry eyes, particularly when people are in an
atmosphere in which there is movement of air
(such as wind) or when it is dry or in work
conditions where there is a constant flow of air

across the eyes. This occurs because these
conditions facilitate evaporation and a further
loss of tears.
Dry eye patients are often under the false
impression that they cannot wear contact lenses.
Dry eye syndrome itself is not a contraindication
for contact lens use, but patients suffering from
any of its conditions have increased risks of
complications and should be carefully instructed
to the correct use and management of contact
lenses, and to the appropriate lubrication of their
eyes in order to avoid complications (Figure
4.12). Some rare conditions which are contraindications for contact lens use: xerostomia,
erythema
multiforme
(Stevens-Johnson
syndrome), ocular cicatricial pemphygoid, etc.
People with inadequate tearing (dry eye
syndrome) usually cannot tolerate contacts, but
only severe or extreme dry eye conditions make
it preferable to avoid the use of contact lenses.
When facing a patient with dry eyes, always try
contact lens fitting after a period of proper
artificial corneal lubrication. Instruct your patient
to stop the use of contacts as soon as he/she
feels any sign of complication or discomfort.
In case of discomfort, contacts should be
temporarily discontinued at once. The simplest
and most effective measure to treat contact lens
wear related complications is for the patient to
abandon lens wear.
Dry eye cannot be cured, but the eyes
sensitivity can be lessened and measures taken
so that the eyes remain healthy by means of the
use of artificial tears or tear substitutes. In some
cases, small plugs may be inserted in the inferior
lachrymal point to slow drainage and loss of tears.
Tear lysozyme and lactoferrin concentrations are decreased in dry eyes. Although the
reduces the dehydration that occurs in most soft

contact lenses. Clinical studies have demonstrated an improvement in comfort and in signs
of dryness on the surface of the eye with this
contact lens when compared to a group of other
lenses to which it was tested. Nevertheless, contact lenses alone have no place in the treatment
of dry eyes: concomitant use of artificial
teardrops (and periodic check-up) is essential.
Signs and symptoms of a contact lens wearer
with a dry eye (i.e. needing extra lubrication)
Signs:
1. Frequent loss of the contact lenses (bad
corneal adhesion)
2. Presence of bubbles between the contact lens
and the cornea
3. Increased corneal deposits (Figure 4.10)
4. Conjunctival hyperemia at 3 and 9 oclock
5. Changes in corneal thickness (frequent
changes of refraction)
6. Loss of contact lens reflex
Symptoms
1. Increased foreign body sensation
2. Increased glare (increased halos)
3. Changing visual acuity
4. Best visual acuity just after opening the eyes
CONTACTS AND AIR CONDITIONING
FIGURE 4.12: Some soft contact lenses (like therapeutic

or bandage contacts) may prevent evaporation from the
ocular surface, and provide a benefit by moistening and
covering an eroded portion of the cornea, but may also be
responsible of conjunctival erosions due to overuse and
inadequate ocular wetting. The use of an artificial tear
substitute is essential to prevent complications in contact
lens users.
Section
tests are neither sensitive nor specific as a

diagnostic test for keratoconjunctivitis sicca, they
are helpful in determining the bacterial resistance
of the tears. Patients with low levels of lysozyme
and/or lactoferrin have increased risk of ocular
infections (conjunctivitis, corneal abscesses). In
these patients, the intermittent use of artificial
tears with preservatives can help to avoid
infections.
Several varieties of contact lenses can aid in
the treatment of dry eye: hard contacts may
stimulate reflex tearing and thus increase the
volume of tears. Some hard scleral contact lenses
may be beneficial by preventing evaporation
from a large portion of the ocular surface. The
American Food and Drug Administration (FDA)
has approved one type of contact lens for dry
eyes. This contact lens is the Proclear Lens. It is
a soft lens that has some unique properties. Not
only does it have a high water content like other
soft lenses, but also has a component that retains
water better than most other soft lenses. This
41
Tears leave the eye via three mechanisms: (a)

flow to the nasolacrymal sac through the puncti
and canaliculi, (b) evaporation and (c) conjunctival absorption.
The rate of evaporation (approximately 3
microliter/hour at 30 percent relative humidity)
is significantly reduced in humid environments
(tropical climate) and increased in dry
environments (desert environment, air dryers).
42
Contact lens wearers living or working under air

conditioning and/or air heating, have an
increased rate of evaporation and, therefore,
need extra artificial eye wetting via artificial tear
substitutes. Direct air currents should be avoided.
The use of a humidifier is highly recommendable.
Certain working conditions, such as exposure
to chemical fumes, smoke or air conditioning,
may be undesirable for contact lens wearers.
Notice that smokers are at higher risk of seeing
their contacts lenses turn yellowish due to smoke
and nicotine: just as it happens to their fingers.
CONTACTS AND COMPUTER

VISION SYNDROME
Section
The use of contact lenses is no reason for stopping

the use of computers. When facing a computer
monitor, the blinking rate decreases. This leads
to dry eye, responsible for most of the symptoms
referred by the contact lens user. Adequate eye
lubrication with artificial tears and resting 5-10
minutes per hour should be enough to avoid
discomfort in front of the monitor.
Recent studies have shown that you can
decrease the evaporation of tears from your eyes
if the computer screen is below the level of your
head by about ten inches.
WHY SHOULD WE PREFER PRESERVATIVEFREE ARTIFICIAL TEARS?
Preservatives are used in most artificial tear
solutions and eye medicines to prevent bacterial
contamination and to allow longer shelf-life. The
most commonly used are: thimerosal,
chlorhexidine, phenylmercuric acetate, chlorobutanol, paraben and benzalkonium chloride.
Thimerosal is specially notorious in the
incidence and severity of adverse ocular effects.
Contact lens wetting solutions and artificial tear

products may contain these chemicals or
preservatives which can change the tear films
osmolarity and cause dryness or cause an allergic
reaction.
The most frequent preservative agent is
benzalkonium chloride, also known as bak, in
variable amounts. Benzalkonium chloride
electrostatically binds with soft contact lens
materials (hydrophilic) and can reach toxic levels.
For that reason, bak is not used as a preservative
in soft lens rinsing solutions. It is used as a
preservative in rigid lens solutions, since it does
not bind with rigid lens materials as readily. Some
people are very sensitive to benzalkonium
chloride, and show toxic corneal insult even at
relatively low concentrations. If the patient is
using various eyedrops at a time (like
glaucomatous contact lens wearers), there may
be a concern with the amount of benzalkonium
chloride they are using, because cumulative effect
may result. Since preservatives may cause toxic
reactions in patients who use artificial tears
frequently, for these patients (like contact lens
users), preservative-free tear substitutes or
disposable lenses are preferable. It is also possible
to shorten the wearing time for the contacts.
The ophthalmologist is sometimes also able
to substitute one or more of the ocular drops
with something not preserved with benzalkonium
chloride.
Contacts may be ruled out in allergy to lenscare products. When a patient is experiencing a
lot of mucus build-up, excess debris in the tear
(Figure 4.13) film, and a viscous-appearing tear
film which makes his or her vision blurry,
approximately one hour after inserting the
lenses, one possibility is that he/she has
FIGURE 4.13: Foam in the tear film is a result of meibomian

gland dysfunction; it often accumulates in the temporal
carthus, flowing in the opposite direction to tears.
Sleeping with lenses on, in general, is not a good

idea. Regardless of whether the patient has dry
eyes or not, sleeping with a lens increases the
risk of infection over ten times what it would be
if the patient took the lenses out each night.
Under normal conditions, the average person
secretes about 1 g of tears during a 24-hour
period, mostly during the waking hours. At
night, our eyes produce almost no tears, so the
eyes become a dry environment and can
become mildly inflamed. For these reasons, it is
generally not recommended that patients wear
lenses overnight.
There are lenses approved by the FDA for
DOES GOOD CORNEAL WETTING ALLOW

PATIENTS TO USE CONTACTS OVERNIGHT
(WHILE ASLEEP)?
overnight wearing, but we recommend against

this because there is an increased risk of infection
with overnight lens wearing.
The most serious safety concern with any
contact lens is related to overnight use.
Extended-wear (overnight) contact lensesrigid
or softincrease the risk of corneal ulcerations
that can lead to blindness.
When the eyes are open, tears carry adequate
oxygen to the cornea to keep it healthy. But
while sleeping, the eye produces fewer tears,
causing the cornea to swell. With the binding
down of a rigid contact lens during sleep, the flow
of tears and oxygen to the cornea is further
reduced. This lack of oxygen leaves the eye
vulnerable to infection and neovascularization.
Some people believe that proper eye
lubrication at daytime allows overnight contact
lens wear: this is completely false. In contact lens
wearers, proper eye lubrication reduces the risk
of complications due to improper wetting of the
cornea (epithelial defects, corneal ulcers, corneal
abscesses) but does not avoid complications
related to the lack of oxygen.
Generally, contacts should be removed at
bedtime due to risk of infection and risk of
contact lens intolerance. Occasionally it is OK, if
it is an accident.
Section
developed a sensitivity to the solution. We instruct

our patients to thoroughly moist the eyes with a
preservative-free artificial tear drops, and to try
a different solution.
Contact lens wearers should monitor closely
expiration dates of preservative-free lubricants:
and outdated medication should not be used.
43
DOES GOOD CORNEAL WETTING AVOID

CORNEAL RESHAPING DUE TO HARD
CONTACTS?
Hard contacts and also extended-wear rigid
lenses can cause unexpected, sometimes
undesirable, reshaping of the cornea (corneal
warpage). This phenomenon is more common
with decentered contacts or in case of improper
fitting. Soft extended-wear lenses also bind down
on the closed eye, but they are porous and allow
44
Section
some tears through during sleep. Because they

have so little form, their binding has little effect
on the shape of the eye.
Before refractive surgery is performed, if
corneal reshaping is diagnosed by means of computerized corneal topography, contacts should
be discontinued as early as possible before
surgery (weeks and months before in some
cases), good corneal lubrication is mandatory
until the reshaping disappears. Corneal warpage
may take months to completely disappear in a
long-term rigid contact lens user.
The FDA approved extended-wear lenses
could be used up to seven days before removal
for cleaning. Still, there are risks with use of
extended-wear lenses, even if it is just one night.
Daily-wear lenses are removed daily for cleaning
and are a safer choice, provided they are not
worn during sleep. Proper eye lubrication
reduces but does not eliminate the risk of
complications in extended-wear lens users.
DOES GOOD CORNEAL WETTING
PROTECT FROM ACANTHAMOEBA
KERATITIS?
Acanthamoeba keratitis is a very uncommon

sight-threatening infection in Europe. More
common in the USA, it is caused by improper
lens care. It is a difficult-to-treat parasitic infection,
and its symptoms are very similar to those of
corneal ulcers.
The use of home-made saline from salt
tablets and water is one of the biggest
contributors to Acanthamoeba keratitis in
contact lens wearers. The use of salt tablets is
not acceptable today as a correct contact lens
maintenance method. Microorganisms can also
be present in distilled water, so always use
commercial sterile saline solutions to dissolve

enzyme tablets. Heat disinfecting is the only
method effective against Acanthamoeba, and it
also kills organisms in and on the lens case.
Proper care gives a safer contact lens wear. Good
corneal lubrication with artificial tears does
not prevent from Acanthamoeba keratitis,
although artificial tear preservatives might lower
the risk.
DOCTOR, CAN I MAKE MY OWN TEAR
SUBSTITUTE
Some patients prefer to make their own artificial
tear mixtures, from a combination of herbs (like
camomile) and spring water; this practice has to
be discouraged. Sterility is of the utmost importance in contact lens users, because Pseudomonas and Acanthamoeba are contaminants
of spring and tap water, and even distilled water
may not be sterile. Osmolarity is also important,
and it cannot be easily measured at home.
Human mouth is septic; saliva should not be
used for contact lens cleaning or lubrication! (yes,
it happens in some countries).
DOES CORNEAL WETTING EASE
CONTACT LENS FITTING?
Soft lenses are much more comfortable than
rigid lenses, thanks to their ability to conform to
the eye and absorb and keep water. A patient
can get used to soft lenses within days, compared
with several weeks for rigid. An added benefit is
that soft lenses are not as likely as rigid lenses to
pop out or capture foreign material like dust
underneath. Extra-thin soft lenses are available
for very sensitive people. Artificial tear substitutes
are sometimes useful to ease contact lens fitting,
specially for those patients used to eyedrops.
45
CONTACT LENS MAINTENANCE

AND ARTIFICIAL TEAR
SUBSTITUTES
Beta-blockers are known to decrease aqueous

tear secretion. If your patient is using topical eye
medication, instruct him or her to apply artificial
FIGURES 4.14 and 4.15: Protein and lens calculi on a soft

piano therapeutic lens. Some people build up deposits on
their contact lenses, including oil and proteins, which make
it difficult for the tears to cover the contact lenses with a
smooth surface. Lids act like a windshield wiper and patients
are blinking to clear it up. Deposits on the lenses need to be
cleaned or contacts need to be replaced. Deposits, like the
protein deposits shown, are more frequent in contact lens
wearers with no extra moistening of the eyes, since
cholesterol and protein concentrations are increased
(because of the decreased tear volume). This problem is
worse with soft (gel) lenses. The deposits are basically
made of cells, granular and trabeculated mucus, calcium,
pigment and proteins or lipids, and provide nourishment to
bacteria and fungi. The presence of deposits on the contact
lens suggests bad corneal lubrication, and may be
responsible for contact lens intolerance.
CONTACT LENSES AND

GLAUCOMA PATIENTS
Section
Rigid lenses generally give clearer vision, can be

marked to show which lens is for which eye,
they do not rip or tear, and are easy to handle.
Also, rigid lenses do not absorb chemicals, unlike
soft lenses, which are like sponges. Soft lenses
suck up any residues on your hands: soap, lotion,
or whatever. While the ability to hold water
increases oxygen permeability of soft lenses, it
increases their fragility as well.
Proper contact lens maintenance should
include proper ocular lubrication; in soft contact
lens wearers, artificial tears help to clean any residues absorbed by the lens (Figures 4.14 and
4.15).
Soft lenses additionally come as disposable
products (defined by FDA as used once and
discarded) or as planned-replacement lenses. In
such cases, artificial ocular lubrication is not so
essential, since the contact will be in place for a
short period.
For patients who produce a higher level of
protein in their eyes or do not take as good care
of their lenses, it might be healthier to replace
the lenses more frequently, despite the adequate
use of artificial tears.
The appropriate wearing time for each patient
will depend on the type of lens prescribed. The
more the lenses are used, the more necessary
good lubrication becomes (Figure 4.17).
tears first, waiting at least 10 minutes to apply

antiglaucoma topical medication. Most lubricants
may be safely used in addition to any eye care
product or medication the patient uses (suspensions or solutions).
46
Contact lens users, under latanoprost (alone

or combined with timolol), will feel more
comfortable applying an artificial tear before
latanoprost; contact lens tolerance is increased,
and eye redness and photophobia become more
rare. The same applies to other prostaglandin
analogues.
Normally, filtering blebs are asypmtomatic;

occasionally, contact lens users with small flat
blebs may experience some discomfort, that is
addressed with topical tear substitutes. We prefer
0.18% sodium hyaluronate solution (Vislube,
Lab. ChemedicaGermany, distributed by
Thea in Spain), two or three times-a-day.
GLAUCOMA FILTERING BLEBS
CONTACT LENSES AND

OINTMENTS
Section
The filtering bleb (Figure 4.16) is a subconjunctival reservoir where remains the aqueous that
bypasses obstructed or insufficient physiological
outflow through the operative fistula. Filtering
blebs may take on a wide variety of clinical
aspects. The aspect of the bleb does not always
reflect its function, though helps to establish
prognosis. Most patients with a filtering bleb do
require additional lubrication, to increase comfort
and to reduce the risk of bleb infection.
FIGURE 4.16: Large or multicystic blebs really do well in

IOP control, but their paper-thin and transparent cyst walls
are more prone to leakage and infection. This kind of bleb is
more common in fornix flap-based approach. In such patients
we always prescribe the daily use of artificial tears to help
avoiding bleb infection. Contact lenses are not well tolerated:
they can erode the paper-thin walls of the bleb resulting in
bleb infection, and are easily lost by the patient due to the
bad adhesion between the contact lens and cornea. Giant
filtering blebs are contraindication for contact lenses.
Some patients find that instillation of an ointment

with a petroleum base prevents dryness of the
eyes and increases comfort. But because
ointments remain in contact with the ocular
surface longer than solutions or suspensions,
sensitivity to preservatives may be increased, and
contact lenses can become greasy.
Do not use ointments with the contact lens
in place. In case of severe dry eyes, contact
lenses ought better be avoided; users of contact
lenses with severe dry eyes should avoid the use
of ointments; if the patient wants to continue
lens wear, instruct him or her to use ointments
at night time (when sleeping), and rinse the eye
thoroughly with an artificial tear before putting
the contact lens in place. Warn your patient
that using ointments makes contact lens to be
very carefully cleaned and replaced more
frequently.
Some ointments may not be compatible with
all contact lenses materials, and the contact may
result irreversibly damaged even by very small
quantity of product. Ask the manufacturer of
the contact lens before prescribing an ointment
in a contact lens user.

THERAPEUTIC CONTACT LENSES
viscid lubricants may precipitate on the cilia,

causing some discomfort to the patient.
We always try to use the least toxic
products to keep corneal epithelium in the best
condition. To keep cornea in good condition,
we prescribe a treatment with a 0,18% sodium
hyaluronate solution (Vismed or Vislube,
Lab. ChemedicaGermany, distributed by
Thea in Spain), two or three times-a-day. Most
of our patients have a high degree of satisfaction,
and feel very comfortable with the use of sodium
hyaluronate solution.
Section
Correcting vision is not the only use for contact

lenses. Some soft contacts are used as bandage
lenses after photo-refractive keratectomy (PRK)
surgery for nearsightedness. The surgery creates
a large abrasion on the eye, being reported by
the patients as excruciatingly painful if you do
not have a protective covering on the cornea
after the anesthetic wears off (Figure 4.17).
Providing increased comfort by means of proper
corneal moistening is always desirable.
Eye bandage lenses (like Bausch & Lombs
plano T therapeutic contact lenses) are used
to relieve pain from abrasions or sores on the
cornea, or after a corneal graft, to enhance reepithelialization. Patients feel more comfortable
with intensive preservative-free eye moistening.
47
WHICH IS OUR PREFERRED ARTIFICIAL

TEAR SUBSTITUTE IN CONTACT LENS
WEARERS ?
There is not any one drop that has been proven

clearly superior to all others. Most artificial tears
replace the volume of tears that are missing,
however, no artificial tear has all the ingredients
that natural tears have. A number of the artificial
tears try to approximate the constituents of
natural tears and some have more ingredients
than others. They all also have thickening agents
in them to make them last longer. In general,
we now recommend that people who are using
eyedrops more than three or four times a day
to use tears that do not contain a preservative,
as those can be irritating to the eye. The best
solutions are those that stay on the eye as long
as possible; they are generally viscid and contain
mucomimetic ingredients. Nevertheless, some
FIGURE 4.17: Epithelial defect due to extended contact

lens wear may worsen by the long use of tear substitutes
containing preservatives. Notice the stromal and epithelial
damage in a patient that used rigid contact lenses for months
without extra lubrication, and without rest! If possible,
preservative-free artificial tear substitutes should be
preferred.
Another excellent corneal lubricant is BSS

from Alcon Laboratories, the same product
we use for intraocular surgery (available in 10
ml bottles). The eye surface depends upon the
tear films electrolyte balance for its normal
biologic functioning. Each drop of BSS provides
this balance.
Artificial tears have been a treatment mainstay
for soothing dry-eye symptoms. Some (most) are
accepted in contact lens users. They lubricate and
48
Section
offer temporary relief from the irritations that

occur on the ocular surface. In healthy patients,
we do not prescribe artificial ocular
lubrication for treating symptoms, but to
prevent them. We have a tray of artificial tear
solutions for contact lens users such as Filmabak
(Thea) Theratears (Advanced Vision Research),
Refresh and Celluvisc 0.5% (Allergan), Tears
Naturale and Bion Tears (Alcon), and
GenTeal and HypoTears (NovartisCiba
Vision). Patients and doctors typically go through
several brands until they find something that feels
better and that is what the patient will stick with.
Our experience shows that products
have to be rotated for best results. In that
sense, we instruct our patients to use alternatively
two different artificial tear drops (two
different products, once one product and later
the other one), so that the eye does not get used
to the same product. Most patients are really
satisfied; they feel that relief and comfort last
longer. Good combinations are: 2% Povidone
plus 0,18% sodium hyaluronate, and polyvinyl
alcohol plus 0,18% sodium hyaluronate.
Some artificial tears are delivered in singledose preservative-free small bottles that fit easily
into the pocket or purse, and can be used quickly
and conveniently, any time and anywhere. But
for daily use, at home, 10 ml drop containers
are cheaper; some modern containers, like the
BAK systems from Thea, have a special filter
that retains preservatives, and prevents from
external contamination.
CAN WE SAFELY USE CONTACTS AFTER
REFRACTIVE SURGERY?
Laser surgery is an alternative to the use of lenses.
The most common procedure is LASIK (laserassisted in situ keratomileusis). Unfortunately, for
people with dry eyes, the LASIK procedure can

worsen dry eyes, at least temporarily. This is
because when the flap is made, some of the
nerves to the cornea are cut. These nerves are
important in sending signals back to the tearproducing glands, telling these glands to produce
more tears. When these nerves are cut, those
signals are interrupted. The nerves eventually
grow back; but in patients in whom there is
already an insufficient amount of tears, this
disruption of nerves can worsen the symptoms
of dry eyes.
Although the results of radial keratotomy
(RK) (Figure 4.18) and photorefractive keratectomy (PRK) for myopia are good, some
patients still require contact lenses to optimize
their postprocedure vision. Contact lenses may
provide the best vision for post-PRK and postRK patients with regression, anterior stromal
haze, irregular astigmatism, halos and anisometropia. Modern corneal topography provides the
detailed analysis necessary to select an appropriate lens for the postsurgical patient. Contact
lenses are generally fit when corneal topography
stabilizes, 3 to 6 months after RK, and 6 to 12
months after PRK. After RK and PRK, rigid gaspermeable (RGP) lenses are more frequently fit
than soft lenses, because of their superior oxygen
permeability, better movement on the altered
corneal surface and good visual acuity.
In postrefractive surgery patients, we have
noticed that acuities that could not be corrected
to the preoperative level with spectacles were
easily corrected to preoperative acuities with
RGP lenses. Contact lenses can be an excellent
option to optimize vision after refractive surgery
if time is taken to obtain a well-fitting lens and to
counsel the patient regarding lens wear and
expectations.

Contact lenses can be effectively used after
unsuccessful refractive surgery, but care has to
be taken not to worsen postoperative eye
dryness. These patients need intensive eye
lubrication with preservative-free solutions.
Contacts should only be used for short periods
of time.
Is it safe to use any artificial tears with

contact lenses? Most times, there is no problem, because most brands offer preservative-free
drops for corneal lubrication. Contact lens
lubricants are artificial tears that have been tested
for use with contact lenses. Basically, they are
synthetic human tear fluid with extra water. But
not all are created equal; for instance,
TheraTears is available in the USA from
Advanced Vision Research, of Woburn, Mass. It
is not available in Europe at the moment these
lines are written. It is the first eyedrop for dry
LUBRICATION WITH THE DIFFERENT

TYPES OF CONTACT LENSES
eye shown in preclinical studies to not only wet

and lubricate the eye, but also to promote
healing and restore conjunctival goblet cells.
TheraTears is hypotonic enough to lower
elevated tear osmolarity, rehydrating the tear film
so water can move back to rehydrate the eye
surface. TheraTears provides electrolyte
balance for corneal normal biologic functioning.
Contact lenses promote evaporation of tears
from the surface of the eye. In addition, soft
contact lenses, which contain lots of water, can
dehydrate when they are on the surface of the
eye. This is not a problem when people have
plenty of tears; but when a patient has marginal
amounts of tears, the stress of a contact lens and
a depleted tear film can lead to a lack of comfort
and reduced wearing time of lenses.
Many types of contact lenses are available.
The type of contacts prescribed depends on
every patients particular situation. We are able
to choose from the following types of lenses.
PMMA lenses: They were developed in the
1960s and were the first lenses, rigid or hard.
They are made of a type of a very durable plastic
called PMMA (polymethyl methacrylate). PMMA
does not allow oxygen in the air to directly reach
the cornea. When the eye blinks, the lens moves,
allowing the oxygen dissolved in the tears to
reach the cornea. Being rigid lenses, they are
the least comfortable type of contacts and are
not really in use anymore. Some people still
prefer them for their durability and lower cost.
Section
FIGURE 4.18: Wide parallelopiped topographic view of radial

keratotomy scars. Most cases need extra correction with
time. Contact lenses can be used after radial keratotomy,
but care has to be taken not to worsen postoperative corneal
stability. These patients also need intensive eye lubrication
with preservative-free solutions, to avoid recurrent painful
erosions and vision fluctuations.
49
Rigid gas-permeable lenses (Figure 4.19):

These lenses are also known as RGPs. They
are new kind of rigid or hard lenses made of
plastics combined with other materials, such as
silicone and fluoropolymers, which allow oxygen
in the air to pass directly through the lens. For
50
this reason, these are called gas permeable

(GP). With these lenses, a good tear film is
essential to allow friction-free movement over
the cornea. Protein or lipid deposits are
extremely rare with this kind of contacts; they
only appear in extremely damaged surfaces
(excessive use, bad maintenance). Rigid lenses
need to be soaked overnight in a wetting/
soaking/disinfecting solution (multipurpose
solution, also called universal solution).
Toric contact lenses: They correct moderate

astigmatism. They are available in both rigid and
soft materials. They are sterile, isotonic and free
of particulate matter.
Aphakic contact lenses can be used in
patients with monocular or binocular aphakia
(Figure 4.19).
Section
Soft contact lenses: These lenses are made

of plastic materials that incorporate water
(hydrophilic). The water makes them soft and
flexible, allowing oxygen to reach the cornea
diffusing through the lens. The water content in
soft contact lenses varies from 35 to 75%, being
the property that determines the oxygen
permeability. More than 80% of contact lens
wearers in the United States use soft lenses.
Unfortunately, contact lenses with higher water
content do not work consistently for dry eye
condition. These lenses tend to be thinner, lose
their integral water more readily (dehydration),
and are more likely to fold and dislodge in a
patient with dry eye. New contact lenses have
recently become available that are specifically
designed for patients with dry eyes. They work
by retarding the evaporation of water that is
contained within the contact lens. They are more
prone to superficial deposits that may act as food
for bacteria and fungi.
Some contacts contain silicone and fluorine
(hydrophobic polymers): they have much higher
oxygen permeability but need extra wetting.
Daily disposable lenses: Although generally

more expensive, carry a lower infection risk. A
pair of contacts is used and discarded daily. Not
to be used more than 8-10 hours-a-day.
Extended wear contact lenses: Made of

material designed to last 2-4 weeks. Extendedwear lenses should be worn no longer than seven
days.
FIGURE 4.19: Once a major reason for wearing contact

lenses, correction after unilateral cataract surgery has
become a rarity in the recent years due to the use of
intraocular lenses. Figure shows an aphakic contact lens in
a patient that had surgery in only one eye in the early 1980s,
and who still retains fairly normal sight in the other eye. The
contact lens prevents from aniseikonia, Without extra
lubrication, patient refers foreign body sensations
There are also bifocal (or multifocal) contact

lenses designed to provide good vision at a
distance and for reading for people who are in
an age group who require different focusing for
distance and near vision. These lenses require
that one look out of a slightly different portion
of the lens for near vs. distance vision. They come
in different designs with lenses from different
companies using slightly different optical
principles to provide two different focuses. One
for distance and one for reading. They need to
Proper contact lens maintenance is essential for

safe contact lens wear. This starts with instruction
on proper insertion and removal of contact
lenses. The contact lens prescriber will select a
lens care system suited to the individual patients
lens type, eye health and lifestyle. Patients should
consult their contact lens prescriber before
switching contact lens solution brands. Switching
lens care products can cause allergic reactions
which can damage the patients eyes and contact
lenses. Contact lens care involves timely cleaning
and disinfecting procedures. Improper lens
maintenance can decrease lens performance and
shorten lens life. The patient should always
carefully wash their hands before handling
contact lenses.
Contact lens wearers who use one-step
multipurpose solutions may be at increased risk
for a rare but potentially serious eye infection.
That risk can be minimized, however, by
replacing storage cases frequently and following
other good lens hygiene practices, like adequate
corneal moistening.
Special directives for contact lens wearers:

1. For relief of dry eyes and contact lens
irritation, apply artificial tears often, always
before contact lens insertion
2. Lightly mist directly onto contact lenses prior
to insertion.
3. Mist as often as necessary, but not in excess.
Most preservative-free products fit easily into
pocket or purse and can be used quickly and
conveniently, any time, anywhere.
4. Instruct your patient to also enjoy the breath
of moisture once the contact is out.
CONTACT LENS CARE
Section
be very carefully fitted so that they are well

centered, and they can be very effective. The
same lubricating measures apply to these lenses.
The suggested lubrication guidelines in this
chapter do also apply to cosmetic tinted
contact lenses.
For soft lens care, instruct your patient to use
only products designed for soft lenses; for rigid
lens care, instruct your patients to use only
products designed for rigid lenses. A good
wetting solution for both soft and rigid lenses is
Liquifilm Eye Drops from Allergan, a
polyvinyl alcohol lubricant solution, that can be
used either as a wetting solution or as an artificial
tear, directly onto the eye.
Wetting solutions for hard lenses include
methylcellulose and derivatives, polyvinyl
alcohol and povidone. Most wetting solutions
for hard lenses are preservative-free saline
solutions (buffered isotonic solutions with NaCI).
Most commercially available artificial tears can
be used with most contact lenses without
problems. Brand names and compositions vary
widely. Some products (like gels) can
crystallize around the cilia, making the
lens wear uncomfortable.
51
DOCTOR, HOW OFTEN SHOULD I HAVE

TO PUT DROPS IN MY EYES WHEN
WEARING MY CONTACT LENSES?
That depends on every patients needs. Some
people do not have to put drops in their eyes at
all. It depends on the amount of tears they have
and the environmental conditions in which they
are wearing the contact lenses. For instance,
being in an aeroplane, which is very dry, people
always experience more comfort if they put
drops in their eyes. We always instruct our
patients to enjoy the breath of moisture always
52
before the contact is in, and once the contact is

out. Then two or three more times-a-day may
be enough in most cases. Excessive drops (even
without preservatives) may result in paradoxical
dry eye: artificial tears dilute the own lipids and
mucus of the natural tear film, thus increasing
the rate of evaporation. Excessive drops (even
preservative-free ones) may result in a reduction
of conjunctival goblet cells, distorting the normal
electrolyte balance of the tear film.
DOCTOR, ONE OR MORE DROPS EACH
TIME?
Section
The normal eye can retain around 10 microliter

of fluid (adjusted for the effect of blinking). The
conjunctival sac already contains 10 microliter.
An average dropper delivers 25 to 50 microliter
per drop. The value of more than one drop is
more than questionable if it is not intended to
rinse the ocular surface. Once one exceeds the
capacity of the conjunctival sac, fluid in excess
spills over the edge of the eyelid or will be
drained via the punctum into the nasolachrymal
system.
If the patient is under other topical
medications (like prostaglandin analogues for
glaucoma), the best interval between drops is
more than 10 minutes. This interval ensures that
the first drop is not flushed away by the second
or that the second drop is not diluted by the
first.
DOCTOR, DOES SMOKING A PACK OF
CIGARETTES PER DAY MAKE DRY EYES
WORSE?
There is no good definitive data on the roll of
smoking and dry eyes. There is no doubt
howeverthat the irritative effects from smoke
on the eyes certainly worsen the symptoms of

dry eyes on the patients, whether they wear
contact lenses or not.
We always instruct our contact lens patients
to stop smoking (or to smoke less cigarettes)
when they are at work, specially if they work
with computers.
FURTHER READING
1. Albert, Daniel M, Jakobiec, Frederick A (Eds).
Principles and practice of ophthalmology. Second edition,
Philadelphia: WB Saunders Company, 2000.
2. Bontempo A, Rapp J. Lipid deposits on hydrophilic
and rigid gas permeable contact lenses. CLAO J,
1994;20(4):242-245.
3. Brewitt H, Boushausen D, Joost P et al. Rewetting of
contact lenses: Clinical data on efficacy and indications. Contactologia 1994; 4:15-20.
4. Duran de la Colina, Juan A et al. Complicaciones de las
lentes de contacto. Ponencia Oficial de la Sociedad
Espanola de Oftalmologia 1998, Tecnimedia
Editorial, Madrid, Spain.
5. Elie, Gabriel, Heitz, Robert. Guide de contactologie: la
pratique de ladaptation et de la surveillance des lentilles
de contact rigides et souples. Hors serie de la revue
Contactologie. Enke, Stuttgart (Germany), 1988.
6. Farris RL. Staged therapy for the dry eye. CLAO J
1991;37:207-215.
7. Farris RL. The dry eye: Its mechanisms and therapy
with evidence that contact lens wear is a cause.
CLAOJ 1986;12:234-246.
8. Farris RL. Tear analysis in contact lens wearers.
CLAO J 1986;12:106-111.
9. Fraunfelder, Frederic T, Hampton Roy F. Current
Ocular Therapy. Philadelphia: WB Saunders
Company, 2000.
10. Gilbard JP, Rossi SR. An electrolyte-based solution
that increases corneal glycogen and conjunctival
goblet-cell density in a rabbit model for keratoconjunctivitis sicca. Ophthalmology 1992;99:600604.
11. Hart D, Tidsale R, Sack R. Origin and composition
of lipid deposits on soft contact lenses. Ophthalmol
1986;93(4):495-503.
12. Holly FJ. Tear film physiology and contact lens
wear: 1. Pertinent aspects of tear film physiology.
Am J Optom Physiol Opt 1981;58:324-330.
13. Holly FJ. Tear film physiology and contact lens
wear: 11. Contact lens-tear interaction. Am J Optom
Physiol Opt 1981;58:331-341.
27. Mishima S, Maurice DM. The oily layer of the tear

film and evaporation from the corneal surface. Exp
Eye Res 1961;1:39-45.
28. Murube del Castillo, Juan (Ed). Ojo seco - Dry Eye.
Proceedings of the 73 Congreso de la Sociedad Espanola
de Oftalmologia, Tecnimedia Editorial, Madrid,
Spain, 1997.
29. Roth HW. Ojo seco en portadores de lentes de
contacto. En: El ojo seco, MA Lemp, R Marquard
(Eds) Barcelona: Springer Verlag Iberica, 1994; 221243.
30. Simon, Jose Ma. Glaucomas: hipertensiones oculares.
Editorial Jims, Barcelona, Spain, 1973. SimonCastellvi, Jose Ma. Los o/os del ciudadano. Club de
Autores Ediciones, Barcelona, Spain, 2000.
31. Simon-Castellvi, Guillermo L., Simon-Castellvi,
Sarabel, Simon-Castellvi, Jose Ma., Simon-Tor, Jose
Ma.. Tips and tricks for successful refractive surgery. In
Refractive surgery. Jaypee Brothers Medical
Publishers, New Delhi, India, 1998.
32. Simon-Castellvi, Guillermo L., Simon-Castellvi,
Sarabel, Simon-Castellvi, Jose Ma., Simon-Tor, Jose
Ma. Assessment and management of filtering blebs. In
Textbook of Ophthalmology, vol. 3. New Delhi:
Jaypee Brothers Medical Publishers, 2000.
33. M-non-Castellvi, Guillermo L., Simon-Castellvi,
Sarabel, Simon-Castellvi, Jose Ma., Simon-Castellvi,
Y Cristina. Fundamentals on cornea! topography. In
Lasik and beyond Lasik: Wavefront analysis and
customized ablation. Highlights of Ophthalmology,
Panama, 2001.
34. Tripathi R, Tripathi B, Silverman R. Morphology of
lens deposits and causative effects. In Ruben M,
Guillon M (Eds): Contact Lens Practice, Vol. 1, 10991117. London: Chapman and Hall, 1994.
35. van Bijsterveld OP. Diagnostic tests in the sicca
syndrome. Arch Ophthalmol 1969;82: 10-14.
Section
14. Jones Lyndon W, Jones Deborah A. Common contact

lens complications: their recognition and management.
Oxford: Butterworth-Heinemann, 2000.
15. Larke John R. The eye in contact lens wear. London:
Butterworths & Co. (Publishers) Ltd., United
Kingdom of Great Britain, 1985.
16. Lee James R. Contact lens hand book. Philadelphia:
WB Saunders Company, 1986.
17. Lemp MA, Holly FJ, Iwata S, Dohiman CH. The
precorneal tear film: 1. Factors in spreading and
maintaining a continuous tear film over the corneal
surface. Arch Ophthalmol 1970;83:89-94.
18. Lemp MA. Surfacing the precorneal tear film. Arch
Ophthalmol 1973;22:165-176.
19. Lemp MA, Hamill JR. Factors affecting tear film
breakup in normal eyes. Arch Ophthalmol
1973;89:103-105.
20. Lemp MA, Holly FJ. Ophthalmic polymers as ocular
wetting agents. Ann Ophthalmol 1977; 4:15-20.
21. Lemp MA. Report of the National Eye Institute/
Industry workshop in clinical trials in dry eye. CLAO
J 1995;21:221-232.
22. Maissa C, Franklin V, Guillon M, Tighe B. Influence
of contact lens material surface characteristics and
replacement frequency on protein and lipid
deposition. Optom Vis Sci 1998;75(9):697-705.
23. McMonnies CW. Dry eyes and contact lens wear. In:
MG Harris (Ed). Contact lenses: Treatment options
for ocular disease. St Louis: Mosby, 1996;23-50.
24. Minarik L, Rapp J. Protein deposits on individual
hydrophilic contact lenses: Effects of water and
ionicity. CLAO J 1989;15(3):185-188.
25. Mishima S, Gasset A, Klyce SD, Baum JL.
Determination of tear volume and tear flow. Invest
Ophthalmol 1966;5:264-276.
26. Mishima S. Corneal physiology under contact lenses.
In: Gasset AR (Ed). Soft contact lenses. St Louis:
Mosby, 1972:19-36.
53
54
Chapter
Contact Lens Materials

and Properties
Soosan Jacob, Amar Agarwal,
Athiya Agarwal, Sunita Agarwal
Section
INTRODUCTION
The main materials used for making contact

lenses are:
1. Rigid contact lenses:
a. PMMA
b. Gas permeable
a. CAB
b. Silicone acrylates (copolymers of siloxanes and methylmethacrylates)
c. Pure silicone resin
d. Butylstyrenes
e. Fluoro copolymers
f. Polysulfone copolymers
2. Hydrophilic soft contact lenses:
a. HEMA
b. Non-HEMA e.g., the CSI lens (dihydroxypropylmethacrylate)
RIGID LENS MATERIALS

PMMA was the first plastic material used. It is
light, highly wettable, transparent and scratch
resistance. PMMA is no longer used now and
has been replaced by permeable materials which

are less likely to compromise the cornea.
CAB (cellulose compounded with acetic and
butyric acids) was the first RGP material used.
Its disadvantages are that it warps easily and is
also not very wettable.
Silicone acrylate: The most commonly
used RGP materials are silicone acrylate. It has
DK values ranging from about 15 to 55. Those
with the highest values can be used for extended
wear. Its advantages are that it combines the
hardness and optical clarity of PMMA with
increased oxygen permeability due to its silicone
content. Its disadvantages are that the silicone
component is hydrophobic and hence has less
wettability. Changing the proportions of these
substances and adding other ingredients (such
as methacrylic acid) gives different material
qualities with no two materials being exactly
alike. The main aim is to increase oxygen
permeability while maintaining hardness.
Silicone resin lenses: These are pure silicone
polymers in a rigid state. Their disadvan-
Contact Lens Materials and Properties

tages are that they have poor wettability and
flexibility.
Fluoropolymer lenses: These are manufactured by incorporating a fluorinated monomer with silicone material or nonsilicone polymers. This acts by increasing the oxygen
permeability and their Dk values are as high as
150. It has very good wettability and resistance
to flexure and also a greater resistance to
formation of deposits. It is also stronger than
the other RGP materials. Addition of coreactants
to the polymer changes its properties, such as
N-vinyl pyrrolidone (for wettability) and
methylmethacrylates (for physical strength).
Non-HEMA copolymers are also used to

manufacture soft lenses. The materials can be
copolymers of MMA and GMA, MMA and NVP,
MMA and PVA, etc. Their advantage is that they
have higher modulus of elasticity and tensile
strength, higher water content and greater
resistance to protein deposition.
FDA CLASSIFICATION OF HYDROGEL
MATERIALS
Group 1 :
Group 2 :
Group 3 :
Group 4 :
Low water content (<50%)

Non Ionic
High water content (>50%)
Ionic
Low water content (<50%)
Non Ionic
High water content (>50%)
Ionic
CONTACT LENS PROPERTIES
The most commonly used soft lens material is a

polymerized version of HEMA. HEMA is inert
and is well tolerated by the cornea. It is often
crosslinked with small amounts of ethylene glycol
dimethacrylate. Polyvinylpyrrolidone (PVP) is
combined with HEMA in the higher water
content lenses. A number of other monomers
can also be added to HEMA, which results in a
change in its properties. On absorption of water,
HEMA becomes softer while still remaining
strong and highly transparent. It is capable of
maintaining its shape after folding or being
turned inside-out. Oxygen permeability depends
on the specific polymer used and the water
content of the lens. A 10% increase in water
content results in a doubling of Dk value. Water
content ranges from 37.5% to 79%. Lens
thickness is another parameter which affects
transmissibility. Doubling the lens thickness cuts
the Dk/L value in half. Dk/L values of HEMA
lenses range from 5 to 15.
NON-HEMA MATERIALS
Section
SOFT LENS MATERIALS
55
Transparency: This refers to the clearness of a

material. It is a function of the chemistry, purity
and hydration of the material (among other
factors). No material is completely transparent,
as some light will always be reflected, absorbed
and/or scattered. It is often denoted as a
percentage of incident light of a certain
wavelength that passes through a sample of
the material. Values for most clear (nontinted) contact lens materials range from 92 to
98%.
Hardness: It is important for estimating the
durability of the lens material. Hardness is an
attribute, which is more relevant to rigid lens
materials than soft materials.
56
Stiffness: It is the degree of flexibility of a

material & is an important factor when choosing
a lens material for a patient. More flexible
materials usually result in better initial comfort
but may not mask or correct astigmatism.
Tensile strength: The tensile strength of a
material is a value that expresses how much
stretching force can be applied before it breaks.
Materials with high tensile strength tend to be
more durable, as they are better able to
withstand the forces applied during lens handling
procedures (i.e., cleaning, inserting, etc.) without
tearing.
Section
Modulus of elasticity: This is a constant value

that expresses a materials ability to keep its shape
when subjected to stress.
Specific gravity: It is the ratio of the weight in
air of a material to the weight of an equal volume
of water in air at the same temperature. Specific
gravity can be important clinically when lens
weight or mass is significant (for instance, when
high plus powers are involved).
Refractive index: It is the ratio of the speed of
light in air to the speed of light in the material.
For soft (hydrophilic) lens materials, the index
of refraction is related to the water content.
Wettability: It is specified by the contact angle

(also known as wetting angle) formed by a drop
of water, saline solution or tears on the surface
of the material in question. In general, the more
wettable the lens surface the more even and
stable the tear film will be.
Hydration (water content): Most contact lens
materials, both hard and soft absorb some water.
The amount absorbed is usually expressed as a
percentage of the total weight. Materials that
absorb less than 4% of water by weight are
referred to as hydrophobic materials; those that
absorb greater or equal to 4% water are termed
hydrophilic polymers.
Ionic charge: Contact lens materials may carry
an electric charge or they may be electricity
neutral. This attribute is specially important in
soft (hydrophilic) lens materials, as it affects
factors such as solution compatibility and deposit
formation.
Oxygen transmission (Dk/L): The passage of
oxygen through a contact lens is critical in
maintaining normal corneal physiology. This
attribute is one of the most important aspects of
contact lens materials.
Topographic and Pachymetric Changes Induced by Contact Lenses
Chapter
57
Topographic and
Pachymetric Changes
Induced by Contact Lenses
Melania Cigales
Jairo E Hoyos
Jorge Pradas
Hartstein1 was the first to note contact lensinduced changes in corneal shape and to refer
to them as corneal warpage.
More recent publications2 define the term
corneal warpage as denoting all contact lensinduced changes in corneal topography, reversible or permanent, that are not associated with
corneal edema.
Patients with contact lens-induced corneal
warpage are commonly asymptomatic.3 These
patients frequently do not use glasses and
depend on their contact lenses for their refractive
error. Some may also notice intolerance to
contact lenses or decreased visual acuity with
glasses.
Reported signs of contact lens-induced
corneal warpage1,4-7 include changes in refraction
and keratometric readings (relative steepening
of mean corneal curvature in some patients, and
flattening in others) and distortion of keratometer
or keratoscope mires. But the keratometer
evaluates corneal curvature from only four

paracentral points, approximately 3 mm apart.
The keratoscope provides information from a
larger portion of the corneal surface, but the
data are qualitative in nature. For these reasons,
the best system to study contact lens-induced
corneal warpage is computer-assisted topographic analysis of videokeratoscopic images.8
Contact lens-induced topographical abnormalities of the cornea include
Central irregular astigmatism
Loss of radial symmetry
Reversal of the normal topographic pattern
of progressive flattening of corneal contour
from the center to the periphery
Keratoconus-like images.2,3,9-12
Some studies13,14 show corneal thickness
modifications induced by contact lens wear.
There have been reports of increased corneal
thickness measured by an optical pachymeter
which have shown that this finding is mainly
due to oxygen deprivation leading to corneal
edema. Other researchers15 have found, in
Section
INTRODUCTION
58
histopathological studies, that there is a reduced

corneal thickness resulting from epithelial
thinning. We have not found reports of studies
done with the use of ultrasound pachymetry.
REFRACTIVE SURGERY IN
CONTACT LENS WEARERS
Section
Laser-assisted in-situ keratomileusis (LASIK) is

a refractive surgery technique in which an
attempt is made to correct ametropia by
modifying the anterior surface of the cornea.
Contact lens wear may induce transient
modifications on the corneal surface, with
refractive changes that have a negative impact
on the predictability of the procedure.
In some cases, contact lenses may even
produce corneal thinning, requiring the surgeon
to program a smaller optic zone in order to
correct the ametropia to avoid removing too
much tissue. Hence, the importance of knowing
the length of time, such patients should
discontinue the use of contact lenses before
undergoing surgery, as well as the parameters
that might allow us to suspect corneal warpage
derived from contact lens wear.
Studies have demonstrated that topographic
alterations are common in normal wearers of
soft and rigid gas-permeable (RGP) contact
lenses. It is important to identify such topographic
abnormalities before surgery, because they are
likely to have an adverse effect on predictability
and other determinants of the efficacy of refractive surgical procedures. Patients with contact
lenses are required to discontinue their use
before refractive surgery. Some authors16
recommend 1 week for soft lenses and 2 weeks
for RGP lenses, while others17 recommend 2
weeks for all types of contact lenses.
It is our routine practice to discontinue

contact lens wear before refractive surgery, 1 or
2 weeks for soft lenses and 1 month for RGP
lenses. Despite this practice, we have found
topographic patterns of corneal warpage in 22
eyes of 12 patients, 13 eyes with RGP lenses,
and 9 eyes with soft lenses, followed every 2 to
4 weeks. At each visit, these patients were checked
by topography, cycloplegic refraction, visual
acuity and ultrasound pachymetry. Follow-up
was continued until a topographic pattern,
normal or abnormal, was found to persist
without changes for at least 1 month.3
All eyes returned to their normal topographic
pattern, except for one RGP lens wearer, who
improved substantially and stabilized at 8 weeks,
but never returned to a normal pattern. The
mean time required for returning to a normal
(or abnormal but stable), topographic pattern
was 9 weeks (range from 4 to 10) for soft contact
lens wearers, and 11 weeks (range from 8 to
16) for RGP contact lens wearers. These results
are comparable to those obtained by Wilson et
al.3
Before refractive surgery, RGP contact lenses
must definitely be discontinued for a longer
period of time than soft contact lenses. A period
of 1 or 2 weeks for soft lenses and 1 month for
RGP lenses may be appropriate, but if there are
any topographical signs of corneal warpage,
patients must be delayed until their patterns
normalize and/or stabilize.
PARAMETRIC DESCRIPTORS OF
CORNEAL TOPOGRAPHY
Topographic analysis is the most sensitive
method to detect subclinical or occult corneal
warping, and as such should be the indicator

for the time during which contact lens wear must
be discontinued before refractive surgery.
In our study, we used a computerized topographic analysis with the TMS-1 topographer
(Computed Anatomy Inc, software release 1.61,
New York, NY). This instrument includes 25
videokeratoscopic rings covering almost the
entire corneal surface, and digitizes 256 points
along each mire. The international scale color
code mapping was used to monitor corneal
topography. Three topographic parameters were
analyzed for follow-up: (i) simulated keratoscope
reading (Sim K), (ii) surface asymmetry index
(SAI), and (iii) surface regularity index (SRI).3,10,18
Simulated Keratoscope Reading (Sim K)
The SAI is the centrally weighted sum of the

differences in corneal power between
corresponding points on the TMS-1 mires located
180 apart. The power distribution across a
normal corneal surface is highly symmetrical,
making the SAI a useful quantitative indicator
for monitoring changes in corneal topography.
Surface Regularity Index (SRI)

The SRI is a quantitative descriptor which, like
SAI, attempts to correlate the optical quality of
the corneal surface with PVA. The SRI is
calculated on the basis of the local regularity of
the surface over the corneal area enclosed by
an average virtual pupil of approximately 4.5
mm. Like SAI, the SRI of normal corneal surfaces
is relatively low, and higher SRI values indicate
surface of lesser optical quality.2,3
SOFT LENS-INDUCED CORNEAL

CHANGES
Our results were consistent with those of previous
studies3,10,11 showing that soft contact lens-induced
corneal warpage determines a topographic pattern of corneal steepening and increased myopia.
Changes occurring between the first and the
last examinations revealed a reduction of myopia
in 88.9 percent of the eyes, with an average of
2.11 D (range from 1 to 6), associated with
an average topographic flattening of 1.64 D
(range from 0.05 to 4.15). These changes
proved to be statistically significant and there was
a positive correlation between them (p<0.05).
The greater changes were found in cases of
corneal warpage with keratoconus-like images.
Figures 6.1A and B show a clinical case of
corneal warpage in a soft contact lens wear, with
typical topographic pattern. Figures 6.2A and B
show a clinical case of soft contact lens-induced
corneal warpage, with keratoconus-like image.
Surface Asymmetry Index (SAI)
Normal corneas generally have SAI values lower

than 0.5. The SAI is correlated with potential
visual acuity (PVA) as originally described by
Klyce and Wilson, and is, to our knowledge, the
first attempt at correlating the optical quality of
corneal surfaces to visual acuity.2,3
Section
The Sim K is calculated from the maximum

meridian powers of rings, 6, 7 and 8. The display
includes the average of those maximum powers,
the axis at which the average value occurs, and
the average power of the corneal surface for
the same rings at the meridian located 90 away.
Clinically insignificant cylindrical readings lower
than 0.20 diopters (D) are not reported; instead,
the spherical equivalent is reported in those cases.
Sim K is used to quantify the dioptric power of
the cornea in order to calculate the value of the
cylinder and of the topographic axis, thus
identifying differences between the initial and
final examinations.18
59
FIGURE 6.1A (Case study 1): Soft contact lens-induced corneal warpage. Forty-eight-year-old female, permanent
soft contact lens (CL) wearer for 2 years (removes them every 6 months for cleaning)
Section
60
FIGURE 6.1B (Case study 1): Corneal warpage in a soft contact lens wear with typical topographic pattern
61
Section
FIGURE 6.2A (Case study 2): Soft contact lens-induced corneal warpage. Thirty-eight-year-old male, soft contact
lens (CL) wearer for 20 years, 16 to 18 hours/day
FIGURE 6.2B (Case study 2): Corneal warpage in a soft contact lens wear with keratoconus-like
image in the topography
62
Our study did not reveal changes in average

astigmatic values after discontinuing contact lens
wear. However, these values were found to be
reduced in 55.5 percent of cases, increased in
44.5 percent, and with axis modifications of
more than 20 in 22.2 percent of cases.
Visual acuity improved from one to five
Snellen lines in 66.7 percent of cases, coinciding
with improved regularity and radial symmetry in
the topographic image (SAI and SRI decreased
in 90 and 100 percent of cases, respectively,
reaching a final value < 0.5 in all cases). Improvements in visual acuity, and their relationship with
symmetry (SAI) and regularity (SRI) indices have
been described by other authors.3,8,10,16,18
Central corneal thickness was followed with
ultrasound pachymetry (DGH-500 pachymeter,
DGH Technology, Inc USA), revealing an
increase in corneal thickness after discontinuation
of soft contact lens wear in 90 percent of cases.
The average increase in thickness was 20 microns
(range from 0 to 30) and was statistically
significant (p<0.05). Wilson and Klyce3,9,11 have
associated this corneal thinning with the presence
of keratoconus, but our results show topographic
and pachymetric reversibility once contact lens
wear is discontinued, ruling out the presence of
keratoconus in those cases. In only one case did
we diagnose keratoconus on the basis of
persistent topographic alterations and corneal
thinning, and this case was excluded from the
study.
To summarize, soft contact lenses may
induce corneal warpage with topographic
steepening (with an occasional keratoconus-like image) and increased myopia, as
well as central corneal thinning. If all
factors are not taken into consideration
Section

before refractive surgery, the result will be
overcorrection and the selection of a
smaller optic zone.
RGP LENS-INDUCED CORNEAL

CHANGES
Our results show that RGP contact lens-induced
corneal warpage is reflected in a topographic
pattern of central corneal flattening and
decreased myopia, and in cases of contact lens
decentering, there is a keratoconus-like image.
These results are consistent with the findings of
other reported studies.2,3,10-12
Changes occurring between the first and the
last examination revealed an increase in myopia
in 77 percent of eyes, with an average of 0.53
D (range from +1 to 1.12), associated with an
average topographic steepening of 0.43 D (range
from 0.15 to 0.95). These changes proved to
be statistically significant, and there was a positive
correlation between them (p<0.05). In this
group, there were a few cases of relative
topographic flattening with increased myopia
after discontinuing RGP lens use. This coincided
with decentered lenses, causing a flattening at
the site of contact with the cornea and steepening
on the other side, giving rise to a keratoconuslike image.3
Figures 6.3A and B show a clinical case of
corneal warpage in a RGP contact lens wear,
with typical topographic pattern. Figures 6.4A
and B show a clinical case of RGP lens-induced
corneal warpage, with keratoconus-like image.
Our study did not reveal changes in average
astigmatic values after discontinuing contact lens
wear. However, these values were found to be
reduced in 18.2 percent of cases and increased
in 18.2 percent, and there were axis modifi-
63
Section
FIGURE 6.3A (Case study 3): Rigid gas-permeable (RGP) contact lens-induced corneal warpage. Thirty-seven-yearold male, RGP contact lens (CL) wearer for 20 years, 16 to 18 hours/day
FIGURE 6.3B (Case study 3): Corneal warpage in a RGP contact lens wear with typical topographic pattern
64
Section
FIGURE 6.4A (Case study 4): Rigid gas-permeable (RGP) contact lens-induced corneal warpage. Twenty-six-yearold female, RGP contact lens (CL) wearer for 10 years, 14 hours/day
FIGURE 6.4B (Case study 4): Corneal warpage in a RGP contact lens wear with keratoconus-like image in the
topography

CONCLUSION
It is essential to perform a critical evaluation of

the corneal topography of all candidates prior
to refractive surgery. The tendency to proceed
immediately to surgery if the topography
appears normal should be avoided because the
initial topography may depart significantly from
the one obtained before contact lens fitting.
Contact lens wear should be discontinued
before refractive surgery for a period of 1 to 2
weeks for soft lenses, and 1 month for RGP
lenses. However, in the event that any topographic signs of corneal warpage are observed,
they must be followed until they normalize and/
or stabilize. Therefore, topography will dictate
the timing for refractive surgery.
The presence of topographic signs of corneal
warpage must lead us to suspect the possibility
of corneal thinning as a result of contact lens
wear, requiring close topographic as well as
pachymetric follow-up in these patients.
Careful operative evaluation and management are likely to improve the quality and
predictability of corneal surgery of individual
surgeons. Perhaps more importantly, the overall
efficacy of procedures such as LASIK might be
enhanced once unpredictable variables of
contact lens-induced warpage are controlled.
Section
cations of more than 20 in 27.3 percent of

cases.
In our study, we have found greater cylinder
changes when soft contact lenses are
discontinued (reduction in 55.5% and increase
in 18.2% of cases) than the ones found in RGP
lens wearers (reduction in 18.2% and increase
in 18.2% of cases). Wilson and Klyce3 report
that astigmatic modifications are greater in RGP
lens wearers in terms of a cylinder increase when
lens wear is discontinued, contrary to what
happens with soft contact lenses.
There was an improvement of one to four
Snellen lines of visual acuity in 38.5 percent of
cases, coinciding with improved regularity and
radial symmetry in the topographic image (SAI
and SRI decreased in 92% and 61.5% of cases,
respectively, reaching a final value < 0.5 in all
cases). Improvements of visual acuity, and of
symmetry and regularity indices, have been
described by other authors.2,3,8,10,16,18
Follow-up on central corneal thickness with
ultrasound pachymetry showed an increase in
corneal thickness after RGP lenses were discontinued in 90 percent of cases, with an average
increase of 15.5 microns (range from 0 to 25),
which was statistically significant (p<0.05). No
differences were observed concerning pachymetric modifications in soft and RGP contact lens
wearers.
To summarize, RGP contact lenses may
induce corneal warpage with topographic
flattening (with keratoconus-like images when
decentered) and decreased myopia, as well as
central corneal thinning. If all factors are not
taken into consideration before refractive
surgery, the result will be undercorrection and
the selection of a smaller optic zone.
65
REFERENCES
1. Hartstein J. Corneal warping due to wearing of
corneal contact lenses. Am J Ophthalmol 1965;60:
1103-04.
2. Wilson SE, Lin DTC, Klyce SD et al. Rigid contact
lens decentrationa risk factor for corneal warpage.
CLAO J 1990;16: 177-82.
3. Wilson SE, Lin DTC, Klyce SD et al. Topographic
changes in contact lens-induced corneal warpage.
Ophthalmology 1990;97:734-44.
66
Section
4. Rengstorff RH: Corneal curvature and astigmatic

changes subsequent to contact lens wear. J Am
Optom Assoc 1965;36: 996-1000.
5. Levenson DS: Changes in corneal curvature with
long-term PMMA contact lens wear. CLAO J 1983;9:
121-25.
6. Levenson DS, Berry CV: Findings on follow-up of
corneal warpage patients. CLAO J 1983;9:126-29.
7. Koetting RA, Castellano CF, Keating MJ: PMMA
lenses worn for twenty years. J Am Optom Assoc
1986;57:459-61.
8. Wilson SE, Klyce SD: Advances in the analysis of
corneal topography. Surv Ophthalmol 1991;35:26977.
9. Wilson SE, Lin DTC, Klyce SD: Corneal topography
of keratoconus. Cornea 1991;10:2-8.
10. Ruiz-Montenegro J, Mafra CH, Wilson SE et al:
Corneal topographic alterations in normal contact
lens wearers. Ophthalmology 1993;100:128-34.
11. Wilson SE, Klyce SD: Screening for corneal
topographic abnormalities before refractive surgery.
Ophthalmology 1994;101:147-52.
12. Benavides J, Gutierrez AM: Estudio del sndrome de

deformacin corneal inducido por lentes de contacto
en diez ojos. Arch Soc Am Oftal Optom 1994;24:
19-22.
13. Miller D: Contact lens-induced corneal curvature
and thickness changes. Arch Ophthal 1968;80:43032.
14. Millodot M: Effect of hard contact lenses on corneal
sensitivity and thickness. Acta Ophthalmologica
1975;53:576-84.
15. Bergmanson JPG: Histopathological analysis of the
corneal epithelium after contact lens wear. J Am
Optom Assoc 1987;58:812-18.
16. Gimbel HV: Effect of contact lens wear on photorefractive keratectomy. CLAO J 1993;19: 217-21.
17. Pallikaris IG, Siganos DS: Excimer laser in situ
keratomileusis and photorefractive keratectomy for
correction of high myopia. J Refract Corneal Surg
1994;10: 498-510.
18. Wilson SE, Klyce SD: Quantitative descriptors of
corneal topography. Arch Ophthalmol 1991;109:
349-53.
Chapter
7
Advanced
Orthokeratology
Adrian S Bruce
Christa Sipos-Ori
HISTORICAL PERSPECTIVE
Section
The term orthokeratology was not the original

terminology used by Jessen when he first
reported the procedure. He referred to it as the
orthofocus technique (Jessen, 1962). In this
thesis, the term traditional orthokeratology refers
to the use of regular tricurve rigid lenses for the
flattening of corneal curvature.
Orthokeratology has its origins in a clinical
observation that hard contact lenses could
reduce the progression of myopia (Morrison
1958; Jessen 1962; Rengstorff 1965; 1967;
1969a; 1969b; 1969c). The nature and the
causes of these changes; however, were not
understood clearly at the time.
Jessen (1962) believed that the reduction in
myopia following hard contact lens wear was
purely a mechanical effect. As a result he started
fitting hard PMMA lenses flatter than the flattest
corneal meridian as measured by keratometry,
so the tear lens corrected for the refractive error.
This can be regarded as the earliest orthokeratological fitting technique. Later many different
techniques evolved as new lens designs and new

thoughts about the procedure occurred. A
summary of the main fitting techniques is shown
in Table 7.1.
The four main early studies that employed a
proper scientific design were performed by
1. Kerns (1976a, 1976b, 1976c, 1977a,
1977b, 1977c, 1977d, 1978),
2. Binder et al (1980),
3. Coon (1982 & 1984),
4. Brand et al (1983) and Polse et al (1983a,
1983b).
Although they used different techniques and
different control conditions their conclusions
were consistent with regard to the safety and
effectiveness of the procedure, despite all of these
studies employing PMMA lenses.
Most of the controlled studies agreed that
the degree of possible myopia reduction was
approximately 1.00-2.00 D (Brand et al, 1983;
Coon, 1982 & 1983; Polse et al, 1983a). The
orthokeratology groups showed a greater
myopia reduction than the conventional contact
lens wearing group and this change was
70
Section
Table 7.1: Summary of early orthokeratology fitting techniques

Author(year)
BOZR
Other lens parameters
Consecutive lenses
Timing lens
change-over
Jessen (1962)
flatter than Kf
pl. power, tear lens

corrects myopia;
TD=7.6-9.2 mm
none
none
Nielson et al (1964)
0.12-0.37 D
flatter than Kf
BOZD=Kf;
TD=Kf+1.3 mm
TD=8.5-10.2 mm
0.50 D flatter each

than previous
NA
Gates (1971)
1.50D flatter than Kf TD=8.7-9.6 mm
none
retainer, when
refractive error
is -0.50 D
Nolan (1971)
flatter than Kf
pl. power if myopia

<-2.25D
TD=7.7-9.8mm
none
alter wear time to

get desired result
Nolan (1972)
1-1.50 D steeper
than Kf
TD=7.5-8.5mm
0.25-0.50 D flatter each

than previous
NA
Fontana (1972)
1 D flatter than Kf
1 D flatter than previous
NA
Freeman (1974) *
0.50-1 D flatter
than Kf
one-piece bifocal
design; paracentral
curve fitted on- Kf
NA
NA
NA
Ziff (1976)
on- Kf to 1 D flatter
than Kf
TD=8.8 mm
NA
change lens when

K changes or to
induce change
Carter (1977)
1-1.50 D flatter
than Kf
TD=8.9-9.3 mm
NA
change lens when Kf

changes by 0.50 D
May-Grant (1977)
on- Kf
TD=BOZR+1.8 mm
TD=8.5-10.2 mm
BOZD= Kf (mm)
0.50 D flatter
change lens when

0.25 D change
occured
Coon (1984)
Tabb method
on- Kf
BOZD=70% TD
reduce BOZD by
TD= Kf +1 mm
small amounts
BPZR1=BOZR+1 mm
BPZR2=BPR1+1 mm
BPZR3=BPR2+1 mm
BPZD1=BOZD+0.2 mm
BPZD3=TD-0.2 mm
cited by Carney (1994)
* cited by Marsden and Kame (1997)
statistically significant. Most refractive and

unaided visual acuity changes occurred in the
initial phases especially the predictable and
uniform changes (Kerns, 1976c; 1977a; Binder
et al, 1980; Polse et al 1983a).
Binder et al (1980) did not find any significant changes in anterior chamber depth, axial
length, corneal thickness, crystalline lens parameters, intraocular pressure or corneal integrity
due to orthokeratology. Coon (1984), however,
Advanced Orthokeratology
The sometimes complex and inconsistent fitting

techniques (eg. Grant, 1981; Grant and May
LIMITATIONS OF EARLY
ORTHOKERATOLOGY
1970, 1971), non-standardized measurement

protocol and the varying choice of control
groups do not allow a simple comparison of the
different studies and therefore produce
contradictory conclusions.
In all of the early studies, the major problem
was lens decentration, which was even harder
to control once topographic changes have
occurred. Unpredictability of initial response and
recovery aspects were another common
observation. Authors also cited the length of the
orthokeratology procedure as a drawback,
together with the unknown mechanism for
corneal changes and time-course of regression.
The controlled studies described above
effectively reduced interest in orthokeratology
for a number of years, having drawn the
conclusion that the procedure is long and often
unpredictable and only minor corneal changes
result (Safir, 1980). While there were numerous
articles published in the 1970s and 1980s concerning traditional orthokeratology, particularly
using PMMA lenses, a Medline search shows that
from 1985 to 1993 only two articles were
published (Figure 7.1). Although there have
been some additional works published in other
(non-Index Medicus) refereed journals such as
International Contact Lens Clinic and Clinical
and Experimental Optometry, it is only in recent
years that there has been a resurgence of interest
in orthokeratology.
Section
noted a statistically significant degree of central

corneal thinning and peripheral corneal
thickening. Central corneal flattening occurred
in conjunction with peripheral corneal steepening
(Kerns, 1976; Coon, 1984). Results were more
variable and less predictable if the fit of the
contact lens was too flat. The horizontal
curvature changes were more predictable than
the vertical ones (Kerns, 1976).
Corneal topographic changes are not in a
direct relationship with the base curve of the
contact lens (Kerns, 1977a). Timing of lens
changeover was more crucial to success than the
length of lens wear or cornea-to-lens base-curve
relationship (Kerns, 1977a). The maximum
myopia reduction possible was found to depend
on the initial shape of the cornea (Freeman,
1978). The greater the corneal asphericity, the
higher is the probability of a successful outcome
and the greater the myopia reduction. When
the cornea changed to a spherical shape
further refractive changes could not occur
(Kerns, 1976).
All studies noted that the effect is not
permanent and regression to initial values
occurred within months of cessation of lens wear
(Kerns, 1977b; Polse et al, 1983a; Coon, 1984).
An interesting finding was that the refractive
change was greater than the corneal curvature
change (Erickson and Thorn, 1977; Erickson,
1978). Grant and May (1972) found the visual
acuity improvement was greater than expected
on the basis of the myopia reduction.
71
REVERSE GEOMETRY LENSES

A significant new development came in 1989,
when a new lens design, termed reverse geometry lenses revolutionized the orthokeratology
process. The time-course of corneal flattening
was reduced from a few years to a few months
72

Orthokeratology
9
8
7
6
Number of
publications 5
in Medline 4
3
2
1
0
1965 1970 1975 1980 1985 1990 1995 2000
Year of Publication
FIGURE 7.1: Medline articles on orthokeratology
Section
and the effects were doubled. This process was

called accelerated orthokeratology.
The reverse geometry lens (RGL) design is a
tricurve lens, with a secondary curve steeper than
the base curve and the peripheral curve flatter
than the base curve. Its design and use was shown
in the late 1980s to work faster and in a more
predictable way (Harris and Stoyan, 1992;
Wlodyga and Bryla, 1989). Figures 7.2A to C
show the fluorescein patterns for conventional
tricurve lenses, with alignment and flat fittings
B. Conventional tricurve 8.2/10.0/-3.00 (approximately 2D

flat) OZ and periph as above
C. Reverse geometry lens (tricurve) OK704 8.2/10.2/pl

OZ=7.0, -0.73(1.1), +1.5(0.5)
FIGURES 7.2A to C: Fluorescein patterns for different
lenses used for orthokeratology
A. Conventional tricurve 7.8/10.0/-3.00 (alignment fit)

OZ=8.0, +0.8(0.6), +1.5(0.4)
(Figures 7.2A and 7.2B), and a RGL (Figure

7.2C). The RGL has a four zone fluorescein
pattern (Mountford, 1997a), showing:
1. Light central touch (3-3.5 mm)
2. 360 degree ring of mid-peripheral pooling
(deep tear reservoir)
3. Light peripheral touch
4. Moderate edge clearance
The earliest studies done with the RGL still
used a flatter than flattest K reading fitting philo-
73
Table 7.2: Summary of orthokeratology fitting techniques for reverse geometry lenses
Author(year)
BOZR
Other lens parameters
Consecutive lenses
Timing lens
change-over
Harris, Stoyan (1989) 1-1.50 D flatter

than Kf
TD=9.5 mm
reverse geometry lens
(Ok3)
0.5 D flatter than

previous lens
when lens steepens or

no movement
Soni and Horner

(1993)
1-1.50 D flatter
than Kf
OK3 lens
2 to 3 pairs of lenses,
Second curve 3D steeper each 0.1 mm flatter
TD from 9.5 to 10.5
as cornea flattens,
over first 3 months
Mountford (1997a)
BOZR matching
sag of cornea over
same chord
lens parameters chosen

for individual patients
reverse geometry lenses
none
none
Day et al (1997)
NA
TD = 10 mm
BOZD = 6 mm
TRW = 1.1 mm
none
none
due to any ocular axial length change, since the

average axial length actually increased during
the course of their study. A lower intra-ocular
pressure measurement was also linked to a
greater change in auto and subjective refraction
(Joe et al, 1996).
Although all studies have stressed the
improved centration, faster results and safety of
the reverse geometry lenses, orthokeratology still
did not gain scientific acceptance due to lack of
controlled studies. Another big problem was that
practitioners still relied on using the keratometer
for fitting, rather than computerized topographic
systems. This again hindered the process of fitting
in a more accurate way.
While there have been a number of continuing education articles on orthokeratology in
recent years, they still tend to present only very
simple fitting protocols, either fitting from the
flat keratometer reading, empirical observation
of fluorescein patterns and corneal response, or
using computer programs with unspecified
algorithms (Dave and Ruston, 1998; Horner and
Section
sophy, by about 1-1.50 D, and utilized a 3 D

steeper secondary curve, the OK603 lens (Harris
and Stoyan, 1992). This method still relied on
frequent lens changes, each time flattening the
base curve by 0.50 D or 0.1 mm (Table 7.2).
Soni and Horner (1993) recommended
ordering three to four pairs of lenses initially,
each differing by 0.1 mm in base curve flatness.
The time-course of corneal flattening appears
to be a non-linear saturation curve, with the
greatest change in the first few days or weeks
(Stanford, 1995).
Newer studies (Joe et al, 1996; Carkeet et
al, 1995) looked at subject parameters with
potential predictive value. The eccentricity value
of the cornea was found to be a predictor for
final unaided visual acuity, but not a good
predictor for final subjective and auto refraction
(Joe et al, 1996). The change of eccentricity
value was in a good correlation with refractive
change and apical corneal power change
(Mountford, 1997b). Johnson and Lakin (1995)
showed that the reduction in myopia was not
74
Bryant, 1994; Hunter, 1993; Lakin et al, 1995;

Potts, 1997; Ruston and Dave ,1997; Winberry,
1995; Winkler and Kame 1995).
Patient Selection Criteria
Section
Suitable candidates for the procedure are people

with low-to-moderate amounts of myopia, with
no against the rule astigmatism, free of any
ocular surface disease and keratoconus
(Mountford, 1997a). Lens tolerance is more of
an issue in day-therapy. People with large pupils
are not good candidates as in the orthokeratology procedure the area of central
flattening may not be large enough. Loose or
excessively tight lids will make lens action and
centration more difficult.
Some studies draw conclusions about initial
patient parameters that could be used as
predictive tools for determining initial ideal
patient settings. From Mountford (1997a) data
it is apparent that certain corneal shapes are
more responsive to orthokeratology than others.
It seems that one dioptre of myopia can be
reduced for each 0.21 of eccentricity of the
cornea.
Permanency and Regression
As orthokeratology relies on the elasticity and
malleability of the corneal tissue, it is not a
permanent solution to myopia. This can be
considered as one of its advantages, since later
in life, when presbyopia occurs, some myopia
can be left untreated, or reintroduced to help
with near tasks.
There are few formal studies of permanency
and regression of the corneal shape change in
orthokeratology. Mountford (1998b) noted a
more permanent effect of overnight wear after
one month and three months, compared to the

effect after seven days wear. Soni and Horner
(1993) observed that the maximum myopia
retention was reached after about three months
of wear, although this was with daily lens wear
rather than overnight. Little is known about the
recovery aspects in the initial stages; most of the
research done in this area refers to complete
lens withdrawal.
Day versus Night Therapy
An issue confronting orthokeratology practitioners relates to the contact lens wearing
schedule of patients. As patients resort to
orthokeratology in order to be free of visual aids
during their waking hours, it makes sense to use
the contact lenses overnight and remove them
during the day. Furthermore, night therapy
allows a greater degree of corneal flattening and
a faster response (Grant 1995, Mountford
1997a). Overnight orthokeratology is now an
established modality of correction (Mountford
1997a, Nichols et al 2000) although studies with
daily wear have also been recently reported
(Swarbrick et al 1998, Lui and Edwards 2000a,
2000b). However night therapy is not exactly
the same as extended wear, since lenses are
removed daily during waking hours and
therefore the cornea is allowed to recover from
any disturbance that might have developed.
Another issue here refers to the quality of vision
after removal of contact lenses in the initial phases
of the therapy, when the effects of the procedure
are not lasting all day.
ADVANCED ORTHOKERATOLOGY
The next major advances in orthokeratology
were the advent of custom fitting of the lens
mid-peripheral steeper zone, and flattens off

towards the periphery (Mountford, 1997b).
However, the aspect of lens fitting highlighted
in advanced orthokeratology is that observation
of the lens fluorescein pattern etc is not
sufficiently accurate by itself. It is the precise
corneal topography measurement, subsequent
sag fitting calculations, and then assessment of
corneal topography response to lens wear that
give the advances in the precision and success
of orthokeratology. Consequently there is a
greatly reduced reliance on the inspection of lens
fluorescein patterns. These aspects will be briefly
reviewed below.
CORNEAL TOPOGRAPHY
ASSESSMENT
It is well accepted that all corneas have a shape

that is somewhat different from a perfect sphere
(Kiely et al, 1982b). In the past, when only the
central part of the cornea could be measured, it
was believed that some corneas were spherical.
Now, with the advance of computerised surface
measuring devices, the actual corneal shape can
be described with different parameters of a
conical section (Lindsay et al, 1998).
Section
peripheral curves, as well as the use of overnight

lens wear (Mountford, 1997a). A variety of terms
have been applied to orthokeratology performed in this way, including precision corneal
molding (Teig, 1997) and controlled keratoreformation; (El Hage et al, 1997) however, for
the purposes of this chapter the term advanced
orthokeratology will be used (Day et al, 1997).
The characteristics of advanced orthokeratology are as follows:
Use of videokeratoscopy, with shape indice
e
Selection of lens parameters via sag calculations (Mountford, 1997a)
Individual fitting of the lens tangential edge
using the cone angle
Use of a High Dk lens material and Night
therapy
Of the different fitting philosophies listed in
Table 7.2, the sag fitting method advocated by
Mountford (1997a), appears to have the most
well developed scientific basis. In this technique
the contact lens is chosen so that its sagittal height
matches the sagittal height of the cornea over
the same chord, with an allowance for a minimal
central tear layer of 10 m. The method requires
computerised corneal topography units for exact
determination of apical corneal radius and
corneal eccentricity values. The sag fitting
procedure is described more fully below.
The appearance of an advanced orthokeratology lens on the eye is as described above for
reverse geometry lenses and as shown in Figure
7.2C. In brief, for a satisfactory fit the lens should
show adequate movement, and the fluorescein
pattern should show an area of central touch
of around 3 mm. The resultant corneal shape
has an approximately spherical central zone, a
75
Keratometry Limitations
Keratometry measures the surface curvature of
a cornea by determining the distance between
two reflected points on the cornea. The radius
of curvature is measured by aligning the
horizontal and vertical mires, giving the two
perpendicular central corneal radii for
approximately the central 3 mm zone (the area
measured depending on the curvature as well).
The accuracy of the keratometer is within
0.25 D of the actual power (McMahon, 1997).
76
The major disadvantage of the keratometer

is the assumption of the cornea being spherical
and that there is no information about the shape
of the cornea within or outside the measured
points. Therefore, keratometry is inadequate for
orthokeratology, where knowledge is required
of both the central and peripheral cornea.
Corneal Topography Principles
Section
Currently used methods of measuring the

surface curvature of the cornea, use a video
camera for recording images, which are then
analysed by a computer algorithm. For those
instruments that use the Placido-principle, one
question is how large an area can they map.
The size of the cone and the number of projected
rings vary between models, as does the distance
at which the cone is placed from the eye. The
instruments with a small cone must be positioned
close to the eye and are less susceptible to
vignetting from the patients nose or brows,
which may allow better coverage of the corneal
periphery for orthokeratology. However, patients
with deep-set eyes may occasionally be difficult
to measure with the small cone instruments.
The topographer analyses the reflected image
according to algorithms in a number of locations.
This determines the dioptric value of the given
point on the basis of which topography maps
are constructed, which can be displayed in a
number of different ways.
Corneal Topography Maps
Most often a standard map is produced, which
shows the paraxial refractive power. Here each
point has the power of a sphere, whose centre
lies on the axis of the video-keratoscope. It can
be displayed as either a power (D) or shape

(mm) map of the cornea. This is the most
commonly used map for orthokeratology,
despite the fact that the paraxial approximations
lead to inaccuracies for non-spherical surfaces.
A refractive power map is a slight
modification of the standard one, taking into
consideration the spherical aberrations as well.
In this format, it is an excellent indicator for
corneal power, but not shape (Roberts, 1998).
A third way of displaying the topography
information is an instantaneous map, in which
every point is represented as the local radius of
curvature independent of any axis (Mandell,
1996). This map is good for expressing the true
shape of the cornea, but may show more local
variations in the map due to any artifacts of tear
film breakup or discontinuity of the mires.
Topography is sometimes presented as an
elevation from a reference surface, most often a
sphere with a radius equal to the central corneal
radius (Applegate et al 1995; Salmon and
Horner, 1995). The elevation and instantaneous
radius map displays are useful in cases where
the shape of the cornea is changed dramatically,
like keratoconus, photorefractive keratotomy or
orthokeratology.
Maps can be compared with each other in a
differential plot, to allow a before and after
treatment evaluation, which is very useful for
orthokeratology. For quantitative comparison
some statistical indices, derived from surface
measurement are also given (Wilson and Klyce,
1991). The most important of these for
orthokeratology are the eccentricity value and
the apical corneal power. Multiple measurements
may be averaged to improve accuracy.
Sources of Error
Heath and co-workers (1991) have shown

that measurements with the TMS instrument
were highly repeatable if properly aligned, and
that spherical and toroidal surfaces yielded more
accurate results, while aspheric surfaces gave less
accurate, but still clinically acceptable measures.
Similar results were found by Tang et al (2000),
who showed that the TMS was accurate for
measuring surface elevation for spherical
surfaces, slightly less accurate for aspheric and
bicurve and worse for multicurve surfaces. The
accuracy of the TMS instrument decreases for
surfaces with varying curvatures, with largest
errors at sharp transitions (Priest and Munger,
1998), but is similar for smooth asymmetric and
symmetric surfaces (Hilmantel et al, 1999). The
error of measurement is not correlated to the
surface toricity (Grievenkamp et al, 1996).
None of the Placido-based systems measure
the central and peripheral corneal surface with
equal accuracy. The TMS instrument seems to
be more accurate centrally, while the EyeSys
instrument in the mid-peripheral region, when
measuring standard spherical surfaces, but on
human corneas they perform in a comparable
way (Wilson et al, 1992). The TMS-2 gives 0.5
D steeper Ro values, while the EyeSys gives 0.15
lower e values on average, but the ideal fitting
RGL calculations were affected only for subjects
with significantly flatter or steeper corneas
(McMonnies and Boneham, 1997).
Section
Experience has shown that errors in topography

are a critical source of variability in advanced
orthokeratology lens fitting.
a. Random errors can occur due to human
error in alignment, focusing or misjudgement
of mires before processing. Mire quality can
be maximised by the patient blinking a few
times before the picture is taken so that the
eye does not dry out, as the tear layer is very
important in deriving a quality image. If the
alignment is not perfect, the computer asks
the examiner to manually centre the mires
on the fixation light and processing can then
follow. The TMS 2 (Tomey, New York USA)
has a Picture Perfect setting, which automatically corrects for misalignments and displays
X, Y and Z-axis errors. These should be less
than 0.3 mm if Picture Perfect is on and
should be less than 0.125 mm if Picture
Perfect is off. The TMS instrument is more
sensitive to focusing than to misalignment
errors (Roberts, 1995).
b. Systematic errors also occur and these
depend on calibration and calculating algorithms. Calibration checks should therefore
be performed regularly. The TMS has
spherical biased algorithm for calculations
(Brenner, 1997) and systematic errors are a
result of this (Priest and Munger, 1998).
The precision of an instrument, or the
repeatability of results, depends on the settings
used and the calculation algorithms, while the
accuracy, or validity also depends on the shape
of the measured surface (Heath et al, 1991).
Instantaneous radii measurements are more
variable (McMahon, 1997) and less accurate
(Roberts, 1995).
77
SAGITTAL HEIGHT FITTING METHOD

Fitting orthokeratology lenses by analysis of tear
layer thickness is an accurate method, since the
peripheral curves of the lens, as well as corneal
78
asphericity, are taken into account. It enables

the individualised fitting of lenses, tailoring the
entire lens to the particular cornea,(Mountford,
1997a).
The tear layer thickness is calculated mathematically by subtracting the sagittal height of the
cornea from the sagittal height of the contact
lens at the chord equal to the lens diameter. The
formulae to calculate the sagittal heights are
based on the apical corneal radius of curvature
(Ro) and shape factor of the cornea(e) and the
back radii and diameters of the lens (Young,
1996). Corneal measures are now easily derived
from topographical assessment.
Section
Sagittal Height Formulae

The basis of the calculations is:
TLT =TLTC+CSH-LSH,
Where TLT is tear layer thickness, TLTC is
the central TLT, CSH is the corneal sag height
and LSH is the lens sag height.
Lens Designs
Mountford (1997b) has described the IDEAL
lens design as consisting of:
Back optic zone radius (BOZR)= determined
from calculations
Back optic zone diameter (BOZD)= 7 mm
Tear reservoir (TR) = 4D
1st peripheral radius (BPR1)= 4D steeper
than BOZR
1st peripheral diameter (BPZD1)= 8.4 mm
2nd peripheral Cone Angle (CA)= determined from Ro, e, and chord diameter
Chord diameter for 10.6 mm lens (CD)=
9.5 mm
Total diameter
(TD)=10.6 mm
An improvement to the original RGL design

is the use of a tangential portion as the peripheral
curve, with a conic angle customised for the
individual cornea. The tangent cone angle is the
angle formed between the tangent portion of
the lens and the apical corneal radius. This is
diagrammatically presented in Figure 7.2 of
Mountford (1997b). This design aids centration
and reduces the time-course of treatment further.
It has also enabled a more predictable and
consistent fitting procedure, which may not
require multiple lens change-overs. Case reports
exist showing that even with only one set of lenses
some patients achieve longer lasting visual
improvement, needing to use their lenses only
every fourth or fifth night (Liubinas and de Jong,
1998).
A spreadsheet (Table 7.3) is used to vary
BOZR until the central tear layer thickness is
10m, and the mid-peripheral tear layer
thickness under the tangent periphery is zero at
about 9.5 mm diameter. The required tear layer
profile for the IDEAL lens design is shown in
Figure 7.3.
A lens may be ordered directly from this data,
without further inspection of trial lenses on eye.
If a sufficiently similar trial lens is available, then
a one hour period of unilateral closed eye lens
wear may be undertaken to introduce the patient
to the procedure, as well as assess the response
to the lens via changes in topography and
unaided vision.
An approximation to the use of sagittal height
calculations is a simple rule of thumb formula
for OK704 lenses (Contex Inc, Sherman Oaks,
California, USA), where the BOZR of the fitted
lens is approximately equal to the sum of Ro
79
Table 7.3: Spreadsheet for calculating tear layer profile in orthokeratology OK704T
Based on the spreadsheet formula of Young (1996)
Label
Apical radius
eccentricity value
corneal shape factor
Back optic zone radius
Back optic zone diameter
Tear reservoir (D)
1st peripheral radius
1st peripheral diameter
Chord diameter for 10.6mm lens
Cone Angle
Ro (mm)
e
SF
BOZR (mm)
BOZD (mm)
TR (D)
BPR1 (mm)
BPZD1 (mm)
CD
CA ()
Total diameter
Lens sagittal depth 1
TD (mm)
LS1
LS2

(tangent periphery)
Central tear layer thickness (m)
Integer (0-30) indicating
horizontal dist from center
Lens sagital depth at a point
corresponding to refH (mm)
LS3 (tan)
=(1-e^2)
=337.5/((337.5/C8)+C10)
= 90-arcsin((chord/2)/sqrt(Ro^2+(chord/2)^2(chord/2)^2*(SF))
=BOZR-SQRT(BOZR^2-(BOZD/2)^2)
=LS1+(BPR1-SQRT(BPR1^2-(BPZD1/2)^2))-(BPR1SQRT(BPR1^2-(BOZD/2)^2))
=LS2+0.5*(TD-BPZD1)*TAN((90-CA)*PI()/180)
TLT
RefH
Clinical decision to keep central TLT to >10-20 m
LSH
CSH
=IF(RefH<=(30*BOZD/TD),(BOZR-SQRT(BOZR^2(TD*RefH/60)^2)),
IF(RefH<=(30*BPZD1/TD),(LS1+(BPR1-SQRT(BPR1^2(TD*RefH/60)^2))-(BPR1-SQRT(BPR1^2
-(BOZD/2)^2))),(LS2+(TD*RefH/60)*TAN((90-CA)*PI()/
180))-(BPZD1/2)*TAN((90-CA)*PI()/180)))
=(Ro-SQRT(KH^2-SF*(TD*(RefH/60))/SF
TLTH
=TLT+CSH-LSH
(expressed in mm) plus the eccentricity value,

e. This formula was arrived at by inspection of
data collected in our laboratory in 1997. The
data for the seven subjects is displayed in Table
7.4. We later analysed Mountfords (1997b)
published data for 60 subjects and found the
best approximation for OK704T lenses was
Ro+e+0.1. A formula similar to this has since
been applied by Contex in design of lenses
(Nichols et al 2000). It should be emphasised
that this formula is an approximation and
superior success rates will be achieved, with fewer
non-responding subjects and better centration
Corneal sagital height at a point

corresponding to RefH (mm)
Corneal tear layer thickness at
point RefH (m)
Formula if applicable
Section
Parameter
of lens fitting, if exact sagittal height calculations

are made using the spreadsheet approach
outlined above.
The IDEALens design is similar to the
OK704T and both are available from Contex
(Sherman Oaks, California, USA, http://
www.oklens.com). Contex OK lenses were
approved in 1998 by the Food and Drug
Administration (FDA) for daily wear
orthokeratology for the temporary reduction of
myopia up to 3.00D (http://www.fda.gov/fdac/
features/1998/298-lens.html). This enabled
Contex to design and market their ortho-
80

Table 7.4: Summary of initial Ro, e and BOZR
Subj
Ro
Ro+e
BOZR
Error:{BOZR-(Ro+e)}
1
2
3
4
5
6
7
Av
8.00
7.89
7.89
7.64
7.60
7.60
7.85
7.78
0.63
0.48
0.66
0.54
0.27
0.42
0.59
0.51
8.63
8.37
8.55
8.18
7.87
8.02
8.44
8.29
8.45
8.30
8.50
8.10
7.90
8.05
8.40
8.24
-0.18
-0.07
-0.05
-0.08
+0.03
+0.03
-0.04
-0.05
Tear layer profile for OK704T 8.455/10.6

on cornea with Ro-7.92, e=0.45
60
Section
TLT (mm)
50
40
30
20
10
0
0.0
1.0
2.0
3.0
4.0
5.0
6.0
Chord radius from center of lens (mm)
FIGURE 7.3: Tear layer profile for orthokeratology lens
keratology lens design in the USA, something

other companies could not do at that time.
However, practitioners can order reverse
geometry lenses from any laboratory as an offlabel prescription (Kame 1998).
The DriemLens, developed with the aim of
targeting specific patient parameters, is a custom
reverse geometry lens, designed to reduce the
exact amount of myopia that is present (Day et
al 1997). The lens is available from Euclid Systems
(http://www.euclidsys.com) and the company
reports that FDA trials are underway. Practitioners
are required to supply the manufacturers with
initial patient information. The lens design has a
10 mm total diameter, a 6.00 mm optic zone and
a 1.1 mm wide reverse geometry width. Thus,

this lens has a wider tear reservoir, and narrower
optic zone and periphery than the OK704T lens.
The authors claim that 4.00 D of myopia should
be able to be eliminated during all waking hours
after only three to seven days of night only therapy.
However, questions have been raised about the
visual quality if the optical zone is too small (Hom,
1997).
The BE lens (Capricornia Contact Lenses,
Springwood,
Qld,
Australia,
http://
www.capricorniacontactlens.com.au/) is also a
proprietary lens design, where practitioners enter
the patient information (corneal shape and
refraction) into a software program, and then
send the results of the design to the laboratory
for supply of a suitable lens. Modifications to the
lens are made based upon the corneal response
to lens wear.
The advantage of the BE lens, over an earlier
lens design such as the IDEALens, is that the
manufacturer has developed a software program
to relate the required refractive error correction
to lens tear reservoir design. As with the Dreim
lens the design is not public-domain information,
whereas the IDEALens is probably the most
advanced of the public-domain lens designs.
Many other contact lens companies manufacture
reverse geometry lenses for orthokeratology;
however, the practitioner will need to find out
the characteristics of particular lens designs
available.
Tear Reservoir Depth
Lens Materials
6D
Lens
tear
4D
reservior
depth
2D
0.0
improvement in unaided vision after 6 hours

was on average 4, 5 and 6 lines, for the 2 D,
4 D and 6 D lenses, respectively.
The implication of this work is that a patient
who has only 1.00 D myopia will require a
different lens design to a patient with a higher
degree of myopia. The limitation of a deeper
tear reservoir is the smaller area of cornea that
is flattened, leading to a practical upper limit in
the amount of myopia that can be corrected
with orthokeratology that appears to be in
the range of 4.00 D to 6.00 D. The principles
of corneal refractive change would appear
to be similar to those for refractive surgery,
where the possible corneal refractive change is
limited by the treatment zone and the maximum
depth of corneal ablation (Munnerlyn et al
1988).
A further interesting aspect of our work was
that 75 percent of the corneal flattening occurred
within the first hour of lens wear. This result
supported the use of one hour as a useful time
interval for an initial trial of closed eye lens wear,
as mentioned above under Lens Designs.
0.2
0.4
0.6
0.8
1.0
1.2
1.4
Flattening of apical corneal power (Ro,D)
FIGURE 7.4: Effect of orthokeratology lens tear reservoir

depth on apical corneal flattening, after 6 hours closed eye
wear (N=7).
Section
The most common tear reservoir depth is 4D,

in the Contex (Sherman Oaks, California USA)
lens design known as the OK704T. This lens
has a 7.0 mm optic zone and a 10.6 mm total
diameter. The secondary curve is 4D steeper than
the BOZR.
Recent research in our laboratory has shown
that the depth of the tear reservoir influences
the degree of corneal flattening (Bara, 2000).
While a lens with a 2 D reservoir (an OK702T)
caused only 0.5 D of apical corneal flattening in
6 hours of closed eye lens wear, a 4 D tear
reservoir caused 0.75 D corneal flattening and
a 6 D tear reservoir caused 1.00 D of flattening
(Figure 7.4). By comparison, the control
condition of no lens wear resulted in minimal
change in corneal curvature (<0.25 D). The
81
The most commonly used lens materials today

in Australia are different kinds of RGP polymers
that can be made into lenses with a high degree
of oxygen transmissibility (Dk, measured in Fatt
units: cm ml (O2) / sec ml mmHg). The
Holden-Mertz (1984) criterion for an ideal
oxygen transmissibility index for daily wear is
24 10-9 and for overnight wear is 87 10-9.
RGP lens materials currently available in Australia
which satisfy this criterion are: Boston 7 (Dk=73),
Boston Equalens (Dk=120), Quantum II
(Dk=210), Fluoroperm 92 & 151 (Dk=92 &
105 respectively), Fluorex 900 (Dk=90) and
82
Menicon Super EX (Dk=162) (Tighe, 1997) (Dk

cited at 20C).
Troubleshooting
Section
The ideal corneal topography pattern after lens

wear shows a circular, well-centered, area of
corneal flattening, with a diameter larger than
that of the pupil. There may well be midperipheral steepening. This will be best observed
from a difference topography plot, where the
after-wear plot has been subtracted from the
pre-wear plot (Figure 7.5).
Bearing in mind that the order of accuracy
required in advanced orthokeratology is in
microns, rather than in tens of microns as is
required for normal rigid lens fitting, sub-optimal
outcomes will occur. These outcomes may be
addressed as follows:
Lens flat this may be evidenced by a smileyface topography pattern, where inferior
steepening is evident indicating superior
decentration of the lens (Mountford and
Noack, 1999). There may also be central
bearing or abrasions. Cease wear for several
days to allow corneal recovery, then
remeasure topography with several maps to
average the Ro and e values and obtain a
more accurate baseline. Expect the next lens
order to be slightly steeper.
Lens steepthis may be evidenced by a
central island of steepening in the topography
pattern (Figure 7.6) and no reduction in
myopia (Mountford and Noack, 1999). The
lens may be too steep in the BOZR or too
tight in the tangential periphery (Cone angle
too steep). As above, reassess topography
FIGURE 7.5: Topographycentral flattening
more accurately and then expect the next
lens order to be slightly flatter.
Sometimes if there is a systematic error in
the topographer in measuring the sag of the
cornea, then a process of trial and error using
known trial lenses and observing the subsequent corneal response, may be required
to fine-tune the fitting process.
Too shallow or too steep a tear reservoir (TR)
will change the hydraulics. If the required
degree of myopia reduction is not being
achieved then an increased TR depth or a
reduced apical clearance may be necessary.
Conversely if less myopia reduction is needed
the TR may be reduced.
83
POSSIBLE MECHANISMS
A summary of the proposed mechanisms for
orthokeratology was collated by Marsden and
Kame (1997):
In the early stages it was believed that a flat
fitting rigid lens worn in daily wear creates a
local mechanical pressure which flattens the
cornea centrally. A contemporary application
of this theory would perhaps be that a RGL
worn in closed eye conditions may cause
corneal tissue molding (Mountford, 1997b).
In this model the collagen fibres can bend
although they do not change length and the
corneal surface area stays constant (Day et
al 1997).
Section
FIGURE 7.6: Topographycentral distortion
84
The eyelid pressure and blinking pattern

produce a massaging effect through the lens.
Tear hydraulics: The tear lens between the
cornea and contact lens creates a uniform
pressure gradient over the cornea, to yield a
more spherical shape, particularly for day
wear (Harris, 1978). This theory would
require a closed tear fluid system to operate.
Ciliary spasm may be reduced because the
contact lenses larger depth of field and
reduced prismatic effects. This explanation
can only be useful for pseudomyopia or very
small amounts of myopia (Worrell, 1995).
Rigid contact lenses may reduce the
progression of myopia by reducing the
growth of the posterior chamber, by a
mechanism not yet known (Kerns, 1981;
Grosvenor et al 1991; Keller, 1997).
Some other factors which may contribute to
the orthokeratology effect are individual
response to induced stress due to corneal
tissue rigidity and elasticity (Mountford,
1997a; Pye et al 1997; Polse et al 1983c)
Corneal shape change due to central
epithelial thinning and peripheral thickening
(Coon, 1984). This mechanism has been
recently gaining scientific support. Swarbrick
et al (1998) have measured central epithelial
thinning of 7.17.1 m and midperipheral
epithelial thickening of 13.011.1 m after
28 days of orthokeratology daily wear.
Nichols et al measured significant central
corneal thinning of 1211 m but no
significant change in the mid-periphery
following 60 days of orthokeratology night
therapy.
With modern orthokeratology, in general,
only highly oxygen permeable materials are used
Section

for lens manufacture, thus more or less eliminating oedema considerations. The mechanical
factors are likely to be the most important.
Mountford and Noack (1998) hypothesise
that with orthokeratology the central cornea is
made spherical. With their calculations, where
the corneal surface area or Bowmans membrane chord length is assumed constant, a
maximum of 2.00 D of refractive change is
thought to be theoretically possible for a cornea
of Ro = 7.80 mm, e = 0.50. They assume a
chord of 12 mm; however, they do not comment
on the theoretical flattening possible if only the
central cornea is flattened.
POSSIBLE COMPLICATIONS
Orthokeratology is generally considered a safe
procedure (Grant, 1980; Barr 1998), although
as with any contact lens wear complications are
possible. As contact lenses are in contact with the
surface of the eye, there is a risk of altering some
of the ocular parameters due to physical or
physiological reasons. In most circumstances the
cause of the corneal shape change can be
attributed to one or a combination of the
following: mechanical pressure exerted by the
lens and the eyelid, oedema caused by the contact
lens, or lens binding due to tear abnormalities
(Efron, 1997). With the use of gas permeable
rigid lenses, the chances of corneal oedema are
reduced, but the mechanical ones remain.
Corneal Distortion
A decentered or poorly fitting rigid lens can
induce unwanted corneal shape change or
distortion. Maeda and co-workers (1994)
showed that flattening of the cornea was most
likely to occur under the decentered lens, with
possible adjacent steepening. The lenses were
often decentered superiorly and had insufficient
mobility. Keratometry measurements revealed
that corneal distortion during contact lens wear
and its recovery thereafter are related to the time
of wear, and the rate of change is faster in the
initial time period (Bailey and Carney, 1970).
85
Surface Asymmetry and Irregularity
Corneal Erosion or Infection
Some keratometric steepening occurred initially

with early rigid lenses (both PMMA and low Dk
RGP). This is believed to be due to central corneal oedema (Miller, 1968), but others argued
for the existence of localised irregular zones
(Hodd, 1965). The level of oedema is inversely
proportional with the oxygen permeability and
flexibility of the lens. Hyperopic changes of more
then 0.25D, due to oedema, are rare with higher
Dk RGP lenses (Efron, 1997).
While daily wear orthokeratology is generally

considered a safe procedure (Grant, 1980), the
lenses are fitted flat with apical bearing and so
there is a risk of central epithelial erosion if the
fitting is not optimal (Levy, 1982). With night
therapy there is a slightly increased risk of corneal
infection compared to daily wear. The likelihood
of infection remains very low, since high-Dk lens
materials are used and the lenses are removed
each day allowing replenishment of the postlens
Central Steepening
Corneal Indentation
Section
Lens binding can occur either with overnight wear

or occasionally with day wear of rigid lenses.
Corneal indentation almost always occurs as a
result of lens binding. An impression of the lens
edge is evident on the cornea, with fine punctate
staining around it. The most probable cause for
lens binding is mucous adhesion beneath an
immobile lens (Bruce and Brennan, 1990). In
cases where the lens binds during the day, another
possible mechanism is the negative pressure that
forms between the lens and the cornea, acting as
a source of suction and thereby holding the lens
immobile and causing indentation.
Binding is very much dependent on patient
attributes. It is likely that if a patient had bound
lenses before, they will have this later as well
(Swarbrick, 1989).
Corneal shape changes are quantified by the

surface asymmetry index and the surface
regularity index, both of which are calculated
by algorithms in the TMS topography system
on the basis of corneal power measurements.
The asymmetry index gives an idea of the radial
symmetry of the cornea, comparing the
difference in corneal power of two points 180
apart at every ring, over the entire cornea. The
surface regularity index correlates to the potential
visual acuity, being a measure of the local central
corneal power fluctuations. The unprocessed
mires of a videokeratoscope can also provide a
good qualitative guide of the regularity of the
cornea, by examining the clarity and geometrical
regularity of the circles projected onto and
reflected from the cornea. Changes in regularity
and symmetry of the cornea in contact lens wear
are most likely due to physical compression
(Kerns, 1978). It has been noted that
asymmetry and regularity indices are correlated
to lens decentration (Maeda et al, 1994). It is
also plausible to hypothesise that corneal rigidity
plays a part as well, so that less rigid corneas are
deformed more easily.
86
tear film and recovery from any superficial

epithelial changes. However, it is conceivable
that, as with any contact lens wear, under some
circumstances the risk of an infectious keratitis
could be increased. One such situation could be
if a non-compliant patient omitted to remove
the lenses as instructed and if there was a breach
of epithelial integrity, in concert with poor lens
and general hygiene. A second example would
be if there was pre-existing ocular surgery (Gupta
and Weinreb, 1997).
SUMMARY
Section
Orthokeratology has become a viable procedure

with the advent of accurate corneal topography,
modelling of tear layer profiles, and accurate
reverse geometry lens manufacture. While the
fitting is more complex than with conventional
contact lenses, orthokeratology lenses carry the
additional key benefit to the patient of good
unaided vision after lenses have been removed.
ACKNOWLEDGMENTS
John Mountford (Brisbane, Australia) assisted
in the development of some of the concepts and
research reported in this chapter. The research
was supported in part by scholarships to CS-O
from the Contact Lens Society of Australia and
the Orthokeratology Society of Australia. Contex
Inc (Sherman Oaks, California USA) supplied
contact lenses used in the studies.
FURTHER READING
1. Applegate RA, Nuez RN, Buettner J, Howland HC.
How accurately can videokeratographic systems
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2. Bailey IJ, Carney LG. Distortion and recovery of the

cornea after contact lens wear. J Am Optom Assoc
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3. Bara C. The mechanism of action of reverse geometry
gas permeable contact lenses in orthokeratology.
M.Optom thesis, University of Melbourne, 2000.
4. Barr JT. Is O-K Okay? (Editorial). Optom Vis Sci
1998;75: 773.
5. Binder PS, May CH, Grant SC. An evaluation of
orthokeratology. Ophthalmology 1980;87: 729-744
6. Brand RJ, Polse KA, Schwalbe JS. The Berkley
orthokeratology study, Part I.: General conduct of the
study. Am J Optom Physiol Opt 1983;60:175-186.
7. Brenner D. Modelling the cornea with the Topographic
Modelling System videokeratoscope. OptomVis Sci
1997;74: 895-898.
8. Bruce AS, Brennan NA. Corneal pathophysiology
with contact lens wear. Surv Ophthalmol 1990;35:
25-57.
9. Carkeet NL, Mountford JA, Carney LG. Predicting
success with orthokeratology lens wear: a
retrospective analysis of ocular characteristics.
OptomVis Sci 1995;72: 829-898.
10. Coon LJ. Orthokeratology, Part I. Historical
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11. Coon LJ. Orthokeratology, Part II. Evaluating the
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12. Dave T, Ruston D. Curent trends in modern
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13. Day JH, Reim T, Bard RD, McGonagill P, Gambino
MJ. Advanced orthokeratology using custom lens
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14. Efron N. Contact lens-induced changes in corneal
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16. Erickson PM. Accounting for refractive changes in
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22. Grant SC. OrthokeratologyA safe and effective

treatment for a disabling problem. Surv Ophthalmol
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25. Greivenkamp JE, Mellinger MD, Snyder RW,
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26. Grosvenor T, Perrigin D, Perrigin J, Quintero S. Rigid
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27. Gupta N, Weinreb RN. Filtering bleb infection as a
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28. Harris DH. Corneal changes in myopia reduction.
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33. Hodd FAB. Changes in corneal shape induced by the
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34. Hom MM. Advanced orthokeratology. Int Contact
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35. Horner DG, Bryant MK. Take another look at todays
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36. Hunter WA. Reconsider orthokeratology. Contact
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37. Jessen GN. Orthofocus Techniques. Contacto 1962;
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38. Joe JJ, Marsden HJ, Edrington TB. The relationship
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Section
90
Chapter
Rigid Gas-Permeable
Contact Lenses
Milton M Hom
INTRODUCTION
Section
For many practitioners, rigid gas-permeable

(RGP) lenses are the first choice when fitting
contact lenses. They offer excellent vision, longterm comfort and durability compared to soft
lenses.1 Although RGP lenses are superior to soft
lenses in almost every category, the main reason
soft lenses are more prevalent is comfort. The
time for adaptation to RGP lenses are days to
weeks, while soft lenses typically take minutes to
adapt to.
When dealing with comfort issues, RGP
experts advocate the use of positive terms while
presenting rigid lenses to patients. Terms such as
pain and hurt should not be used. Instead
of hurt, the term initial sensation is better.
Other terms such as edge awareness, lid
sensation and tickling sensation are also
recommended.2
The major advantage RGP lenses possess is
better vision over soft lenses. Soft lenses conform
to the eye and poorly mask astigmatism. Rigid
lenses are made from stiffer materials and offer
superior optics. Many patients that switch from
rigid lenses to soft lenses often complain of the

loss of visual quality. If a patient is a fully adapted
rigid lens wearer, switching to soft lenses is often
met with poor success.
Another worthwhile benefit of rigid
lenses is myopia control. Studies have
shown RGP lenses reduce the progression
of myopia in children. RGP lenses reduced
the progression of myopia an average of
one-third when compared to the control
group.3 The effect is more pronounced
when fitting aspheric RGP bifocal lenses
on patients that are esophoric at near.
Some clinicans report a complete stoppage
of the myopia for these patients.4
PMMA REHABILITATION
In the past, RGP lenses have been utilized as a
tool for polymethylmethacrylate (PMMA)
rehabilitation. Presently, RGP materials have
virtually replaced PMMA as a prescribed lens
material. The major problem is that PMMA lenses
are not oxygen permeable and almost 98 percent
of the patients have edema.5 Biomicroscopy can
Rigid Gas-Permeable Contact Lenses
The hallmark property of RGP lenses is the

oxygen permeability. Oxygen permeability is
measured most commonly by Dk. The Dk
value is considered the industry standard.
D represents diffusion and k represents
solubilty. The higher the Dk value, the more
permeable the material. Sometimes, the
oxygen transmissibility is expressed as Dk/L. L
represents the total thickness. The thicker the
lens (higher L value), the lower will be the total
oxygen permeability.10 In the past, the L value
was an issue of concern especially amongst
manufacturers when comparing materials.
Currently, most materials can be cut at low
thickness and still maintain optimal performance
making the L value a non-issue.
RGP MATERIALS
Oxygen permeability is achieved by

adding monomers to the lens polymer.
Most modern RGP materials contain silicone and fluorine. They make up the RGP
material class of fluorosilicone acrylates
(FSA). Previous to FSA, the predominant
material was silicone acrylates (SA). Silicone and
fluorine add permeability to the lens polymer.
Oxygen relies on diffusion to move through the
voids in the material created by the addition of
silicone. Fluorine allows the material to be
permeable via solubility. Oxygen dissolves in a
fluorine-containing polymer. Solubility is where
the fluorine soaks up the oxygen like a sponge.11
Fluorine also adds low co-efficient of friction and
low surface tension to the polymer. This prevents
deposits from sticking and demonstrates the similar properties of another fluoropolymer, Teflon.
Weekly enzyme cleaning is not needed as much
with fluorine-containing polymers than the older
silicone acrylates. Another inherent property of
fluorine is acute hydrophobicity. Hydrophobicity
makes the polymer attract deposits. Silicone is
also hydrophobic and attracts deposits. One
challenge of a polymer chemist is to synthesize
the proper combination of monomers to take
advantage of fluorines deposit resistance and
counteract the deposit affinity of silicone.12
Another commonly used monomer, methylmethacrylate (MMA) makes the RGP rigid. It
adds stability, optical clarity and machinability
to the lens. Many of these same qualities are
found in a related material, polymethylmethacrylate (PMMA). Cross-linkers such as
ethylene glycol dimethacrylate are also added
for more stability and reduction of flexure.13 The
permeability of silicone depends on diffusion.
The more loosely packed the polymer chains,
Section
show fluorescein staining, microcystic edema,

neovascularization, and central corneal clouding.7
Signs and symptoms of edema are spectacle blur
of more than 30 minutes, distortion of keratometric mires, decreasing wearing time, and poor
endpoint of refraction.6 For PMMA wearers, an
immediate refitting into RGP lenses is advised.7
Rengstorff found that initially myopia decreases
during the first 3 days after cessation of PMMA
wear and increases several weeks until it stabilizes. However, the curvature measured immediately after removal is similar to the curvature
found after the cornea stabilizes. Based on these
findings, immediate refitting is recommended.8
RGP lenses can be worn on a full-time basis following immediate refitting. One common finding
for patients undergoing immediate refitting is an
increased sensation to foreign bodies. The
corneal sensitivity returns to a more normal state
because RGPs allow better respiration.9
91
92
Section
the more permeable the material. The main

drawback with higher permeability is the material
subsequently becomes softer. The cross-linkers
are added to stiffen the material and allow it to
be cut thinner.10,13
Because of the hydrophobic nature of
fluorine and silicone, wetting agents are added.
Methacrylic acid, N-vinyl pyrrolidone, polyvinyl
alcohol and hydroxyethylmethacrylate (HEMA)
are used.10 In the past, the polymers affinity for
water was measured with wetting angles. The
lower the angle, the better will be the wettability.
Manufacturers have made the comparison of
wetting angles an issue in the past. However,
experts of today question the value of wetting
angles. The lens is rapidly covered by a coating
or pellicle when placed onto an eye. The pellicle
gives all materials essentially the same wetting
angle.14 Lipid-based deposits are more frequently seen on FSA lenses than older generation
materials. The lipid deposit appears oily and
greasy.15
Other rigid materials include fluorocarbons
(Advent Lens by Ocular Sciences, South San
Francisco, CA), Novalens (by Nova Vision,
Morrisville, North Carolina), silicone elastomers,
cellulose acetate butyrate (CAB), and polystyrene (rigid center portion found in Softperm
lens by Wesley-Jessen, Des Plaines, IL).
RGP DESIGNS
There are several methods of fitting and
designing RGP lenses. The majority of lenses are
prescribed empirically by the contact lens
laboratories.16 However, diagnostic fitting is
preferred by most experts. Higher success rates
and improved patient confidence are seen with
diagnostic fitting. Performance factors such as
residual astigmatism and centration can be

corrected in advance with diagnostic fitting.17
There are several fitting philosophies for RGP
lenses. These include: interpalpebral, Bennett,
Korb, inside-out, and Mandell. Interpalpebral
or small and steep is actually a PMMA fitting
philosophy. The diameters used are 8.0 to 8.6
mm. Sometimes there is upper lid contact, but
the lens is meant to center primarily between
the lids. The initial base curve is found by adding
25 to 33 percent of the corneal toricity to the
flat K.18 For corneal cylinder 0 to 0.75 D, a base
curve of 0.25 D steeper than flat K is used. This
fitting philosophy is not utilized as often because
the smaller size has a greater chance for flare
and glare. In the past, larger diameters were not
reasonable with PMMA because of the risk of
edema. Currently, the interpalpebral fitting
method is used as a problem solving option
where a larger diameter is not suitable.
Bennett philosophy uses a tricurve or
tetracurve design. The diameter ranges from 9.2
to 9.4 mm with optic zones (OZ) between 7.6
and 8.2 mm. If a larger lens is needed, a 9.6
mm diameter with a 8.2 mm OZ is used. The
initial base curve chosen is 0.50 flatter than the
flat K reading.17 For every 0.25 D change in base
curve, there needs to be an adjustment of 0.50
mm in OZ. If the OZ is increased by 0.50 mm,
then the base curve needs to be steepened by
0.25 D. The peripheral system is either tricurve
or tetracurve. The tricurve is much more
prevalent than the tetracurve. For the tricurve,
a secondary curve 1.0 to 1.5 mm is added to
the base curve. The peripheral curve is 1.5 to
2.0 mm added to the base curve. The widths
are 0.3 to 0.4 mm.19 Edge thickness is
approximately 0.08 to 0.10 mm. Plus lenticular
generations of RGP material, the flexure is

reduced by cross-linkers in the polymer, while
maintaining or increasing the oxygen permeability.
Inside-out design begins with the base curve
(inside) and designing the lens outward to the
peripheral curves. Diameters are usually 9.2 mm
for a horizontal visible iris diameter of 11.5. The
base curve is 0.50 mm flatter than flat K with a
7.0 to 7.5 mm OZ. The secondary or accordian curve is 1 mm flatter than the base curve.
The peripheral or limbal clearance curve is 12.25
mm with a 0.4 mm width. A myoflange or minus
lenticular is needed for 2.00 and below and all
plus powers. A plus lenticular or hyperflange is
needed for higher minus. Center thickness is
0.18 mm for plano and decreases 0.01 mm for
every diopter to 5.00.24,25
Mandells philosophy utilizes a diameter of
9.2 mm with a 7.8 OZ. For corneas flatter than
42.00, a 9.6 mm diameter is used. For corneas
steeper than 44.00, a diameter of 8.8 mm is
used. Base curve selected is on flat K or 0.25
flatter than flat K for spherical corneas. 0.25 to
1.00 D of toricity, a base curve of on flat K or
0.25 D steeper than K is used. 1.00 to 2.00 of
toricity indicates a base curve of 0.50 D steeper
than K. Toricities more than 2.00 indicate adding
half the toricity to flat K.
For peripheral systems, base curves of 41.00
to 41.50 has a secondary curve or width of 9.5/
0.4 mm and peripheral curve/width of 11.1/0.3
mm. Base curves 42.00 to 43.00 has a secondary
curve/width of 9.0/0.4 mm and peripheral
curve/width of 10.8/0.3 mm. Base curves 43.50
to 44.50 has a secondary curve/width of 9.0/
0.4 mm and peripheral curve/width of 10.5/0.3
mm.26
Section
design is needed for 5.00 D and greater. Minus

lenticular design is needed for less than 1.50 D
and all plus powers.17,18
Korb philosophy is also known as lid
attachment or the original Polycon fitting
philosophy. The basic concept behind the
Korb philosophy is the contact lens acts
as an additional thin layer attached to the
tear film. The lens is attached to and moves
with the upper lid.20 A strong emphasis on
correct blinking is made with the Korb philosophy. If the blink is poor, undesirable staining
can result. Poor blinking can be corrected with
blink exercises.21
To facilitate lid attachment, Korb originally
designated a 9.5 mm diameter with a 8.4 mm
OZ. 9.5 mm was preferred by 86 percent of the
105 patients studied.22 Because many of the
patients were refitted from PMMA lenses, a 9.5
mm diameter was sometimes too large and
caused discomfort. A fully adapted patient
develops areas of contact that are less sensitive
to the rigid lens. Since most PMMA philosophies
utilized smaller diameters, a refit into a larger
9.5 mm RGP lens brought new areas of contact
and subsequent comfort problems. A 9.0 mm
and 8.5 mm diameter were later introduced.
Base curve recommended was 0.25 mm flatter
than flat K for a 9.0 mm diameter.23
Another issue with the Korb or Polycon
design was lens flexure. The original Polycon
material was cut thin (0.7 mm) to follow Korbs
concept of a thin lens attached to the tear film.
Unfortunately, the lens would flex on the eye
and not correct astigmatism as well as PMMA.
This was somewhat solved by making the lenses
thicker. However, a thicker lens reduces the total
amount of oxygen permeability. In later
93
94
A careful look at rigid philosophies reveal

many similarities. The current philosophies use
diameters between 9.2 and 9.4 mm and base
curves on flat K or slightly flatter than flat K. The
diameters can vary according to corneal curvature. Steeper corneas customarily take smaller
diameters and flatter corneas take larger
diameters.
Another philosophy by Bruce emphasizes lid
geometry when choosing diameters.27 There are
four types of lid geometries: narrow, ideal,
unusual, and wide aperture.
A narrow aperture is characterized with a low
upper lid and high lower lid. The fit used for a
narrow aperture is interpalpebral. The lens needs
to reside primarily between the lids because of
the lid geometry.
An ideal aperture is characterized with a low
upper lid and low lower lid. Because the upper
lid is low, lid attachment can be achieved rather
easily. A larger diameter lens (9.5 mm or larger)
may be needed. When the lower lid is located
far below the lens, the upper lid can hold the
lens in place without interference. A fitting philosophy such as Korb can be used. Fortunately,
rigid gas permeable lenses allow the practitioner
the option to fit with larger diameters.
An unusual aperture is characterized with a
high upper lid and high lower lid. A 9.4 to 9.6
mm diameter can give the patient good comfort
and centration. The aperture is designated
unusual because the upper lid is normally lower
and the lower lid normally higher.
A wide aperture is characterized with a high
upper lid and low lower lid. Centration can be
achieved with a 9.5 to 10.0 mm or larger
diameter lens.27
Section

CALCULATIONS
Power is normally determined by overrefraction
when diagnostically fitting RGPs. Power can also
be calculated based on spectacle refraction after
accounting for vertex distance. Vertex distance
should be taken in consideration for powers over
+/ 4.00 D. It can be calculated or found in
tables. The vertex calculation for power (F) is:
F (power vertexed) = F (spectacle power)/
1d(vertex distance) F (spectacle sphere power)
An example is a spectacle power of +14.50
3.00 010, the meridian powers are
+14.50 and +11.50. For a 12-mm vertex
distance, each meridian is:
+14.40/1(0.012)(+14.50) = +17.55
+11.50/1(0.012)(+11.50) = +13.34
The final vertex prescription is +17.55 4.21
010.17
The tear layer power can change the power
of the rigid lens. Plus tear layers are created with
steeper lenses. Minus tear layers are created with
flatter lenses. The SAMFAP rule can be used:
steeper add minus, flatter add plus. 24 For Ks of
45.00/46.50 (7.50 mm/7.25 mm), spectacle
power 3.50 D, a rigid lens with a base curve of
44.50 (7.58 mm) creates a 0.50 minus tear layer
(lens is flatter by 0.50 D). According to SAMFAP,
flatter add plus. The 3.50 D lens adds 0.50 in
plus to yield 3.00 (3.50 + 0.50 = 3.00).17
Diopters conversion to millimeters are
necessary. The formula is:
Radius (in mm) = 337.5/Power (in diopters)
TROUBLESHOOTING
Decentration is the one of the major problems
facing an RGP fitter. A decentered lens creates
FIGURE 8.1: An example of a superiorly positioned lens
influence. Thickening the center thickness to

increase mass and steepening the lens can work
if the upper lid does not have influence. Another
factor may be corneal toricity. A with-the-rule
(WTR) cornea will cause the lens to ride either
high or low. Designing a toric lens for corneas
with 1.50 to 2.00 D of toricity or greater is
effective.29
Lateral decentration is usually caused by
against-the-rule (ATR) toricity. Utilizing a toric
lens or aspheric design are worthwhile options.
Increased diameter to allow the upper lid to help
center the lens is another alternative.24
Discomfort for an already adapted patient is
another problem that may arise. The usual cause
is poor edges. The edges need to be examined
with a magnifier for nicks, roughened areas,
and chips. If a discomfort problem arises, some
practitioners routinely polish the edges. High
edge lift is another cause of discomfort. Lowering
the edge lift by narrowing the peripheral curves
or using an aspheric design may help.31,32
Decentration can also cause comfort problems.
The edge of the upper lid is sensitive and a lens
not in constant contact will create lens awareness.24 Correcting the decentration will treat the
discomfort.
Peripheral corneal desiccation or 3 and 9
staining comes from inferior decentration or a
poor tear film (Figure 8.2). Correcting the
centration should be considered as a first option.
If the lens is centering properly, tear film integrity
and blink should be checked.29
Poor wettability of the lens surfaces can be
initial or acquired (Figures 8.3 and 8.4). If the
wettability is initial, it is usually caused by the
manufacturing process. Sometimes, cleaning the
lens and soaking it in a conditioning solution
overnight will resolve the problem. If the
Section
symptoms such as night glare or poor vision.

Some patients can adapt to a decentered lens
with time. However, there are many patients who
cannot adjust and needs the fit improved.
Enlarging the diameter will work for some cases,
but can worsen the situation for others. There
are basically three types of decentration: inferior,
superior and lateral.
Inferior decentration is usually influenced by
upper lid force. If the lens is large enough to
have lid attachment, then the lens will ride higher.
However, if the upper lid is positioned too high
(as in wide aperture or unusual aperture),
increasing the diameter will only increase the
mass and cause the lens to ride lower. For these
cases, the lens mass needs to be decreased.
Overall mass can be reduced by a lenticular
design, decreased center thickness or changing
to a lower specific gravity material.29,30 Increasing
the edge lift can make the edge act as a hook
for enhanced lid attachment.
Superior decentration usually occurs when
the upper lid pulls the lens too far upward (Figure
8.1). Reducing the diameter or thinning the edge
with a lenticular design can decrease upper lid
95
FIGURE 8.2: Peripheral corneal desiccation
FIGURE 8.5: A heavily deposited lens prior to cleaning
FIGURE 8.3: An example of poor initial wettability
FIGURE 8.6: The same is shown after cleaning

with a laboratory cleaner
Section
96
problem still persists, surface polishing or use of

a laboratory cleaner is indicated (Figures 8.5 and
8.6). If the wettability problem arises at a later
time, the lens is usually dirty. Better cleaning
techniques and the use of an abrasive cleaner
are indicated.
FLUORESCEIN PATTERNS
FIGURE 8.4: This lens wets poorly because of the heavy
deposits
The ability to interpret fluorescein patterns

is essential to fit RGP lenses. The fluorescein pattern gives the fitter a 3-dimen-
97
When the eccentricity is high or low, the pattern

will change. High eccentricity corneas appear
steeper than actual. Low eccentricity corneas
appear flatter than actual. Most of the patterns
appearing in textbooks are rendered for normal
eccentricity.33
Areas of clearance or vaulting appear as
pooling or light areas in the fluorescein pattern.
Areas of bearing appear dark.34 A steep lens
normally has pooling in the center and bearing
in the periphery (Figures 8.7 and 8.8). A flat
lens has bearing in the center and pooling in the
periphery (Figures 8.9 and 8.10). An alignment
FIGURE 8.7: Here is a lens fitted 1D steep
FIGURE 8.9: Here is a lens fitted 1D flat
FIGURE 8.8: This is a steep pattern. The lens is 2 D steep
FIGURE 8.10: This lens is 2 D flat
Section
sional view of the tear layer underneath the

lens. Sometimes, patterns are difficult to
interpret. There are two factors that may make
patterns confusing to read. One is the
concentration of fluorescein. If there is a high
concentration of fluorescein, the pattern will
generally look steeper than it actually is. This
scenario usually occurs when the fluorescein is
first instilled. As the fluorescein runs out and the
concentration decreases, the pattern will appear
flatter than the actual relationship. This needs to
be kept in mind when reading patterns. The
other confusing factor is corneal eccentricity.
98
FIGURE 8.11: This is a lens fitted with an alignment

pattern. There is total darkness throughout the optic-zone
FIGURE 8.12: The dumbbell pattern is shown for a withthe-rule cornea
pattern appears either as dark or a dim glow of

tears within the OZ of the lens (Figure 8.11).34
Fluorescein dye fluoresces above a certain
threshold or thickness of the tear layer. Sixty
microns of tear thickness is needed for 0.025
percent concentration for fluorescence.35 There
is greater intensity of fluorescence with a thicker
tear film. For alinement, a tear layer thickness
just above the threshold thickness would have a
dim glow. A tear thickness just below the
threshold and thinner would show darkness.
Therefore, both darkness and a dim glow would
define an alignment fit.
Toric corneas appear different than spherical
corneas. A WTR cornea will have a bearing area
that appears as a dumbbell pattern along the
180 degree meridian (Figure 8.12) An ATR
cornea has the dumbbell pattern along the
90 degree meridian.34
The pattern can be read as a bulls eye
from the central to the periphery. The movement
and centering needs to be noted. Observing
movement can offer valuable keys when the
fluorescein pattern is confusing. A steep lens
usually has little to no movement. A flat lens

usually has excessive movement. Lens
positioning is also important. An alignment fit
usually yields a centered lens. A fluorescein
pattern should be read as: central, midperipheral, peripheral, movement and centering.
For example, a flat lens may be central bearing,
midperipheral pooling, peripheral pooling, large
amount of movement, and inferior positioning.
A steep lens may read as central pooling,
midperipheral pooling, peripheral bearing, no
movement and excellent centering. Noting all
five of these factors can provide detailed
information about the rigid lens fit.
Section
RGPs FOR PRESBYOPIA

Presbyopia can be treated with monovision or
RGP bifocals. Fitting monovision with RGPs is
similar to fitting soft lens monovision. One eye is
designated for distance and one eye is for near.
The distance eye is usually the dominant eye.
Typically, a maximum add power of +1.50 is
utilized, although other add powers have proved
successful.
This works especially well for computer users.

Alternating vision works like a conventional
spectacle bifocal. The top portion of the lens is
usually meant for distance, the bottom portion
is meant for near. The lens needs to move or
translate for proper vision.37
There are 2 types of RGP bifocals commonly
in use today: aspheric and translating. Aspheric
bifocals uses simultaneous vision and is best suited
for the early presbyope, especially for those
already wearing RGP lenses. The maximum
effective add for aspherics is usually below
+2.00. There are some manufacturers who offer
higher adds by grinding more plus power on
the front surface. However, the quality of the
optics may not be as good. For adds less than
+2.00, an aspheric RGP bifocal is the most
successful contact lens bifocal modality. The
distance and near vision offered is superior to
that of any soft lens bifocal. Aspheric bifocals
are also relatively easy to fit.
Aspheric lenses can either be center distance
or center near. Back aspherics are center
distance, while front aspherics are center near.
Center distance are more commonly used. Of
the lenses in the back aspheric class, there are
high eccentricity lenses and low eccentricity
lenses. Higher adds are obtained with higher
eccentricities. Lower add powers have lower
eccentricity base curves.38 A good way of telling
the difference is the manufacturers guidelines
for fitting.39 If the guidelines call for initial base
curves 2.00 D or more steeper than flat K, the
lens is probably a high eccentricity lens. Initial
base curves that are not as steep usually indicate
a low eccentricity lens.
The fluorescein patterns of the high and low
eccentricities lenses are different. The high eccentricity lenses have much more apical clearance
Section
When two eyes are used instead of one, visual

performance greatly increases. This is called
binocular summation. The binocular contrast
sensitivity is about 42 percent higher than
monocular. When the visual performance is
worse binocularly than monocularly, it is called
binocular inhibition. It has been shown that
monovision adds up to +1.50 D produce
binocular summation.36 Adds higher than +1.50
D produce binocular inhibition. Therefore, to
best take advantage of binocular summation,
adds less than +1.50 D should be prescribed.
The critical add power when binocular
summation crosses over to binocular inhibition
is between +1.00 D and +1.50 D. Clinically,
we have found the best add power to target for
our early presbyopes is +1.25 D to +1.50 D,
the maximum add affording the patient binocular summation.
Normally, an adaptation time of 2 to 6 weeks
are needed. The patients can complain of hazy
vision, eye strain, and mild eye twitching.
Sometimes, switching the distance and near eye
can relieve symptoms. Patients can also be
sensitive to small changes in prescription. Even
changing one eye as little as 0.25 can mean the
difference between success and failure. For many
monovision patients, as well as RGP bifocal
patients, wearing an overcorrection in spectacles
is needed. If the monovision or bifocals contact
lenses are adequate for 80 percent of the time,
it is considered a successful fit.37
There are two types of bifocal systems:
simultaneous and alternating vision. Simultaneous vision places both the distance and near
images on the retina at the same time. Simultaneous vision has the advantage of usability in all
fields of gaze. Intermediate distances appear
clearer with a simultaneous vision aspheric lens.
99
100
in the pattern. The low eccentricity lenses also

have apical clearance, but a much smaller
amount. A low eccentricity lens alignment pattern
appears much closer to a spherical lens alignment pattern. Alignment for a high eccentricity
lens will look steeper. When compared to a
spherical lens fluorescein pattern, the pattern can
be interpreted as excessively steep. However,
because the lens is an aspheric with a high
eccentricity, the lens is actually an optimal fit.
Other drawbacks of aspheric lenses are pupil
size, decentration and verification. Large pupil
sizes can induce flare and poor visual acuity.
Smaller pupil sizes are much more successful.
The aspheric distortions increase moving from
the center of the lens out to the periphery. Larger
pupils will have a greater area of distortion. The
distortion will manifest itself as poor visual acuity
and flare under scotopic conditions.39
Another problem is decentration. Because
the lens is aspheric, the lens will naturally position
itself where the corneal apex is located. If the
apex is not perfectly centered, the lens will
decenter. If the lens is not centered, then visual
acuity will suffer. The patient will be sighting
through an area with an increased aspheric
distortion.
Many long-term practitioners do not like
aspherics because of the difficulty in verifying
the parameters in the office. There are really no
simple ways available to identify and measure
aspheric curvatures. Some experts contend that
verification is not necessary anymore. Computercontrolled lathes in use today have extremely
high accuracy. The increasing reliability of the
lens manufacturing process is good enough to
make verification obsolete in the near future.
Concentric designs are another type of bifocal
that uses simultaneous vision. The center portion
Section

can be for either distance or near. Concentric
bifocals have definite distance and near zones.
This differs from aspheric lenses which have
indistinct zones.37 The Acuvue bifocal is a soft
lens with a concentric design with multiple zones.
Alternating or translating bifocals usually have
the best vision for a contact lens bifocal. The
ability to offer an increased add over an aspheric
makes it the preferred choice for later
presbyopes.40 The main drawback is the greater
difficulty in fitting. The Tangent Streak (Firestone
Optics, Kansas City, MO) and Fluoroperm ST
(Paragon Vision Sciences, Mesa, AZ) are both
translating designs. The differences are that the
Tangent Streak is a one-piece, monocentric,
prism ballasted, truncated design resembling an
executive spectacle bifocal. The Fluoroperm ST
is a monocentric, encapsulated segment
resembling a flat top spectacle bifocal. Each
bifocal translates or moves when the patient
looks downward. The patient looks through the
lower add power as the lens moves upward.37 A
key aspect to choosing a translating design is the
lower lid apposition. The lower lid needs to be
located at or just above the limbus. If the lower
lid is below the lower limbus, the lens would be
unable to translate properly. An aspheric bifocal
would be a better choice.
The main problems when fitting translating
bifocals are poor translation and lens rotation.41
When evaluating the lens, special attention needs
to be paid to the movement on downward gaze.
As the patient looks downward, the upper lid
should be lifted to note the lens positioning. The
lens should be displaced upward partially on the
upper conjunctiva. If the lens is still centered on
the cornea on downward gaze, it is not translating
properly. The primary reason for poor lens
performance is lack of an alignment fit. A tight
Rigid lens care systems are necessary for proper

lens maintenance. Care systems commonly
consists of 2 solutions: wetting and soaking and
daily cleaning. The wetting and soaking solution
provides cushioning when applying the lens. The
wetting and soaking solutions also serve to
CARE SYSTEMS
disinfect the lenses and condition the surfaces.

These solutions include Claris Cleaning and
Soaking solution preserved with benzyl alcohol
(Allergan, Irvine, CA), Boston Advance preserved
with PAPB and Boston Original solutions
preserved with chlorhexidine (Bausch & Lomb,
Rochester, NY).44
Taking a cue from soft lens solutions, Boston
Simplicity (Bausch & Lomb, Rochester, NY) is a
multipurpose system for RGP lenses. Wetting and
cleaning are combined into one solution. The
solution contains a betaine surfactant and silicone
glycol wetting agent. It is preserved with
chlorhexidine, EDTA and PAPB.45
Daily cleaning removes debris from the lens
surfaces prior to placing into the wetting and
soaking solution. Opti-Clean (Alcon, Fort Worth,
TX), Opti-Free (Alcon, Fort Worth, TX) and
Boston Advance (Bausch & Lomb, Rochester,
NY) and Boston Cleaner (Bausch & Lomb,
Rochester, NY) are considered to be abrasive
cleaners. The lens should be placed in the palm
of the hands and rubbed with a circular motion
for 15 to 20 seconds on both sides.44
There have been complications reported in
the past with regards to RGP lenses cleaning and
care systems. Some have been related to BAK
(benzalkonium chloride) sensitivities. Patients
experience red, irritated eyes with keratitis and
associated hazy vision. Switching to solutions
without BAK solves the problem.46
Complications related to cleaning include the
morning RGP lens ritual, left lens syndrome
and self-modification. The morning RGP lens
ritual occurs because daily cleaning in the
morning is not as effective as in the evening.
Cleaning in the evening immediately after wear
is better than waiting until the morning. The
deposits and debris are still fresh and easier to
Section
or steep lens would produce little to no

movement that is needed for translation. If the
lens is already aligned, then the cause of poor
translation must be ascertained. If there is
excessive superior lens impingement, reducing
the diameter is necessary.42 If the lower lid is not
catching the lower lens edge, widening the
truncation may help.
Lens rotation will adversely affect vision.
Rotation is usually caused by the lids forces upon
blinking. Many times, the rotation is intermittent
and harder to detect. It is important to have the
patient blink several times while evaluating the
lens. Patients commonly have two types of blink:
hard and soft or flick. The patient should
demonstrate both types of blinks in all fields of
gaze to adequately detect rotation.
If there is rotation, several strategies are
available to solve the problem. If the rotation is
unsteady, then increasing or adding prism will
stabilize the lens. If the rotation is stationary, the
prism axis can be changed to compensate.
Normally, 15 degrees of nasal rotation in prism
ballased RGPs is expected by many experts. A
right lens with 15 degrees of nasal or
encyclorotation would need a prism axis of 105
degrees to compensate. A left lens with the same
rotation (nasal) would need a prism axis of 75
degrees to compensate.37 A change of greater
than 20 degrees of rotation is not recommended.42,43
101
102
loosen up. The morning RGP ritual results in a

faster build-up of deposits on the lens.
Left lens syndrome is when the left
lens has greater deposits than the right
lens. Typically, a patient will clean the first (right)
lens better than the second lens. The right lens
is favored with more careful cleaning because it
is done first. The results are one lens is always
more cleaner and requires less frequent
replacement or polishing than the other lens.
Self-modification comes from overaggressive
cleaning with an abrasive cleaner. The hard
rubbing of the lens on the central OZ can add
minus to the lens. Changing to gentle cleaning
with the pinkie finger can help remedy this
problem.47
Bitorics are the most commonly used designs

for astigmatism. Bitorics can be fit empirically or
with a diagnostic set. Spherical power effect
(SPE) and cylindrical power effect (CPE) are two
types of bitorics.
Bitorics can be designed empirically by
defining the fit factor of the lens. A fit factor is
needed to allow tear exchange. A toric lens fitted
without a fit factor is called a saddle fit.67 A saddle
fit employs full alignment of the principal corneal
meridians, an on-K fit of each principal
meridian. Adding a fit factor allows for mild
clearance or undercorrection in the steeper
corneal meridian. Another term for this design
is low toric simulation.67 Mandell-Moore guide
describes the fit factor as depicted in Table 8.1.66
Table 8.1: Fit factor
Section
FITTING TORIC CORNEAS
Spherical lenses usually work for corneas up to

1.50 to 2.00 D of toricity. Greater amounts of
toricity indicate a lens with a toric base curve.
There are many combinations of toric lenses:
toric back surface, toric front surface and bitorics.
Toric back surface lenses or base curve torics work
best when the residual overrefraction cylinder is
more than 0.75 D and at or near the same axis
as the corneal toricity. The amount of residual
cylinder is about 50 percent of the corneal toricity.
Many experts do not fit back surface torics and
use a bitoric instead. Toric front surface lenses
work best for spherical corneas and residual
astigmatism of 1 D or more. The lenses are
normally prism-ballasted to maintain proper
orientation. Front surface torics are rarely used.
Soft torics are used in their place since a soft
toric behaves optically like a front surface toric.
A front surface toric is used when a soft toric is
not feasible.
Corneal cyl
Flat meridian
Steep meridian
2.0
2.5
3.0
3.5
4.0
5.0
on K
0.25 D
0.25 D
0.25 D
0.25 D
0.25 D
0.50
0.50
0.75
0.75
1.00
1.25
D
D
D
D
D
D
flatter
flatter
flatter
flatter
flatter
flatter
D flatter
D flatter
D flatter
D flatter
D flatter
The fit factor is added to each meridian of

the K readings to determine the base curve. The
power of each meridian, when vertexed, is also
compensated to give the powers of the lens.
Bitorics utilizing a low toric simulation for the
back surface are the most commonly prescribed.
Example:
A patient with K readings of 42.00 180/
46.00 90 (corneal toricity 4 D) and a spectacle
Rx of 2.00 = 4.50 180 (at corneal plane)
and is now fitted with a low toric simulation
design. Accounting for the fit factor, the toric
base curve radius is 41.75/45.00

Determine the final toric lens powers:
Step 1:
46.00
45.00
1.00
|
|
|
(180) + 42.00 + 41.75 + 0.25
|
|
|
(90)
K
Ordered BC
Lacrimal Lens
Step 2:
6.50
+ 1.00
5.50
|
|
|
(180) + 2.00 + +0.25 + 1.75
|
|
|
(90)
Spectacle Rx Lacrimal Lens
Final CL Rx
(vertex adjusted) Compensation
Final air powers to order

3.00 (flat)/6.00 (steep)
Or, Rx: 3.00
= 3.00 flat meridian.67
If acuity is poor with a spherical overrefraction, then residual astigmatism exists. A
CPE bitoric will be needed. A spherocylindrical
overrefraction is performed. If the axes are at or
near the principal corneal meridians, the
appropriate power is added to the power of the
corresponding meridian in the diagnostic lens.67
Example
Diagnostic SPE
42.00 45.00 Toric
base
Diagnostic SPE
Plano/3.00 Air powers
Over-refraction
1.00 = 1.25 180
Observing the rules of prescription power
meridians, we add 1.00 D to the 180 th
meridian, and we add 2.25 D to the 90th
meridian giving a CPE bitoric.67
Final air powers to order:
1.00 (flat)/5.25 (steep)
Or, Rx: 1.00 = 4.25 flat meridian 67
Section
The final toric lens Rx may be written as

1.75 flat meridian (180) and 5.50 steep
meridian. It can also be given in spectacle Rx
form: 1.75 = 3.75 180. Another acceptable
notation is: 1.75 = 3.75 flat meridian.67
Spherical peripheral curves are recommended when corneal toricity is less than 3 D. If the
corneal toricity exceeds 3 D, then a toric
peripheral curve system is recommended.67
The other types of bitorics are SPE and CPE.
The SPE has a toric base curve, that is neutralized
by an equal but opposite plus cylinder generated
on the front surface. The axis is made co-incident
with the axis of the flatter meridian of the toric
lens. An optically spherical system is created.
An SPE bitoric is ideal because the toric base
curve gives a good fit and allows for excellent
visual acuity inherent with optically spherical
system for this patient.
A diagnostic SPE bitoric is placed on the eye
and a spherical overrefraction is performed. If
visual acuity is good, the overrefraction is added
to each meridian.
Example
Diagnostic SPE 42.00 45.00 Toric base
Diagnostic SPE Plano/3.00 Air powers
Overrefraction: 3.00 D (add to each
meridian)
103
FITTING KERATOCONUS
Fitting keratoconus has always been challenging
to contact lens fitters. Unfortunately, no one
design works for all keratoconics. Corneal
topography is an essential aid for fitting. Position
of the apex and the basic surface patterns can
be determined for the particular cornea. Vision
should be improved with contact lenses over
spectacle best corrected visual acuity (BCVA).
However, it may not improve to 20/20.
In the past, three topographical keratoconic patterns have been traditionally
identified. They are: nipple cone (the
steepest dioptric value is smaller in shape
and somewhat central in location), oval or
104
sagging cone (the steepest dioptric portion

of the cone is larger, inferior and
decentered somewhat nasally) and combination (the majority of the cornea is
thinned and steep in its dioptric values).
With the advent of the topographer, many variations are now seen. Sometimes it can be difficult
to decide exactly what the cone should be
described as. No one keratoconic eye is exactly
the same.
RGPs are the first choice in fitting
keratoconus because of the superior optics.
The ideal fitting relationship is to evenly
distribute the lens weight over the cornea.
For the keratoconic cornea, a light
kissing touch over the cone is preferred
rather than apical bearing.
Keratoconic fitting sets commonly include
multicurves with specific parameters. One rule
of thumb is to make the base curve
approximately equal to the optic zone. The
peripheral system should be progressively flatter
to align the cornea as best as possible.
The Soper Cone (circa.1970s) is a bicurve
contact lens with two posterior curves. The
curvature of the central posterior curve (base
curve) steepens as the diameter increases and
subsequently increases the vaulting effect of the
lens. The peripheral curve is a standard 7.50
mm unless the central base curve is flatter than
6.49. Then the peripheral curve is 7.85.
Intermediate curves can be added by standard
techniques, if needed. The trial set consists of
10 lenses, named by the letters: A-H. Three
groups of a given diameter/optic zone
relationship are offered.
The McGuire keratoconic lens system,
introduced in 1978, is a modification of Sopers
design with a series of four peripheral curves.
Section

The peripheral system is well blended to create
an aspheric-like lens. There are three groups:
nipple cone (D/OZ 8.1/5.5), the oval cone (D/
OZ 8.6/6.0) and the globus cone (D/OZ 9.1/
6.5).
KAS by GBF Contact Lens Inc, of Virginia
Beach, VA is a true aspheric lens. It has a
paraboloidal ocular surface geometry with a
spherical front surface. The periphery is
considered to be hyperboloidal. Diameters can
range from 7.5 to 10.0 mm and furnishes up to
a +2.25 add.
The ComfortKone, Infinity Cone and Valley
K are spherical OZ with aspheric peripheries.
Visual acuity is usually many times sharper and
more stable than other types of keratoconus
lenses. ComfortKoneTM by Metro Optics of
Austin, TX has a 4.0 mm spherical optic zone
and flattens into the aspheric A curve, which is
considered the fitting curve. The greater the A
value, the greater will be the change from the
base curve to the peripheral fitting curve. The
diameter is either 8.5 or 9.0. There is a choice
of base curves of several A values: 5, 10, 15,
or 20. One can specify any A curve from 3
to 20.
Infinity Cone by Infinity Optical Inc fits on
the sagittal value principle with larger diameters
(9.0, 9.5, 10.0, and 10.5 mm). The optic zone
is usually 1.5 mm smaller than the diameter. The
periphery of the lens sits on the peripheral area
of the cornea as far away from the ectastic area
as practical. There is a standard aspheric
peripheral system of a proprietary nature. The
fitter has the option to vary the base curve,
diameter and/or peripheral system to maximize
the fit.
Valley K by Valley Contax of Springfield, OR
is modeled after the McGuire lens. The peripheral
mm can have a second base curve of 0.4 mm,

0.5 mm or greater. Lens diameter and optic zone
can vary.
For special cases, Menicon of Clovis, CA
makes a keratoconic lens that has a decentered
optic zone. The best candidates are those with
decentered apices below the midline of the
cornea. The lens has a prism and it increases as
the base curve steepens and more minus power
is needed. The initial base curve chosen is around
the topographic ring that corresponds to the base
of the cone. The OZ should be about 1mm
larger than the cone and should be fairly close
to the base curve. Now Menicon has suspended
business in the United States market.48
One fitting method is to identify the cone by
topography and select the appropriate lens.
Once the shape and location of the cone is noted,
an initial lens design and lens needs to be
selected. A suggested initial lens selection for
specialty design selection is as follows.
Nipple type cones are smaller, steeper and
more centrally located. Spherical OZ with an
aspheric periphery, the Rose K or possibly an
aspheric design are good choices for an initial
lens. Centration is usually good since lenses tend
to center over the steepest part of the cornea.
However, the limitation of these designs is usually
not the final fluorescein patterns, but vision.
Smaller diameter or optic zone combinations
may not be large enough to maintain sharp,
stable vision. If this occurs, a larger OZ is needed.
The Infinity lens with its larger diameter or optic
zone might be an ideal choice in this situation.
The Nicone lens is also a good lens of choice if a
larger optical zone is needed.
Oval sagging cones are more difficult to fit.
Because the contact lens will center over the
steepest part of the cornea, the lens will usually
Section
system is actually aspheric and not 4 blended

spherical peripheral curves. The peripheral
system can be made flatter or steeper for a given
base curve. The optic zone is standard at 5.0
mm with a 9.0 mm for the flatter base curves
and 8.5 mm for the steeper base curves.48
In recent years, keratoconus custom designs
have appeared. One of the most popular of these
types of lenses is the Rose K (Lens Dynamics,
Lakewood, CO). The Rose K contains computergenerated peripheral curve systems resulting
from several hundred fittings by Paul Rose. The
lens has a standard peripheral system that can
be ordered in flatter or steeper combinations.
These combinations are available 1.0, 1.5, 2.0,
2.5 and 3.0 flatter and 0.5 and 1.0 steeper than
the standard peripheral curve system. The optic
zone decreases as the base curve steepens. Toric
curves are available on both the front and rear
surface and as well as peripherally.
Another lens, the NiCone Lens, is available
from Lancaster Contact Lens, Inc of Lancaster,
PA. The NiCone has multiple back surface
vaulting system designed with proprietary
scientific formulas. The lens has three base
curves and a peripheral curve of 12.25 mm.
There are three fitting sets (the #1 cone for mild
keratoconus, #2 cone for the average cone and
# 3 cone for advanced keratoconus). These are
designations of curvatures between the numbers
1, 2 and 3 base curves, depending on the
selection of the primary base curve. Each time
the central posterior radius is changed, regardless
of whether it is a number 1, 2, or 3 cone, all of
the formulas of the second and third base curves
change as well. The second base curve is a 0.3
mm transitional zone between the ectactic and
normal areas of the cornea for lens diameters
up to 10.5 mm. A diameter larger than 10.5
105
106
end up positioned inferiorly. Vision can be

compromised if a smaller lens and optic zone is
used. Larger lenses with larger optic zones are
usually more successful if decentration is a
problem. Another alternative is to attempt to fit
over the more normal superior cornea and use
lid attachment. Unfortunately, lid attached lenses
usually fit flatter and excessive pressure on the
cone can be harmful.
For displaced cones, Menicons decentered
optic zone works well. Even though the visual
axis is through the secondary curve, acuity can
be, at time, exceptionally good. The Nicone
design can also work well with a sagging cone
when designed with a larger optic zone. The
larger diameter Infinity lenses can also be
successful with these larger sagging cones due
to the larger optic zone.
Combination or large cones are difficult to
fit. Initial recommended lenses are Infinity Cone
or Nicone.48
If the fitting system has variable OZ diameters
(such as the Infinity Cone or Nicone), diameters
can be increased while maintaining the base
curve. The Rose K decreases the optic zone as
the base curve steepens so you may have to
make changes of larger increments to accomplish
what you want.
To find the proper base curve, one method
is to continue to steepen the base curve until
there is apical clearance and then work
backwards.49 A light feather or kissing touch is
the goal. Sometimes, a steeper lens will not work
and the optic zone diameter may need to be
altered. A design switch may also help.
Air-bubbles are commonly seen and are
usually located in the pooling around the base
of the cone despite a good base curve-cone
relationship. The best way to eliminate bubbles
Section

is decreasing the optic zone. To maintain the
same sagittal depth and fluorescein pattern, the
base curve should be steepened. However, the
smaller optic zone may interfere with the visual
acuity.
Paracentral or midperipheral areas should be
fitted for alignment. Unfortunately, a fitter should
be prepared for disappointment. There are
corneas that no matter how the curves are
altered, the ideal alignment pattern never
appears. Keep in mind, that heavy bearing that
allows for seal off should never be accepted.
Tears need to be exchanged for a healthy fit.
The peripheral area of the lens can be viewed
by looking at the amount of edge lift. There
needs to be enough tear pumping under the
lens but not a great amount to cause patient
discomfort. Too little edge lift will predispose the
patient to peripheral corneal desiccation as well
as not allow good tear exchange.
Patients need to be followed up at least two
times a year even if it seems they are doing well.
Remind them that keratoconus is a progressive
ectasia and an acceptable fit can easily change.
FITTING PENETRATING
KERATOPLASTY
There are several reasons why a postpenetrating
keratoplasty patient needs a contact lens correction. The major reason is an irregular surface
or high corneal astigmatism as a result of the
surgery. Anisometropia is another reason.
Approximately 20 percent of patients who
undergo a penetrating keratoplasty will benefit
from a contact lens correction.
RGP lenses are the optimal choice. If
RGPs are not viable, soft lenses, piggyback
fits (soft lenses in combination with a rigid
larger in diameter and flatter in base curve. The

periphery of the lens should rest on the
peripheral area of the cornea as far away from
the surgery as possible. The spherical optic zone
is 1.5 mm smaller than the diameter of the lens.
The aspheric peripheral curve system has three
edge lift values available.
Reverse geometry designs can also be useful.
The secondary curve is steeper than the base
curve of a lens creating a plateau shape. Some
of the US proprietary designs are: The PK Bridge,
NRK, OK series and Plateau Lens.
The PK Bridge by Conforma Labs of Norfolk,
VA has a secondary curve that is a reverse
aspheric surface. It progresses from the center
towards the paraperipheral region. The amount
of steepening is about 3 D. The peripheral curve
has an aspheric flattening. The downside of this
lens is that it induces some cylinder when verified
on radioscope and lensometer.
The NRK by Lancaster Contact Lens of
Lancaster, PA is a patented design that is steeper
in the periphery than the central base curve.
Diameters are 10.0 mm or larger with an 8.0mm optic zone.
The OK series by Contex of Sherman Oaks,
CA offers many reverse geometry designs. The
second steeper curve is designated by the name
on the lens.
OK-3 is 3 diopters steeper than the base
curve,
curve,
curve, etc.
The secondary steeper curve can be spherical
or aspherical. The peripheral curve is aspheric.
Larger diameters are recommended. A good
starting point is a 10.2 mm diameter, and an
8.0-mm optic zone, with the OK-3 design.
Section
corneal lens), scleral RGPs and hybrid

lenses are other alternatives.
Topographic maps can help to determine the
shape factor. Several surface patterns can be
found following a graft. Regular astigmatism can
be seen as both a prolate shape (steeper centrally and flattening peripherally), oblate pattern
(flatter centrally and steepening peripherally) or
combination butterfly pattern of a mixed prolate
oblate within the donor cornea. Asymmetric
astigmatism can result from uneven suturing or
healing. It is seen 2 steep semimeridians are not
aligned along a single meridian. The topographic
pattern can be also seen as a steep red area on
one side which becoming progressively flatter
toward the other side (steep to flat). Finally, every
once in a while a cornea gives a similar
appearance to that of a keratoconic pattern.
There is inferior steepening with a more normal
appearance superiorly.
Larger diameters usually work better for
fitting the graft. Standard lens designs as well as
aspheric, biaspheric lenses (the Boston Envision)
and bitoric lenses should all be considered. Two
US companies make lens designs specifically for
penetrating keratoplasties: The post-PK and The
PSC (Post Surgical Cornea).
The Post PK by Lens Dynamics of Lakewood,
CO consists of two basic designs. Both designs
have a 10.4 diameter. One has a 9.0-mm-fixed
optic zone, the other has a floating optic zone.
The OZ decreases as base curve steepens. There
are proprietary sets of peripheral curves that
flatten outwardly from the BC to fit the outer
portion of the host cornea as if prior to surgery.
The PSC (Post Surgical Cornea) is a lens by
Infinity Optical fits on the sagittal value principle.
It has the same basic concept as their keratoconic
lenses. The difference is that these lenses are
107
108
Section
The Plateau Lens by Menicon USA of Clovis,

CA is a proprietary design consisting of a
spherical base curve, and a secondary curve
steeper than the BC. The secondary curve is
usually around 3 diopters but can be as high as
7 diopters. All parameters can be designated by
the fitter, however the standard lens has a 10.0
mm/8.0 mm (D/OZ) and a secondary curve that
will be 3 diopters steeper than the designated
base curve.
Type of graft topography can be used to
determine initial lens selection. Tripoli et al has
designated different topographies after the
sutures are removed.51
Prolate pattern has a steeper central area and
a flatter periphery seen in 31 percent of the
corneas (Figure 8.13) The donor cornea is
protruding. A large diameter sphere, aspheric,
or biaspheric (the Boston Envision) lens would
be a good initial choice. Depending on the
amount of toricity, a toric base or bitoric lens
FIGURE 8.13: Prolate pattern
FIGURE 8.14: An example of an oblate pattern
would be a reasonable choice.

Oblate pattern is plateau shaped seen in 31
percent of the corneas (Figure 8.14). The flatter
donor cornea is surrounded by steeper host
cornea. A reverse geometry is ideal for this type
of pattern. Depending on the amount of
astigmatism present a toric basic curve or bitoric
reverse geometry design might allow for better
weight distribution. On occasion, a standard
design (spherical, aspheric or toric) might be
successful if there is good lid attachment, but
usually there is too much edge lift and central
bearing.
Mixed prolate oblate pattern has a steep side
and a flat side of the cornea (Figure 8.15). There
is a roughly symmetrical astigmatism present
seen in 18 percent of the corneas. A toric base
curve or bitoric design proves to be the most
successful in these cases.
Asymmetric astigmatism is a combination of
all patterns (Figure 8.16) The cornea looks
irregular and distorted and is seen in 9 percent
of the corneas. Large biaspheric (Boston
Envision) or standard design works well for these
FIGURE 8.15: This is a mixed prolate oblate topography
109
FIGURE 8.17: Steep to flat pattern
Section
symmetrical astigmatism seen in 13 percent of

the corneas. This is the most difficult pattern to
fit because the lenses are easily ejected from the
eye. The lens wants to center over the steepest
part of the cornea and often leads to a
decentered lens onto the sclera. Large diameters
are needed so the optic zone will cross the visual
axis. One could start with a large spherical,
aspheric or biaspheric (Boston Envision) design.
Good lid attachment is needed for stabilization.
The PSC or Post-PK might be another optimal
choice.
Keratoconic type of topography is when the
cornea protrudes a great amount and a keratoconic pattern appears (Figure 8.18). A keratoconic design could be a good starting point.
Another alternative is a large, high riding lens.
When evaluating the fit, remember to
observe the center of the graft. If there is too
much bearing, an attempt should be made to
vault the area more. Sometimes, toricity may
be present and a toric base curve is indicated.
An air-bubble present would suggest too much
FIGURE 8.16: Asymmetric astigmatism
patterns. On occasion, a bitoric design will

distribute the weight of the lens more
appropriately. The Post-PK or PSC designs might
be a good choice in these situations.
Steep to flat topography is steep on one side
and flat on the other side (Figure 8.17). It is like
a mixed prolate oblate pattern without the
110
FIGURE 8.18: An example of a keratoconus

type of topography is shown
Section
vaulting and a steep pattern. The paracentral or

midperipheral area of the lens usually directly
relates to the graft host junction. This area needs
to be aligned as best as possible. Many times it is
difficult to accomplish this goal. The periphery
of the lens should provide adequate edge lift to
promote good tear exchange. In some cases,
excessive lift can result due to a sharp junction
where the host and donor corneas meet.
There are times when an acceptable fit may
not be possible. One can follow all of the normal
fitting protocols and rules of rigid contact lenses
and have all lenses ejected out of the eye. For
these cases, keeping any lens on the eye is a
success. Attempting to fit a lens that rides high
attached to the eyelid usually yields the best
success. The alternative after this is piggyback,
scleral lenses, hybrids, etc.
FITTING POSTREFRACTIVE
SURGERY
The majority of patients presenting for contact
lens correction after refractive surgery are
commonly those that have had radial keratotomy

(RK) when it was popularized in the early 1980s.
Many of these patients, most of which are now
presbyopic. They are symptomatic from the
overcorrections and hyperopic drifts since their
original procedure. Ten years after the prospective evaluation of radial keratotomy (PERK)
study, 58 percent of PERK study patients felt
some type of optical correction was still required;
23 percent of patients had overcorrections or
induced hyperopia greater than 1 D, and 17
percent had undercorrections or residual myopia
greater than 1 D.52
Now that excimer laser is used in most
refractive procedures, fewer photorefractive keratotomy (PRK) and LASIK patients
proceed to contact lens fitting compared
to RK because of greater predictability and
accuracy. However, over and undercorrections still exist.53
Rigid gas-permeable lenses are preferred for irregular astigmatism following
refractive surgery. RGP lenses have been
safely fit 8 to 12 weeks after surgery. For
LASIK, most surgeons agree that the
integrity of the flap after 3 months is
sufficient to withstand the minor trauma
and movement of an RGP lens. By three
months, refraction and corneal thickness
changes stabilize.54-56
The postoperative oblate corneal shape
makes RGP fitting difficult. This is one of the
most difficult corneal contours to fit with standard
RGP designs and fitting techniques. Although
standard RGP designs are often used successfully,
new fitting guidelines are required. Traditional
RGP fitting nomograms are originally designed
for prolate corneal contours. The nomograms
are not appropriate for lens base curve or optical
preoperative RGP lens performance . This is due

to the increased negative pressure created by
the steep central tear layer.57
Initial RGP base curve selection for standard
lens designs varies depending on the method of
corneal curvature assessmentpreoperative
keratometry, postoperative keratometry, or
postoperative corneal topography. Some fitters
advocate the use of standard RGP designs after
excimer laser procedures instead of reverse
geometry lenses (described below) designed for
oblate corneal shapes. Preoperative keratometry
or K readings from the unoperated eye can
be reasonable predictors of initial diagnostic lens
base curves after PRK or LASIK. If using
presurgical keratometry, the initial trial base curve
selected should be 0.5 to 1.0 D flatter than flat
K to account for the flattened central cornea.58
The base curve can be adjusted. It can be
steepened if the fit is too flat with excessive
peripheral lift off, or flattened if the lens fits too
steep with excessive peripheral impingement and
central pooling.53
Sometimes, only postoperative keratometry
readings are available. One study reported that
fitting based on flat postoperative keratometry
readings was acceptable after refractive surgery
such as RK, although most of the final base curves
were ultimately steeper than the postoperative
flat K when the fitting was completed.59
Therefore, the initial lens chosen should be, at
minimum, 1.0 to 1.5 D steeper than the flat K
postoperatively. This lens fit can be refined to
achieve the goal of midperipheral corneal
alignment and central pooling.53
Section
zone selection postrefractive surgery. The tear

lens is also altered due to lacrimal lens formation
above the ablation zone and lens power
calculations may need to be modified. Trial lens
fitting is mandatory and needed to determine
lens power, base curve, and optical zone
diameters.
Rigid gas-permeable lenses can be fitted with
either lid attachment, or interpalpebral fit. Lens
movement will vary with the fitting approach
a lid attachment fit may move <1 mm with each
blink while an interpalpebral centered fit may
move more. Centrally, the contact lens vaults
the flatter corneal surgical zone resulting in fluorescein pooling and a plus powered tear lens.
This plus powered tear layer must be compensated for by adding additional minus power in
the RGP lens, ironically resulting in a lens power
which approaches the patients preoperative
sphere power. The lens usually rests paracentrally
on the highest point of elevation which is the
knee or bend in the corneal contour surrounding the flattened ablation zone. This transitional
area is referred to as the inflection zone or point.
There should be minimal fluorescein accumulation over the inflection zones, with a 1 to 2
mm wide band of midperipheral bearing. As
with keratoconus, peripheral edge lift should be
sufficient to prevent peripheral adherence and
seal off. A standard 0.12 mm axial edge lift can
be used.53
Since the peripheral cornea is essentially
unchanged after LASIK (as well as PRK), RGP
lens fitting is simplified compared to the post RK
patient. After RK, asymmetric steepening
surrounding the flatter optical zone may affect
lens centration, which is not usually encountered
after LASIK. Often, there is improved RGP
centration after LASIK compared to a patients
111
REVERSE GEOMETRY LENSES

Since many postsurgical oblate corneas are often
difficult to fit with standard RGP contact lenses,
112
reverse geometry lens (RGL) designs have

become popular. Reverse geometry lenses
incorporate secondary curvatures usually
3 to 6 D steeper than their central
curvatures, but peripheral curves have been
fitted up to 15 D steeper than the central
posterior curve in some postsurgical
settings. Reverse geometry lenses also assist in
lens centration after RK or penetrating keratoplasty (PK), because isolated steep areas
surrounding the RK optical zone or the corneal
graft can cause RGP decentration over the
steepest hemimeridian of the cornea. Although
RGP decentration is usually not a problem after
PRK, automated lamellar keratoplasty (ALK), or
LASIK, RGL fitting still achieves better alignment
along the central and midperipheral cornea.
Several RGL designs have been developed in
the US, some of which were originally advocated for orthokeratology, and include: Plateau
(Menicon USA, Ltd, Clovis, CA), OK Series
(Contex Inc, Sherman Oaks, CA), RK-Bridge
(Conforma, Norfolk, VA), and the NRK lens
(Lancaster Contact Lens, Inc, Lancaster, PA).
Select the initial base curve approximately 1
D steeper than the postoperative simulated flat
K to allow for a moderate tear layer over the
flatter optical zone. Occasionally, the base curve
is up to 3 D steeper than the simulated flat K
to allow for a smooth tear layer if significant irregularities, astigmatism, or central islands persist
over the ablation zone. Some manufacturers
recommend that the base curve can be selected
1 D steeper than average keratometry reading
if greater than 2 D of corneal astigmatism
persists.63 To achieve midperipheral alignment,
begin by measuring the average midperipheral
curvature at the knee of the transition zone on
the axial topography map. The interactive cursor
Section

on topography instruments can be moved to
different quadrants on the bend of the surgical
optical zone. Next, calculate the average dioptric
change from the center of the map to the
transitions. Select a steeper RGL secondary curve
in an amount equal to or up to one-third flatter
than the average change noted on the axial
topography map across the transition zone . For
example, if the topographic steepening is 3 D, a
secondary curve 2 to 3 D steeper than the base
curve can be ordered in the RGL.
Diameters selected are often larger lenses
than typically used for normal eyes. Common
diameters range from 9.2 to 10.5 mm, with
optical zones ranging 1 to 4 mm smaller than
the overall diameter, depending on the surgical
optical zone and lens design.
The choice of which RGP design to use after
LASIK, PRK, or ALK depends on a combination
of fitter preferences, the corneal contour, patient
comfort, and previous RGP lens performance.
There may not be one correct design selection,
and often many designs are physiologically and
visually acceptable.
Standard RGP designs with traditional flatter
secondary and peripheral curve systems work
well on symmetrical corneas, with no isolated
areas of abrupt corneal contour changes
surrounding the flap or surgical optical zone. This
occurs most often in uncomplicated LASIK or
PRK and the patient is seeking contact lens
correction for residual, regular undercorrection
or overcorrection.
Standard lens designs also work well on eyes
which had higher than average preoperative
corneal eccentricity (e > 0.55). The average
cornea has an eccentricity of approximately e =
0.55. On an eye with rapid peripheral flattening
(e.g. e = 0.75), the secondary and peripheral
1. Hom MM (Ed): Rigid lens design and fitting. Manual

of Contact Lens Prescribing and Fitting (2nd ed),
Butterworth-Heinemann: 1997;77-103.
2. Bennett ES: How to present rigid lenses more
effectively. Rev Optom 131 (Suppl): 1994;8A-10A.
3. Grosvenor T, Perrigan D, Perrigan J et al: Rigid gaspermeable contact lenses for myopia controleffects
of discontinuance of lens wear. Optom Vis Sci
1991;68(5): 385-89.
4. Hansen DW: Bifocal RGP lenses for progressive
myopia. Contact Lens Spectrum 11997;1(10): 15.
5. Grohe RM, Bennett ES: Problem solving. In Bennett
ES, Weissman BA (Eds): Clinical Contact Lens
Practice Lippincott: Philadelphia 1991;29: 1-6.
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7. Moore CF: Eliminating persistent refitting problems.
CL Forum 1986;11(2): 21-26.
8. Rengstorff RH: Corneal rehabilitation. In Bennett ES,
Weissman BA (Eds): Clinical Contact Lens Practice
Lippincott: Philadelphia 1991;48: 1-10.
9. Moore JW: Researchers turn to RGP materials,
complications. CL Forum 1987;12(12): 60-62.
10. White P: RGP material and immaterial cliches. CL
Spectrum 1988;3(11): 63-65.
11. Caroline PJ, Ellis EJ: Review of the mechanisms of
oxygen transport through rigid gas-permeable lenses.
Int Eyecare 1986;2(4): 210-13.
12. Grohe RM, Caroline PJ: Surface deposits on contact
lenses. In Bennett ES, Weissman BA (Eds): Clinical
Contact Lens Practice Lippincott: Philadelphia
1992;24: 1-12.
13. Weinschenk JI: A look at the components in fluorosilicone acylates. CL Spectrum 1989;4(10): 61-64.
14. Benjamin WJ: Pellicle, biofilm, mucin layer, surface
coating, or contact lens camouflage. ICLC 1989;16:
183-84.
15. Ames KS: The surface characteristics of RGP lenses.
CL Spectrum 1991;6(6): 45-48.
16. Bennett ES: How important are diagnostic lenses in
RGP fitting? CL Spectrum 1993;8(12): 19.
17. Bennett ES: Basic fitting. In Bennett ES, Weissman
BA (Eds): Clinical Contact Lens Practice Lippincott:
Philadelphia 1991;23: 1-22.
18. Bennett ES: Lens design, fitting, and troubleshooting.
In Bennett ES, Grohe RM (Eds): Rigid Gas Permeable
Contact Lenses Professional Press: New York
1986;189-224.
19. Bennett ES: Master the art of rigid lens design. Rev
Optom 1994;131(Suppl): 11A-14A.
20. Korb DR, Korb JE: A new concept in contact lens
design-parts I and II. J Am Optom Assoc
1970;41(12): 1023-32.
21. Collins M, Heron H, Larsen R et al: Blinking patterns
in soft contact lens wearers can be altered with
training. Am J Optom Physio Optics 1987;64: 10003.
22. Williams E: New design concepts for permeable
rigid contact lenses. J Am Optom Assoc 1979;50(3):
331-36.
23. Rouault CE, Sagan W: Effects of base curve and
diameter changes on the cornea with RGP lenses. CL
Spectrum 1988;3(11): 87-90.
24. Caroline PJ, Norman CW: A blueprint for rigid lens
design: Part 1. CL Spectrum 3(11): 39-49, 1988.
Section
curve systems of a standard RGP design may be

sufficient to allow satisfactory midperipheral
corneal alignment. Conversely, on an eye with
a low preoperative corneal eccentricity (e.g. e
= 0.3), a large disparity may exist between the
peripheral corneal and RGP curvatures if the
lens has been fit appropriately to the central
cornea. Therefore, eyes with low preoperative
corneal eccentricities often deserve a RGL design
for best performance. Reverse geometry designs
also work best on corneas with abrupt contour
changes surrounding the surgical optical zone.
Standard spherical lenses may decenter.
Some experts do not use aspheric designs
on oblate corneal shapes, although the successful
use of a low eccentricity lens design (Boston
Envision) after PRK has been reported in the
literature.64 High-eccentricity RGP lens designs
flatten excessively in the lens periphery, and are
counterproductive to achieving better midperipheral corneal alignment on oblate corneal
shapes. Additionally, if an aspheric lens decenters, visual acuity can be compromised from
unanticipated power changes positioned over
the entrance pupil.
113
114
25. Caroline PJ, Norman CW: A blueprint for rigid lens

designdiagnostic lens fitting and fluorescein pattern
interpretation: Part III. CL Spectrum 1992;7(1): 3339.
26. Mandell RB: Fitting methods and philosophies. In
Mandell RB (Ed): Contact Lens Practice Thomas:
Springfield 1988;203-42.
27. Bruce AB: RGP lens fitting and eyelid geometry. In
Hom MM (Ed): Manual of Contact Lens Prescribing
and Fitting (2nd ed), Butterworth-Heinemann:
Boston 2000.
28. Bennett ES: Basic fitting. In Bennett ES, Weissman
BA (Eds): Clinical Contact Lens Practice Lippincott:
29. Schwartz CA: 10 worst fitting problems and how to
solve them. CL Forum 1988;13(8): 32-37.
30. Sobara L, Fonn D, Holden BA et al: Centrally fitted
versus upper lid attachment rigid gas-permeable
lenses: Part 1design parameters affecting vertical
decentration. ICLC 1996;23: 99-103.
31. Picciano S, Andrasko G: Which factors influence
RGP lens comfort? CL Spectrum 1989;4(5): 31-33.
32. Ames KS, Schnider CM: Rigid gas-permeable lens
design, fitting and problem solving. In Bennett ES
(Ed): Contact Lens Problem Solving CV Mosby: St.
Louis 1995;1-17.
33. Hom MM, Bruce AB, Watanabe R: RGP fluorescein
patterns. In Hom MM (Ed): Manual of Contact Lens
Prescribing and Fitting (2nd ed), ButterworthHeinemann: Boston 2000.
34. Hom MM (Ed): Fluorescein patterns. Manual of
Contact Lens Prescribing and Fitting (2nd ed),
Butterworth-Heinemann: Boston 2000.
35. Young G: Fluorescein in rigid lens fit evaluation.
ICLC 1988;15: 95-100.
36. Pardhan S, Gilchrist J: The effect of monocular
defocus on binocular contrast sensitivity. Ophthal
Physio Opt 1990;10(1): 33-36.
37. Hom MM (Ed): Monovision and bifocals. Manual of
Contact Lens Prescribing and Fitting (2nd ed),
Butterworth-Heinemann: Boston 2000.
38. Ames K: Aspheric rigid gas-permeable lenses. In
Schwartz CA (Ed): Specialty Contact Lenses: A
fitters Guide Saunders: Philadelphia 1996;49-57.
39. Hansen DW: For more natural vision try aspheric
RGP multifocals. CL Spectrum 1995;10(6): 15.
40. Weiner B: Dispelling the myths of multifocals. CL
Spectrum 1993;8(10): 22-29.
41. Mandell RB (Ed): Presbyopia. Contact Lens Practice
Thomas: Springfield, 1988;785-823.
42. Bridgewater BA: The fluoroperm ST bifocal. CL
Spectrum 1992;7(5): 24-31.
43. McLaughlin R: How to stabilize a rotated bifocal
lens. CL Spectrum 1993;8(12): 15.
Section

44. Bennett ES, Grohe RM, Snyder C: Lens care and
patient education. In Bennett ES, Weissman BA
(Eds): Clinical Contact Lens Practice Lippincott:
45. One bottle RGP regimen debuts. CL Spectrum 1995;
10(10): 5.
46. Sterling JL, Hecht AS: BAK-induced chemical
keratitis? CL Spectrum 1988; 3(3): 62-65.
47. Hom MM (Ed): Rigid gas permeable lens care and
patient education. Manual of Contact Lens
Prescribing and Fitting (2nd ed) ButterworthHeinemann: Boston 2000.
48. Cutler SI: Newer designs for Keratoconus. In Hom
MM (Ed): Manual of Contact Lens Prescribing and
Fitting (2nd ed), Butterworth-Heinemann: Boston
2000.
49. Edrington TB: Contact lens management of
keratoconus. In Schwartz CA (Ed): Specialty Contact
Lenses: A Fitters Guide. Saunders: Philadelphia
1996;142-51.
50. Caroline PJ, McGuire JR, Doughman DJ: Preliminary
report on a new contact lens design for keratoconus.
Contact Intraocul Lens Med J 1978;4: 69-73.
51. Tripoli NK, Ibrahim OS, Coggins JM et al: Quantitative and qualitative topography classification of
clear penetrating keratoplasties. Invest Ophthal Vis
Sci 1990;30 (Suppl): 480.
52. Waring III GO, Lynn MJ, McDonnell PJ et al: Results
of the prospective evaluation of radial keratotomy
(PERK) study 10 years after surgery. Arch
Ophthalmol 1994;112: 1298-1308.
53. Szczotka LB: Contact lenses following LASIK. In
Hom MM, Szczotka LB: LASIK: Clinical Comanagement Butterworth-Heinemann: Boston 2000.
54. Perez-Santonja JJ, Bellot J, Claramonte P et al: Laser
in situ keratomileusis to correct high myopia.
J Cataract Refract Surg 1997;23: 372-85.
55. Pallilkaris I, Siganos D: Laser in situ keratomileusis
to treat myopia: Early experience. J Cataract Refract
Surg 1997;23: 39-49.
56. Wang Z, Chen J, Yang B: Comparison of Laser in situ
Keratomileusis and Photorefractive Keratectomy to
Correct Myopia from 1.25 to 6.00 Diopters. J
Refract Surg 1997;13: 528-34.
57. Shipper I, Businger U, Psarrer R: Fitting contact
lenses after excimer laser photorefractive keratectomy
for myopia. CLAO J 1995;21(4): 281-84.
58. Schivitz IA, Arrowsmith PN, Russell BM: Contact
lenses in the treatment of patients with overcorrected
radial keratotomy. Ophthalmol 1987;94: 899-903.
59. Lee AM, Kastl PR: Rigid gas permeable contact lens
fitting after radial keratotomy. CLAO J 1998; 24(1):
33-35.

60. Campbell MD, Caroline P: A unique technique for
fitting post RK patient. Contact Lens Spectrum 1994;
12: 56.
61. Chan J, Burger D: The use of peripheral corneal
measurements for fitting an RK/PRK patient. Optom
Vis Sci 1996;73(12s): 235.
62. Edwards KH, Hough DA, Kersley HJ: Designing
rigid lenses for the post PRK eye. Optom Vis Sci
1995;72(12s): 13.
63. Menicon Plateau Fitting Guide Menicon USA, Clovis,
CA, 1996.
64. Shipper I, Businger U, Psarrer R: Fitting contact
115
lenses after excimer laser photorefractive keratectomy

for myopia. CLAO J 1995;21(4): 281-84.
65. Edrington TB: Rigid gas-permeable lenses for
astigmatism. In Hom MM (Ed): Manual of Contact
Lens Prescribing and Fitting (2nd ed), ButterworthHeinemann: Boston 2000.
66. Sarver MD, Mandell RB: Toric lenses. In Mandell RB
(Ed): Contact Lens Practice Thomas: Springfield
1988; 284-309.
67. Silbert JA: RGP Bitorics for Treatment of High Corneal
Astigmatism Pacific University online education, 1996,
1997 http://www.pacificu.edu/oce/course10/
Section
116
Chapter
Soft Contact
Lens Fitting
Arthur B Epstein
INTRODUCTION
Hydrophilic soft lenses were the result of

pioneering work by Czechoslovakian biochemist
Otto Wichterle. Wichterle, a brilliant scientist and
inventor, developed the first hydrophilic plastic
and recognized the potential for use in the contact
lens field. The first soft lens material was
hydroxyethyl methacrylate (HEMA), a polymer
combining water. The water content significantly
increased oxygen permeability, especially compared to the impermeable PMMA (polymethylmethacrylate) rigid lenses of the day. The majority
of soft lenses are still HEMA-based, although
there have been a variety of proprietary material
enhancements over the years. All HEMA-based
lenses share a serious limitation: relatively low
permeability to oxygen and other gases. This is
a serious limitation. Soft lens-related corneal
hypoxia is believed to play a key role in the
Section
SOFT LENS HISTORY, MATERIALS

AND DESIGN
Section
Few things in ophthalmic practice can produce

greater or more instant patient satisfaction as
successfully fitted soft contact lenses. Soft lenses
are safe and appropriate for a broad variety of
patients, including children. They can be easily
modified and, under normal circumstances,
produce little if any irreversible changes to the
eye.
Soft lenses have evolved tremendously over
the past three decades. Modern lenses dramatically ease the fitting process even for complex
refractive errors. Patients with high degree of
astigmatism, advanced presbyopia and even
keratoconus can be successfully fitted with
modern soft lenses. A few years ago this was
inconceivable.
Skill at fitting soft lenses can be a great practice
builder and can serve as the foundation of a
large and healthy refractive practice. While the
majority of patients can be successfully fitted with
relative ease, understanding the fundamentals
of soft contact lens design, materials and fitting
strategies will improve the fitters success and
enjoyment of this process. This chapter will serve

as an overview and practical guide to soft lens
fitting and patient management for the clinician.
Soft Contact Lens Fitting
Properly fitting a soft lens is an exercise in applied

engineering. From a fitting perspective, the
ocular environment is complex, and a variety of
BASIC FITTING CONCEPTS
forces affect a soft lens within the eye.

Simplistically, capillary attraction pulls the lens
inward, gravity pulls it down while the eyelids
exert several harder to predict forces. The ideally
fitted soft lens floats upon the eye suspended by
a thin layer of tears in a perfect ballet of subtle
movement and balance. In reality, few lens fits
achieve or require such perfection.
Sagittal depth describes the height of a vertical
dropped from the inside surface of a hemispherical or aspheric surface to the base that it
rests upon. In contact lens fitting, the average
radius of curvature and total diameter of a contact
lens determines its effective sagittal depth. The
larger the diameter of a lens for a fixed radius of
curvature, the greater is its sagittal depth.
Likewise, the steeper the curvature (smaller the
radius) for a given lens diameter, the greater is
the lenss sagittal depth. Matching the average
topography of the cornea by varying the sagittal
depth of a soft contact lens is the essence of
proper lens fitting.
The goal of effective lens fitting is to achieve
a balanced distribution of lens-bearing forces on
the ocular surface. Failure to do so will result in
corneal disruption, warpage or other related
problems. Because of the inherent flexibility of
soft lenses, a wide range of varying topography
can be accommodated by a limited number of
lens parameters. Soft lens specifications typically
include power, diameter and base curvature.
Soft lenses are semiscleral designs, fitting over
the corneal and perilimbal scleral surfaces.
Modern lens designs have broad fitting
characteristics and excellent centration over the
normal distribution of corneal topography.
Although corneal curvature is generally thought
of as the most important determinant of lens fit,
Section
genesis of a variety of serious complications. The

quest for materials with greater permeability
remains a primary mission for contact lens
manufacturers.
Silicone hydrogel lenses represent the latest
soft lens material breakthrough. Despite relatively
low water content, oxygen transmission remains
high because of the silicone content. Although
lenses made from these materials have been
available for a relatively short time, they have
already shown tremendous clinical promise.
A variety of manufacturing techniques have
been used to fabricate soft lenses. The first lenses
were manufactured by spin casting, a method
that utilized a spinning mold to create the lens
surfaces. The outside of the mold fixed the outer
surface while the inner surface was created by
the action of centrifugal force on the liquid
polymer. Later, lenses were lathe cut, a technique
that had been used to manufacture rigid lenses
for many years. Lathe cutting permitted the
construction of more complex designs such as
toric lenses.
Fueled by the development of disposable
lenses in the late 1980s, molding has become
an increasingly common manufacturing
technique. It offers improved reproducibility and
greater cost efficiency. The latest technology,
such as CIBA Visions Lightstream process, allows
for totally automated fabrication of vast numbers
of contact lenses in short periods. Such
manufacturing techniques are the basis of costeffective single-use contact lenses.
117
118
corneal diameter and, to a lesser extent,

eccentricity (a measure of asphericity) play
important roles. These elements are interactive.
For example, a small steep cornea would seem
to require a lens with a steep base curve.
However, because the sclera is significantly flatter
than the cornea, the added scleral contribution
shifts the average topography sufficiently to be
best fitted by a midrange lens.
It is not unusual for a single, well-designed
lens to fit corneal diameters ranging from 11 to
13 mm. Likewise, keratometry readings of 40.50
to 49.50 can be acceptably fitted with a single,
well-designed soft lens. One reason for such
forgiving fitting characteristics is that smaller
corneas tend to be steeper while flatter corneas
are typically larger. Hence, the average corneal
sagittal depth remains relatively constant despite
a wide variation in curvature and diameter. The
exceptions are generally the source of most fitting
difficulty. In such cases, lenses that come in a
variety of parameters or, in some cases special
lens designs, may be necessary.
In selecting an initial soft lens for a patient,
the following pointers should be kept in mind:
The lens should center over the cornea
The lens should cover the entire cornea
The lens should move freely on the eye
Keratometry readings can be a helpful
starting point and are useful as a baseline for
future comparison. Computerized corneal topography is rapidly replacing keratometry in
contact lens practice. It provides information that
is far more detailed and is especially useful for
visualizing any effect of a lens upon the eye. If a
choice is possible, a flatter base curve is better
than a steeper one, provided lens movement is
not excessive. Ideally, soft lenses should move
freely with the blink, approximately 1 to 1.5 mm
Section

in primary gaze and 2 mm in upgaze. Lens
diameter should be selected to provide
approximately 1.5 to 2 mm of scleral coverage.
While it is possible to fit a larger and flatter lens
and achieve a functional fit, there is a risk of lens
tightening or asymmetric bearing. Fitting a lens
too tightly can tap metabolic waste and debris
causing an acute red eye reaction. Lens
decentration and asymmetric bearing are risk
factors for surface disturbance and corneal
warpage. As mentioned previously, lenses that
are fitted too tightly do not move well.
Excessively flat lenses can actually produce folds
in the far periphery of the lens (Figure 9.1).
Clinically, comfort is an important indicator of
proper lens fit. Loose lenses are particularly
uncomfortable, generally upon insertion. Steep
lenses tend to become less comfortable after a
period of wear.
FIGURE 9.1: Flat lens showing folding at the edge
REPLACEMENT FREQUENCY
Originally, soft lenses were replaced at approximately yearly intervals. Lenses were costly, and
patients tended to defer replacement for as long
as possible. Some patients were able to achieve

significantly longer wearing times, and many
would present with filthy, deposit encrusted lenses
(Figure 9.2). Increased awareness of the risks of
wearing debris- and bacteria-laden lenses combined with technological improvements made
more frequent replacement a de facto standard
of soft lens fitting. With each passing year, the
ratio of frequent replacement lenses increases
while conventional replacement lenses are more
likely used for expensive specialized designs.
119
SPHERICAL SOFT LENSES
In the United States, the majority of new

spherical fits are two-week disposable lenses. In
Europe, monthly replacement schedules are
more frequent. Single-use lenses are gaining in
popularity, especially in Europe and Japan.
Disposable and frequent replacement lenses
were initially available only in spherical designs.
Today, a wide range of FRP and disposable
spherical, aspheric, toric, and bifocal or
multifocal lenses are available.
While increased cost remains a minor factor
in the decision to select a conventional vs a
frequent replacement lens, the advantages of
FRP lenses make a compelling argument for their
FIGURE 9.2: Heavy deposits on a conventional soft lens
Section
use. Patients always have spare lenses on hand

and can instantly replace a lost or damaged lens.
Complications and unscheduled visits are
reduced.1 The relationship between lens spoilage
and contact lens complications has been
suggested by numerous studies. More frequent
lens replacement reduces problems for both
patient and practitioner. Single-use disposable
lenses have been shown to have the lowest rate
of complications.2 Single use lenses provide
unprecedented convenience and cleanliness.3
They are also helpful with allergic patients and
are of particular benefit for patients who wear
lenses only infrequently or on special occasions.
From a practice management perspective,
providing patients with an entire years supply
of lenses has been shown to increase patient
retention by reducing the impetus for the patient
to purchase lenses elsewhere.
Because the majority of ametropic patients have

spherical or near spherical errors, spherical soft
lenses are the most common type of lens fitted.
Modern spherical lenses come in a wide range
of plus and minus powers. Most will intrinsically
correct minor amount of astigmatism: up to
0.75 D in most patients. Adding approximately
two-third of the spherical equivalent of the
cylinder to the sphere power will often improve
acuity and increase patient acceptance. Thicker
lenses and lenses that resist flexure will usually
correct greater amounts of astigmatism. Recently,
soft lenses incorporating panfocal aberrationreducing optics have been introduced. These
lenses subjectively improve visual acuity and are
helpful with astigmatic patients who need more
astigmatic correction than a conventional soft
120
lens can afford, but not enough to require a

toric lens.
Many spherical lenses fit a wide range of
corneal topography with a single base curve diameter combination. Several leading disposable
lenses are fitted using this one-size-fits-all
philosophy. Other disposable and frequent
replacement lenses come in two or three base
curves. Conventional soft lenses typically come
in three base curves and, in some cases two
diameters, accommodating almost all patient
fitting requirements. Custom spherical designs
are available in even broader variation allowing
for fitting of unusual patients such as infants.
Spherical soft lens fitting for most patients is
not complicated but problems do arise on
occasion. Visual problems can arise from several
causes. The most common are listed.
Lens fitted too steeply: The patient reports
clarity immediately after the blink and
worsening blur within seconds as the lens
looses central support.
Lens fitted too flat: The patient reports blur
immediately after the blink, which clears
quickly. Vision also tends to be unstable and
the lens tends to be uncomfortable.
Residual astigmatism caused by lens correcting corneal cylinder: Even though soft lenses
generally do not mask significant corneal
astigmatism, there are exceptions. In the case
where corneal astigmatism and lenticular
astigmatism are balanced, a soft lens can
upset the balance.
Excessive cylinder: Patient has excessive
cylinder that is not being adequately
corrected by the soft lens.
Unwanted cylinder: Patient has excessive
corneal cylinder and the resultant lens
deformation induces unwanted cylinder.
Section

Lens-induced corneal warpage: Soft lenses
can induce both long- and short-term corneal
topographic change. This can produce visual
changes.
Lens coating: The lens is coated with debris.
Diagnosis of visual problems requires overrefraction of the lenses and preferably,
retinoscopy. Retinoscopy is helpful as it allows
the examiner to objectively evaluate what the
patient is seeing though the combination of
contact lens and visual system. Variability is
especially evident on retinoscopy and may be
seen as a scissors reflex or localized optical incongruity reminiscent of visualizing a keratoconus
patient. Slit-lamp examination is also helpful in
revealing an improper fit.
Comfort problems are generally easier to
identify and diagnose. The majority are due to
the following:
Damaged lens: Discomfort can be intermittent
as the ripped portion alternately unopposes and
then reapposes.
Flat fit: Usually associated with excessive lens
movement.
Tight fit: Usually associated with scleral
deformation and blanching of the perilimbal
vessels.
Lens deposits: These are generally visible on slitlamp examination.
Solution sensitivity or reaction: It may be allergic
or toxic in origin.
Preexisting problems: Preexisting problems such
as dry eye can dramatically contribute to soft
lens comfort problems.
Poor edge design: Different lenses perform
differently on individual patients. Some edge

designs can be irritating for some while not for
others.
Soft lens fitting problems are best solved by
methodical analysis of possible problems and
dogged persistence in solving them. A detailed
history is of extreme importance because contact
lens problems may be ephemeral. Because different designs have different fitting characteristics,
trial fitting of a variety of lenses will typically lead
to success. The contact lens fitter should have
several spherical trial sets on hand since spherical
lenses will likely be the most frequently prescribed
soft lens modality. If contact lens fitting becomes
a specialty, additional trial sets, especially of lenses
with multiple parameters, will be helpful for fitting
the greatest number of patients.
Although patients may not know that soft lenses

correcting astigmatism are available, such lenses
have been manufactured for more than two
decades. The first toric soft lenses were
inconsistent in manufacture and difficult to fit.
However, modern lenses are now stable, predictable and reproducible. A variety of toric lens
designs are available. Because the astigmatic axis
must remain at a fixed position, toric lenses
require some method of stabilization. Prism
ballasting is a commonly used method to reduce
lens rotation. Thin zone design removes material
from the superior and inferior aspects of the lens
and lid forces on these thinned zones retard
rotation. Other methods such as periballasting
(similar to prism ballasting) and truncation have
fallen out of favor, especially with the advent of
frequent replacement toric lenses, which are for
the most part molded. Soft astigmatic lenses are
available in front and back surface toric designs.
Functionally there is little difference between

the two. However, some fitters believe that back
surface lenses are more stable and perform better
on corneas with significant toricity, while front
surface lenses are better for spherical corneas.
Several methods are commonly used to fit
toric soft lenses. Ordering directly from the
spectacles prescription is an approach that many
practitioners use with good results. This
technique has become even more effective with
recent improvements in lens design and more
predictable lens performance. When ordering
any contact lens from a spectacles prescription,
it is important to account for vertex distance
induced differences in effective lens power.
Vertex power differences become significant
when prescriptions exceed approximately
4.00 D. Minus powered lenses become more
effective when moved back from the spectacles
plane while plus powered lenses become less
effective. Hence, less minus power and more
plus power (than the spectacle prescription) is
required in a contact lens. In a toric lens,
each meridian should be calculated and compensation incorporated into the contact lens
prescription.
Most advanced contact lens fitters prefer trial
fitting of toric lenses. Trial fitting serves several
purposes. It insures that the lens fits properly
and allows the clinician to evaluate lens rotation,
a common occurrence with soft toric lenses. If
the trial lens is stable, rotation can be measured
and compensation incorporated into the lens
prescription. The LARS approach is most
commonly used. LARS is an acronym for Left
Add, Right Subtract. Lens rotation can be
observed by looking at lens markings, usually
single or multiple lines at the 90 degree or 180
Section
ASTIGMATIC LENSES
121
122
degree position. If a toric lens rotates left, the

amount of rotation is added to the spectacle
prescription. If right, the amount of rotation is
subtracted. For example, if a lens rotates 10
degrees left and the patients astigmatic axis is
180, 10 degrees should be added and an axis
10 ordered. Another similar observational
method is to think of lens rotation as in or out
relative to the nose. Axis is then added in the
opposite direction to compensate for the
movement. For example, if a right lens of axis
10 rotates 20 degrees in, the lens should be
ordered at axis 160. By doing this calculation,
the shift in ordered axis places the actual axis
(after rotation) at the desired orientation.
Toric lens prescriptions can also be calculated.
A trial soft toric lens is placed on the eye and
allowed to equilibrate. An overrefraction is then
performed and the spherocylindrical power of
the lens and the overrefraction are mathematically combined. Several small pocket
computers are offered by toric lens manufacturers that perform this calculation. Alternatively,
the results can be telephoned to the manufacturer who will calculate the correct parameters.
The mathematical resultant describes the lens
needed to correct the patient. Rotation does
induce some degree of additional spherocylindrical refractive error. However, compensating
for this induced error complicates the calculation.
When the amount of rotation and cylindrical
powers are small, rotation can be ignored in
calculating the final lens.
All soft toric lenses should be evaluated when
dispensed. When ordering using LARS, it is
important to verify that the amount of rotation
is similar to that of the trial lens. Stable rotation
can be compensated for and the lens reordered.
Section

Instability will result in unpredictable lens rotation
and variable vision. Such instability can be
maddening for patients. Because higher amounts
of cylinder will accentuate the perceptual and
visual effects of rotational instability, use the least
amount of cylinder necessary to correct the
patient. Larger lens diameters and changes in
base curve will often improve stability. In some
cases, different lens designs will be necessary.
The greatest instability will be encountered with
oblique cylinders due to toric lens construction.
With-the-rule ( 180) toric lenses will generally
be most stable.
Variable vision may also be caused by the
same types of lens fitting problems that affect
spherical lenses. The increased rigidity of toric
lenses accentuates the visual effects of poor fit.
Prism-ballasted soft toric lenses tend to have
reduced oxygen transmission and increased lens
bearing forces in the inferior cornea. This may
induce inferior corneal neovascularization, which
is a common finding with these lenses.4,5 Inferior
neovascularization can be managed by switching
lens designs to a thin zone lens or refitting the
patient with a rigid gas-permeable (RGP) lens if
warranted. Mild neovascularization is generally
not of concern although it should be monitored
frequently for progression.
Toric soft lenses are available in two-week
disposable, monthly and quarterly frequent
replacement as well as conventional designs.
Lenses that are worn for prolonged periods
(greater than one month) need to be
scrupulously cleaned. The inherent lack of
rotation in a soft toric allows for excessive buildup, especially in the inferior paracentral area of
the lens. This build-up can be so thick so as to
obscure vision (Figure 9.3).
FIGURE 9.3: Inferior neovascularization associated with

a prism-ballasted soft toric lens
In the United States, the presbyopic population

continues to grow more rapidly than any other
segment. Many of these patients are successful
contact lens wearers who wish to continue lens
wear but are frustrated by the need for secondary
reading correction. Effective and simultaneous
near and distance vision correction in a soft lens
has been the holy grail of contact lens manufacturers for well over a decade. Bifocal lens designs
have included concentric, segmented and diffractive bifocals.6 More recently aspheric progressive
multifocal designs have become popular.
Many practitioners prefer monovision, a technique where one eye is fitted to accommodate
near vision and the other is set for distance.
Monovision relies on conventional lenses and is
generally less costly to the patient than bifocal
or multifocal lenses would be. Success rates
average in excess of 70 percent. Clinically, fitting
monovision can range from simple to frustrating
depending upon the patient and his or her
degree of tolerance and binocularity.7 Determining the dominant eye is a critical first step. Several
methods work effectively. The simplest is to have
the patient point as if he or she was aiming a
pistol. The overwhelming majority will close the
non-dominant eye and aim through the
dominant eye. An alternative is to have the
patient sight thought a circle made with the
fingers of his or her dominant hand. Ask him or
her to place your head in the center. The
dominant eye will be seen though the circle.
Finally, a trial (spectacle) lens of the approximate
power needed for near vision is alternately held
in front of each eye. The eye that shows the
least degradation of distance vision is the one to
be used for monovision.
Monovision prescriptions are determined
empirically. Initial powers are calculated from
age-based charts for expected add. However,
most patients will require slightly less add power
in a monovision lens. Once the add is selected,
the appropriate lens is tested on the eye and
refinements made. It is important to use handheld trial lenses for this testing. Testing in a
refractor will yield specious readings.
While most patients tolerate monovision, not
all will do so effectively. The best candidates are
hyperopic patients with naturally poor binocularity. Patients who respond aversely to monovision
at the outset will rarely do well, but many with a
tentative response will often acclimate after
sufficient experience. Monovision does preserve
a good deal of binocularity, however, patients
should be cautioned about driving or performing
critical tasks requiring binocular vision with care,
until they adjust. Because monovision is a
compromise that will degrade most patients
overall visual performance, a third distance
Section
CORRECTION OF PRESBYOPIA
123
124
contact lens is sometimes prescribed for patients

who engage in distance vision critical sports or
vocations. Keep in mind that toric lenses can be
used for monovision.
When monovision does not work or patients
desire binocular function at both distance and
near, consider fitting a bifocal soft lens.8 Success
with these designs has risen dramatically over
the past few years. However, proper fitting still
largely depends on practitioners skill and a
conviction that the lens will indeed work. No
bifocal or multifocal lens is perfect, and most
patients will need to adapt. Still some patients
do remarkably well with minimal refinement
while others require numerous trial fitting among
several different brands and types of lenses. The
greatest success is generally found in early
presbyopes who are more adaptable and require
lens add power.
Fitting bifocals and multifocal lenses successfully requires a large number of trial sets since
lenses that work on one patient will not work
for another and vice versa. In some cases, one
brand will work in one eye while the other is
best fitted with a different brand lens. It is generally wise to follow manufacturers recommendations for fitting these complex lenses, at least
until the practitioner becomes familiar with the
vagaries of each design. In general, most patients
can tolerate a little more plus in most bifocal
designs than they would with pure distance
lenses.
If bifocal or multifocal lens fitting fails,
modified monovision can be attempted using
the same lens. In this case, one lens is biased
more for distance and the other for near.
Generally, most bifocal fittings fail with the lens
performing well only at distance or at near, but
not at both. The lens prescription should be
Section

adjusted for acceptable near vision in the nondominant eye and good distance vision in the
dominant one. Regardless of technique, after
trial fitting the prescription is refined and the trial
lens dispensed. It is important to allow the patient
time to adapt to the lens in his or her habitual
environment. The only way to gauge success is
to allow the patient to confirm it under habitual
conditions.
Fitting bifocals or multifocal soft lenses can
be a patient management challenge. Patients
need to know from the outset that the best
bifocal is a compromise and that nothing will
restore the vision that they had when they were
in their twenties. Bifocal fitting can also be prolonged and tedious. Patients should be prepared
for this possibility and charged appropriately.
EXTENDED WEAR SOFT LENSES

Interest in extended wear lenses goes back to
the origin of contact lenses. Indeed, some
patients wearing PMMA hard lenses would
successfully sleep with their lenses in place. Others
were not so lucky and were awakened by pain
and severe corneal abrasions. Therein lies the
paradox. Extended wear means minimal lens
care and ease of use. However, it has also been
associated with numerous complications, some
serious.9,10
Soft extended wear lenses were initially
approved in the United States in the early 1980s.
These first lenses were conventional soft hydrogel
spheres and were fitted in the same manner as
conventional lenses. Later extended wear
developments included toric and other designs.
Although popular with patients, by the mid1980s, it became apparent that the growing
number of complications being encountered with
DRY EYE
Contact lens candidates may have varying
degrees of dry eye. Provided the condition is
SPECIAL SITUATIONS
manageable and is not seriously exacerbated by

contact lens wear, dry eye is not an absolute
contraindication to soft contact lenses. Most cases
of dry eye associated with contact lens wear have
an evaporative component. Toxicity and dryness
associated with meibomian gland dysfunction
can wreak havoc with soft lens wear. Aggressive
treatment using lid hygiene and warm compresses applied daily will often ameliorate many
contact lens related dry eye symptoms.
Several lens materials have been specifically
developed for dry eye patients. Although these
materials are not a panacea for all patients, they
do work wonders for some.16 Prism-ballasted
lenses have also been reported to help alleviate
dry eye symptoms for some patients. The exact
mechanism of how prism-ballasted lenses work
remains unclear, however, wicking may play a
role. Single-use lenses are another option for
reducing symptoms in dry eye contact lens
wearers. The reason why single-use lenses work
so well is uncertain. Perhaps it is reduced buildup of toxins and contaminants due to the more
frequent replacement schedule.
Section
extended wear was the tip of the iceberg. In

1989, Schein and Poggio reported a link between microbial keratitis and overnight wear.11,12
Although the Schein studies probably overestimated the incidence of serious complications,
extended wear was dealt a serious blow.13 In
response, the FDA curtailed extended wear
schedules from 30 days to a maximum of seven.
Disposable lenses were originally developed to
reduce extended wear complications, however
little evidence suggests they have had a significant
beneficial effect. Despite continued negative
reports in both the scientific journals and lay
press, the relative risk of a serious complication
while wearing extended wear lenses is less than
or comparable to other non-fatal life risks.14
Over the past two decades, researchers have
attempted to identify the actual cause of
extended wear complications.15 Hypoxia appears
to play a significant role with other lens related
factors contributing. Recently high permeability
soft silicone hydrogel lenses have been used for
extended wear with promising results. Typical
hypoxia-related problems seen with conventional lenses such as corneal edema are almost
nonexistent. As the parameters of silicone
hydrogel lenses broaden, extended wear should
again become a viable option for patients. In
the interim the risk-to-benefit ratio should be
weighed carefully before prescribing conventional extended wear lenses. For some patients,
the risk is minimal compared to the potential
benefit.
125
IRREGULAR ASTIGMATISM
A variety of conditions produces visual distortion
and irregular astigmatism, including previous
trauma, keratoconus and pellucid degeneration.
While soft contact lenses will not work perfectly
in all situations, they can be helpful adjuncts in
many cases.
Thick or resilient soft lenses can correct a
surprising amount of corneal distortion. Special
designs are available specifically for that purpose.
The Softperm is a unique hybrid lens that
contains a rigid center fused into a soft skirt. The
current version suffers from limited oxygen permeability. Despite this, the lens has been extre-
126
mely helpful for patients with ectatic conditions

as well as postsurgical and posttraumatic cases.
Soft lenses may also be used as
piggyback carriers in which a rigid lens is
placed atop a soft lens. The soft carrier lens
acts as a cushion, increasing the comfort
and often the stability of the rigid over-lens.
In keratoconus, a soft carrier tends to
effectively flatten and elevate the cone.
Piggyback fitting can be especially helpful in
managing advanced keratoconus.17,18 Topography taken over the soft carrier provides a
starting point for rigid lens fitting.19 Because of
the decreased oxygen transmission inherent in
such a thick combination, piggyback fitting is
generally best reserved as a last resort. Soft lens
choice in piggyback fitting is dictated by patient
topography. The carrier lens must be stable and
comfortable enough for prolonged wear. Ideally,
high Dk hydrogel lenses would be best.
Unfortunately, the narrow range of available
fitting parameters limits their use. Care of a
piggyback system often requires two separate
systems: one for the rigid lens and another for
the soft carrier. Combination products such as
CIBA Visions SoloCare are approved for both
soft and rigid lenses and may minimize confusion
and increase compliance.
Keratoconus specific soft lens designs such
as the Flexlens Harrison TriCurve series (Paragon
Vision Sciences) are available and may work
acceptably well in early to moderate
keratoconus. Trial fitting sets are a requisite for
fitting these lenses. Pellucid degeneration
represents a special case where soft lenses are
generally the most effective way of managing
the condition. The central cornea in pellucid
degeneration typically has large amounts of
Section
FIGURE 9.4: Heavy lens deposits characteristic of a

rotationally stable toric lens
mostly regular against-the-rule astigmatism. The

inferior ectasia has a sharp knee immediately
superior to the area of greatest thinning. RGP
lenses tend to abrade this area and easily
decenter below the visual axis. A custom soft
toric lens can adequately correct the refractive
error while the prism ballast is locked in and
stabilized by the inferior thin zone. Most pellucid
patients do well with soft toric lenses (Figure 9.4).
SOFT LENS COMPLICATIONS

Soft contact lens wear has been associated with
a variety of complications. Complications arise
from specific problems, many of which can be
identified and managed. They include the
following lens or care product related problems
Metabolic disturbance
Mechanical disturbance
Allergic response
Infection
Fitter error
Patient error or noncompliance.
interferes with oxygen exchange and impedes

waste removal and tear clearance of the corneal
surface. Epithelial and, less commonly, stromal
edema can result from hypoxia. Epithelial edema
can disturb normal barrier functions, exposing
the cornea to increased risk of microbial infection
and enhanced toxin penetration.22 It may be
appreciated with fluorescein stain as waffling of
the corneal surface (Figure 9.6). Edema may
also increase adhesivity and thus the infectiousness of microbes like Pseudomonas. Soft lenses
can block the first line defensive response of
inflammatory cells to early corneal surface
infection, which may play a role in the genesis
of more severe infection, especially with
extended wear.23
Chronic hypoxia may have several other
untoward effects including superficial punctate
keratitis (Figure 9.7), infiltrative keratitis (Figure
9.8), peripheral neovascularization (Figure 9.9),
corneal surface changes and limbal stem cell
damage (Figure 9.10).24 Hypoxia-related corneal
damage is likely caused by tissue breakdown and
toxicity or secondary metabolic dysfunction.
FIGURE 9.5: Contact lens associated red eye (CLARE)
FIGURE 9.6: Waffled appearance of epithelial edema
Section
In addition to the above, preexisting conditions such as dry eye, lid disease and
lagophthalmos predispose contact lens wearers
to complications. Treatment of existing ocular
disease is an important first step in avoiding
contact lens complications and assuring patient
success.
The cornea has a substantial physiologic
reserve, which allows it to function within a wide
range of environmental conditions. Exceeding
the corneas reserve may result in an acute
red eye inflammatory response termed
Contact Lens Associated Red Eye (CLARE)
(Figure 9.5). It is sometimes referred to
as tight lens syndrome,20 which is a
misnomer. Lens tightening is actually
caused by hypoxia and secondary acidosis
rather than a tightly fitted lens being the
cause. Endogenous bacteria may also play a
role in inflammation.21 Contact lenses increase
the physiologic demands on the cornea. While
there is significant individual variation, soft
contact lenses can turn a marginal situation into
a problematic one. The relation between contact
lens and cornea is complex and interactive. Lens
wear, especially of lower Dk hydrogel materials,
127
128
FIGURE 9.9: Peripheral neovascularization
Section
FIGURE 9.7: Superficial punctate keratitis associated

with contact lens wear
FIGURE 9.8: Infiltrative keratitis
FIGURE 9.10: Corneal surface changes associated

with limbal stem cell damage
Corneal surface distortion and warpage have

also been encountered with long-term chronic
hypoxia which appears to make the cornea more
susceptible to molding effects (Figure 9.11). It is
important to consider that powered contact
lenses have differential thickness which may be
translated by repeated lid movement into frank
changes in corneal shape. Induced molding or
warpage may be mild or severe. It can also be
transient or permanent.
Chronic hypoxia taxes corneal homeostatic

mechanisms, which can result in upregulation
of stem cell activity. Stem cell depletion may
occur in patients with limited stem cell reserves,
from toxicity or from direct trauma. This can
lead to conjunctivalization of the corneal surface
and profound corneal surface problems.
Infiltrative keratitis due to hypoxia is caused
by localized cell death. The resultant focal mopup response mobilizes an inrush of inflammatory
129
Section
cells to the affected areas. Other causes of focal

sterile infiltrates in contact lens wearers include
solution toxicity causing focal areas of cell damage and immune response to bacterial proteins.
Peripheral neovascularization is most commonly observed with higher minus power lenses
and prism-ballasted lenses. Oxygen transmission
in hydrogel lenses is dependent on local lens
thickness and permeability, which is lowest in
the periphery of minus powered lens designs.
Stem cell deficiency may also foster peripheral
neovascularization in soft lens wearers.
Soft lens-induced mechanical disturbance to
the cornea is generally caused by poor fitting
relationships: lenses that are fitted too steep or
FIGURE 9.11: Corneal topography demonstrating warpage and irregular astigmatism from soft lens overwear
flat, lenses that are damaged or lens insertion

errors. Superficial punctate keratitis (SPK), alternately termed punctate epithelial keratopathy
(PEK), can arise from several of causes: excessive
lens bearing, response to lens care products or
endogenous toxins or, as discussed before,
chronic hypoxia. Soft lenses can cause corneal
abrasions. Focal abrasions are generally associated with damaged lenses, contact lens deposits
and foreign objects trapped under lenses. Full
thickness abrasions may occur from damaged
lenses (Figure 9.12). Sharp, elevated parts of a
damaged lens will lock into the abraded area
and the action of the lids will slowly grind away
the remaining underlying epithelium. Abrasions
130
FIGURE 9.12: Full thickness corneal abrasion caused

by damaged soft lens
Section
caused by contact lenses should not be pressure

patched. Patching yields a warm, moist environment and may interfere with corneal protective
mechanisms. There have been several reports
of secondary infection after patching soft lens
wearers.
Because soft lenses are relatively stable and
move little in primary gaze, the constant and
repeated action of the lids on the lens can cause
compression damage to the underlying corneal
surface. This can best be visualized with fluorescein stain and may assume a variety of patterns.
Elevated deposits on soft lenses can also cause
underlying damage of the epithelium though the
action of the lids (Figures 9.13A and B).
Soft lens materials are inorganic and cannot
cause an allergic response by themselves.
However, lens care products, particularly earlier
generation products, have been associated with
a variety of lens-associated allergic reactions.
Thimerosal was a frequent cause of allergic red
eyes in soft lens wearers.25 It should be noted
that allergic reactions are associated with itching
while toxic reactions generally are not. Reactions
B
FIGURES 9.13A and B: Large jelly bump deposit and
underlying surface damage
to modern solutions are rare. Soft lenses may

also gather allergens from the environment and
produce or exacerbate an existing allergic
response. Because seasonal allergy is a factor in
contact lens dropout, treat it proactively. New
generation, twice-daily dose antiallergy medications like Patanol (olopatadine hydrochloride
ophthalmic solution, Alcon) are ideal for the
contact lens wearer since they can be applied
prior to lens insertion and after lens removal.
FIGURE 9.14: High riding soft lens in GPC
FIGURE 9.15: Classic cobblestone papillae of the upper

lid in GPC
enigma. Protein build-up on the surface of the

lens appears related to the persistence and
progression of GPC. Effective lens cleaning is
helpful in eliminating or reducing the severity of
the problem. Miraflow (CIBA vision), an alcoholbased surfactant cleaner works well at solubilizing
and removing protein. Enzymatic lens cleaning
is also helpful, the new liquid SupraClens (Alcon)
being most effective. Low water content, nonionic lenses such as the CSI (Wesley Jessen)
ameliorate the problem as do more frequent
replacement schedules. In severe cases single use
lenses may be effective. Mast cell stabilizers like
cromolyn sodium have been helpful in the
medical management of GPC. Newer combination antiallergy medications like Patanol
(Alcon) are also effective. A new steroid,
Lotemax (Lopredenol etabonate, Bausch &
Lomb) has been approved by the FDA for the
treatment of GPC.26,27
Corneal infection is perhaps the most serious
contact lens complication. Although many bacterial species have been isolated, Pseudomonas
and Serratia are common pathogens associated
with lens-related infection. As discussed previously, extended wear is a common factor in
lens-related microbial keratitis. The reasons for
this remain obscure, however, hypoxia is
believed to be a primary factor. Pseudomonas
has been shown to adhere preferentially to
epithelial cells that have been subjected to
prolonged hypoxia. Pseudomonas has been
found to concentrate around large deposits on
the lens surface.28,29 Large deposits are typically
seen in extended wear and have been shown to
damage the underlying corneal surface. This may
play a role in infection. Infection by Acanthamoeba, a ubiquitous protozoan, has been jointly
linked to contact lens wear and exposure to
Section
Giant papillary conjunctivitis (GPC) was the

first soft contact lens complication described.
Affected patients complain of increased lens
awareness and lens movement. A soft lens riding
up beneath the upper lid is a classic finding
(Figure 9.14). Upon eversion, the upper tarsus
shows inflammatory changes, primarily large
cobblestone papillae and mucus (Figure 9.15).
Despite the prevalence of GPC, the etiology has
never been fully understood. GPC incidence
increases during periods of high seasonal allergy.
However, there is no concurrent increase in the
number of mast cells or elevation in levels of
tear-borne histamine. This makes GPC an
131
132

important cleaning adjunct although several
manufacturers are currently testing no-rub, just
rinse care products.
Patient factors have driven the industry,
spurring developments in antimicrobial effectiveness, cleaning power and ease of use. For most
patients, single bottle care systems provide the
best balance between ease of use and effectiveness. The easier a system is to use, the greater
the chances of the patient properly using it.
Patient noncompliance is an important but
difficult to quantify factor in the complex mosaic
that underlies most contact lens complications.
Studies have suggested a possible link between
poor compliance and microbial keratitis. Proper
lens care is important. It should be reinforced at
each follow-up visit.
SOFT LENS CARE
Although contact lenses can add a good deal to

the ophthalmic practice, they can also exact a
huge toll. Proper planning and organization are
prerequisites for success. Disorganization and
poor planning are an invitation to chaos and
confusion.
First, decide on the type of lenses that you
intend to fit. Spherical soft lenses are a good
start. They are easy to fit and require minimal
investment or experience. Manufacturers of
disposable lenses will usually provide complete
trial fitting sets at little or no charge which permit
fitting patients without risk. Because space in the
modern office is at a premium, manufacturers
have designed trial sets to be size efficient and
contain lenses in powers and fitting parameters
most likely to be needed. Initially, a single set
will be adequate but as you gain experience,
Section
contaminated water. Lens, lens case and care

product contamination is a common finding in
patients who have microbial keratitis.30,31
Strategies for preventing infection include
frequent lens case replacement and appropriate
care system selection and use.
Although most minor contact lens complications are clinically insignificant, small problems
often give rise to larger ones. Disturbance in
barrier functions caused by epithelial edema or
SPK are likely factors in the genesis of more
profound complications. For that reason, it is
important to find and address even minor
problems. Routine slit-lamp examination with
fluorescein is important. Fluorescein reveals even
subtle problems that would otherwise be
overlooked. Fitting relationships play a role in
lens bearing and any asymmetry can give rise to
surface disturbance.
Since the inception of soft contact lenses, care

products have evolved from rudimentary lens
cookers using home-made saline solution to
carefully engineered and easy to use single bottle
disinfection systems. Modern solutions are gentle,
comfortable and exceeding easy to use. More
important, these new solutions are marvels of
broad-spectrum disinfection.
Early care systems required separate lens
cleaning solutions. Patients found this inconvenient and with improvements in lens care
science, lens cleaners have fallen out of favor.
They are still helpful with patients who soil lenses
rapidly, those who have allergies or GPC and
patients with conventional replacement lenses.
Both surfactant and enzymatic cleaners are
available and effective. Digital rubbing is an
PATIENT AND PRACTICE

MANAGEMENT
a dedicated assistant will be necessary. In addition

to inserting and removing trial lenses on patients,
the technician is responsible for patient training
in care and handling, lens ordering, dispensing
and returns, when necessary. Do not underestimate the complexity of contact lens practice.
It is easy to be buried in clerical work, especially
if you get behind. This is especially the case with
conventional specialty trial lenses, which can
erode profits when not returned for credit.
Patient training is critical. Some patients will
learn contact lens insertion and removal immediately, while others, especially young males, will
find the process intimidating. Discomforted
patients will require patience, understanding and
for some, multiple training sessions. To overcome
fear of touching the eye, a viscous agent, like
Celluvisc can be used on the fingertip as a training
aid. Efficiency dictates that training should be
performed by a skilled assistant, not the doctor.
Successful contact lens wear requires patient
involvement. Explain the fitting process as goal
oriented rather than product focussed. Patients
need understand that the onjective of proper
contact lens fitting is acceptable vision, good
comfort and above all, health and safety of their
eyes. Convinced of the need for their active
participation, most patients will be cooperative.
Patients should be provided with an informed
consent that details possible complications,
warning signs to be aware of and emergency
procedures including telephone numbers. The
financial terms of the fitting process should be
detailed, including refunds if any. A graduated
refund policy that shares the risk of failure is
usually advisable. With each successive visit,
greater amounts of professional time are
consumed and it is unfair for either party to bear
all of the risk.
Section
additional trial sets will increase your ability to fit

more patients. As your contact lens practice
continues to expand and your experience grows,
you may want to add a limited number of
conventional soft trial lenses. Powers of 2.00
to 3.00 and +1.00 to +2.00 will be adequate
for most patients. A small number of highpowered lenses and unusual base curve
diameter combinations will increase success with
unusual patients.
With increased experience, specialty lenses
like toric and bifocal designs should be added.
Although fitting complex lenses is initially more
time consuming, the financial results can be
extremely rewarding, especially with greater
experience. Since cost of conventional specialty
lenses and the need for careful inventory control
becomes an issue, disposable and frequent
replacement specialty lenses are most costeffective since they are usually supplied by the
manufacturer at no risk as an adjunct to the fitting
process.
Depending on how busy the practice is, lens
fitting can either be scheduled as a separate office
visit or added as a part of the comprehensive
examination. Patients should be queried at the
time of appointment regarding the purpose of
the visit and and time scheduled accordingly.
With disposable lens trial sets, it has become
possible to dispense lenseseven toric and
bifocal lenses at the conclusion of the fitting visit.
The practice management benefits of instant
patient gratification are substantial and unless it
is disruptive to office flow, every attempt should
be made to dispense lenses the same day.
An active contact lens practice requires a
skilled assistant. This is especially true with same
day dispensing. Initially, an interested ophthalmic
technician will suffice, but as the practice grows,
133
134
Section
At the conclusion of the dispensing visit, a

follow-up examination should be scheduled.
Failure to do so trivializes the fitting process and
sends a message to the patient that the doctors
supervision is unnecessary. Although most visits
will be routine, occasional problems will need to
be addressed or refinements in fit or prescription
made. Lenses that are more complex will
typically require multiple follow-up visits which
should be reflected in the initial fee charged.
Although some practitioners prefer to charge for
materials and a per visit fee, most patients prefer
a global fee for materials and professional
services. It is important to specify limits for the
number of visits included in the initial fee to avoid
misunderstandings later on.
Fees for contact lens services should be based
on the complexity of the fitting process as well
as the time required. Office overhead and
materials costs must also be factored in. In a busy
general practice, the fees must be sufficiently
high to offset lost income from routine
examinations that could be performed during
the time spent working with contact lens patients.
In busy offices, delegating contact lens services
to an assistant or associate may be more costeffective. That way the benefits of a contact lens
service are retained while the primary care
provider is freed to perform more financially
productive work.
CONCLUSION
Soft contact lens fitting is a skill that is best learned
by trial and error. It is a forgiving art, allowing
the beginner great success with minimal effort.
With increased experience, new insights become
obvious and greater understanding develops. It
is my sincere hope that this chapter is an inviting
introduction to this wonderful part of patient

care.
REFERENCES
1. Poggio EC, Abelson M: Complications and
symptoms in disposable extended wear lenses
compared with conventional soft daily wear and
soft extended wear lenses. CLAO J 1993;19(1): 3139.
2. Hamano H, Watanabe K, Hamano T et al: A study
of the complications induced by conventional and
disposable contact lenses CLAO J 1994;20(2): 10308.
3. Solomon OD, Freeman MI, Boshnick EL et al: A 3year prospective study of the clinical performance of
daily disposable contact lenses compared with
frequent replacement and conventional daily wear
contact lenses. CLAO J 1996;22(4): 250-57.
4. Eghbali F, Hsui EH, Eghbali K et al: Oxygen
transmissibility at various locations in hydrogel toric
prism-ballasted contact lenses. Optom Vis Sci
1996;73(3): 164-68.
5. Hallak J, Cohen H: Localized edema with soft toric
contact lenses. J Am Optom Assoc 56(12): 1985;92021.
6. Josephson JE, Caffery B: Bifocal hydrogel lensesan
overview. J Am Optom Assoc 1985;57(3): 190-95.
7. du Toit R, Ferreira JT, Nel ZJ: Visual and nonvisual
variables implicated in monovision wear. Optom
Vis Sci 1998;75(2): 119-25.
8. Kirschen DG, Hung CC, Nakano TR: Comparison of
suppression, stereoacuity, and interocular differences
in visual acuity in monovision and acuvue bifocal
contact lenses. Optom Vis Sci 1999;76(12): 832-37.
9. Silbert JA: Complications of extended wear. Optom
Clin 1991;1(3): 95-122.
10. Chalupa E, Swarbrick HA, Holden BA et al: Severe
corneal infections associated with contact lens wear.
Ophthalmology 91987;4(1): 17-22.
11. Schein OD, Glynn RJ, Poggio EC et al: The relative
risk of ulcerative keratitis among users of dailywear and extended-wear soft contact lensesa casecontrol study: Microbial Keratitis Study Group. N
Engl J Med 1989;321(12): 773-78.
12. Poggio EC, Glynn RJ, Schein OD et al: The incidence
of ulcerative keratitis among users of daily-wear
and extended-wear soft contact lenses. N Engl J Med
1989;321(12): 779-83.
13. Epstein AB, Freedman JM: Ulcerative keratitis among
users of contact lenses. N Engl J Med 1990;322(10):
700.
24. Clinch TE, Goins KM, Cobo LM: Treatment of contact

lens-related ocular surface disorders with autologous
conjunctival transplantation. Ophthalmology 1992;
99(4): 634-38.
25. Mondino BJ, Salamon SM, Zaidman GW: Allergic
and toxic reactions of soft contact lens wearers. Surv
Ophthalmol 1982;26(6): 337-44.
26. Bartlett JD, Howes JF, Ghormley NR et al: Safety
and efficacy of loteprednol etabonate for treatment
of papillae in contact lens-associated giant papillary
conjunctivitis. Curr Eye Res 1993;12(4): 313-21.
27. Asbell P, Howes J: A double-masked, placebocontrolled evaluation of the efficacy and safety of
loteprednol etabonate in the treatment of giant
papillary conjunctivitis. CLAO J 1997;23(1): 31-36.
28. Aswad MI, John T, Barza M et al: Bacterial adherence
to extended wear soft contact lenses. Ophthalmology
1990;97(3): 296-302.
29. Butrus SI, Klotz SA: Contact lens surface deposits
increase the adhesion of Pseudomonas aeruginosa.
Curr Eye Res 1990;9(8): 717-24.
30. Bowden FW 3d, Cohen EJ, Arentsen JJ et al: Patterns
of lens care practices and lens product contamination
in contact lens associated microbial keratitis. CLAO
J 1989;15(1): 49.
31. Gray TB, Cursons RT, Sherwan JF et al:
Acanthamoeba, bacterial, and fungal contamination
of contact lens storage cases. Br J Ophthalmol 1995;
79(6): 601.
Section
14. Myers RI, Weiss E: Ulcerative keratitis from overnight

contact lens wear compared with other life risks.
CLAO J 1995;21(1): 31-34.
15. Brennan NA, Coles ML: Extended wear in perspective.
Optom Vis Sci 1997;74(8): 609-23.
16. Lemp MA, Caffery B, Lebow K et al: Omafilcon A
(Proclear) soft contact lenses in a dry eye population.
CLAO J 1999;25(1): 40-47.
17. Yeung K, Eghbali F, Weissman BA: Clinical experience
with piggyback contact lens systems on keratoconic
eyes. J Am Optom Assoc 1995;66(9): 539-43.
18. Kok JH, van Mil C: Piggyback lenses in keratoconus.
Cornea 1993;12(1): 60-64.
19. Soni PS, Gerstman DR, Horner DG et al: The
management of keratoconus using the corneal
modeling system and a piggyback system of contact
lenses. J Am Optom Assoc 1991;62(8): 593-97.
20. Netland PA: Tight lens syndrome with extended
wear contact lenses. CLAO J 16(4): 308, 1990.
21. Holden BA, La Hood D, Grant T et al: Gram-negative
bacteria can induce contact lens related acute red
eye (CLARE) responses. CLAO J 199622(1): 47-52.
22. McNamara NA, Polse KA, Fukunaga SA et al: Soft
lens extended wear affects epithelial barrier function.
Ophthalmology 1998;105(12): 2330-35.
23. Lawin-Brssel CA, Refojo MF, Leong FL et al:
Scanning electron microscopy of the early host
inflammatory response in experimental Pseudomonas
keratitis and contact lens wear. Cornea 1995;14(4):
355-59.
135
136
Chapter
10
Advances in
Soft Lens Fitting
Adrian S Bruce
Section
Soft lenses are the most popular type of contact

lenses, accounting for some 88% of lens wearers
(Barr 1995). In the United States alone there
are more than 75 companies manufacturing at
least 185 types of lenses (Tyler 1995).
GENERAL FEATURES OF SOFT

LENSES
Some of the key factors responsible for the

popularity of soft lenses are the initial comfort,
relatively low unit cost and ease of fitting. The
initial comfort provides a short adaptation time
due to minimal movement and less tearing,
relative to rigid gas permeable lenses. The
relatively low cost makes them suitable for planned
replacement systems, and makes it possible for
practitioners to maintain an inventory. With the
ultrathin lens designs characteristic of disposable
lenses, most manufacturers have found that a
single diameter and two back optic zone radii
(BOZRs) are sufficient to fit most patients,
meaning that achieving an acceptable fitting is
usually relatively easy for the practitioner.
As well as initial comfort, the large diameter
of soft lenses also gives several other advantages.
In comparison with rigid gas permeable lenses,
soft lenses are good for sporting activities since
they are rarely dislodged and there is less foreign
body trapping. The large optic zone makes for
minimal visual flare. Coverage of the entire
visible iris diameter also means that soft lenses
can be used to change apparent eye color.
Section
There are a number of recent developments in

soft lens fitting. The physical fitting of hydrogel
lenses has become relatively simple: most disposable lenses are available in only one diameter,
the power is chosen to match the patients ocular
refraction, and the main choice is whether to fit
a steep or flat BOZR. However, at the same time
there has been a breath-taking increase in the
number of modalities available- everything from
conventional hydrogel lenses, to the common 2
and 4 week disposable lenses, daily disposables
and extended wear, as well as toric, multifocal
and colored opaque lenses. In addition there
are choices in the hydrogel materials that affect
the critical issues of oxygen transmissibility and
resistance to dehydration.
Advances in Soft Lens Fitting
There are three principal parameters which

may be varied in fitting any soft lens to the eye,
in order to achieve a satisfactory physical fitting
and appropriate optical correction. These are
the:
1. Total diameter (TD)
2. Back optic zone radius (BOZR)
3. Back vertex power (BVP)
Note that the other key issues in fitting a soft
lens are selection of an appropriate material, and
a modality of lens wear (conventional, disposable,
daily disposable or extended wear). These
choices are discussed later in this chapter.
SELECTION OF LENS
PARAMETERS FOR FITTING
In practice most disposable lenses are

available in only a single TD, in the range of
14 to 14.5 mm, and so no selection is necessary
by the clinician. Medium water content lenses
are generally closer to 14 mm and higher water
lenses are fractionally larger to allow for the effects
of dehydration. Toric lenses are usually around
14.5 to maximize stabilization. If custom lenses
are being fitted, then the TD is usually about
2 mm larger than the horizontal visible iris
diameter.
The BOZR of a hydrogel lens is usually
selected as 0.6 to 0.8 mm flatter than the average
corneal curvature measured with keratometry.
If a lens BOZR is too flat for the cornea, then
the lens centration, may be poor (Bruce 1994)
as shown in Figures 10.1A and B. If the lens
BOZR is too steep, the lens may not conform
properly to the eye during wear.
With disposable contact lenses, the lenses are
thin and usually conform closely to the ocular
surface. For this reason most brands of lens are
available in only one or two BOZRs, usually
either a single BOZR of 8.6 mm, or in 8.4 mm
and 8.7 mm. To avoid lens decentration, a
steeper lens fitting is often required on steeper
corneas D44.00D (7.65 mm) to D47.20 (7.20
mm) (Bruce 1994). A cornea steeper than about
47D (7.2 mm) may be difficult to fit with a
disposable soft lens, and indeed may be considered outside the normal range and suspicious
of keratoconus (Bruce and Bohl 1992).
It is important to note that changing the
BOZR of most disposable soft lenses does not
significantly alter lens movement (Roseman et
al 1993, Young et al 1993). Current lenses tend
to have low levels of movement (0.1 mm to 0.4
mm) with blinks and flattening the lens may only
lead to decentration. A second issue to note is
Section
Until recently, the most notable limitation of

soft lenses was the restricted oxygen transmissibility. Conventional hydrogel materials continue
to present difficulties for corneal oxygenation in
the correction of high ametropia or extended
wear. However, with the advent of siliconehydrogel materials, oxygen transmissibility
limitations appear to have been solved.
In recent years there has also been progress
with some of the other possible physiological
sequelae of soft lens wear. Some drynessresistant materials have become available and
lens designs have improved to facilitate lens
movement and post-lens tear exchange. While
soft lenses continue to require care and
maintenance, the solutions have been simplified
and are more effective, with the intention of
limiting the possible adverse effects of noncompliance and increasing convenience for the
patient. Of course, since soft lenses lack any
rigidity they are unsuitable for the correction of
corneal distortion or irregular astigmatism.
137
138

vertex distance in m. Important for spectacle
powers >4.00D.
EVALUATION OF SOFT LENS FIT
Section
B
FIGURES 10.1A and B: Soft lens decentration. (A) Poor
centration, with lens located superiorly, (B) Inferior
decentered Acuvue with BOZR more than 1.0 mm flatter
than the flat BOZR
that thicker soft lenses (such as higher plus or

minus powers) are more rigid and need more
careful selection of BOZR.
The Back vertex power (BVP) of a soft lens
is simply selected from the ocular refraction. The
ocular refraction is calculated from the spectacle
refraction, by adjusting for effectivity consideration. Required contact lens power is calculated
from F = Fv/(l-d.Fv), where F= back vertex
power of contact lens at the eye (D), Fv = back
vertex power of spectacle lens (D) and d =
The comfort of a soft lens is perhaps best assessed

before other aspects of the fitting. Comfort of a
soft lens is considered optimal if the patient has
only slight awareness of the lens presence. If there
is no sensation at all then lens adherence may
be present, whereas excessive lens awareness
may result from excess lens movement.
Any discomfort or irritation will invalidate
subsequent assessment of lens fitting. If there is
a foreign body sensation, then it must be rectified
by either removal and rinsing of the lens or by
gentle swishing of the lens over the surface of
the eye. Lens defects can be reported as a foreign
body sensation, and in-compatible care solutions
as a stinging on lens insertion. Any discomfort
will lead to tearing by the patient, which changes
the tonicity of the tear film and affects the lens
fitting. Thus the lens should be comfortable
before proceeding with the quantitative
assessment of the fit.
If the soft lens being worn has the appropriate BVP for the patient, then vision should
be assessed before any lights have been used,
to avoid after-image affects. If 6/6 (20/20) vision
is achieved, and the vision is stable between
blinks, then several characteristics of the fit will
be implied:
No significant residual myopia or astigmatism
Acceptable conformity of the lens to the
surface of the eye
Adequate lens centration
Good prelens tear film stability
As discussed above, the centration of a soft
lens is a key objective characteristic of the fitting
(Figures 10.1A and B). It is assessed as optimal
139
A
FIGURE 10.2: Soft lens centration. A well centered lens
shows symmetrical overlap onto the conjunctiva
Section
if the lens edge shows uniform and symmetrical

overlap onto the sclera in all meridians (Figure
10.2). Furthermore, if the lens is decentred, such
as with the pushup test, it should regain optimal
centration in less than one second. Centration is
usually assessed in primary gaze, but observing
the consistency of centration in the other cardinal
gaze directions can also be useful.
Lens movement is considered important as
it is the only means of promoting postlens tear
film exchange and mixing (Efron and Fitzgerald
1996). Movement is quantified as the vertical
change in lens position before and after a normal
blink (Figures 10.3A and B). Clinically, the
degree of the lens movement can be compared
to the overlap of the lens edge onto the sclera,
which is usually approximately 1 mm (Figure
10.4). Young (1992) observed:
Inadequate lens movement can be taken as
<0.1 mm
Excessive movement as > 1.0 mm
Well-fitting lathed lenses show about 0.3 mm
of movement
It is interesting to note that movement may
be less with disposable lenses than with
B
FIGURES 10.3A and B: Soft lens movement assessment.
(A) Prior to the blink, the inferior lens edge sits low. (B) After
the blink, the inferior lens edge is pulled higher for a moment.
The difference is the amount of lens movement, in this
example about 0.5 mm
FIGURE 10.4: Clinical estimate of movement. Compare the

degree of lens movement with overlap of the lens edge
140
Section
conventional lenses. Acuvue lenses often show

only 0.2 mm movement, and movement may
be minimal in the first 10 minutes after lens
insertion (Little and Bruce 1994). Indeed it may
be that the best time to evaluate lens movement
is not soon after lens insertion, but after the
patient has worn the lenses for some hours or at
an aftercare visit (Brennan et al 1994).
Keratometer mires can be examined on the
anterior lens surface in order to detect any lens
distortion on the eye. Any mire irregularity would
be considered abnormal. In addition the Keeler
Tearscope can be used to ensure the lens front
B
FIGURES 10.5A and B: Pre-lens tear film breakup time
seen with the Tearscope
surface is wetting adequately between blinks

(Figures 10.5A and B).
TEAR FILM AND BLINKING

EFFECTS ON FITTING
The fitting of soft lenses, as evidenced in terms
of the movement with blinks, is not always consistent or predictable. The amount of movement
has been observed to fluctuate during wear, for
both conventional lathed and disposable lenses
(Brennan et al 1994, Little and Bruce 1994).
Lens movement appears to be affected by
interactions between the lens and upper lid, via
the lubricative properties of the prelens tear film,
the surface quality of both lens and lid, and the
nature of the blink. Furthermore, the postlens
tear film appears to influence lens movement,
since hypotonic solutions can thin the postlens
tear film and cause lens adherence (Little and
Bruce 1995a). The prelens and postlens tear films
can influence each other, via the porosity of the
soft lens material, known as the water flow
conductivity (Fatt 1978). If a soft lens material
(such as pure silicone) lacks water flow conductivity then lens adherence may result (Holden
et al 1994).
Tear exchange and the postlens tear film may
be evaluated clinically using observation in
specular illumination with the biomicroscope.
High magnification (x30 or more), a wide angle
of observation (>60) and a narrow slit beam
(0.1 mm) are needed (Bruce and Brennan
1988). An optimal lens fit requires an aqueous
postlens tear film, which is observed as amorphous or non-patterned in specular reflection.
Patterned or colored postlens tear film
appearances are taken to indicate reduced tear
exchange (Little and Bruce 1994).
MATERIAL CHEMISTRY
Soft lens materials are like a sponge, with a porous
structure containing water. The material itself
consists of cross-linked polymer chains, with
spaces between the chains creating the porous
structure. The polymer chains are made up of
small building blocks called monomers, and it is
the combination of different monomers that is
the key to the variety of soft lens materials that
are now available.
Most hydrogel materials contain one or the
other of the following two monomers:
Hydroxyethylmethacrylate (HEMA) is one of
the most frequently used and well known
CHARACTERISTICS OF
HYDROGEL MATERIALS
hydrophilic monomers. It may be polymerised to form poly HEMA, which has a

water content of 38%, or combined with
other monomers.
Methylmethacrylate (MMA) is a monomer
which although hydrophobic, adds strength
and stability to hydrogel lens materials. If can
also be polymerised to form Polymethyl
methacrylate (PMMA), the original oxygenimpermeable rigid lens,material.
These monomers may be combined with
other monomers to give a higher water content
or vary other material properties:
n-Vinyl-pyrolidone (NVP) is a more hydrophilic monomer than HEMA because of the
presence of a carboxyl group (C=O), rather
than a hydroxyl group (-OH). In combination
with HEMA or MMA, it can be used to create
materials with a water content up to 74%
(Table 10.1).
Methacrylic acid (MAA) is a monomer commonly used in disposable lenses. The acidic
units (-COOH) become charged at neutral
pH (-COO) changing the conformation of
the material and increasing the water content
(Su 1991). This can lead to a tightening of
the fitting soon after lens insertion (Little and
Bruce 1994). Such ionic materials are also
susceptible to low pH hydrogen peroxide lens
solutions (Bruce 1989).
Other monomers being used to improve the
wetting of contemporary hydrogel materials
include Glycerylmethacrylate (GMA), Phosphorylcholine (PC) and Polyvinyl alcohol
(PVA).
Silicone-hydrogels are a new class of
hydrogels introduced in the late 1990s
(Alvord et al 1998). The siloxane moiety (SiO) forms the backbone of the silicone
Section
A number of factors have been shown to

affect lens movement:
The process of lens settling after insertion. In
this equilibration process, the tear film
trapped behind the soft lens appears to be
squeezed out by the initial blinking leading
to a reduction in lens movement (Golding,
Harris et al 1995; Golding, Bruce et al 1995).
Reflex tearing on lens insertion may also lead
to a transitory reduction in lens movement
(Little and Bruce 1994).
Eye closure can also affect lens movement.
Periods of eye closure as short as 15 minutes
can reduce lens movement to near zero
(Bruce and Mainstone 1996). The reduction
lens movement appears to be due to a
thinning of the postlens tear film.
Air movement at the anterior surface of the
lens can lead to a reduction in lens movement
due to postlens tear film thinning (Little and
Bruce 1995b).
141
142
Section
Table 10.1: Major hydrogel lens materials categories

Material category
Water content Description

and Dk
Examples
HEMA
38%
Dk 7.5
Original soft lens material,

used mostly for lathed custom
lenses. A strong and stable
material, but with a low Dk.
FDA group 1, low water
content and non-ionic.
Benz 38, Igel 38. (Custom lenses - various

companies)
Polymacon B (Hydron Acti Toric 43%)
HEMA
and n-Vinylpyrolidone
(NVP)
55-70%
Dk 32.7
Common category of mid and

high water materials for custom
lenses and some disposable lenses
FDA group 2, high water and
non-ionic. Higher Dk. Can be
prone to dehydration and
deposits.
Benz 55, Custom lenses-various companies

Igel 56, Ultravision-Capricomia Encore 56
UV disposable lenses
Hefilcon C, 57% B & L Gold Medalist toric
Alphafilcon A B & L Soflens 66/ toric.
(HEMA, NVP & 4-tertiary butyl-2hydroxy-cyclo-hexyl methacrylate)
Hilafilcon-A. 70% B&L Soflens one day
MMA
and n-VinylPyrolidone
(NVP)
58-74%
Dk
16.7-31.5
As for HEMA and NVP

materials (above).
Igel 58, Custom lenses-various companies

Igel 67, Custom lenses-various companies
ActiFresh 400, 73%, Hydron ActiFresh 400 UV
Vasurfilcon-A 74%, W-J Preceision UV
Menicon 72, Sphere and Toric. (NVP and
DMMA=N-dimethyl Acrylamide)
The CSI lens is deposit

resistant. Benz materials
(45G, 55G) became available
in custom lenses in the 1990s
claiming lower dehydration.
Crofilcon- A 42% (MMA, GMA)

Ciba Vision- Wesley-Jessen CSI
Benz 45G (HEMA, GMA) Custom lenses
various companies
Benz 55G (HEMA, GMA) Custom lenses
various companies
Most common disposable lens

materials. Good for moulding.
FDA group 4 high water ionic
materials. Highest level of
protein disposition. PH- sensitive
materials, thus avoid acidic
H O system.
Ocufilcon D, 55% Ocular Sciences lenses

Vifilcon A. 55% Ciba Vision Focus
2- weekly, monthly and toric
Etafilcon A. 58% Johnson & Johnson
Acuvue, range of lenses
Methafilcon A. Cooper-Vision Frequency 55.
Spheric. Xcel toric and aspheric
Glyceryl
methacrylate
(GMA)
materials
HEMA
and Metha
-crylic acid
(MAA)
materials
55-58%
Dk
14.8-16.7
HEMA
and Methyl
methacrylate
55%
Dk 14.8
FDA group 2 non-ionic material.

Successful as an opaque tinted
material.
Conventional and disposable lenses.
Phemfilcon-A, Wesley-Jessen Durasoft 3

conventional, Freshlook
Colourblends disposable,
HEMA
and
Phosphor
-ylcholine
62%
Dk 19.6
May relieve symptoms of

dryness- FDA approved claim.
Low dehydration due to high
bound water. FDA group 2
non-ionic high water.
Omafilcon A, Proclear BioCompatibles

disposable lenses
Polyvinyl
alcohol
64-69%
Dk
21.9-25.9
High water and deposit resistant.

FDA group 2 non-ionic high
water.
Nelfilcon A. 69% Ciba Vision Focus Dailies

Atlafilcon A. 64% Ciba Vision Excelens.
Contd...
143
Contd...
Siliconehydrogel
24-36%
Dk
New generation of hyper Dk

extended wear soft lenses
Lotrafilcon A. 24% Ciba Focus Night & Day.

Balafilcon-A. 36% B & L Pure Vision
(Silicone vinyl carbamate, NVP,
siloxane crosslinker, vinyl alanine
wetting monomer).
ANSI Dk values @ 35 C are calculated from the water content, using Dk=1.67*EXP(0.0397*WC) (Morgan and Efron,
1998). These values are lower than early values since they are corrected for boundary layer and edge effects (Fatt & Ruben
1994; Morgan & Efron 1998)
2
-11
Dk Units are Barrer = (cm /sec)(mlO /ml x mmHg) x 10 . To convert to ISO units (which use hectopascals rather than
2
mmHg) multiply by 0.75006 (Benjamin, 1996).
WATER CONTENT
THICKNESS
Current hydrogel lenses are made as thin as
practical in order to maximize the oxygen
transmissibility (Brennan et al 1991), but not
made too thin since this may compromise lens
handling for the patient or lead to desiccation
staining of the cornea (Little and Bruce 1995c).
There is no single thickness for a soft lens,
being a dimension that varies continuously
across the surface of a lens as a function of the
BVP (Fatt 1997). While the center thickness is
the most commonly cited value, these values
are misleading since for a minus powered lens
the center thickness is the minimum value for
the entire lens.
Table 10.2 shows thickness measurements
made for a range of soft lens materials and
powers. The center thickness varies from 0.036
mm to 0.267 mm, for a low water content low
minus power lens and a high water plus powered
lens, respectively. A similar range of values can
be seen for the peripheral thickness values,
For the materials listed in Table 10.1, there is a

large range of water contents available, from 24
to 74% water. How does the clinician choose?
For normal hydrogel lenses, the optimum water
content to maximise oxygen transmissibility is
with high water materials of 60% water content
or more (Brennan and Carney 1987; Morgan
and Efron 1998). Low water content lenses
(38%) do not allow sufficient oxygen
transmission for high minus (>-4.00) or plus
(>+1.00D) prescriptions (La Hood 1991).
While higher water materials tend to be more
fragile and prone to deposits; in this era of daily
disposable lenses these concerns are of less
clinical relevance. In some patients the higher
water content materials may exhibit clinically
significant dehydration on eye, and this issue is
discussed below (Dehydration and wetting). The

newest alternative in choosing materials by water
content are the silicone-hydrogels, which
combine the benefits of low water content (2436%) with a high oxygen transmissibility.
Section
polymer phase, with a hydrophilic phase

contributing to material biocompatibility.
Silicone-hydrogel materials require surface
treatment for adequate wetting, restricting
their use to mass-produced disposable lenses.
The wide range of hydrogel lens materials
available are shown in Table 10.1. More detailed
descriptions of lens materials and monomers are
available (Refojo and Dabezies 1984; Su 1991).
144

Table 10.2: Some soft lens thickness and Dk/ts
Results of individual lenses, in categories of silicone-hydrogels, high minus, moderate minus, moderate plus and toric.
These examples illustrate the variation of thickness across a lens, as well as between lenses of different materials and lens
powers. Note the reduced Dk/t for low water lenses and disposable torics.
Section
Lens
Power of
lens
tested
Water
content
% and (Dk)
Thickness
(t, mm)
Oxygen
Transmissibility
(Dk/t) a,b
Centre
Periphery
Centre
Periphery
Ciba Vision Focus

Night & Day
-5.50
24%
(140)
0.079
0.147
177.2
95.2
Bausch & Lomb

Purevision
-5.25
36%
(99)
0.098
0.208
101.0
47.6
BiocompatiblesHydron Actifresh 400
-12.00
73%
(30.3)
0.108
0.289
28.1
10.5
Johnson & Johnson

1-day Acuvue
-10.00
58%
(16.7)
0.060
0.193
27.8
8.6
Ciba Vision Dailies
-5.50
69%
(25.9)
0.081
0.166
32.0
15.6
Johnson & Johnson

Acuvue 2
-5.25
58%
(16.7)
0.066
0.195
25.3
8.6
Bausch & Lomb

Soflens 38 Medalist
-5.00
38%
(7.6)
0.036
0.193
21.1
3.9
CIBA Vision (W-J)

Precision UV
+4.00
74%
(31.5)
0.267
0.185
11.8
17.0
Johnson & Johnson

Acuvue 2
+4.00
58%
(16.7)
0.190
0.127 (mid)
0.194 (edge)
8.8
13.2 (mid)
8.6 (edge)
Bausch & Lomb

Soflens 38 Medalist
+3.75
38%
(7.6)
0.090
0.048 (mid)
0.125 (edge)
8.4
15.8 (mid)
6.1 (edge)
Bausch & Lomb

Soflens 66 toric
-1.00/
-1.25x 170
66%
(22.9)
0.22
0.298 (inf)
0.160 (sup)
10.4
7.7 (inf)
14.3 (sup)
CIBA Vision (W-J)

Freshlook Toric
-3.00/
-1.00x180
55%
(14.8)
0.124
0.310 (inf)
0.148 (sup)
11.9
4.8 (inf)
10.0 (sup)
BiocompatiblesHydron Actitoric
-2.00/
-1.00 x30
43%
(9.2)
0.146
0.249 (inf)
0.122 (sup)
6.3
3.7 (inf)
7.5 (sup)
a. Oxygen transmissibility (Dk/t) of a contact lens is proportional to the oxygen permeability of the lens material (Dk,
Barrer) and inversely related to the lens thickness (L, cm).
b. These results can be compared to Dk/t criteria cited by Benjamin (1996): Low Dk/t (<12); Medium Dk/t (12-25); High
-9
Dk/t (26-50); Super Dk/t (51-80); and Hyper Dk/t (>80) with units of Barrer/cm (cm/sec)(mlO /ml x mmHg) x 10 .
2
A Hyper Dk/t material is one that would be expected to have minimal effect on corneal oxygen supply.
145
although naturally the influence of lens design is

in reverse with maximum thickness values for
the high water content high minus lens. The toric
lenses are the thickest overall, due to the
incorporation of prism into the lens design for
the purpose of lens stabilisation. Note that the
overall oxygen transmissibility is a function of
both the material and the thickness, and this is
discussed further in the next section.
OXYGEN TRANSMISSIBILITY (Dk/t)
FIGURE 10.6: Water content and oxygen permeability
can be seen from Figure 10.6. that there is good

agreement between this new data and the Fatts
theoretical adjustment to his initial equation. The
revised method for measuring Dk/t has been
formalised in a recent American contact lens
standard (ANSI Z80.20 for Ophthalmics- Contact
Lenses) (Benjamin 1998).
CRITICAL Dk/t VALUES
Section
Oxygen transmissibility (Dk/t) of a contact lens

material is directly proportional to the oxygen
permeability of the lens material (Dk, Barrer)
and inversely related to the lens thickness (t, cm).
The Dk unit Barrer = (cm2/sec)(mlO2/[ml
mmHg]) 1011 (Refojo 1988), also known as
Fatt units. If metric units are desired, using hectopascals rather than mmHg, then multiplying the
Barrer/Fatt unit values by 0.75006 will give the
appropriate value (Benjamin 1996).
CO2 transmissibility is directly related to the
oxygen transmissibility for both soft and hard
lenses, being numerically 7 and 21 times greater
for rigid gas permeable and soft lenses,
respectively (Ang and Efron 1989). Therefore if
a lens has acceptable oxygen transmissibility, then
the carbon dioxide transmissibility will also usually
be sufficient.
The relationship between water content (WC)
of soft lens materials and the Dk was the subject
of early controversy. The initial equation of Fatt
and Chaston (1982) Dk=2.00e0.0411*wc was
shown to be in error, with accurate values being
about 77% of early values (Fatt et al 1987, Fatt
and Ruben 1994). The errors were known as
edge and boundary layer effects. Morgan and
Efron (1998) have fitted an equation Dk
=1.67e0.0397*wc to their own measured data. It
Now that there is agreement about the validity

of Dk/t values for soft lenses, there is also a need
to be able to relate Dk/t values to the oneye response. The earliest widely accepted critical
Dk/t criterion is that of Holden and Mertz
(1984). They found an ideal Dk/t value to be
24 Barrer/cm for daily wear and 87 Barrer/cm
for extended wear, although clinically acceptable
values were 15-20 and 34 Barrer/cm for daily
wear and extended wear, respectively.
Since the original Holden and Mertz study
there have been advances in methodology and
understanding. Fatt (1996) criticises the HoldenMertz study because:
Limited sample size (N=14), considering
contact lenses are worn by millions of people
146
No statistical analysis- no estimate of the

standard deviation
Non-standard Dk values: Dk values were cited
at room temperature (not 35C); and the
Dk data is from 1977-1978, which predates
measurement corrections for edge and
boundary layer effects. However, these effects
may cancel out to some extent.
Dk/t values were based on the average
thickness of the powered lenses. While this
may be predictive of corneal stromal edema,
it has limited use in predicting local epithelial
hypoxia at different points on the cornea.
The clinician may be concerned with the
epithelial cell health under the thickest point
of the lens.
The Holden-Mertz criterion has served the
contact lens industry well for many years. It has
served as a goal toward which enormous
research and development activities have been
devoted, culminating in the release of the high
Dk silicone-hydrogel lenses in 1999. However
for clinical use, in evaluating and differentiating
individual lenses, a different approach may now
have more validity and benefit.
Papas (1998) evaluated the effect on limbal
vessel hyperemia from open-eye wear of a range
of soft lenses, with a peripheral Dk/t ranging from
5 to 71. He concluded that a peripheral lens
Dk/t of at least 55 Barrer/cm was required to
avoid limbal hyperemia.
Benjamin (1996) Dk/t categories the Dk/t of
lenses in terms of the equivalent oxygen
percentage received by the normal eye under
various conditions:
Low (Dk/t <12): corneal oxygenation less
than that available in the normal closed eye
Moderate (Dk/t = 12-25): corneal oxyge-
Section

nation similar to that in the normal closed
eye
High (Dk/t = 26-50): corneal oxygenation
significantly above that available in the normal closed eye, although can be significantly
affected by lens design
Super (Dk/t = 51-80): corneal oxygenation
significantly above that available in the
normal closed eye, with lens design having
reduced effect, but substantially below that
received by the central cornea of the open
eye
Hyper (Dk/t >80): corneal oxygenation just
below that received by the central cornea of
the open eye, with minimal effect of lens
design
It is interesting to review the Dk/t values in
Table 10.2, in the context of the criteria given
by Benjamin (1996). While a majority of the
lens examples have a central Dk/t > 12; only a
minority of the lenses have a peripheral Dk/t in
excess of this value. Thus many plus powered
and toric lenses in hydrogel materials have a low
Dk/t in at least one part of the lens.
IONIC CHARGE
Contact lens materials may have an ionic (electrical) charge or may be non-ionic (electrically
neutral). The most prominent group of ionic materials are those containing Methacrylic acid (MAA),
a monomer with a negative charge, as described
above (Material Chemistry). Many disposable
lenses materials with a 55 to 58% water content
are included in this group (Table 10.1).
The presence of ionic charge, in combination
with the water content of a material, forms the
basis for the U.S. Food and Drug Administration
(FDA) classification of lens materials:
DEHYDRATION
CONVENTIONAL DAILY WEAR LENSES

Conventional daily wear is the original modality
of soft lens wear. The majority of conventional
daily wear lenses are custom manufactured by
lathe-cutting, which is labor intensive and hence
makes for the most expensive of the available
lenses. The lenses are usually worn until they
are lost, damaged or their performance deteriorates. Conventional daily wear has also been
defined as wearing lenses with a replacement
interval of over six months (Barr, 1995).
The most significant problem with conventional daily wear has been a higher rate of
adverse reactions than with disposable or rigid
lenses. The important advance that has helped
reduce the incidence of complications with
custom lenses is the introduction of planned
replacement. Planned replacement reduces the
effects of lens deterioration, such as those due
to deposition of protein, lipid and mucin.
Another effect of lens deterioration is decreased
visual acuity (Gellatley et al 1988). Planned
replacement also assists with lens wear and
maintenance compliance, since the patient
attends regularly for both aftercare and lens
replacement.
The most common nominated replacement
interval is 12 months, although semi-annual and
quarterly are also used in some cases, depending
upon the rate of soft lens deterioration in
individual patients. Bleshoy et al (1994) made a
general recommendation that group II lenses
(high water content non-ionic) should be
replaced every 3 months and group IV (high
water content ionic) each month to maintain
optimal lens performance. Another study found
average lens lives of 6 months for group IV lenses
All soft lens materials dehydrate during wear, to

a greater or lesser extent. The dehydration will
at times reduce the comfort of the lens for the
patient (Brennan and Efron 1989), and will also
slightly decrease the Dk/t of the lens. One study
observed an absolute reduction of water content
ranging from +0.5 to -5.3% for different lens
brands, with group 4 (high water content, ionic)
material lenses showing the greatest dehydration
(Efron and Morgan 1999). A group 2 lens,
(Proclear, Biocompatibles, UK) has been shown
to have improved comfort compared to certain
other lenses which appears to be related to
minimal dehydration in vivo (Young et al 1997;
Lemp et al 1999). Anecdotally, other lens
materials including the Benz Extreme H2O and
silicone-hydrogels may also assist in relief of
symptoms of dryness.
CHOICE OF SOFT LENS MODALITY
Section
Group 1 Low water content, non-ionic

polymers
Group 2 High water content, non-ionic
polymers
Group 3 Low water content, ionic polymers
Group 4 High water content, ionic polymers
The presence of an ionic charge in contact
lens materials is frequently not of great clinical
significance. As mentioned above, ionic material
lenses may tighten their fitting soon after insertion
(Little and Bruce 1994), which can have the
effect of maximising initial comfort. Ionic
materials are also susceptible to low pH hydrogen
peroxide lens solutions (Bruce 1989), although
these are now uncommonly used solutions.
Finally, high water content, ionic (FDA group 4)
materials tend to attract the highest level of
protein deposition, and this may be of clinical
significance for some patients.
147
148
Section
and 11 months for group I (low water content,

non-ionic) lenses (Haig-Brown 1985). It would
seem reasonable to conclude that all soft lenses
should be replaced at least annually. However,
Norman et al (1995) comment: if the new lens
feels much better than the one it replacedit
was supplied too late.
In order to maximise lens life, conventional
daily wear lenses require more complex care
systems that include enzymatic protein removal.
Thus while the lens cost alone is lower per year
to the patient than for disposable lenses, the cost
of care systems is higher. Overall, there is a similar
cost to the patient for conventional daily wear
and fortnightly/monthly disposable lenses.
In this era of disposable lenses, the advantage
of conventional daily wear lenses is that they
can be custom fitted in a wide range of spherical,
toric, and multifocal designs and with a variety
of lens materials. However, with the growth of
stock disposable lenses, there has been a marked
decrease in use of conventional daily wear over
the last ten years, until now it is prescribed for a
minority of lens wearers. Nevertheless, this lens
modality retains an important role in speciality
contact lens practice, for high prescriptions,
extremes of corneal curvature and in high quality
thinner toric and multifocal designs.
FORTNIGHTLY/MONTHLY DISPOSABLE
LENSES
Disposable lenses were developed to deal with
the most common problem associated with conventional daily wear lensesthat of lens
deposition (Tripathi et al, 1980). Disposable
lenses were initially envisaged as an inexpensive,
fortnightly or monthly replacement lenses. In
addition, disposable lenses reduce the need for
lens maintenance, reducing the cost and

compliance burden on the patient (Collins and
Carney 1986).
The breakthrough in creating disposable
hydrogel lenses arose with the introduction of
moulding technology, which brought the unit
cost of lenses down sufficiently to make it viable
to dispose of a lens rather than protein cleaning
it. Thus no protein remover tablets are used with
either fortnightly or monthly disposable lenses.
This reduces cost and is more convenient for
the patient. The second key advance was the
innovative multiple packaging of lenses, rather
than individual packaging in glass vials, which
allowed convenient replacement schedules since
the patient need not return to the practitioner
for every new pair of lenses.
The regular replacement has significant
physiological benefits. The incidence of giant
papillary conjunctivitis has been greatly reduced
(Kotow et al 1987, Nilsson and Soderqvist
1995). Disposable lenses can be made thinner,
as they need not be so durable, which enhances
oxygen transmissibility and comfort.
Disposable lenses have a number of
secondary advantages over conventional daily
wear lenses:
The patient always has spare lenses, in case
of lens loss or damage
Inventory of lenses is maintained by the
practitioner, so that patients initial trial is often
with the exact prescription. It is also possible
to do a day or week trial of speciality lenses
such as torics, or multifocals.
Compliance can be enhanced as the patient
must attend at least every six months for an
aftercare visit, in order for a new set of
disposable lenses to be ordered. However,
FIGURE 10.7: Inversion markings. The 123 mark on the

Acuvue2 lens is made of a dot-matric pattern. If the numerals
are backwards when the lens is viewed from the outside,
then the lens is inside-out
Extremes of back vertex power (BVP) and back

optic zone radius (BOZR) may not be available,
and so not all patients can be fitted (Norman et
al 1995). Similarly not all materials are
sufficiently resistant to dryness to be comfortable
all day for every patient, and some trial and error
may be required in such cases. Also, mild papillary
conjunctivitis is seen in many patients with
disposable lens.
Many of the earlier disposable toric lenses
do not have a prism-free optic and so they are
relatively thick with low oxygen transmissibility.
There are substantial variations in the design and
performance of disposable toric lenses from
different manufacturers, and generally speaking,
the more recently released lenses are thinner
and more stable.
Patients may voice a preference for conventional lenses over disposable lenses, because
the lens cost alone per year is lower. However
such a comparison ignores the cost of the care
and maintenance solutions, which are hidden,
since the patient is free to buy solutions as they
use them during the year. Lens costs can be
estimated for fortnightly and conventional lenses
with annual replacement at approximately US$
184 and $70 per year, respectively. Estimate of
solution costs can be made, based on a daily
consumption of 5 ml of disinfection solution for
storage of lenses in a flat lens case, 5 ml for
irrigation or rub and rinse of lenses, 1 ml of
cleaner, and a weekly enzyme cleaning. On this
basis, the maintenance of disposable and
conventional lenses may cost approximately $57
and $156 per year, respectively. (Assumes a
multipurpose solution is used for both
disinfection and cleaning for disposable lenses).
Thus, overall costs for fortnightly disposable and
Section
this advantage may be nullified if the patient

can purchase replacement lenses from a
pharmacy, the internet or mail order.
A handling tint (about 10% density) is
generally included as a standard feature. This
is particularly beneficial for hyperopic and
presbyopic patients. Furthermore some
lenses such as the Acuvue 2 (Johnson and
Johnson, Fl) also include a UV absorber and
an inversion indicator as a standard features
(Figure 10.7).
The widest choice of materials now exists for
fortnightly/monthly disposable lenseswider
than for conventional daily wear lenses or
daily lenses. The range of water contents
available is from 24% (CibaVision Night &
Day) to 74% (CibaVision PrecisionUV). There
are also dryness-resistant materials available,
such. Biocompatibles Proclear and Benz
Extreme H2O, as well as silicone-hydrogel
materials.
The potential disadvantages of fortnightly/
monthly disposable lenses are relatively few.
149
150
conventional
comparable.

hydrogel
lenses
appear
is wearing daily disposable lenses for only a few

nights per week, then the cost can be lower than
any other modality.
DAILY DISPOSABLE LENSES
Section
Daily disposable lenses were a logical

development, since in this modality there is zero
care and maintenance. The lenses are single use
and are disposed of each night, rather than being
subject to cleaning or disinfection. Even a lens
storage case is no longer required. McLaughlin
(1995) states that the FDA defines disposable as
single use, which may mean a single period of
extended wear or one day of daily wear.
Daily disposable lenses appear to reduce or
eliminate many of the problems that may occur
with conventional soft lenses, as well as providing
maximum convenience for the patient (Kame
et al 1993; Nilsson and Soderqvist 1995). The
lenses offer the potential for maximum comfort
and vision, since any accumulation of deposits
is minimised. Without solutions or lens storage
case, potential sources of contamination are
minimised and any possible solution reactions
are negated. In addition, part-time wearers do
not have to worry about long-term lens storage
issues.
The limitations of daily disposable lenses
primarily relate to the increased cost and
limitations in parameters. With full-time wear, a
patient requires 14 to 30 times more lenses than
in fortnightly/monthly disposable lens wear, and
the overall cost to the patient is consequently
higher. Parameters are Limited, since at present
only spherical BVP lenses are available. At
US$30/box of 30 lenses, daily replacement
lenses cost at least three times more than the
overall cost of fortnightly/monthly lenses.
However, it is interesting to note that if a patient
SILICONE-HYDROGEL EXTENDED WEAR

DISPOSABLE LENSES
The other modality available for patients who
wish to minimise any inconvenience associated
with contact lens wear is extended wear. In the
1980s, wear of conventional hydrogel lenses
for periods lasting 7 to 30 nights became
popular; however, an increased incidence of
complications, particularly microbial keratitis,
curtailed the popularity of this wearing modality.
The complications were attributed to an
insufficient oxygen transmissibility in hydrogel
lenses, as well as effects of lens spoliation.
In 1999 silicone-hydrogel materials were first
introduced to the marketplace. The inclusion of
silicone allows Dk/t values in excess of 100,
considered sufficient for overnight lens wear with
the majority of patients. Furthermore, the lenses
are monthly disposable, in order to address
problems related to lens deposition seen in the
initial phase of extended wear some 10 years
earlier. Indeed, the silicone-hydrogel materials
are not available for custom-made lenses, since
the material requires a surface modification
treatment by a plasma batch process in order to
ensure in vivo wettability.
Silicone-hydrogel materials have a water
content of 20 to 40% gives sufficient water
transmissibility to ensure rapid recovery from any
lens adherence after overnight wear (Holden et
al 1994). The aqueous phase of the tear film is
able to penetrate the lenses, replenish the
postlens tear film, and thereby restore lens
movement with blinks.
151
Section
The two new high-Dk lenses, Night & Day

(CIBA Vision) and PureVision (Bausch & Lomb),
are not identical. The Night & Day lens is a
fluorosilicone-hydrogel (FDA group I) with
nominal water content of 24% and central Dk/t
(-3.00) of 175. The PureVision is a siliconehydrogel (FDA group III) with a nominal water
content of 36% and central Dk/t (-3.00) of 110.
However, both lenses are monthly disposable
lenses, initially approved for 30 day extended
wear in Europe and 7 day extended wear in the
USA. The regular replacement will help to minimise any inflammatory, allergic or mechanical
complications related to lens deposition.
The monthly replacement, high Dk, hydrogelcontaining contact lenses are expected to keep
to a minimum the incidence of microbial keratitis
in extended wear; however, non-infectious
inflammatory reactions may still occasionally
occur. Additional patient education and aftercare
is usually required for patients fitted with
extended wear lenses.
COLORED LENSES
Enhancement tints can be used to modify
apparent iris color for patients with a lightly
colored iris. The lens color adds to the iris color,
so for example an aqua tint covering a light
green iris may look like a medium blue. They
are similar to a handling tint, except with greater
density. Examples are Focus monthly and
Freshlook Enhancers (both from CIBA Vision).
Opaque color lenses offer a realistic change
of eye color for patients with a dark iris (Figures
10.8A and B). The key to creating a natural
appearance is having the color as a matrix of
opaque dots, which allows some of the natural
iris color to be seen. Perhaps the most widely
B
FIGURES 10.8A and B: Colored lenses. (A) Durasoft
aqua. (B) Durasoft Colourblends Grey
used examples are in the Durasoft Colors range

(CIBA Vision). The main limitations of these lenses
are that there may be a slight loss in visual field
sensitivity, usually less than about IdB (Good and
Ricer 1993), and the comfort may be slightly
reduced, possibly due to surface irregularities
created by the coloration (Steffen and Barr 1993).
CHOOSING LENSES FOR PATIENTS

In this era of disposable hydrogel lenses, one of
the skills in fitting lenses is being able to choose
152
Section
the most suitable lens for a particular patient.

Some of the key issues that need to be
considered are:
1. What refractive error correction is required?
This is a key issue, as the different brands
and types of disposable lenses vary in the
range of powers available, particularly with
higher powers, astigmatic and presbyopic
corrections.
2. Is a steep or flat fitting required? In particular,
a corneal curvature steeper than 44.00D
(7.65 mm) usually needs a steep fitting lens
(e.g. 8.4 or 8.3 mm BOZR) to avoid lens
decentration (Figure 10.1) (Bruce 1994).
3. Selection of lens type/modality. The five
common choices are rigid lens, soft
conventional (custom) lens, 2-week/monthly
disposable, daily disposable, and siliconehydrogel extended wear disposable. Some
of these options may potentially be ruled out,
given the responses to the first two issues
mentioned above. A variety of patient
preference factors may also influence this
choice, as discussed earlier in this chapter.
4. Is there dry eye or a patient history suggestive
of a tear film anomaly? Certain materials are
available which may be more comfortable
or compatible.
Some patient examples follow to illustrate
these points. The first examples are related to
refractive error.
The lens type usually preferred for such high

prescriptions is a rigid lens, since this allows
maximum oxygenation. However, rigid lens
fittings are not always successful in terms of
physiological changes or patient comfort and so
soft lens fitting may be necessary.
The maximum water content material is
desired for such a high minus prescription, since
the highest DK soft materials- the silconehydrogels are not presently available in over 10.00D. The highest water materials available
are in spherical disposable lenses- the CIBA
Vision/ Wesley-lessen Prevision UV (74% water)
and Biocompatibles-Hydron (U.K.) Actifresh
400 (73% water).
Do such high water lenses have a sufficient
Dk/t? Their edge thickness reaches 0.29 mm,
but the 73% material Dk is 30 Fatt units, and so
the Dk/t at the edge is 10.5. Such a Dk/t is usually
clinically acceptable although the patient should
be advised to limit wearing time to perhaps 8
hours per day. Another issue that may arise is
that these lenses may have a reduced optic
diameter and if the lenses decentre then vision
will be adversely affected (Figure 10.9).
HIGH MYOPIA
A patient with a refraction of 11.00D to
16.00D. The two issues here are:
Will the indicated lens be too thick to allow
adequate oxygen to the eye?
Which of the lens brands are available in the
required power?
FIGURE 10.9: Soft lens decentration. The decentered

position of the optic zone is clearly visible in this poorly fitting
minus soft lens. Vision was also affected. Lens centration
was improved by refitting with a steeper BOZR

HYPERMETROPIA
All disposable and custom made lenses are

available for low to moderate degrees of myopia,
ensuring the widest possible choice in lens designs
and modalities. Alternatives including daily
disposable, Hi-Dk extended wear, multifocal and
colored lenses are worthy of consideration
since they offer the latest benefits to the
patient in terms of convenience or aesthetics. A
ASTIGMATISM
Perhaps the most significant issue with toric
disposable contact lenses is the increased
thickness of many designs, compared to an
equivalent spherical lens. As the Dk/t values show
in Table 10.2, some toric disposable lenses have
inadequate oxygen transmissibility. It can be a
difficult clinical choice, since the prism ballasted
lens designs that are thicker may show the
greatest rotational stability. Generally speaking,
the toric lenses with a thin zone design have a
prism-free optic and a lens thickness that is closer
to that of a spherical lens. Thinner toric lenses
should be the lens type of first choice for the
clinician, with thicker prism ballasted lenses being
used only if rotational stability is a problem with
the higher Dk/t lenses.
Conventional soft lenses retain an important
role in toric lens fitting, since they are frequently
thinner and available in a far greater range of
parameters than disposable lenses. This is
particularly an issue for patients with
hypermetropic astigmatism, where the range of
disposable lenses is the most limited. There are
no toric multifocal disposable lenses available at
this time, whereas some of the conventional toric
multifocal lenses can work well. One example is
the Speciality Ultravision SA-Multifocal which is
available in toric powers.
LOW TO MODERATE MYOPIA
newer alternative in fortnightly disposable lenses

is the aspheric design, promising sharper acuity.
Examples are the Ultravision Specialty Choice
A.B., and CooperVision Frequency 55 Aspheric.
Section
Problems with handling may be more frequently

encountered by patients with hypermetropia
since their vision at near is poor when uncorrected, unlike patients with myopia. Older patients
are also more likely to be hypermetropic, and
so this difficulty may be compounded by poorer
dexterity and tactile sensation.
One possible approach is to assist handling is
to prescribe lenses with a slightly darker handling
tint. The Ciba Focus disposable lens is available
with custom tints. A second possible alternative
is the silicone-hydrogel lenses that have recently
become available in plus powers. Extended wear
could be very successful with many older patients,
since lens handling is minimised and the
incidence of immune and inflammatory reaction
may also be lower.
Speciality lens designs including opaque
colored, multifocal and astigmatic may not be
available for higher hypermetropic prescriptions.
Such lenses may be so thick that from an ocular
health perspective, lens wear may be problematic
even if they can be custom-ordered.
Hypermetropic contact lenses maybe relatively
thick to begin with, as are some toric lenses, and
combining these lens designs could result in a
lens with inadequate Dk/t (Table 10.2).
153
PRESBYOPIA
The most common method of contact lens
correction in presbyopia is monovision, This
154
Section
technique involves correcting one eye, usually

the non-dominant eye, for near vision. An
advantage of the technique is that normal singlevision disposable or conventional soft lenses can
be used, with no additional cost to the patient.
It can also be used part-time, since the patient
may have extra lenses for a distance correction
in both eyes at times such as for driving.
For the patient to be successful in monovision
requires them to have well developed
interocular blur suppression (Collins and
Goode 1994). In other words, they must be able
to suppress the vision in one eye whilst using
the other for a particular visual task. Not all
patients can wear monovision comfortably and
the success rate is reported as 64% (Gauthier et
al 1992). Collins et al (1993) found that that
the presence of residual astigmatism was less
tolerated in monovision than with normal
binocular distance vision.
Simultaneous vision contact lenses are a lens
design with more than one focus- either a central
or peripheral zone of additional optical power
are the other main alternative. Examples of
disposable multifocal lenses are: AcuvueBifocal
(Johnson and Johnson Vistakon) and Focus
Progressives (CIBA Vision). These lenses
should be expected to perform differently, since
the AcuvueBifocal is a centre-distance design and
the Focus Progressives is a centre-near design.
The success rate with the AcuvueBifocal has been
reported as 53% (Key and Yee 1999)., Toric
multifocals are available in conventional lenses
(see Astigmatism, above).
STEEP CURVATURE CORNEA
A steeply curved cornea could be defined as one
with keratometric curvature greater than 44.0D
(7.65 mm).
B
FIGURES 10.10A and B: Soft lens edge effectafter
wear of a silicone-hydrogel on a steep cornea
Centration of soft lenses may be poorer if

the cornea has a steep curvature (Bruce 1994),
unless a correspondingly steep curvature lens is
fitted. A number of brands of disposable lenses
have only one BOZR available (typically an
8.6mm) and such lenses may be less likely to
centre well. The lens of choice is often one with
a steeper BOZR, for example the Acuvue2
(Johnson and Johnson, Vistakon). Alternatively,
a steeper conventional soft lens may be suitable.
If a silicone-hydrogel lens edge digs in near
the limbus of patients with a steeply curved
cornea, then bulbar conjunctival staining and
hyperemia may result (Figures 10.10A and B).
155
hydrogel extended wear lenses in this situation.

SYMPTOMS OF DRYNESS
Patients with symptoms of dryness with their
present lenses, may show signs including inferior
superficial puncate corneal staining and poor prelens tear film stability (Figures 10.12A and B).
FIGURE 10.11: Use of a silicone-hydrogel in revers-piggy

back configuration with an RGP lens in keratoconus
Section
The more rigid material of the silicone hydrogel

may be the cause of this limitation.
If the curvature is steeper than about 47D
(7.20 mm) then the possibility of keratoconus
should be considered (Bruce and Bohl 1992),
in which case a rigid lens fitting would be likely
to be indicated. If rigid lenses are not well
tolerated in keratoconus, then fitting a silicone
hydrogel over the top of the rigid lens may assist
with lens stability and comfort (Figure 10.11).
PART-TIME WEARER
Sometimes a patient indicates that they are
interested in lens wear for only a few days per
week, perhaps for weekend social or sporting
activities. It For these patients daily disposable
lenses may be particularly suitable, since there
are no contact lens solutions required and there
is no problem with lenses becoming contaminated if they are left in solution for too long an
interval between wears.
The other way to consider such patients is
that if their lenses were more convenient or
comfortable then they may become full-time
wearers. It may be worth considering silicone-
B
FIGURES 10.12A and B: Comparison of soft lens front
surface wetting in a 20-year-old Asian female patient. The
Omafilcon A (Proclear) lenses were prescribed due to the
better wetting and comfort. However, 12 months later, the
wearing time even with these lenses was limited and needed
lubricant drops. Some SPK inferiorly o.u. (A) Ocufilcon D
monthly disposable lens 8.6/14.2/-4.25. (B) Omafilcon A
monthly disposable lens 8.6/14.2/-4.00
156

Table 10.3: Internet addresses for some contact lens and lens care companies
These provide further information about lenses and solutions

Company
Web sites ( to check)
Allergan (Irvine, California)

Alcon Laboratories (Fort Worth, Texas)
Bausch & Lomb (Rochester, New York)
www.allergan.com
www.alconlabs.com
www.bausch.com
www.polymer.com (for Boston)
www.renu.com
www.extreme-h2o.com
www.proclear.com
www.hydron.co.uk/hydron_main_directory.html
www.cvworld.com
www.cibavision.com
www.wesley-jessen.com
www.coopervision.com
www.coopervision.co.uk
www.gelflex.com
www.acuvue.com (1996)
www.johnsonandjohnson.com
http://www.ocularsciences.com/
Benz Research and Development Corporation

Biocompatibles Hydron International
(Farnham, UK)
CIBA Vision (Duluth, Georgia)
(including Wesley Jessen)
Section
Cooper Vision (Fairport, New York)

Gelflex Contact Lenses (Perth, Australia)
Johnson and Johnson Vistakon
(Jacksonville, Florida)
Ocular Sciences/American Hydron
(South San Fransisco, California)
Ultravision-Capricornia Contact
Lens Pty Ltd.
Some lens alternatives which may be more comfortable include the Proclear (Biocompatibles,
UK), the ExtremeHbO (Benz Research And
Development) and silicone-hydrogels may also
assist in relief of symptoms of dryness. These
options offer high Dk/t as well as dryness resistance.
FURTHER INFORMATION
Soft lens fitting has become a dynamic area, with
new lenses and designs being produced all the
time. Keeping up to date is an ongoing challengeone way to keep in touch is to visit the company
websites. Table 10.3 lists a number of websites
related to some of the more prominent contact
lens and solution companies. Different brands
of lens and modalities will suit different patients.
Furthermore, patients will often appreciate being
www.ultravision.com
www.capricorniacontactlens.com
www.igel.co.uk/igel/index1.htm
http://www.linearcapital.com/uvc/uvc.htm
offered alternatives, particularly newer options

for which they may not have been aware existed.
FURTHER READING
1. Alvord L, Court J, Davis T et al. Oxygen permeability
of a new type of high Dk soft contact lens material.
Optom Vis Sci 1998;75: 30-36.
2. Ang JHB, Efron N. Carbon dioxide permeability of
contact lens materials. Int Contact Lens Clin 1989; 16:
48-58.
3. Barr JT. A hopeful economy within the contact lens
industry. Contact Lens Spectrum 1995; 10:1:25-30.
4. Benjamin WJ. Wiggle Room and the transitional
Dk statistic. Int Contact Lens Clin 1998;25: 118-20.
5. Benjamin WJ. Downsizing of Dk and Dk/L: The
difficulty in using hPa instead of mmHg. Int Contact
Lens Clin 1996;23: 188-189.
6. Bleshoy H, Guillon M, Shah D. Influence of contact
lens material surface characteristics on replacement
frequency. Int Contact Lens Clin 1994; 21:82-95.
7. Brennan NA, Carney LG. Optimizing the thicknesswater content relationship for hydrogel lenses.
Contact Lens Assoc Ophthalmol J 1987; 13: 264-67.
26.
27.
28.
29.
30.
31.
32.
33.
35.
36.
37.
38.
39.
40.
34.
lenses and flat samples in air. Int Contact Lens Clin

1987; 14: 389-402.
Fatt I and Ruben CM. Oxygen permeability of contact
lens materials: A 1993 update. Contact Lens Anterior
Eye 1994;17:11-18.
Gauthier CA, Holden BA, Grant T, Chong MS.
Interest of presbyopes in contact lens correction and
their success with monovision. Optom Vis Sci
1992;69:858-62.
Gellatly KW, Brennan NA, Efron N. Visual decrement
with deposit accumulation on HEMA contact lenses.
Am J Optom Physiol Opt 1988; 65: 937-41.
Golding TR, Harris MG, Smith RC, Brennan NA. Soft
lens movement: effects of humidity and hypertonic
saline on lens settling. Acta Ophthalmol Scand 1995;
73: 139-144.
Golding TR, Bruce AS, Gaterell LL, Little SA,
MacNamara J. Soft lens movement: effect of blink
rate. Acta Ophthalmol. 1995: 73; 506-11.
Good GW, Ricer CS. Effect of opaque iris contact
lenses upon visual field testing. CL Spectrum 1993;
8(3): 33-40.
Haig-Brown G. A clinical study of high water content
contact lenses in the daily wear regime. Trans BCLA
Clin Conf; 1985; 12-16.
Holden BA, Mertz GW. Critical oxygen levels to
avoid corneal edema for daily and extended wear
contact lenses. Invest Ophthalmol Vis Sci 1984; 25:
1161-67.
Holden BA, Sweeney DF, Cox I, Fleming CM,
Trokanski M, Ho A, Cornish R, Newton-Howes J.
Water in a contact lens material of similar modulus
and design prevents lens adherence. Optom Vis Sci
(suppl) 1994; 71:79.
Kame RT, Farkas B, Lane I, Atwood JD, Dubow
BW, Cannon W, Rigel L. Patient response to
disposable contact lenses worn on a daily disposable
regimen. CL Spectrum 1993; 8(6):45-49.
Key JE, Yee JL. Prospective clinical evaluation of the
Acuvue Bifocal contact lens. Contact Lens Assoc
Ophthalmol J. 1999;25:218-21.
Kotow M, Holden BA, Grant T. The value of regular
replacement of low water content contact lenses for
extended wear. J Am Optom Assoc 1987; 58: 46146.
La Hood D. Daytime edema levels with plus powered
low and high water content hydrogel contact lenses.
Optom Vis Sci. 1991; 68(11):877-80.
Lemp MA, Caffery B, Lebow K et al. Omafilcon A
(Proclear) soft contact lenses in a dry eye population.
Contact Lens Assoc Ophthalmol J 1999; 25: 40-47.
Little SA, Bruce AS. Hydrogel (Acuvue) lens
movement is influenced by the postlens tear film.
Optom Vis Sci 1994; 71: 364-70.
Section
8. Brennan NA, Efron N. Symptomatology of HEMA

contact lens wear. Optom Vis Sci 1989; 66: 834-38.
9. Brennan NA, Efron N,Weissman BA, Harris MJ.
Clinical application of the oxygen transmissibility of
powered contact lenses. Contact Lens Assoc
Ophthalmol J 1991;17:169-172.
10. Brennan NA, Lindsay RG, McCraw K, Young L,
Bruce AS, Golding TR. Soft lens movement: temporal
characteristics. Optom Vis Sci 1994; 71(6):359-63.
11. Bruce AS: Hydration of ionic hydrogel contact lenses
during hydrogen peroxide disinfection. J Am Optom
Assoc 1989;60:581-582.
12. Bruce AS. Influence of corneal topography on
centration and movement of low water content soft
contact lenses. Int Contact Lens Clin 1994; 21:45-49.
13. Bruce AS, Bohl GN: Topographic modelling system
in assessment of keratoconus. Clin Exp Optom
1992;75: 149-152.
14. Bruce AS, Brennan NA: Clinical observations of the
post-lens tear film during the first hour of hydrogel
lens wear. Int Contact Lens Clin 1988;15: 304- 310.
15. Bruce AS, Mainstone JC. Lens adherence and postlens
tear film changes in closed eye wear of hydrogel
lenses. Optom Vis Sci 1996; 73:1-7.
16. Collins MJ, Carney LG. Compliance with care and
maintenance procedures amongst contact lens
wearers. Clin Exp Optom 1986; 69: 174-77.
17. Collins M, Goode A, Brown B. Distance visual acuity
and mono vision. Optom Vis Sci. 1993;70:723-8.
18. Collins MJ, Goode A. Interocular blur suppression
and monovision. Acta Ophthalmol (Copenh). 1994;
72:376-80.
19. Efron N, Fitzgerald JP Distribution of oxygen across
the surface of the human cornea during soft contact
lens wear. Optom Vis Sci 1996;73:659-65.
20. Efron N, Morgan PB. Hydrogel contact lens
dehydration and oxygen transmissibility. Contact
Lens Assoc Ophthalmol J 1999;25:148-51.
21. Fart I. Water flow conductivity and pore diameter in
extended wear gel lens materials. Am J Optom
Physiol Opt 1978; 55:43-47 2 March 2001.
22. Fatt I. New physiological paradigms to assess the
effect of lens oxygen transmissibility on corneal
health. Contact Lens Assoc Ophthalmol J. 1996
Jan;22(l):25-9.
23. Fatt I. Comparative study of some physiologically
important properties of six brands of disposable
hydrogel contact lenses. Contact Lens Assoc
Ophthalmol J. 1997;23:49-54.
24. Fatt I and Chaston J. Measurement of oxygen
transmissibility and permeability of hydrogel lenses
and materials. Int Contact Lens Clin 9: 76-88, 1982.
25. Fatt I, Rasson JE, Melpolder JB. Measuring oxygen
permeability of gas permeable hard and hydrogel
157
158
41. Little SA, Bruce AS (1995a). Osmotic influences on

postlens tear film morphology and lens movement.
Ophthal Physiol Opt; 15:117-24.
42. Little SA, Bruce AS. (1995b) Environmental
influences on hydrogel lens dehydration and the
postlens tear film Int Contact Lens Clin; 22:148-155.
43. Little SA, Bruce AS. (1995c) Role of the postlens tear
film in desiccation staining. Contact Lens Assoc
Opthalmol J 2001;21:175-181.
44. McLaughlin R. Are planned replacement contact
lenses better than disposables? Contact Lens
Spectrum 1995;10:7:35-37.
45. Morgan PB and Efron N. The oxygen performance of
contemporary hydrogel contact lenses. Contact Lens
Anterior Eye 1998;21:3-6.
46. Nilsson SEG, Soderqvist M. Clinical performance of
a daily disposable contact lens: a 3-month
prospective study. JBCLA 1995; 18:3:81-86.
47. Norman C, Wood W, Rigel L, Farkas B. Seven steps
to success with disposables. Contact Lens Spectrum
1995; 10:2:33-40.
48. Papas E. On the relationship between soft contact
lens oxygen transmissibility and induced limbal
hyperaemia. Exp Eye Res. 1998;67:125-31.
49. Refojo MF. Rigid contact lens materials and oxygen
permeability. The cornea: Transactions of the world
congress on the cornea III. Cavanagh HD ed. Raven
Press. New York. 1988.
Section

50. Refojo MF and Dabezies OH. Classification of the
types of material used for construction of contact
lenses. In: Dabezies OH (Ed). Contact Lenses- the
CLAO guide to Basic Science and Clinical Practice.
Little, brown and Company, Boston, 1984;11.1-11.12.
51. Roseman MJ, Frost A, Lawley ME. Effects of base
curve on the fit of thin, mid-water contact lenses. Int
Contact Lens Clin 1993; 20:95-101.
52. Steffen RB, Barr JT. Clear versus opaque soft contact
lenses: initial comfort comparison. Int Contact Lens
Clin 1993; 20:184-186.
53. Su KC. Chemistry of soft contact lens materials. In:
Bennett ES and Weissman BA. Clinical Contact Lens
Practice. Lippincott-Raven, Philadelphia, 1991.
54. Tripathi RC, Tripathi BJ, Ruben M. The pathology of
soft contact lens spoilage. Ophthalmology 1980; 87:
365-380
55. Tylers Quarterly Soft Contact Lens Parameter Guide,
Tylers Quarterly Publications, Little Rock; 1995: 12(4).
56. Young G, Holden B, Cooke G. Influence of soft
contact lens design on clinical performance. Optom
Vision Sci 1993: 70: 394-403.
57. Young G. Soft lens fitting reassessed. CL Spectrum
1992; 7(12): 56-61.
58. Young G, Bowers R, Hah 1 B, Port M. Clinical
comparison of omafilcon A with four control
materials. Contact Lens Assoc Ophthalmol J 1997;
23: 249-258.
11
Special Contact Lens Designs for Unique Problems
Chapter
159
Special Contact Lens

Designs for Unique
Problems
Michael R Spinell
INTRODUCTORY COMMENTS
Section
The fitting and wearing of contact lenses is usually

associated with healthy eyes. The lens wearer is
usually healthy, the eye on which a contact lens
is going to be placed is healthy and the post
wear evaluation of the eye that has just worn a
contact lens is expected to be healthy. A great
deal of contact lens education is based on the
idea that if a well designed contact lens is fit on a
healthy eye, abnormal physiological complications should seldom occur. Nevertheless, a
tremendous amount of educational time is spent
discussing anterior segment complications
associated with the wearing of contact lenses.
For the most part, the wearing of contact
lenses is usually done because somebody desires
to see clearly without the use of traditional
glasses. This has frequently been referred to as
a cosmetic reason for wearing lenses. However,
a definition of cosmetic mentions correcting
physical defects or decorative or superficial
rather than functional. Ironically, this is not
consistent with the traditional use associated with
contact lenses where vanity is frequently a
motive. In some countries, insurance companies

have continuously used the phrase cosmetic
fitting of contact lenses to describe their use with
routine refractive problems. In the relatively few
instances where glasses did not provide adequate
vision, (keratoconus, irregular astigmatism, and
monocular aphakia) the term medical necessity was introduced to differentiate situations
where contact lenses had distinct advantages
compared to glasses.
There are, however, another group of
individuals who could benefit from the wearing
of contact lenses, but, in a much different manner.
Their reasons are really cosmetic since the lens
wearers appearance will be favorably changed.
This group includes people with physical defects
that could be either congenital or from trauma,
disease or a degenerative process. These patients
have a true cosmetic need or desire to wear
contact lenses since their problem or deformity
cannot be resolved by wearing glasses. In many
instances, vision can also be improved to varying
amounts even though that may not have been
the primary objective.
160
Section
This chapter will describe a variety of situations where special contact lenses are designed
to aid the lens wearer in non-conventional ways.
In many cases, the practitioner is working with
individuals who are extremely sensitive to their
present appearance. One should never take their
situation lightly. Helping people could easily be
one of the most rewarding and satisfying
experiences any practitioner may have.
The circumstances related to each situation
can vary greatly. However, it is always important
to try and get some good base line information
prior to seeing the patient and before deciding
on the proposed course of action. This can help
in reducing any future misunderstanding.
Consequently, the practitioner should try and
find out the following information.
WHAT IS THE PATIENTS EXACT PROBLEM
WHICH THEY WANT TO IMPROVE?
It is very important to understand the exact
nature of the problem the patient wants to
address. In some cases, a patient may have
several different problems, but, may be
interested in correcting one. An example of this
occurs with a patient who has a very noticeable
corneal scar that covers the pupil. The patient
may realize that the vision in that eye will never
be useful so is quite content to have a lens fit on
that eye strictly for cosmetic purposes. In other
instances, the patient may believe that by
correcting one thing, everything else might
simultaneously be improved. For example a
patient with a leukokoria who is unable to fixate
simultaneously with the fellow eye often has an
accompanying tropia present. The patient may
naively think that by covering up the white pupil
in the affected eye, the eye might now appear
to look straight, as well. In reality, situations like
this can sometimes be helped by using special

prism-ballasted cosmetic lenses with decentered
irides and pupils. However, this has to be done
with caution, since it might now jeopardize some
central or peripheral vision for a given patient.
There are also situations that occur where a
cosmetic improvement in one thing does improve
other things. An example of this might be a
person who has a deformed pupil which is very
noticeable since they have light irides. They could
also be very photosensitive and even have a
significant refractive error. This complex situation
might be greatly improved by using one of the
sophisticated lenses that will be discussed later
in this chapter. The pupil might be normalized,
the iris made to look like the fellow eye, glare
reduced and the refractive error corrected to
improve vision, all at the same time.
There are times when a patient may be very
sensitive to something that other people actually
find amusing. For example, a patient may have
some form of heterochromia. This could be
either by having two eyes of totally different color
or by having one eye with two distinct colors.
The practitioner should make a careful assessment
of the patients goals to avoid ordering a lens[es]
that will not be worn.
WHAT ARE THE PATIENTS EXPECTATIONS?
As eluded to above, it is imperative that the
patient realizes what can and cannot be done.
Some patients feel that since they have taken
some initiative and sought this type of care from
an experienced specialist, complete resolution
and restoration will occur. Few patients have the
sophisticated ability to appreciate the interrelationships that exist among the various and
complex ocular structures. After a careful
assessment of the problem[s], the practitioner

should present the options honestly, completely
and with a sense of optimism. Keeping things
realistic and practical is important. One should
never promise something that may be very
difficult to achieve.
WHAT ARE THE EXPECTATIONS OF PEOPLE
WHO ARE CLOSE TO THE PATIENT?
Once the patients problem or problems have

been identified, it is up to the practitioner to
decide what course of action to take to resolve
these problems. This is where it is helpful to have
a good working knowledge about what lens
designs exist, who fabricates these lenses, how
long it takes to get these lenses and what the
laboratory cost will be. Most people have no
concept how complex these lenses can be. At
times, the ingenuity and creativity of the
WHAT MODALITIES PRESENTLY EXIST

THAT ADDRESS THE PATIENTS
PROBLEM[S] ?
practitioner may become necessary in order to

get the maximum benefit.
Due to the nature of these problems, it is
common for patients to travel great distances to
see practitioners who specialize in these unique
lenses. It is quite helpful to learn as much as
possible about the patients afflictions before they
arrive for their visit. Getting information from
another healthcare provider who has already
seen this patient can also be helpful. If good
quality color photographs are available, they
should be sent prior to the exam. This gives the
practitioner a chance to make a preliminary
assessment and possibly have a few decent
diagnostic lenses available to use on the initial
visit. If necessary, it also enables the practitioner
to discuss certain options with the different
laboratories prior to this visit. One should realize,
that working with these special problems is
different. Rarely does a practitioner fail to get
help or advice from others when trying to help
these special patients.
As will be seen, many types of problems can
be solved or helped with the use of some very
basic lens designs. Sometimes, nothing more than
a little ingenuity can solve what may seem like a
complex problem. For example, sometimes
using two stock opaque lenses to address a
monocular problem can avoid the use of a single,
expensive, custom painted iris imagery lens.
Section
There are times when a patients relatives or

close friends may influence the patients
perception about what can be done and what
would be the expected results. Consequently, it
is advisable to have somebody with the patient
during the consultation portion of your exam
so that a good understanding of the entire
situation takes place. One must remember that
a great deal of information is exchanged during
each of these visits so it is quite possible that an
apprehensive and nervous patient might
misunderstand, forget or confuse some of the
things that were discussed. Having somebody
present who is hearing things a bit differently,
can be helpful in reinforcing what was said. It is
also wise to keep good records that fully support
what was discussed.
161
GENERAL COMMENTS ON THE

ELEMENTS THAT COMPRISE
LENS PERFORMANCE
Regardless of the lens type being utilized and
the visual and cosmetic requirements that are
involved, all contact lenses must perform properly
according to the basic contact lens edits. All
162
lenses must position properly, move adequately

for the specific situation, be comfortable to wear,
provide vision consistent with the needs of the
patient and the capabilities of the ocular system,
provide an acceptable cosmetic effect and be
physiologically acceptable to the underlying
ocular tissues. As with regular lenses, these
elements are all inter-related. It is up to the
practitioner to distinguish which elements may
have to be evaluated differently considering the
specific problem the patient has. For example, if
one is fitting a opaque cosmetic lens on a nonseeing eye, it is not necessary to worry about
lens power and the patients visual acuity. In this
case, the practitioner may want to use a lens
power that makes the lens easy to handle.
Section
LENS MOVEMENT
It is very important that any lens placed on the

eye demonstrate some movement. Lenses that
dont move will cause limbal indentation which
can also create physiological problems from
trapped debris that cannot get flushed out from
beneath the lens.
However, with some lenses, it is important
that movement be very subtle so the true
cosmetic effect is not lost. Likewise, if the lens
gets sucked on the eye, it may initially appear
satisfactory, but, eventually the eye will get
hyperemic and negate whatever good intentions
were present.
LENS POSITION
It is important that these lenses center on the
eye as symmetrically as possible. This accentuates
as natural an appearance as possible. If a lens is
fit too loose, it will move around too much and
probably decenter with ocular excursions which
will then ruin or reduce the desired cosmetic

effect.
LENS COMFORT
Contact lenses should be comfortable. If a lens
is not comfortable, the reason for the problem
must be determined. Similar to regular lenses,
lens discomfort could be due to:
1. A ripped edge
2. A ripped surface
3. Trapped dirt or debris behind the lens
4. A dirty front surface
5. A dry eye
6. An irritated eye
7. A loose lens moving about too much
8. Edge stand-off
9. A hypersensitive patient
10. A poorly manufactured lens (i.e. poor
edge)
11. An infected eye (i.e. the patient has
conjunctivitis)
NATURAL APPEARANCE
The one main thing that all eye care practitioners
want is to have their patients look as natural as
possible. Under normal conditions, patients
should blink normally and not look like they are
wearing a contact lens that is annoying them.
Head posture should also be normal.
Occasionally, a person who is bothered by a
contact lens will walk around with their nose in
the air in an attempt to get a contact lens further
under the upper lid where it may feel more
comfortable. When working with problems like
the ones that will be discussed in this chapter,
the goal is still to make eyes look normal, but,
one has to realize that 100% perfect matches
may not always be possible. For example, light

irides are more difficult to work with than with
dark brown irides which automatically hide
many iris details so exact matches are not critical.
As mentioned before, sometimes it may be
advantageous to fit both eyes with a stock
opaque lens rather than try to match the difficult
color of the good eye.
VISION
As with any contact lens, these complex lenses

must still fit on the eye so that they do not create
any adverse physiological problems. One must
remember that many times the eyes being fit
with these lenses already have problems like
scars, neovascularization, staining and injection.
Thus, it is important to evaluate the health of
the eye relative to the specific circumstances that
exist. Some of the lenses that may be used could
be quite thick and therefore not allow a great
amount of oxygen to permeate through to the
underlying tissues. In some cases, this may not
OCULAR MEASUREMENTS AND

OBSERVATIONS
CORNEAL CURVATURE
OCULAR HEALTH
be important since the eye may be in such a

terrible way already. However, in other cases it
may be important to monitor corneal changes
carefully. There is sometimes a tendency when
working with non-seeing eyes to concentrate on
the cosmetic effect of the lens and overlook the
physiological part of the exam. Professional
judgment is often needed to decide on just how
much neovascularization or corneal staining is
acceptable. It is a good idea to consider the post
wear condition of the eye and compare this with
the pre-fit situation. One may also want to
consider whether the patient is symptomatic or
not. A good rule to follow is to introduce patients
with the well known triad by Dr Yamanes; If
the eye doesnt look good, see good or feel good
the patient should take the lens out and call their
practitioner.
Section
Many of the situations presented in this chapter

can have both a visual and cosmetic requirement.
Contact lenses can nicely provide both modalities
consistent with the visual capabilities of the eye.
In some difficult situations, like high astigmatism
or simple presbyopia, there is always the
opportunity to wear a pair of glasses with a good
over-correction to refine the prescription. There
are instances where an eye may be amblyopic .
It still may be important to provide as good a
prescription as possible even though it may not
seem like vision is improved at all. One should
always consider both visual quantitiy [what line
on the chart the eye was able to see] and visual
quality [how the person perceives the vision].
163
The customary keratometric reading (Figures

11.1 to 11.3) or a computerized topographical
corneal plot is important to have since that gives
the practitioner a chance to determine what back
curve may be necessary to use. In some cases,
scarring prohibits an accurate reading to be taken.
In these cases, the keratometric reading of the
good eye may be of some help or the practitioner
can just try a few base curves on that eye and
see what happens.
HORIZONTAL VISIBLE IRIS DIAMETER
The HVID of the good eye is useful information
in deciding what size iris to make on the cosmetic
lens. Various measuring devices can be used
including a simple Optistik (Figure 11.6) that has
164
Section
FIGURE 11.1: Illustrates a computerized topographer

Computerize topographical plots of the cornea can be very
valuable in providing the practitioner with information of the
true surface of the cornea. However, when fitting badly
scarred eyes, it often is just as valuable to try on a diagnostic
lens with known parameters, evaluate it according to the
usual contact lens criteria and then make any changes in
lens design based on the results that were seen
FIGURE 11.2: Shows a typical with-the-rule

topographical plot
pre-spaced segments that make this measurement rather easy. Although the actual cornea
may be slightly larger than this measurement, it
still is useful to use since observers will really be
seeing the colored portion of the eyes.
IRIS COLOR AND ARCHITECTURE
This is a very important observation since in
some of the situations that will be discussed the
FIGURE 11.3: Shows a plot of a distorted cornea
color of the iris will be important to match. It is

also important to observe the iris architecture
since this can vary from individual to individual.
Sometimes high quality 35 mm pictures can be
taken of the good eye so the fabricating
laboratory can have a good example to copy.
This, however, can be deceptive since there is
always a chance that the picture may be slightly
over exposed or under exposed or the flash may
alter the actual color. It could be handy to have
a quick developing Polaroid type camera in the
office for these occasions. Some practitioners
may have color templates (Figure 11.4) or old
artificial eyes (Figure 11.5) available that can also
be sent to the lab for their convenience. In some
cases, a corneal scar can be nicely covered by
simply using a light translucent tinted stock lens.
This often occurs when the irides are light such
as blue and green.
PUPILLARY DIAMETER
This relatively easy measurement is quite
important especially when working with light
irides. Unfortunately, this measurement can vary
greatly from patient to patient and for the same
patient under different types of illumination.
Thus, a person with blue eyes can easily appear

Various forms of templates including accurate 35 mm
photographs can be used to match iris color and architecture
165
to have an anisocoria. Practitioners must decide

whether to use a compromise pupil size or use a
pupil size that will be correct for a significant
amount of the time. This problem is minimized
with dark brown irides since it is very difficult to
see the exact pupil size against the dark iris.
LENS CONFIGURATIONS
FIGURE 11.4: Illustrates a template that can be used to

match iris color
SOLID TRANSLUCENT OR OPAQUE LENS
Section
There are several basic lens configurations that

are available that can be used for many of the
problems that will be shortly described. It is up
to the practitioner to utilize whatever means are
available to accomplish the specific goals.
Sometimes, economic considerations on the part
of the patient make the choice of lens design
less than optimum. It is up to the practitioner to
make sure that the patient realizes what the
desired lens configuration will look like prior to
placing an order. This is where the use of good
diagnostic lenses is very helpful.
FIGURE 11.5: Illustrates an artificial eye that can also be

used by the fabricating laboratory to match iris color
FIGURE 11.6: A basic optistik can be used to gather

information pertinent to fitting many of these complex lens
designs. In this case, pupil size was determined by using an
ultra-violet lamp to exstentuate the pupillary opening so that
a measurement could be made
This is one of the most elementary lens designs

since it consists of a solid round color that can
either be translucent or opaque. The coloration
extends out usually about 10 to 12 mm. The
exact diameter of this area would be consistent
with the horizontal visible iris diameter of the
good eye. A clear area around the periphery
of the lens is helpful since that portion of the
lens usually extends out onto the white sclera.
If the lens being ordered is going to be
translucent, then it is important to know the
percent absorption of the tint. One must
remember that absorption and transmission
are complementary concepts. A lens that has a
30% absorption also could be described as one
with a 70% transmission. Some laboratories may
use other ways to describe their lenses. It is
166
important to make sure that you know the exact

way they describe the color or hue and the way
they describe the amount of darkness. This
enables everyone to understand the same rules
and intelligently modify or re-order a lens when
necessary.
SOLID TRANSLUCENT OR OPAQUE
ANNULUS LENS (FIGURE 11.7)
These are much more complex lenses since they

are designed to simulate as completely as possible
the patients good eye. The iris imagery is either
imprinted or painted onto the surface of the lens.
These lenses are usually custom ordered so a
good color and architectural match is possible.
Non seeing eyes will have a black opaque pupil
incorporated in the design. As previously
mentioned, the size of the pupil is important due
to different lighting situations with light irides
Section
This lens design is similar to the above design

except that a clear pupillary portion is now part
of the design. This clear central area allows light
to enter the eye. This design is usually used for
eyes that are capable of seeing. The size of the
pupillary area is important. If it is made quite
small, it may provide a visual advantage with
depth of focus. However, aligning the visual axis
with the pupillary area can be difficult especially
since the lens will be continuously rotating on
the eye. Thus, it is often advisable to make the
clear zone slightly bigger than necessary to allow
for slight misalignments and lens rotation. On
occasion, this clear area may have to be purposely decentered since the patients pupil may not
be located centrally. This lens now has to be
manufactured with prism since it must maintain
its proper orientation on the eye at all times.
SOLID OPAQUE IRIS IMAGERY LENS

WITH CLEAR OR BLACK PUPIL (FIGURES
11.8 AND 11.9)
FIGURE 11.7: Shows an opaque annulus lens
FIGURE 11.8: Shows painted iris imagery lens with black

pupil
FIGURE 11.9: Shows an opaque iris imagery lens with

clear pupil
FIGURE 11.10: Shows a variety of lens types
being much more difficult to copy.

SEMI-STOCK PROSTHETIC LENSES
This is a basic lens design which only has an

opaque black pupil painted or imprinted onto
the surface to cover up an underlying cataract
or central scar. Once again it is important to have
the pupil large enough to insure coverage under
different illuminations and in the event that the
lens does not symmetrically center on the eye.
CORNEAL PROBLEMS
ARCUS SENILIS OR JUVENILIS
Arcus senilis or juvenilis (Figure 11.11) involves
the deposition of lipids out in the periphery of
the cornea. When it involves a youngster, one
should also consider the possibility of systemic
involvement such as hypercholesteremia.
Regardless of etiology, some people are very
sensitive to their appearance. They also should
be reassured regarding their condition since
many people mistakenly think that arcus is some
form of cancer since it appears like a growth.
There are several lens designs (Figure 11.12)
that are quite simple and nicely address this
problem. Depending on the color of the
background iris, one can often use a basic stock
tinted lens to camouflage the white ring. For
example, if the underlying iris is blue, a light blue
lens usually works nicely. If the underlying iris is
brown, a brown or amber lens will help. The
exact effect each lens will have is based on
various factors. The real question is how the lens
PUPILLARY BLOCK LENS
A slightly different version of this lens can be

made where the pupillary area is not opaque
but actually translucent so it lets in varying
amounts of light. This can be useful for a person
who is experiencing different degrees of
photophobia. The amount of translucency has
to be accurately determined.
The best way to discuss the various ocular
problems and their solution that will be described
is to start at the anterior segment of the eye and
systematically work backwards. As one will see,
there are a few special cases where these lenses
are used for problems other than improving
vision and cosmetically improving the appearance of the lens wearer.
Section
Recently, in the United States, Wesley Jessen has

changed its prosthetic lens service to a Special
Eyes Foundation. As part of their changes, they
now suggest using a special prosthetic fitting set
of lenses to match colors. Lenses are available
with a cross section of possibilities (Figure 11.10).
Utilizing their Freshlook Color Blend imagery in
either a single or double dot matrix design,
Freshlook Color Blends lenses are piggybacked
onto either a light or dark underprint lens to see
if acceptable color matches are possible. Various
pupillary sizes and designs are also available. The
practitioner can then order a semi-stock lens in
whatever color, underprint and pupillary design
necessary.
167
168
Arcus senilis or juvenilis can be an annoying thing to some

patients. Frequently, it can be easily eliminated by fitting a
colored soft lens on the eyes. The exact lens color to use is
determined by trying a few different colored lenses to see
which gives the best result
called the Natural Touch by Cooper Vision,

makes use of a peripheral ring as part of their
normal design with the intent of enhancing the
peripheral appearance of the iris. If one did an
unofficial census on the normal population, they
might be surprised to see that a great number
of people naturally have this type of ring already.
Consequently, people who wear these lenses
should not worry about acceptability.
SCARRED CORNEAS (FIGURES 11.13
AND 11.14)
Section
FIGURE 11.11: Shows an eye with noticeable arcus senilis
Many victims of trauma or a disease process

develop various degrees of corneal scarring.
Minor scars can often be ignored because they
are often quite difficult to see especially against
a light iris. If they happen to be close to the visual
axis, they may affect vision, even though they
may still be difficult to see. However, in many
instances corneal scars may be present and
make that person very self conscious. It is not
unusual for these people to be seen wearing
sunglasses a great deal of the time or wearing a
FIGURE 11.12: Shows the same eye wearing a light brown

lens. Note how the arcus has essentially disappeared
works clinically in the real word. A while ago a

lens was available called the Clear Definition Lens
which consisted of a dark peripheral band located
out where the arcus would be located. This lens
was designed to enhance ones appearance, but,
also had applicability as just described. If a stock
tinted lens did not give satisfactory results, then
a custom tinted lens with a higher percentage
absorption should help. An opaque stock lens
FIGURE 11.13: A small peripheral scar can easily go

unnoticed by many especially if the underlying iris is light.
However, in some cases, a stock translucent or stock
opaque lens may be necessary. This scar, though peripheral
in location and small in size, is still noticeable against the
brown iris

hat over one or even both eyes. Thus, the
location and severity of the scar become
important factors.
If a scar is off of the visual axis, then there is
a good chance that useable vision is present and
the practitioner must consider both the cosmetic
effect of the lens and the visual requirements. A
clear pupil will also be necessary.
There are two basic lens configurations that
may be used in these cases. If the scar is off the
axis, an annulus design lens will be useful. This
donut shaped lens can then be either opaque
or opaque with iris imagery (Figure 11.15) and
169
FIGURE 11.16: Shows a full face figure of the lens on patient

A.M. Note how the arcus appears similar to the normal eye
Section
detail. The simplest design of this type is one

that has an opaque donut appearance with no
iris detail (Figure 11.16). Unfortunately, this
simple design is only cosmetically acceptable on
dark brown irides. Using an opaque blue donut
lens on a patient with blue irides would
cosmetically be very disappointing. Thus, a more
complex version of the above lens would be
required. This is where a good quality template
of some sort along with a good close up picture
of the good eye becomes necessary. One has to
be careful when deciding on pupil size in order
to minimize the chances of the patient having
an anisocoria.
However, the results for many iris imagery
lenses are quite good since good color and
architectural detail is possible.
If a scar is central and no usable vision
(Figures 11.17 to 11.19) is present, one can still
use a simple opaque lens design and have the
opaque dark brown diameter equal to the HVID
of the good eye. Once again, if the iris is light, a
painted or printed iris imagery lens will be
necessary to really improve the cosmetic effect.
One can also try the special Prosthetic Lenses
from Wesley Jessen in the manner described
FIGURE 11.14: Patient A.M. has a very noticeable

scarred left eye and arcus senilus
FIGURE 11.15: Shows a close up of the painted iris imagery

lens. Note that at this distance and resolution, it does not
appear as life-like as it will in the full face picture
170
Section
FIGURE 11.17: Patient TR with a heavily scarred left eye
color and seeing how it compares with the good

fellow eye. Various modifications utilizing double
print lenses and light and dark underprints can
be also tried in order to get the best cosmetic
match. If a suitable match is found, then this
information is given to Wesley Jessen for
fabricating the final lens which incorporates all
of these things. If a suitable match is not found,
then one would have to consider utilizing a
different approach such as a special custom iris
imagery lens.
As previously mentioned, it is also possible
when trying to match color, to use two stock
FIGURE 11.18: Shows a close up of the good eye
FIGURE 11.19A: Illustrates how a stock opaque lens can

be used on one eye to nicely match the appearance of the
other eye. Thus, avoiding the necessity of ordering a very
expensive iris imagery lens
FIGURE 11.19: Shows a first generation prosthetic lens.

Note that the color in this lens is too light and had to be
darkened
(Figure 11.19A). For example, if a person has a

bright blue iris, one would try to match color by
using a Fresh Look Color Blend lens in the blue
opaque lenses and to clinically compare the

results. Sometimes, wearing a lens on the good
eye, as well, eliminates the need to order a highly
custom painted lens that is expensive, takes time
to fabricate and will have to be replaced
sometime in the future.
There are various ways of fitting these
complex iris imagery lenses. Some laboratories
will lend practitioners diagnostic painted lenses
to check on the overall fit of the lens. Other
FIGURE 11.20: Shows the young lady wearing a very

unattractive pair of glasses
FIGURE 11.21: Shows her wearing only one opaque dark

brown annulus lens without iris imagery. Note the obvious
microcornea in the eye without the lens
Section
This patient has a combination of problems; bilateral aphakia,

microcornea, nystagmus and aniridia. A special high
powered dark brown opaque annulus lens without iris
imagery was used to improve vision, slow down the
nystagmus, reduce glare and make the eyes appear normal
in size
171
FIGURE 11.23: Shows a full face figure with both lenses

being worn. Note how the eyes appear normal in size
FIGURE 11.22: Shows a close up of the lens on the eye
laboratories will send the practitioner a white

opaque trial lens to be used for determining the
fit. This lens, or a similar lens to it, will be
eventually sent back to the fabricating laboratory
for the iris and pupillary detail to be added.
MICRO-CORNEA (FIGURES 11.20 TO 11.23)
Micro-cornea is a condition where one or both
corneas are significantly smaller in size than the
cornea of a normal eye. There are various causes
including congenital problems, trauma or as a

result of an infection or injury. The goal of the
practitioner is to make the damaged eye(s) larger
and appear as similar to the good eye or a normal
eye as possible. Most of the time these eyes are
not capable of decent vision, but one can
incorporate power in the lens if it seems
worthwhile. This, of course, will require the
pupillary area to be clear. If there is extensive
scarring in the vicinity of the visual axis and the
pupil, there is a chance that some of this scarring
may still be visible. This is where an assessment
of the overall situation becomes important.
172

ABNORMALITIES INVOLVING THE
IRIS AND PUPIL
Because of the intimate relationship between the
iris and the pupil, it is virtually impossible to talk
about one without considering the other. We
will begin this discussion by describing some of
the unique papillary problems.
ANISOCORIA
An anisocoria occurs when the pupils of each eye
are different in size (Figure 11.24). It can be due
to trauma, disease or be congenital and frequently
Section
The measurements that are required for this

problem include the horizontal visible iris diameter and pupil size of the good eye. Naturally,
iris color and pattern will be important to know
especially with the lighter irides. A keratometric
reading is nice to have, but, may not be possible
if there is too much dense scarring. If this occurs,
one can use a diagnostic lens supplied by the
lens manufacturer as a guide. If the lens is too
loose and literally falls off of the eye, then a lens
with a steeper base curve or larger diameter will
have to be used. In bilateral cases, it is best to
use average anatomical sizes as guidelines. For
example, the size of the artificial iris could be
11.5 mm and the pupillary area [whether it be
clear or opaque black] 4 to 5 mm.
One must remember the time and cost
involved in fitting iris imagery lenses and the
greater difficulty in matching light colored irides.
Consequently, one may have to consider the
use of a simple, basic dark brown iris annulus
lens without iris imagery or detail in some cases
where the patients good eye is dark brown.
These frequently provide very acceptable
cosmesis at an economical price. If the eye has
no useable vision, an opaque pupillary block
lens without pupillary opening can be used at
an even lower cost. This is essentially a clear lens
with an 11.0 to 12.0 mm opaque dark brown
pupil printed or painted on it.
One must also remember that it is also possible
to use two stock lenses from an opaque lens
manufacturer to see if good results can be
obtained at a reasonable cost without having to
use the more expensive custom designs. If
necessary, the lens on the bad eye could be
sent to a tinting or dying company to have the
clear opening in this stock lens now made opaque
black to cover up an underlying scar.
FIGURE 11.24: Shows an example of an anisocoria. In this

case, two stock prosthetic lenses were used to make the
eyes appear the same. This is shown in Figure 11.25
FIGURE 11.25
FIGURE 11.26: Shows a tennis player who was seriously

hurt when he turned to see why his partner in doubles had
not yet served and was hit directly in his eye resulting in a
subluxated lens and superior coloboma
Section
involves the third cranial nerve. If this occurs with

dark brown irides, it is usually very difficult to
observe even if the difference between the two
pupils is great. However, if it occurs in lighter
colored eyes, it can be quite noticeable and
alarming. This condition, though not serious, is
nevertheless difficult to completely remedy since
the difference between the two pupils will vary
according to the amount of environmental light.
Several different lens designs (Figure 11.25)
can usually be helpful to improve this condition.
One can try two stock opaque lenses from one
of the many opaque lens manufacturers. This
may modify the normal iris color, but, frequently
is an inexpensive method of solving the
anisocoria. This method will not be as successful
if the smaller pupil is significantly smaller than
the pupillary opening in the opaque lens. In this
case, some of the normal iris will show up in the
pupillary opening.
One can also try to match the pupil size by
trying an iris imagery annulus lens with iris
architecture in the eye with the larger pupil.
These types of lenses are usually quite realistic.
The only problem occurs when the eyes are
exposed to more light and the pupil in the noncontact lens eye constricts causing anisocoria to
occur again. These lenses are usually quite
expensive and custom made.
173
FIGURE 11.27: Shows the opaque iris imagery lens with

clear pupil that was used on his eye to hide the coloboma
and reduce photophobia. The lens also had high plus
prescription in it to correct his refractive error
IRIS COLOBOMA
A coloboma is an enlarged opening in the iris
where the once round pupil is now enlarged
and mis-shapen. Years ago, it was common to
see a surgical coloboma at 12 oclock following
cataract surgery. These are seldom seen now with
the newer surgical techniques. Colobomas that
result from trauma (Figures 11.26 to 11.28),
disease or from a birth defect can be located in
FIGURE 11.28: Shows this lens on his eye. The underlying

iris that is slightly visible in this high resolution Figure is not
apparent to observers.
174
FIGURE 11.30: Shows a close up of the injured eye
any area of the iris. Symptoms and corrective

alternatives depend upon the size of the
coloboma and the amount of extraneous light
that comes in and enters the eye.
If a person has light irides, it is important to
properly match the good eye. This can be done
by using a custom iris imagery lens that is opaque
in color and has a pupillary opening similar to
the good eye.
One can also try using an opaque stock lens
or a diagnostic lens from the Wesley Jessen
Special Prosthetic Set. If the patient has a dark
brown iris, an opaque dark brown annulus lens
with pupillary opening consistent with that of
the good eye should be tried.
Section
POLYCORIA
Polycoria occurs when there is more than one
opening in the iris. Patients are usually bothered
by light scatter, glare, reduced visual acuity and
sometimes diplopia. The location of the pupillary
FIGURE 11.31: Shows a picture of the normal eye
This patient suffered a traumatic injury to his eye resulting in

polycoria and a decentered visual axis. In this case, a pris,
ballasted, opaque dark brown lens with decentered optic
zone was required to cover up the scan and extra pupil and
enable the patient to see much better
FIGURE 11.29: Shows a facial view that nicely illustrates
the scarring and polycoria
FIGURE 11.32: Shows an early attempt at fitting this eye

using a stock prosthetic lens. In this case, the lens did not
position well with the visual axis. This resulted in Ghosting
since the visual axis did not align with the optic zone of the
lens
FIGURE 11.33: Shows an opaque dark brown prism

ballasted annulus lens with decentered pupil and without iris
imagery. The prism and decentered clear pupil were
necessary to make sure the pupillary opening aligned with
the decentered visual axis
This patient has bilateral congenital aniridia resulting in slightly

decreased vision, photophobia and nystagmus
FIGURE 11.34: Shows the aniridia with an underlying
cataract, a very common clinical complication seen with
patients who have aniridia
ANIRIDIA (FIGURE 11.34)
Aniridia refers to a condition where there is no

or very little iris tissue showing. The eye usually
has reduced acuity from macula and possibly
retinal hypoplasia. Usually, when the condition
is congenital, an accompanying cataract is
present and the eye has a predisposition for
glaucoma. The eye frequently displays a
searching form of nystagmus which further
reduces acuity. Afflicted individuals are bothered
by glare and ghostlike images and sometimes
report a from of diplopia caused by the entering
light getting deviated by the lens opacities.
Various forms of lenses incorporating artificial
irides and clear pupils can be used to reduce the
glare, correct any ammetropias, and improve
cosmesis (Figures 11.35 to 11.40). These lens
designs range from the very simple opaque dark
brown annulus design lens with clear pupil to
the custom iris imagery annulus design lens that
is quite expensive. Once again, the special
prosthetic lens designs from Wesley Jessen can
Section
opening is important since it is quite helpful if

one lines up with the visual axis. There are times
when both pupillary openings are decentered
and it becomes a real challenge to line up the
pupillary opening of the lens with the pupillary
opening of the eye. It sometimes become
necessary to use a larger than normal pupillary
opening in the cosmetic lens to cover up one
pupil while allowing light from the visual axis to
enter the eye (Figures 11.29 to 11.33).
If one cosmetic lens is desired, a custom
opaque iris imagery annulus lens with clear
pupillary opening can be tried. As with other
problems, matching iris color and appearance is
important especially with the lighter irides.
Patients with very dark irides can try an economical approach by using an opaque annulus
lens with dark brown iris and pupillary opening
consistent with that of the fellow eye.
One can also try the Freshlook Color Blends
and the Wesley Jessen Prosthetic lenses to see if
good clinical results can be obtained.
175
176
Section
FIGURE 11.37: Shows a blue lens on the aniridic eye. The

color is too shocking considering her habitual appearance
FIGURE 11.35: Shows a special stock opaque lens as

seen under retro-illumination. The idea for using this lens
was to see if a less expensive lens could be used rather
than an opaque annulus type lens. Even though light did get
through some of the clear areas in the dot matrix, vision
was still improved since photophobia was reduced and the
size of the entrance pupil reduced
FIGURE 11.38: Shows a close up of the lens on the eye
FIGURE 11.36: Shows the special lens that was used. At

the time it was a non production color. There are several
colors now available that could be used for this patient.
FIGURE 11.39: Shows a full face view of the two lenses

that were eventually used
FIGURE 11.40: Shows this same patient

Years later wearing an opaque annulus lens with clear pupil.
It is important to make the annulus the proper size to cover
the iris root and to make sure the pupillary opening is large
enough so the visual axis is not disturbed by the edge of the
clear pupil
FIGURE 11.41: Shows a special form of heterochromia

called a quadrant heterochromia. Note how only one
quadrant appears different in color
Section
be used for this condition. There is a tendency

to try and make the pupillary opening small in
these cases so that a pinhole or pseudo pinhole
effect occurs which can aid acuity. However, it is
important to make sure that this opening is
sufficient in size so there is no dispersion of light
hitting off of the edge of the pupillary zone.
One must also consider the affect an iris
imagery lens has on the appearance of the lens
wearer. For years, people were used to seeing
that individual a certain way. Now, with the use
of these lenses, a big difference in appearance
can occur. Consequently, it is important that the
lens wearer be aware that sometimes it may be
prudent to use a subtle color such as light brown
or hazel rather than shock everybody by
suddenly appearing with bright blue eyes.
177
This young man was born with several congenital problems

that eventually caused this very noticeable leukokoria to
occur. An opaque dark brown pupillary block lens was used
to cover up his obvious cataract.
FIGURE 11.42: Shows his normal eye
HETEROCHROMIA
One of the more interesting cosmetic problems
involves the various forms of heterochromia
(Figures 11.41 and 11.42). In some cases, the
color of one eye differs completely from the color
FIGURE 11.43: Shows the noticeable leukokoria
178
FIGURE 11.44: Shows an early lens that did not position

optimally and showed some of the underlying white cataract.
This would have been quite apparent to any observers so
had to be improved
Section
of the other eye. In other cases, one eye can

have two different colors and even differ in color
from the other eye. If there is an area or
quadrant that differs in color the condition is
referred to as sectorial heterochromia.
This unique condition can be perceived quite
differently by those who are afflicted with the
condition. Some feel it is an amusing conversation piece while others feel it is a cosmetic
distraction and are quite sensitive about their
appearance. Depending upon these circumstance, patients do have alternatives. If a person
has absolutely no problem living with this
condition, it is not necessary to do anything.
However, if a person prefers to make the two
eyes the same, then any one of a number of
alternatives can be tried.
Perhaps, the easiest is to try a stock opaque
colored lens from any one of a number of lens
manufacturers. It would have to be determined
clinically if one lens could be used to match the
other eye or if lenses for both eyes would give
better cosmetic results. Some of these lens
designs use the underlying iris as a backdrop so
there is a possibility that the two eyes might no
match perfectly. However, the results may still
be acceptable. If more complex lenses become
necessary, then the patient must be aware of
the additional costs involved.
PROBLEMS ASSOCIATED WITH THE LENS
On occasion, a patient may have a problem with
the lens in the eye. The lens may appear like a
white mass in the pupillary opening especially if
it is contrasted against a dark iris (Figure 11.43).
These patients are usually candidates for cataract
surgery. However, there are situations where the
patient may not want surgery. This could be due
FIGURE 11.45: Shows this same eye wearing a lens that

now positions properly. Note how both eyes appear quite
similar
to religious beliefs, fear of surgery or anesthesia

or due to the fact that interferometry and A or
B scan ultrasound show that the eye is a nonseeing eye so any procedure, no matter how
cosmetically successful, will not improve vision.
In these cases, a special contact lens could be
suggested (Figures 11.44 and 11.45) that
improves the appearance of the eye. This lens
type can also be used with other conditions that
appear as a white mass in the pupillary opening
such as intraocular tumors.
179
PUPILLARY BLOCK LENS
DIPLOPIA
A pupillary block lens is a basic soft lens with an

opaque black pupil either imprinted or painted
on the center of the lens to cover up any
underlying problems. It is important to make
sure that the black pupillary area is made large
enough to cover up the underlying pupil in
different illuminations when the pupil will vary
in size and to insure coverage if the lens does
not perfectly center on the cornea. At times it
will appear that the person has an anisocoria
especially if the irides are light.
This same concept (Figure 11.46) can be used

in cases where the patient is experiencing
diplopia and the only simple remedy seems to
be occlusion of one eye. This sometimes occurs
after strabismus surgery or trauma such as a
whiplash accident or head contusion. Regardless
of etiology, the patient is unable to maintain
fusion, suffers nauseating double vision and in
reality is disabilitated.
AMBLYOPIA
FIGURE 11.46: Shows a close up of the opaque lens on

the eye
This patient was fit with a stock opaque lens that was sent
to a dyeing company so that the clear pupil could be darkened
thus reducing the amount of light entering the eye. The
percent of light absorption was determined by piggy-backing
the stock opaque lens with another lens whose transmission
was known
This student was seriously injured in an automobile accident

resulting in diplopia. Several attempts at encouraging fusion,
including surgery, dit not help. As a last recourse, an occluder
lens was used on one eye to eliminate the very annoying
double vision.
This lens is essentially the same type as the one used
to hide the leukokoria
Another variation of the occluder lens is one in

which there is not total occlusion of the light
entering the eye but a partial occlusion. This can
be used in situations where the patient is
bothered by some form of photophobia and a
lens with partial absorption is required (Figures
11.47 to 11.49). If a diagnostic lens from a lens
tinting company is used, it is vitally important
Section
A variation of the above situation can be used

where total occlusion is desired , but, the eye
does see well. This could occur during amblyopia
training where the good eye is fogged with
the occluder lens thereby forcing the lens wearer
to use the other eye. A soft lens with another
form of fogging such as with an excess of plus
power can also be used for this same purpose.
PHOTOPHOBIA
FIGURE 11.47: Shows a diagnostic lens piggy-backed onto

another translucent lens of known light transmission. This
combination was used to determine the amount of tinting
that would be required to adequately reduce the photophobia
180
Section
FIGURE 11.48: Shows a close up of the lense on the eye
FIGURE 11.49: Is an excellent Figure showing the darkened

pupillary zone of the final lens against the iris and pupillary
opening of the eye
that the practitioner knows the exact amount of

light absorption [or transmission] that this lens
contains, as well as, the exact color of the tint.
This enables easy modification or replacement
to be done. Different lens tinting companies may
use different nomenclatures to identify and
describe their tints. Thus, it is important to try
and use the same company for any given patient
so there is less of a chance of the lens coming
back differently than desired.
COLOR DEFICIENCY
Even though the vast majority of the population
have no difficulty identifying colors, there are
still about 8% of the male population and 0.5%

of the female population who have some form
of color weakness. Abnormalities of color vision
usually are classified into two categories: anomalous trichromats and dichromats. Anomalous
trichromatism is more common and less severe.
It is characterized by the afflicted having to use
more red or green or blue than normal to match
colors. The condition is called deuteranomaly if
they are green weak, protanomaly if they are
red weak and tritanomaly if they are blue weak.
Dichromatism is the other form of color
weakness. In this case, two colors are used to
match other colors. In deuteranopia, severe
problems occur when discriminating green and
red colors and brightness is about 50% of normal.
With protanopia, a substantial loss of sensitivity
to red occurs and brightness is also greatly
reduced.
Regardless of which specific problem a person
has, most people would be more than happy if
they did not have to live with the consequences
of their problem. For example, they have to be
careful how they dress in order to avoid mixing
colors that look horrendous. In some cases, a
color vision problem can be a contraindication
for certain occupations such as a telephone
technician who may have to match various
colored wires. In other cases, such as with an
electrician who must match various colored
wires, a mistake could be potentially dangerous.
In 1971, Zeltzer published the original paper
on a new contact lens called the XCHROM lens
which he had been using on patients with color
deficiencies. The lens, which is dark red,
transmits light from approximately 590 mu to
700 mu which is in the red zone. He found that
when this lens was used monocularly, usually
on the non-dominant eye, color perception was

favorably altered in many people. Even though
it does not cure the problem, it seems to change
the color perception of many lens wearers so
that they see things more vividly or vibrantly.
Some people also feel that their depth perception
is improved. It seems to work best on anomalous
trichromats even though it could still be useful
for some dichromats.
The exact mechanism for how it works still
remains a mystery. One theory proposes that
the brain of the lens wearer now receives new
and confusing information from the two eyes
that through the process of retinal rivalry, a new
perception of color occurs that is helpful to many
181
FIGURE 11.52: The xchrom lens is not very noticeable

when worn by somebody with a dark brown iris as shown in
picture
Section
FIGURE 11.50: Shows a soft xchrom-like lens that has the

red pupillary area too small allowing light to enter the patients
pupil and reduce the desired effect
FIGURE 11.51: Shows a soft lens with a larger red

pupillary area
FIGURE 11.53: This same type of lens look rather obvious

when worn by somebody with a light blue iris as illustrated in
picture.
people. XCHROM lens wearers also seem to

learn how to use this new information as they
wear the lens over time.
Recently, this lens concept became available
in both a gas permeable rigid design and a soft
design. For years it was only available in the
polymethylmethacrylate material. These new
materials may not officially be referred to as
XCHROM lenses (Figures 11.50 to 11.53) even
though the clinical results may be similar. The
rigid material is called Transaire Ex Amsilfocon
and is available from many fabricating
laboratories. Fitting these lenses is essentially the
182
same as fitting a routine RGP lens using the well

known rules for evaluating lens performance.
However, it is important that the center thickness
of the lens not be too thick since this would cut
down on the amount of light entering the eye
and reduce its effectiveness in improving color
perception. Thus, in some cases, the practitioner
may have to utilize lenticular designs to minimize
center thickness or even modify other lens
parameters such as overall diameter in order to
keep the center thickness acceptable. This becomes very important with plus powered lenses.
The soft lens version of this essentially involves
tinting companies adding a special red
translucent pupillary zone to a soft lens. It is
important that this zone be made larger than
the underlying pupil since you do not want to
get extraneous peripheral light into the eye and
reduce effectiveness. It is strongly advised that
one try a known diagnostic lens on a potential
lens wearer and then order the lens from that
manufacturer or tinting company to insure
uniformity. This reduces the chance of receiving
back a lens with a different transmission or hue.
Because these lenses are red, the lens wearer
may take about 0.50 D more plus power [less
minus power] than expected
An interesting observation that often occurs
happens when a practitioner tries one of these
lenses on a patient who seems to appreciate an
obvious improvement in color perception, but,
then decides not to order a lens for their
personal use. Other people, only wear their lens
for specific purposes. It is not suggested that one
drive at night with this lens since it does reduce
the amount of light entering the eye.
One obvious disadvantage to this lens occurs
with patients who have light irides. The lens is
Section

quite noticeable and even appears like an
anisocoria.
Another recent lens design that aids many
color deficient individuals is called the ColorMax
Lens developed by ColorMax Technologies Inc.
The lens shifts the wavelengths of the light
entering the eye towards the longer end of the
visible spectrum. This is said to make it easier for
a person to distinguish differences between warm
colors such as reds, yellows and oranges. Shorter
wavelengths are also shifted so blues and purples
are easier to disntinguish. These lenses do not
normalize color perception, but enhance contrast
between colors.
CONCLUDING REMARKS
From this previous discussion it should become
quite clear that there are many ocular conditions
that exist where traditional spectacles or contact
lenses will not provide the type of care that is
necessary. It is important for the contact lens
practitioner to thoroughly understand the desired needs of the patient and the lens modalities
that are available to address these needs.
Many times the contact lens practitioner must
utilize personal ingenuity and the professional
help of other practitioners and lens manufacturers in order to provide the most complete
care possible. It is almost unheard of for any
professional whose expertise is requested to deny
somebody help in these difficult cases. Perhaps
it is the realization that their expertise is being
required to help an unfortunate fellow human
being that breaks down any artificial economic
or professional barriers and that the real winners
in these situations is everyone. The use of
loaner or library lenses to help in the final design
that is to be ordered should also be practiced.

It is also important that patients who require
these specialized lenses realize that there are
times when certain conditions exist and certain
lens design limitations exist that prevent the
practitioner from always obtaining total patient
satisfaction.
However, the end result in many of these
extreme challenges is frequently a patient who
is quite happy with the results and a contact lens
practitioner who has increased his/her scope of
practice and achieved a high degree of personal
and professional satisfaction.
REFERENCES
14. Berkowitsch A: Cosmetic Haptic Contact Lenses. J

Am Optom Assoc 1984;55:277.
15. Armitage B: A Cosmetic PMMA Lens for a
Congenital Defect. Int Eyecare 1986;2:631.
16. Philadelphia County Optometric Society Digest,
Summer 2000, page 3.
SUGGESTED READINGS
1. Bailey CS, Buckley RJ: Ocular Prosthesis and Contact

Lenses. Cosmetic Devices. BMJ 1991;302:1010.
2. Cannon WM: Putting the Promises into Practice.
Contact Lens Spectrum 1990;5:65.
3. Comstock T: The Use of Tinted Hydrogel Prosthetic
Lenses. Contact Lens Spectrum 1988;12:54.
4. Creighton C: An Improved Fitting System . Alden
Optical Laboratories, Alden, N Y, 1988.
5. Farkas P, Kassalow T, Farkas B: Use of a Pupillary
Lens in Aphakia. J Am Optom Assoc 1976;47:61.
6. Fontana A: Coping with the Nystagmoid Albino: Lens
Designs That Really Work. Rev Optom 1979;116:36.
7. Gienesk N: W-J Opaque Lens Provides Aphakic Power,
MatchingTint. Rev Optom 1989;126:103.
8. Greenspoon M: History of the Cinematic Uses of
Contact Lenses. Am J Optom Arch Am Acad 1969;
46:63.
9. Greenspoon M: Optometrys Contribution to the
Motion Picture Industry. J Am Optom Assoc
1969;58:983.
10. Key J, Mobley C: Cosmetic Hydrogel Lenses for
Therapeutic Purposes. Contact Lens Forum
1987;12:18.
11. Koetting RA: Cosmetic Contact Lens in the Care of the
Child. J Am Optom Assoc 1979;50:1245.
12. McMahon T, Krefman R: A Four Year Retrospective
Study of Prosthetic.
13. Meshel L: Tinted Lenses: New Life for Dead Eyes.
Contact Lens Forum 1978;3:13.
14. Moss H : A Minimum Clearance Molded Scleral
Cosmetic-Refractive Contact Lens. J Am Optom Assoc
1978;49:277.
15. Narcissus Foundation Bulletin. Narcissus Medical
Foundation. Daly City CA.
16. Oleszewski S, Wood J: Painted Iris Lens Improves
Cosmetic Appearance. Rev Optom 1986;123:56.
17. Scheid T: Reverse Piggy-back for Cosmetic Change in
RGP Wearers. Contact Lens Forum 1989;14:21.
18. Schlanger J: Enhancing Color Vision with New
Hydrogel Lens. Contact Lens Forum 1988;13:57.
19. Spinell M: Contact Lenses for Cosmetic Disfigurements. Chapter 23, Silbert JA: Anterior Segment
Complications of Contact Lens Wear, second ed
Butterworth 2000.
20. Zack M: The Cosmetic Treatment of Adies Tonic Pupil
Using Selectively Tinted Hydrophilic Soft Contact
Lenses. Contact Lens J 1984;12:14.
Section
1. Mershel, L.: Prosthetic Contact Lenses: CLAO Guide

to Basic Science and Clinical Practice. Grune &
Stratton, New York 1984
2. Putz J, McMahon T.: Dot Matrix Opaque Black
Pupil: a Modification for us on Disfigured Eyes.
Contact Lens Spectrum 1990;5:59.
3. Cutler S, Sando R: Contact Lens Correction for the
Post-operative Large Pupil. Contact Lens Forum
1989;14:23
4. Wodak G: Soft Artificial Iris Lenses. Contacto
1977;21:4
5. Spinell M, Haransky E: The Use of the New Wesley
Jessen Opaque Lens for a Congenital Aniridia Patient.
Int Contact Lens Clinic 1987;14:489
6. Spinell M, Santilli J: An Unusual Contact Lens Design
for a Patient with Stargardts Disease. Contact Lens
Spectrum 1992;7:17
7. Spinell M, Bernitt D: Cosmetic Occluder Lens. Opom
Monthly 1985;76:21.
8. Bier N: Albinism. Int Contact Lens Clin 8:10, 1981
9. Greenspoon M, Silver R: Applying Contact Lens
Expertise to Patients with Disfigured Corneas.
Optom Today 1992;35.
10. Zeltzer H: The X-Chrom Lens, J Am Optom Assoc
1971;42:933.
11. Amos DM, Robinson JT, Smith G: Case Report: Use
of Cosmetic Contact Lenses for Heterochromia, Iris
atrophy and Opaque Cataract. J Am Optom Assoc
48:105, 1977.
12. Scheid T, Langer P: Therapeutic Application of
Cosmetic Iris Rigid Lenses. Optom Monthly
1982;73:610.
13. Zadnik K: Prosthetic Hard Contact Lens for
Postsurgical, Enlarged Pupil. Contact Lens Forum
1987;12:24.
183
184
Chapter
12
Contact Lens Fitting in

Refractive Surgery
Ashok Garg
Section
Contact lenses have significant role to play in

Modern Refractive surgery. Refractive surgery
whether it is Radial Keratotomy, Photo refractive
Keratectomy (PRK) or latest LASIK surgery, no
system is yet so perfect to achieve 100%
uncorrected emmertropia. In such situations
patients are weary of putting spectacles again
for overcorrected/undercorrected visual acuity
and astigmatism. Contact lenses are the only
viable effective way to achieve 20/20 visual
acuity.
CONTACT LENS FITTING AFTER

RADIAL KERATOTOMY
Till the last decade Radial keratotomy was the
treatment of choice for curing Myopia and to
certain degree Hypermetropia. Although this
technique is now out of favour in developed
countries but in developing countries RK surgery
is still being practised by many. This may be
due to the high cost factor of Modern LASIK
Surgery.
Despite advancements in Diamond Knife and
techniques of Radial Keratotomy about 15 to
20% of patients remain under corrected or over

corrected (1 D or greater). Such patients are
ideally suited for contact lens fitting to achieve
20/20 vision.
INDICATIONS FOR CONTACT LENS
FITTING IN RK SURGERY
Over correction
Under correction
Irregular astigmatism
Regular astigmatism
Anisometropia
Fluctuating vision
Contact lens fitting following RK surgery
poses difficulty to both the patient and ophthalmologist because of the post-RK corneal
topography. The patient may feel emotionally
down due to unfulfilled expectations of being
free of spectacles and contact lenses.
Computerized corneal topography shows
central corneal flattening which reduces the
myopic power of the eye along with relative
steepening of peripheral cornea (Figures 12.1
and 12.2). Epithelium may show dystrophic
changes, hypoesthesia and punctate lesions.
Contact Lens Fitting in Refractive Surgery
185
FITTING PROCEDURE
FIGURE 12.1: Corneal Topography Before and After RK

Surgery (Picture in left showing cornea before RK while one
on the right after RK. Note Blue colouration in the areas of
Keratotomy lines. (Courtesy: Dr. Agarwals Eye Hospital,
Chennai, India)
It is generally recommended to wait atleast for 3

to 6 months after Radial Keratotomy before
contact lens fitting. Generally large rigid gaspermeable (RGP) lenses are lenses of choice in
Post-RK patients because these lenses provide
excellent oxygen transmission, move perfectly
on the cornea and provide good tear exchange
and good visual acuity. These lenses are fitted
by hit and trial method on the basis of the
following primary requisites Good tear exchange
Lens should not move excessively
Lens weight should be uniform over a large
part of the cornea
Proper centration to achieve optimal vision.
If post-RK corneal flattening is not excessive

(about 38 D or greater), then regular RGP lens
(Spherical or aspheric) and of high oxygen
transmissibility can be fitted. Usually a large lens
of 9.5 mm diameter is selected on the basis of
choosing a trial lens 2.5 D steeper than the post
operative Keratometry. Final fitting is done on
the basis of Flourescein pattern. Preferably select
a large diameter RGP lens and achieve optimal
fitting by changing the base curve (Figures 12.3
and 12.4). Trapped air bubbles may be dealt
with fenestration.
For extreme central corneal flattening a
number of special lenses are commercially
available. Menicons Plateau lens is an ideal one
in which the lens periphery is steeper than the
base curve. This configuration suits the post-RK
corneas profile.
The following steps may be used when fitting
RGP lenses following RK surgery.
Section
CHOICE OF RGP TRIAL LENSES
FIGURE 12.2: Corneal Topography in Post-RK cornea

(Note Flat Central Cornea and peripheral steepening).
In intersecting incisions there may be marked

surface irregularity which may lead to decentration, central pool, intermediate touch and
marked ocular irritation due to lifting of edges.
Tear pool stagnation may result in Hypoxic
damage.
In such corneas contact lenses tend to slip
over the steeper part of the cornea which leads
to decentration and improper vision.
186
Section
FIGURE 12.3: RGP contact lens fitting in Post-RK period.
FIGURE 12.4: Ideal Flourescein pattern in Post-RK

Phase with RGP contact lenses.
Large lens diameter (9.5-11 mm) is generally

recommended.
Optic zone should be relatively small in
relation to over all lens diameter (7 mm optic
zone is recommended for a 9.5 mm overall
lens diameter).
Thin lenses should be used for optimum
oxygen transmission. If a problem of lens
flexure arises, switch to thicker lens design.
Base curve of RGP lens after RK = 6.5 +
0.9 postoperative K, where K is average
postoperative Keratometry. Usually, the
contact lens should align with superior
midperipheral cornea. Sometimes postoperative K readings may result in excessive
lens movement and centration problems.
RGP lenses generally have flatter peripheral

curves than the base curve.
Generally lens power is calculated equal to
preoperative spherical equivalent or over
refraction is done. Minus power must be
added in final contact lens fitting as in postRK there is gap between the flat central
cornea and the contact lens which is filled
with tears thus creating a plus power.
Decentration is a common problem in postRK contact lens fitting. If the lens slips too
high than prisms may be added or the lens
diameter can be increased. If the lens rides
low a lenticular lens can be used or lens
diameter can be decreased.
Toric lenses may be given to correct the
residual astigmatism.
Therapeutic lenses can be fittted in High
Myopia cases showing postoperative under
correction. These lenses may be used to
mould the cornea (orthokeratology).
Sometimes an air bubble may become
trapped under the lens in the gap between
the central flattened cornea and contact lens
and tears may pool leading to poor tear
exchange. In such cases corneal edema may
develop leading to poor visual acuity. In such
situations the lens diameter may be decreased,
base curve is flattened or the lens is fenestrated.
Reverse curve lens is available commercially
for reshaping the flattened apical cornea with
steeper peripheral curves. These lenses may
be used in post-RK fitting.
FITTING TECHNIQUE
First fit the flattened central area. Choose the
trial lens 1 D steeper than the flattest curve.
Assess the fit using flourscein staining for
centration and alignment. Generally 7.5 to
POST FITTING COMPLICATIONS AND

FAILURES
CONTACT LENS FITTING AFTER

PHOTOREFRACTIVE
KERATECTOMY (PRK)
In the last decade Phototherapeutic Keratectomy
(PRK) was the procedure of choice for Refractive
Surgery. Since the inception of sophisticated
LASIK Surgery and PRK procedure short-
comings, it has also gone out of favour among

ophthalmologists.
In PRK surgery contact lens fitting has a
significant role specially post operatively.
In Excimer laser PRK it involves an average
50 to 100 m deep ablation over a 5 to 6 mm
wide area of central cornea which results in
central flattening and reduced Myopia. However
Mid peripheral corneal topography remains
unchanged (Figure 12.5).
Besides the general problems associated with

contact lens fitting, sometimes corneal vascularization may develop which ascends into the
incisions from the limbus. The reported incidence
of neovascularisation is as high as 32 to 58%.
There are reports of contact lens failure which
may be due to irritation, fluctuating vision,
neovascularisation and changes in refractive
error.
FIGURE 12.5: Corneal Topography in Post-PRK (Note

Central corneal flattening and unchanged Mid peripheral
cornea)
Section
8 mm of optic zone is standardised but can

be altered depending on the lateral lag.
If lag is less then smaller optical zone is
preferred.
The reverse curve should be 3 D steeper than
the base curve with a variation between 2
and 4 D.
Fit the peripheral curve zone so that there is
touch in the transition zones and a minimal
edge stand off of 0.1 mm.
Soft contact lenses should be reserved for
senstive cases and should be prescribed with
great caution because of potential risk of
infection and vascularization. If soft lenses are
to be fitted than select lenses with high oxygen
transmission. Lens care compliance should
be monitored and lenses should be replaced
frequently.
187
INDICATIONS FOR POST-PRK CONTACT

LENS FITTING
Bandage contact lens to reduce pain in immediate post-surgical period. Following PRK
patient experiences marked ocular pain for
48 to 72 hours which can be sharply reduced
by giving bandage contact lens.
To restore binocular vision by fitting the
lens in the fellow eye in conditions when one
eye is only operated or patient himself is
reluctant for second eye PRK surgery in the
same sitting.
188
To correct over or under correction to achieve

20/20 vision.
As compared to RK surgery, lesser PRK
surgery patients need post surgical refractive correction due to regression, irregular astigmation
or under correction. Generaly PRK patients have
predictable post-surgical corneal topography.
Usually post-PRK refractions are stable at 6
months interval. RGP contact lenses should be
fitted ideally 18 to 24 weeks after surgery. RGP
lenses are genrally fitted in Post-PRK Stage
because of their high oxygen transmissibility. The
lens parameters in preoperative phase are the
best predictors of the lens parameters in PostPRK stage. If the patients has not worn any lens
prior to PRK procedure the non operated eye
or preoperative Keratometric (K) reading can
be safely used for the initial lens selection. Rigid
gas permeable lenses can be fitted with either
lid attachment or inter palpebral fit. Lens
movement shall vary with the fitting approach a lid attachment fit may move <1 mm with each
blink while an inter palpebral central fit may
move more.
Fitting technique of contact lens in Post-PRK
Phase is mentioned as below:
Evaluate presurgical cornea by K reading
or corneoscopic mapping.
Trial RGP lens fit should be assessed by an
alignment flourescein pattern analysis with
marked pooling over the 6 mm laser area.
Do over refraction to determine optimal
visual acuity. By computerized corneal topography select flattest reading of topography
at the 5mm zone for intial base curve.
As the midperipheral corneal topography
remains unchanged after PRK procedure so it is
relatively easier to fit contact lenses after PRK as
Section
FIGURE 12.6: Flourescein pattern of RGP contact lenses

in Post-PRK phase cornea (Showing Peripheral and apical
clearance and Mid peripheral alignment)
compare to Post-RK surgery. Care should be

taken to ensure proper tear exchange under the
lens (Avoid tear pooling) to allow for venting of
debris (Figure 12.6).
Apart from RGP lenses, hydrogel contact
lenses with high oxygen transmission can also
be fitted following PRK procedure as the
Post-PRK cornea is least susceptible to neovascularisation.
CONTACT LENS FITTING IN

LASIK SURGERY
Contact lenses have significant role to play
specially post-operatively in modern Refractive
Surgery like LASIK surgery.
Despite a lot of technological advancements
being made in the field of LASIK Surgery and
other refractive surgeries like New Wave Front
Technology, custom ablation technology laser
MicroKeratomes, Aberrometers, LASEK and
Conductive Keratoplasty (CK) no system is
completely perfect to achieve 100% uncorrected
20/20 visual acuity. Contact lenses provide an
189
excellent alternative to achieve post-LASIK

emmetropia.
CONTACT LENS FITTING BEFORE

LASIK SURGERY
There are certain indications preoperatively
where we can fit contact lenses to the patients.
FELLOW EYE
In day-to-day practice we have seen patients

wearing Rigid or Semi Rigid Gas permeable
lenses (RGP) showing symptoms of corneal warpage leading to Induced Irregular Astigmatism
(Figure 12.7). In such cases RGP lenses are
replaced by soft contact lenses. Patients have to
wait for 1 to 2 weeks before any LASIK surgery
is performed in such eyes to provide time to the
cornea to recover from the warpage effects and
return to its normal anatomical shape (Figures
12.8 and 12.9). After achieving Healthy cornea
switch the patient to spectacles till the three
consistent and stable topography and refraction
readings are obtained before performing LASIK
Surgery.
FIGURE 12.8: PMMA contact lenses
CORNEAL WARPAGE
FIGURE 12.7: Corneal Topography showing RGP contact

lens induced corneal warpage. (Courtesy: Dr. Agarwals
Eye Hospital, Chennai, India)
Section
Usually LASIK Surgery is performed bilaterally.

Sometimes the patient is anxious and wishes to
have only one eye performed in a single sitting
followed by the second eye a few weeks later. In
such cases contact lenses are fitted in the fellow
(unoperated) eye to achieve binocular vision
and emmetropia. This is a temporary arrangement of a lens fitting in the nonlasered eye till
the patient is operated upon for the second eye.
This arrangement restores binocular vision and
confidence and safety in the patient while driving
and in out door movements.
FIGURE 12.9: Corneal topography after 1 week of removing

contact lens in the same patient (Note relative Corneal
flattening superiorly)
190
CONTACT LENS FITTING IN POSTLASIK PHASE

IMMEDIATE POST LASIK SURGERY PERIOD
Following LASIK Surgery the patient experiences
considerable amount of pain which may persist
for 48 to 72 hours.
Bandage contact lenses are advised in
Immediate Post-LASIK period in Conjunction
with Topical Nonsteroidal Medication (Diclofenac
sodium, ketorolac tromathamine or suprofen)
to reduce pain discomfort appreciately. Bandage
contact lenses are currently being prescribed
routinely in the immediate Post-LASIK period for
48 to 72 hours with excellant results.
Section
EARLY POST-LASIK SURGERY PERIOD

In early post-LASIK period contact lenses are
given for:
i. Over correction under correction and
Astigmation (Regular and irregular) to
achieve optimal vision.
ii. For epithelial defects to provide healing of
the cornea.
iii. For high myopia, if residual number
remains.
Usually soft contact lenses are prescribed
which acts as a conformer. In spite of Modern
LASIK Surgery a number of patients are
still confronted with over correction, under
correction or Astigmatism.
For Post-LASIK Contact Lens fitting
integrity of the flap after 12 weeks of surgery
is considered sufficient to withstand the
minor trauma and movement of an RGP
lens. By 12 weeks refraction and corneal
thickness changes get stabilized (Figure
12.10). Epithelial defect develops as a
FIGURE 12.10: Corneal Topography after Lasik (Note the

blue color in the centre showing central corneal flattening
after lasik). (Courtesy: Dr. Agarwals Eye Hospital, Chennai,
India)
result of epithelial basement Dystrophy or

excessive instillation of Topical anaesthetic
drops prior to the use of Microkeratome.
This may result in epithelial sloughing.
The MicroKeratome blade slides across the
epithelium and denudes a portion of the
epithelium. In epithelial defect cases contact
lens is prescribed to hold the flap firmly in
place when there is Myopia of more than
6 Diopters. This prevents wrinkles and leads
to good conformity of corneal flap to the
underlying corneal stroma.
iv. For Proper MoldingSoft contact lenses
are fitted as conforming shell have a smoothing effect specially in irregular corneas and
reduces the risk of wrinkles and folds to
the minimum (Figures 12.11 and 12.12).
v. Unilateral LASIK procedureWhen one
eye is treated by LASIK for more than
one specific reasons including patient
unwillingness, contact lens in the fellow eye
is fitted to obtain binocular vision and
emmetropia.
191
FIGURE 12.13: Corneal Topography of patient with

Keratoconus (Note Red area which is steep cornea).
(Courtesy: Dr. Agarwals Eye Hospital, Chennai, India)
FIGURE 12.12: Corneal Topography showing central

islands after Lasik. (Courtesy: Dr. Agarwals Eye Hospital,
Chennai, India)
FIGURE 12.14: Flourescein pattern (R/E) showing RGP

Contact lens fitting in Mild Keratoconus with excellent
superior and apical alignment.
vi. Pre-enhancement fittingIn certain situations. Utions one eye remains undercorrected and needs enhancement after a
duration of 8 to 24 weeks. In such cases
contact lens is fitted to achieve emmetropia
so that the patients may lead a normal life
specially in relation to driving, reading and
TV viewing etc. Contact lenses are specially
useful when there are central islands that
requires sometime to disappear (Figure
12.12).
viii. Induced KeratoconusKeractesia or induced Keratoconus develops as a result of
too little stroma left after LASIK Surgery.

This condition is rare and develops specially
in High Myopia. Contact lenses specially
tailored for Keratoconus are often fitted in
such cases (Figures 12.13 and 12.14).
viii. In LASIK Surgery contraindicated cases
when patients are unfit for LASIK Surgery
due to Physiological and Pathological conditions, their refractive error can be corrected by contact lenses, which is an
excellent option to achieve optimal vision
without spectacles. Usually Low Pachymetry readings, Slip Lamp abnormalities
Section
FIGURE 12.11: Corneal Topography showing ablation after

a Myopic Lasik (Courtesy: Dr. Agarwals Eye Hospital,
Chennai, India)
192
and abnormal corneal topography observations are main causes of LASIK Surgery
contraindications. Developing cataract,
corneal pathology and associated Retinal
pathologies are other factors for
contraindication of LASIK Surgery.
In the following clinical conditions contact
lenses are treatment of choice and are preferred
to Refractive Surgery:
Healed Keloids which may be adversely
affected by LASIK Surgery.
Patients with thin and irregular corneas
Leading to Keratoconus.
Patients having systemic collagen diseases.
Highly anxious and nuisance patients who
expect only 20/20 vision after LASIK Surgery.
High Myopes (15-20 Diopters) when LASIK
Surgery is contraindicated and patient is not
willing to undergo alternate surgical procedures.
Section

When corneas are extremely thinned for
second laser enhancement.
For achieving emmetropia prospects of
contact lenses in Refractive surgery are quite
bright. Custom designed contact lenses, Bifocal
Contact Lenses of Disposable type, Extended
wear and non disposable type shall help the
patient to maintain optimal vision.
FURTHER READING
1. Amar Agarwal et al: 4 Volume Text Book of
Ophthalmology. New Delhi: Jaypee Brothers Medical
Publishers (P) Ltd, 2002.
2. Amar Agarwal et al: Refractive Surgery, New Delhi:
Jaypee Brothers Medical Publishers (P) Ltd, 2000.
3. Amar Agarwal et al: LASIK and Beyond LASIK,
Highlights of ophthamology, Panama, 2001.
4. Harold Stein: Contact lenses in Refractive Surgery
Highlights of ophthalmology, Vol 1, 10-13, 2002.
5. Harold Stein et al: Contact Lenses. New Delhi: Jaypee
Brothers Medical Publishers (P) Ltd, 1997.
6. VK Dada et al: Text book of contact lenses. New
Delhi: Jaypee Brothers Medical Publishers (P) Ltd,
1996.
Chapter
13
193
Toric Contact Lenses

Ashok Garg
INTRODUCTION
ASTIGMATISM
Astigmatism develops when the cornea does not
have a spherical surface and two corneal
Section
Toric contact lens is a spherocylindrical lens used

to correct astigmatism or cylindrical number (as
it contains cylindrical component) which
standard soft contact lenses do not have. They
differ from spherical lenses in that toric lenses
have different radii of curvature in opposing 90o
meridians. Generally, three types of toric lenses
are available.
a. Front surface toric lenses which have two
different radii of curvature on the anterior
surface of the contact lens while the posterior
surface is spherical.
b. Back surface toric lenses: In these lenses, two
different radii of curvatures are found on the
posterior surface of the contact lens while the
anterior surface is spherical.
c. Bitoric lenses have different radii of curvature
on the anterior and posterior surfaces.
curvatures produce two focal points in the back

of the eye.
There are three types of astigmatism (Figures
13.1 and 13.2).
1. Corneal
2. Lenticular
3. Mixed
1. Corneal astigmatism is of two types:
a. With-the-rule astigmatism
b. Against-the-rule astigmatism
FIGURE 13.1: Astigmatism (Courtesy Bausch & Lomb,

India)
194
Section
FIGURE 13.2: Lenticular astigmatism (Courtesy Bausch &

Lomb, India). (i) Lenticular astigmatis is the result of an
unequal bending of light by the crystalline lens, (ii) Not related
to the cornea
i. In with-the-rule astigmatism vertical

meridian (90 degrees) is steeper (more
curved) than horizontal meridian.
ii. In against-the-rule astigmatism horizontal meridian (180 degrees) is
steeper (more curved) than the vertical
meridian.
2. Lenticular astigmatism is the result of an
unequal bending of light by the crystalline
lens. It is not related to the cornea.
3. Mixed astigmatism include:
i. Oblique astigmatism where two principal
meridians are other than 90o or 180o (or
very close to those meridians).
ii. In regular astigmatism two principal
meridians are perpendicular to each
other. Regular astigmatism is correctable
by spherocylindrical lenses.
iii. Irregular astigmatism is seen when the
cornea is scarred, inflamed or of irregular
shape and focus light on to multiple points
on the retina.
iv. Residual astigmatism: This is the astigmatism that remains after corneal astigmatism has been corrected (left after a wellfitted and well-centered lens). It may be
same or different compared to prefitting
astigmatism. This is primarily based on
lens moulding on the cornea at its back
and initial front surface curvature. More
residual Astigmatism is the result of a toric
crystalline lens. Generally, a small amount
of residual astigmatism (up to 0.50 D) is
ignored unless the patient complains
about vision or when the corrected visual
acuity is poorer than 20/30 20/40.
CONTACT LENS CORRECTION OF
ASTIGMATISM
There are essentially three ways by which
astigmatism may be corrected with contact lenses.
a. Spherical soft lenses
b. Toric soft lenses
c. Rigid gas-permeable lenses (RGPs)
a. Spherical soft lenses can be used for small
degree of astigmatism. If the total astigmatism
(up to 1 D) is not more than 1/3rd of the
spherical correction, then spherical soft lenses
are usually adequate. When spherical soft
lenses are used to correct astigmatism,
generally standard thickness lenses are
perferred over thinner lenses because thicker
lenses maintain their shape and shall correct
more corneal cylinder. Almost 50% of visually
corrected population have significant amount
of astigmatism (0.75 D or more).
b. Toric lenses: Toric soft contact lenses are used
to correct astigmatism of more than 1 D
(Figure 13.3). Toric lenses may be useful for
correcting corneal lenticular astigmatism or
a combination of two types and mixed astig-
195
proper visual results. Stabilizing systems for toric

lenses include (Figures 13.4 to 13.7).
i. Prism Ballasting
ii. Truncation
iii. Ballast combined with truncation
iv. Periballast
v. Posterior toric surface
vi. Dynamic stabilization (double slab off).
vii. Aspheric back surface
viii. Orientation grooves
ix. Carrier flange (Bioflange)thicker inferior
edge.
x. Combination of all.
Prism Ballasting
FIGURE 13.3: Toric Lens (Courtesy

Bausch & Lomb, India)
matism. Soft toric lenses are contraindicated

in cases of irregular astigmatism as a result of
corneal scarring and in lid closure
abnormalities such as Bells palsy. Generally,
toric lenses are recommended to those
patients who are unable to tolerate rigid
lenses, who have unsatisfactory vision with
spherical soft lenses.
A toric soft lens is fitted like any other soft
contact lens with the additional task of selecting
a lens stabilizing system so that lens remains
properly oriented. Lens stabilization is the most
important and crucial part in toric contact lens
fitting.
TORIC LENS STABILIZATION METHOD
A toric lens must show meridional stability. This
will keep the cylinder at proper axis to ensure
Section
Prism ballasting (Figure 13.4) is convenient for

patients with flat corneas, tight lids or oblique
FIGURE 13.4: Prism ballasting (Courtesy Bausch &

Lomb, India)
196
FIGURE 13.5: Truncation (Courtesy Bausch & Lomb, India)
astigmatism. Generally, prism ballast of 0.75

1.50 prism Diopters (PD) is used to increase the
weight of the bottom edge of the lens. This
heavier bottom edge will stabilize in the 6 o clock
position reducing rotation. Increased thickness
from apex to base of lens provides excellent axis
stabilization. Prism ballasting provides consistent
thickness profile across all the sphere powers and
consistent rotational stability and fitting performance. This is the most common used method
of Toric lens stabilization.
Truncation
Section
In a truncated contact lens (Figure 13.5) 0.51.5 mm section of the lower portion of the lens
is removed. Sometimes both the upper and
lower portions of lens are truncated. Truncation
can be combined with prism ballasting to reduce
the weight and thickness of the prism ballasted
edge. A truncated lens edge should be smoothly
levelled so that it can align comfortably with lower
lid. Usually truncated lenses are less comfortable
because truncation loosens the fit.
Periballasting (Figure 13.6)
FIGURE 13.6: Periballasting (Courtesy Bausch & Lomb,

India)
FIGURE 13.7: Posterior toric curvature (Courtesy

Bausch & Lomb, India)
For patients whose astigmatism is caused by a

toric cornea, contact lenses can be stabilized by
making the posterior surface of toric lens. This
technique is generally recommended for
astigmatism where the cylinder correction is
greater than spherical correction. The lens is most
stable when its steepest curve is aligned with the
steepest part of the cornea. Posterior toric
curvature lenses are produced with a spherical
anterior surface and toric back surface to aid
stabilization by matching back surface to
configuration of toric cornea (Figure 13.7).
197
Dynamic Stabilization (Double Slab off)
TORIC LENS FITTING
This process involves creation of thin zones on

the inferior and superior portions of the lens.
This is most comfortable of lens orientation
systems, but it lacks less stability than truncation.
With dynamic stabilization, the lens rotates so
that the thin zones are positioned at the top and
bottom. Pressure from eyelids maintains this position. Trial lens fitting is recommended to determine the parameters for correct lens positioning.
When an aspheric posterior surface is
combined with prism ballasting or truncation,
lens stabilization is enhanced. This is due to
increased drag as a result of aspheric surface
reducing rotational movement.
For evaluation of lens rotation on the eye,
toric soft contact lenses have etch or laser marks
at the 3 and 9 o clock positions or at 6 o clock
position.
Three fitting techniques are generally used:

Diagnostic
Trial
Empirical
Fitting procedure steps include:
Initial lens power selection
Clinical assessment
Final lens power selection
Follow-up care
Following parameters should be kept in mind

before toric soft lens fitting:
Refraction
Corneal health
Tear film assessment
Parameter availability
Patient comprehension and compliance
Parameters for Successful Fit
Lens must center well over the cornea.
Movements should not be more than 1.5
mm
Rotation of axis should not be more than
15
Visual acuity should be normal, stable before,
during and after the blink.
Prefitting Assessment
Empirical trial fitting

Spherical lens is first tried (found to closest
cylindrical power). Refraction and cylinder in
minus cylinder form is calculated. Here, unlike
spherical lenses, there is no need to do spherical
equivalent. Vertex distance compensation of the
sphere and cylinder is done separately.
Fitting of the toric lens is done with trial lens
which has the same criteria of successful fit as
for soft lenses.
For in office diagnostic fitting and trial fitting,
always select sphere/cylinder closest to final
prescription and also vertex sphere and cylinder.
Determine trial lens diameter by adding
2-2.5 mm to the visible iris diameter (VID). All
toric contact lenses have base curve. So select a
base curve by converting the mean of the K
readings to millimeters and add 0.7 mm in
general or add 0.80 mm to the flattest meridian
or the highest reading in mm.
Perform an overcorrection (recorded in
minus cylinder form). Cylinder is determined
doing over-refraction. The diagnostic toric lens
is a sphere with orientation marks.
Select a trial lens as close as possible to
spectacle cylindrical axis (i.e. 170 degrees).
Section
TORIC SOFT CONTACT LENS FITTING
Initial Lens Power Selection
198
For double slab off lenses, select the base curve

by subtracting 4 D from the flattest K reading.
Evaluate the fit and perform the over-refraction.
Give the trial lens fit to the patient. Wait for
15 to 20 minutes before assessing fit of the lens.
Assess fit of lens by assessing:
Full corneal coverage
Centration
Movement
Comfort
Check rotation of lens by means of the etch
or laser marks at 3 and 9 o clock positions or at
6 o clock position. Rotation can be evaluated
by:
Visual examination
Trial frame that is aligned with the lens
markings
Slit lamp exam with reticule that can be lined
up with lens marking
It is not always possible to show vision to a
patient as trial lens axis might not match
spectacle axis. If three factors (full corneal
coverage, centration and movement) are fine,
then axis finalization is done. For axis finalization,
concentrate on the three laser guide marks at
the inferior or lower portion of the lens. Three
things can happen while assessing toric lens
rotation:
No rotation or minimal rotation of 5 degrees.
Rotation to LHS.
Rotation to RHS.
General formula for toric axis finalization is
LARS Method.
L
A
R
S
Left
Add
Right
Subtract
If there is no rotation or minimal rotation of
5 degrees, then there is no change in spectacle
axis, hence the prescription remains the same.
Section

When there is rotation to LHS (clockwise left
rotation), then add amount of deviation to
the spectacle cylinder axis.
If there is rotation to RHS (counter-clockwise
rotation), then subtract amount of deviation
from the cylinder axis of the spectacle
correction. This is LARS method of axis
rotation compensation. After axis finalization,
the final toric lens order is given. The ordered
lens should orient itself on the eye like the trial
lens did. Manually, rotate the lens, with normal
blinking, it should reorient within a minute.
When the lens assumes its final position,
rotation on blinking should be less than 5.
Movement in the same direction on successive
blinks indicates a tight fit. Loose fit is marked
by excessive random rotation.
Toric soft contact lens should be fit slightly
tight if possible. A large diameter lens is suggested
to achieve better centration. Double slab off
lenses are the most comfortable toric lenses.
Thinner lenses and high water content lenses
also provide comfort and oxygen permeability.
Optimum stability is achieved by using a prism
ballasted lens with a beveled truncation. A good
fit is easier to achieve when corneal astigmatism
is close to 90 or 180. A normal blink pattern
helps to stabilize the lens making a successful
toric fit more likely. Failure with the soft toric
lenses is most often related to discomfort or poor
vision. Discomfort may be related to excess
movement contact with the lower lid or lens itself
causing foreign body sensation. Poor vision is
often caused by the inability of the lens to
stabilize properly. Corneal edema or stippling,
destabilized lens, edge lift off, decentration, poor
movement or limbal compression are signs of a
potential bad toric lens fit.
199
USEFUL TIPS FOR TORIC LENS FITTING

Do not make changes in trial lens axis.
Trial lens (Diagnostic lens) fitting is a very
reliable and scientific method of fitting toric
lenses.
Choose trial lens axis as close as possible to
spectacle axis.
If trial lens axis and spectacle axis are
different, then do not try over-refraction as
it can lead to confusion.
Final lens base curve should be same as trial
lens base curve.
Final lens would also show similar rotation
as trial lens.
RIGID TORIC CONTACT LENS

If the spherical RGP (rigid gas permeable) lens
fits poorly because of decentration, poor
alignment or discomfort, the next choice is an
RGP lens with a posterior toric surface (back
surface toric). The front surface of this lens is
spherical. The rule of quarters can be used to
determine the base curve of a back surface toric
lens. To select the base curve, take one quarter
of the total astigmatism and add this value to
flattest K reading then take the same value and
subtract it from the steepest K reading. Rigid toric
lenses are used to correct significant corneal
astigmatism. These lenses are indicated when:
There is decentration of the spherical RGP
lenses.
Residual astigmatism becomes evident after
fitting a spherical lens.
Instruct patients for proper wear and care

procedures.
Schedule patients visits at 3/4 days, 10 days,
1 month, 3 months and every 6 months.
Ask the patients to wear their lenses at least
4 hours prior to the visit.
Evaluate visual acuity, lens fit and slit lamp
exam with and without fluorescein.
Discuss and reinforce proper patient
compliance.
While removing the toric lens, instruct the
patient to either pinch the lens from the
center or else rotate the lens in either direction
(L or R) to avoid lens damage along lens
markings.
Care and maintenance of toric lenses is similar
to standard soft contact lenses.
Multipurpose solutions are recommended
solutions for best results.
Proper insertion and removal to be taught

to the patient to avoid lens damage (Figure
13.8).
Section
DISPENSING AND FOLLOW-UP

CARE OF TORIC LENSES (CARE AND
MAINTENANCE)
FIGURE 13.8: Optima toric lens (Courtesy Bausch &

Lomb, India)
200

Table 13.1: Toric lenses
%water
Spherical power range

(Diopters)
Cylindrical power range

(Diopters)
Optima Toric range Bausch & Lomb
45%
Plano to 6.00 (in 0.25 steps)

6.009.00(in 0.50 steps)
optic zone 8 mm (Diameter 14 mm)
0.753.25 (in 0.50 steps)

Prism ballast
SL 66 Torics range
Bausch & Lomb
66%
Plano to 9.00 (till 6.00 in 0.25 steps )

and 6.00 to 9.00 in 0.50 steps) Optic
zone 8.0 mm (Diameter 14.5 mm)
0.75, 1.25 and 1.75

Prism ballast
Miracon
Bausch & Lomb
45%
Plano to 6.00 (in 0.25 steps)

(Diameter 14.0 mm)
1.25 and 1.75
Torisoft
Ciba Vision
38%
Plano to 6.00
(Diameter 14.5 mm)
1.00 and 1.75
Focus Toric
Ciba Vision
NA
NA
N.A.
Hydron
American Hydron
38%
+ 20.00 to 20.00 (Diameter 13.5,

14 and 14.5 mm)
0.50 to 6.00
Hydrocurve
SofLenses
45%
+3.00 to 6.00
(Diameter 14.5 mm )
1.25 and 2.00
Hydrocurve II
SofLenses
55%
Plano to 25.00
(Diameter 13.5 and 14.5 mm)
1.25 and 2.00
Dura Soft TT
Standard
Wesley Jessen
30 and
38%
+1.00 to 6.00
(Diameter 12.8 and 13.5 mm )
1.25 and 2.00
Cushion
Wesley Jessen
30 and
38%
+20.00 to 20.00
Diameter (13 and 13.5 mm)
0.75 to 4.00
Balflange
Salvatori
43%
Plano 0.75 to 4.00

(Diameter 13.5 and 14 mm)
1.25 and 2.00
Silk Toric
Silk Lens
NA
NA
NA
Hydromarc
Frontier
43%
Plano to 4.50 (Diameter 14.5 mm)
0.75 to 1.50
Section
Commercial lens
Name
Company
BITORIC RGP LENS
FRONT SURFACE TORIC RGP LENS
In a bitoric lens, the posterior surface is derived

from the corneal shape while the front surface is
shaped to correct any residual astigmatism. The
posterior curvature is determined by the rule of
quarters. Lens diameter is selected as for a rigid
spherical lens. When the lens fits well, an overrefraction is done (recorded in minus cylinder
form). This correction is then added to the front
surface.
If after achieving a good fit with a spherical RGP

lens their exists residual astigmatism sufficient to
affect vision, a front surface toric RGP lens is
recommended. These lenses have a sphericla
posterior curvature and toric anterior surface. A
trial lens is used for over-refraction. Prism ballasting (0.75-1.50 PD) is added to the bottom of the
lens to keep the cylinder properly aligned. Various
toric lenses are available commercially in various
powers in spheres and cylinders (Table 13.1).
201
FIGURE 13.9: SofLens 66 toric lens (Courtesy Bausch &

Lomb, India)
FIGURE 13.10: Form Cast Process (Cast molded). SofLens

66 Toric Lens (Courtesy Bausch & Lomb, India)
Section
Internationally, a number of next generation

toric contact lenses are available commercially.
Out of these, SofLens 66 Toric (Bausch & Lomb)
is of excellant quality (Figure 13.9).
It has unique Lo-Torque designTM (minimal
rotational force) to provide optimal visual acuity
and ease of fit.
It is recommended for daily wear and provides the convenience of planned replacement
disposable (PRD) lenses. It is made from form
cast process (cast molded) which provides a high
degree of rotational stability and consistency
ensuring exceptional visual acuity and comfort
to the patient (Figure 13.10).
FIGURE 13.11: Alfafilcon A material (patented strengthening

monomer) (Courtesy Bausch & Lomb, India)
SofLens 66 Toric Lens is made of Alphafilcon

A material. Its water content is 66%high DK
(32.0) and provides high oxygen transmission
specially in high minus / plus power. It has ideal
balance between DK and dehydration resistance
which optimizes corneal health. Alphafilcon A is
nonionic high water (Group II FDA) material
which is a patented strengthening monomer
(Figure 13.11) and it enhances tear strength,
handling and low protein uptake which reduces
the risk of adverse responses.
202
SofLens 60 Toric Lo-Torque Lens design has

following salient features (Figures 13.12 to 13.20).
I. Prism Ballasting Stabilizing Geometry:
Increased thickness from apex to base of
lens provides excellent axis stabilization.
Section
FIGURE 13.12: Toric Lo-Torque Lens design. SofLens

66 toric lens (Courtesy Bausch & Lomb, India)
II. Refined Optic Zone: Anterior and posterior

optic zone diameters are adjusted to minimise variations in thickness providing
optimal stability.
III. 360o Comfort Chamfer: Reduces lens mass
for rotational stability. Comfort chamfer
peripheral curve ensures even thickness
distribution from top to bottom of lens. It
enhances prism ballasting stabilization and
maximizes comfort for all lens powers.
IV. Balanced Vertical Thickness Profile:
Uniform midperipheral thickness at apex,
FIGURE 13.13: Prism ballasting. SofLens 66 Toric Lens

(Courtesy Bausch & Lomb, India)
FIGURE 13.15: 360 comfort chamfer. SofLens 66 Toric

Lens (Courtesy Bausch & Lomb, India)
FIGURE 13.14: Refined optic zone. SofLens 66 Toric

FIGURE 13.16: Balanced vertical thickness. SofLens 66

Toric Lens (Courtesy Bausch & Lomb, India)
203
FIGURE 13.19: Mold alignment. SofLens 66 Toric Lens

FIGURE 13.17: Bicurve posterior design. SofLens 66
Toric Lens (Courtesy Bausch & Lomb, India)
Section
FIGURE 13.20: Axis adjustment. SofLens 66 Toric Lens

FIGURE 13.18: Rounded edge design. SofLens 66 Toric

center and base of optic zone enhances

rotational stability.
V. Unique Bicurve Posterior Design: Flatter
center and steep periphery for optimum
centration and visual acuity.
VI. Rounded Edge Design: Consistent rounded
edge thickness provides consistent comfort
plus smooth optimal movement over
conjunctival tissue.
SofLens 66 toric has three orientation

indicator at 5, 6 and 7 o clock positions
(30o apart). Its toric location is back surface
and centre thickness is 0.195 mm.
FURTHER READING
1. Amar Agarwal et al: 4 Volume Text book of
Ophthalmology. New Delhi: Jaypee Brothers Medical
Publishers (P) Ltd., 2002.
2. Harold A Stein et al: Contact lenses fundamentals
and ctinical use. New Delhi: Jaypee Brothers Medical
Publishers (P) Ltd., 1997.
3. Tylers et al: Soft contact lens. Parameter Guide,
Slack, 1996.
4. VK Dada. Textbook of contact lenses. New Delhi:
Jaypee Brothers Medical Publishers (P) Ltd., 1996.
204
Chapter
14
Therapeutic Lenses or
Bandage Contact Lenses
Soosan Jacob, Amar Agarwal,
J Agarwal, T Agarwal
Section
Wichrterle and Lim of Czechoslovakia reported

the use of hydrophilic polymer (soft) contact lens
in 1960 and soon this was used as a bandage
lens. Bandage contact lenses (BCLs) are used in
a wide range of corneal disorders.
Common conditions where they are used are
filamentary keratitis, dry eye, epithelial defect
after penetrating keratoplasty or keratorefractive
surgery, corneal perforations and descemetocele,
tamponade of postoperative wound leaks,
corneal melting associated with connective tissue
disorders, trauma (mechanical, chemical or
radiation), eyelid abnormalities like trichiasis,
entropion, ectropion. Therapeutic lenses help
the corneal epithelium to heal in cases of
persistent epithelial defect, recalcitrant recurrent
corneal erosion syndrome, painful corneal
endothelial decompensation with epithelial
edema. The therapeutic contact lens hastens
epithelialization of the cornea. It provides very
effective relief of pain and is very good as a
temporary measure until definitive treatment can
be undertaken.
INDICATIONS OF BCL
i. To protect normal epithelium:
a. Trichiasis
b. Lid margin deformities
c. Protection of corneal graft epithelium
d. Protection of epithelium in dry eyes
e. Exposure of keratitis in VII N palsy
ii. To aid in healing of abnormal epithelium:
a. Corneal epithelial dystrophies
b. Chronic corneal ulcers
c. Bilateral corneal abrasions
d. Recurrent corneal erosions
e. Herpes simplex keratitis
f. Chemical, thermal and irradiation burns
g. Filamentary keratitis
h. Neurotropic keratitis
i. Thygesons SPK
iii. Molding and splinting:
a. Following keratoplasty
b. Deep corneal ulcers
c. Descemotocele
d. Wound leaks
Therapeutic Lenses or Bandage Contact Lenses

iv. Relief of painin bullous keratopathy.
v. Drug Delivery.
FITTING OF BANDAGE CONTACT

LENS
1. Permeability: It is permeable to tears and

medication. This allows the free movement
of water-soluble metabolites and drugs
through the lens.
2. Wetting: A constant uniform tear film is
maintained in the interface between the
therapeutic soft lens and the corneal
epithelium.
3. Visual acuity: Vision improves by replacing
the irregular cornea and reducing discomfort,
pain, glare and watering.
4. Protection: It protects the epithelium from
environmental dessication and trauma from
the eyelashes and lids. Recently epithelialized
areas have poor adhesion between basement
membrane and basal epithelium. The thera-
PRINCIPLES OF THERAPEUTIC
EFFICACY
peutic soft contact lens provides protection

till hemidesmosomes attach firmly. In
chemical burns the epithelial stroma releases
collagenases that cause stromal lysis. This
reaction is halted. After keratoplasty, protection of the graft combined with preservation
of tear film is a major reason for applying
therapeutic lens.
5. Splinting: In the cornea weakened by full
thickness lacerations or deep ulcer, therapeutic soft contact lens acts as a splint. In
shallow anterior chamber, following cataract
surgery due to a wound leak or in small perforation a large diameter steep fitting bandage
lens will help to reform the chamber by
preventing aqueous leak. Stromal swelling
will subsequently seal the leak.
6. Pain relief: In recurrent corneal erosion,
bullous keratopathy and filamentary keratitis,
there is disruption of sensitive corneal
epithelium. Dramatic pain relief is obtained
with a therapeutic contact lens.
The BCL may be left in place for weeks or
months with careful monitoring. Using a
therapeutic lens on an already compromised
corneal or conjunctival surface requires frequent
follow-up, careful monitoring of the fit and condition of the lens, and thorough patient education. Complications which may be seen are:
1. Tear film: Stagnation of tear may lead to toxic
accumulation of metabolites and decreased
ocular defence against microbial infection.
2. Conjunctiva: Giant papillary conjunctivitis
(GPC) is common. Viral and bacterial conjunctivitis may also occur.
3. Cornea: Epithelial edema, punctate epithelial
keratitis, superior limbic keratoconjunctivitis
and diminished corneal sensitivity may also
Section
In noninflamed eyes, ultra-thin low water

content lenses are preferred. In inflamed eyes,
high water content lenses are better tolerated.
Ultra-thin lenses may show no movement even
when the fit is correct. A minimum diameter of
13.5 mm is essential for bandage lenses to
protect the fragile corneal epithelium. Patients
who need to wear a therapeutic contact lens for
many months need an initial loose fit as the lens
tightens with time. BCOR 1 mm flatter than K is
given. In patients with loose epithelium where
minimal lens movement is desired, a lens
0.6 mm flatter than K reading is given.
205
206
Section
be caused by therapeutic contact lens.

Prolonged wear that usually accompanies the
use of therapeutic lenses may predispose to
hypoxic episodes with corneal swelling. These
patients are also at risk for microbial keratitis.
Antibiotic drops may be used prophylactically
while a bandage contact lens is in place to
prevent bacterial keratitis. Bandage contact
lens may lead to superficial and deep stromal
neovascularisation. Stromal opacities and

infiltrates occasionally occur. Blebs, polymegathism, polymorphism and endothelial
edema may occur.
4. Anterior chamber: Cell, flare and hypopyon
may be caused. This may be associated with
lenses that are fitted too steeply and may be
related to anterior segment ischemia.
Chapter
15
207
Contact Lenses for Children
Contact Lenses
for Children
The prescription of contact lenses for children is

a unique responsibility for the contact lens practitioner. There are many indications for contact
lens use in the pediatric population. Contact lens
wear has certain benefits as well as complications
and risks. Therefore, it is not in the best interest
of most children to wear contact lenses for the
correction of modest refractive errors until the
teenage years. If the child is comfortable with
spectacles and the clinical benefits are not
obviously advantageous, then it may be in the
childs best interest for the practitioner to
persuade the parents against the idea of contact
lens wear. The age at which contact lenses
are prescribed for above-mentioned reason
depends on the maturity, motivation, and

responsibility level of the child. Once it has been
determined that a child is motivated enough and
capable of wearing and caring for contact lenses,
the actual fitting procedures are very similar to
those used for adults.
Age becomes a less important consideration
when prescribing contact lenses for aphakia,1
marked anisometropia,2 high myopia, high
hyperopia accompanied by accommodative
esotropia and irregular astigmatism.3 Under these
circumstances, benefits often outweigh the
potential risks when good contact lens care is
available. Contact lenses provide more stable
retinal image than glasses because they reduce
prismatic distortion. Image size differences
between the eyes, due to either magnification
Note: The authors have no financial or proprietary interest in any product mentioned in this chapter.
INTRODUCTION
Section
Rupal H Trivedi
M Edward Wilson
David J Apple
Suresh K Pandey
Andrea Izak
Tamer A Macky
Liliana Werner
208
Section
or minification, are lessened while the peripheral

field of view is increased with contact lenses.4
In children with aniridia, albinisim or ocular
disfigurement5 contact lenses can be used to
create a limiting, occlude light, or produce tint
variations. Contact lenses may also assist in the
treatment of amblyopia6 and esotropia.7
For children who have the aforementioned
conditions, the visual and cosmetic improvements may outweigh the inherent risks of lens
wear. Contact lenses for such reasons should be
presented as an option at the age of the original
diagnosis. Children, even those only days or
weeks old, can successfully wear contact lenses.
Success can be defined here as both being able
to physiologically tolerate a contact lens for a
substantial part of the day and benefit from the
use of it. Such contact lens wear can be both
safe and effective for the majority of young
patients when good care, compliance with proper
hygiene and appropriate lens fit is available.
Otherwise, it may become hazardous.
Care of the patient after the contact lenses are
fitted is a shared responsibility. The child should
be trained to report symptoms and the parent or
caregiver must be trained to observe signs that
indicate problems. Working with children and
gaining their trust requires inventiveness and
patience from the practitioner also. However,
reward of contact lenses wear for the appropriate
pediatric patients include improving not only their
vision but also their quality of life.
HOW DOES IT DIFFER FROM ADULT?

Although there are evident differences noted
when working with the younger population,
there are also similarities between the pediatric
and adult contact lens practice. The similarities
include the basic fitting principles used to obtain

well-fit lenses and physiological requirements of
the cornea and anterior segment. The optical
characteristics and contact lens materials are
essentially the same regardless of the age of the
person wearing the lenses. Lens care techniques
are identical for both children and adults,
although the method of handling the lens is
modified for the pediatric patient.
The infantile eye is anatomically different from
the adult eye. The conjunctival fornix is shallower,
the globe is smaller, and the sclera has a steeper
curvature than in the adults.8 These factors are
significant for the fitting of soft lenses, which are
designed to extend over the limbus. The infant
cornea is smaller, steeper, and vault less than
the adults cornea. These factors are significant
for all types of lenses. Continuously changing
refraction in pediatric eyes primarily related to
an increasing axial length and progressive
corneal flattening provides an additional
challenge. Repeated insertion and removal of a
contact lens can be psychologically traumatic to
the child. The major disadvantage of contact
lenses is the frequency of lens loss and
noncompliance. The pediatric practitioner must
create a high level of confidence and comfort
with the patient and parents. With adults, less
time is spent in an attempt to gain the trust of
the patient. Such is not the case with youngsters.
INDICATIONS FOR CONTACT

LENSES IN CHILDREN
REFRACTIVE
Aphakia
The prevalence of blindness (best-corrected
visual acuity less than 3/60) from cataract in

children in developing countries is probably 1
to 4 /10,000, and approximately 0.1 to 0.4/
10,000, children in the industrialized countries.9
Early surgical intervention is recommended to
minimize the effects of deprivation amblyopia.
Animal studies show that deprivation of form
vision during the critical period of visual
development results in permanent and severe
visual loss. Human studies suggest that the first
6 weeks of life may represent a precortical stage
with visual development. Cataract surgery and
optical correction must take place before the
development of cortical control of visual function
209
(from birth to six weeks of age), when a dense

unilateral cataract is present if good visual
functioning is to develop.10
Various modalities have been used to correct
infantile aphakia over the years. Table 15.1
shows the pros and cons of different approaches
to correct infantile aphakia. Contact lenses were
infrequently used to correct aphakic children
before 1960. Most of the problems of aphakic
spectacles can be overcome by the use of contact
lenses. Aphakic spectacles are not appropriate
for monocular aphakia because of relative magnification differences. The patient with binocular
Table 15.1: Pros and cons of different modalities to correct aphakia
Aphakic glasses
Safety
Power can be easily adjusted
Inexpensive
Restriction of visual field to

approximately 30 degrees.
Because of marked retinal size
disparity (approximately 30%
magnification), it is not suitable for
monocular aphakia
Inferior optics
Debilitating visually, cosmetically
and psychologically
Contact lenses
Power can be easily adjusted

Relatively safe
Suitable for unilateral aphakia
Noncompliance of both parents

and patients
Difficulty in insertion
Psychologically traumatic
5 to 9% magnification
Frequency of lens loss
Corneal complication
Epikeratophakia
Reversible
Extraocular
No damage to recipients cornea
IOL implantation
Tissues not readily available

Graft failure
Difficult to achieve target refractive
power
Delays amblyopia therapy
Frequent change of residual
refraction
Correct size is still a problem
in children below 2 years
Potential postoperative
complications e.g. increase uveal
inflammation
Immediate visual rehabilitation

Maximum compliance
Minimum aniseikonia
Least optical distortion
(Table prepared by Abhay R Vasavada, MD FRCS, Rupal H Trivedi, MD)
Cons
Section
Pros
210
FIGURE 15.1: The 3-year-old boy is bilaterally aphakic

and has aphakic glaucoma controlled with topical
medications. He is shown wearing aphakic spectacles
Section
aphakia face the problems of alterations in

peripheral field of vision, induced distortion, and
prismatic effect while wearing glasses. The weight
of high plus spectacles also makes this option
less than optimal for the aphakic child. However,
aphakic glasses are still used today frequently
for bilateral aphakia with reasonable success
(Figure 15.1). Contact lenses can be used in
combination with spectacles for a near addition
and to correct aniseikonia. Power of contact
lenses can also be easily adjusted according to
the growth of the eye. The effectiveness of
contact lens in the management of amblyopia is
emphasized by the fact that in many units
specializing in the correction of infantile aphakia,
rates of successful contact lens wear for the critical
years of visual development approach 90%.11
This makes contact lens the treatment of choice
for infantile aphakia, and the standard against
which other methods of optical correction should
be compared. Literature has reported development of binocular vision and stereopsis after
early removal of infantile cataract in patients with
excellent compliance with contact lens and
occlusion regimens.12
However, Benezra et al13 have reported that

correction of unilateral aphakia by intraocular
lens (IOL) in children after traumatic cataracts
results in better best corrected visual acuity
(BCVA) and binocularity with a smaller incidence
of strabismus than when correction is carried out
by contact lens. In a meta-analysis of 5 large
studies Lambert et al14 found that approximately
50% of patients with unilateral congenital
cataract developed a visual outcome of 20/200
or worse in their aphakic eyes when corrected
by contact lenses.
Mittelviefhaus et al15 have extensively studied
the factors responsible for failure of contact lens
in pediatric aphakia. Twenty out of 90 children
were included in the study.
10 children (50%)parents discontinued the
treatment;
6 children (30%)refused treatment without
any reason. Most of them were 2 to 4 years
of age;
2 children (10%)contact lens-related complication;
2 children (10%)poor visual prognosis.
According to these authors, if successful
contact lens treatment is not achieved within
8 to 12 weeks, IOL implantation should be
considered, especially in unilateral aphakia.
There is a consensus that IOL implantation is
appropriate for most children undergoing
cataract surgery beyond their second birthday.
The advisability of IOL implantation in infancy
is still being questioned. However, failure to use
contact lens in children leads to a question in
physicians mind, why not to use IOL in children?
They would eliminate handling problems, the
high cost of maintaining lenses through loss or
breakage, infection, and the unending commitment of parents to an eye. IOL implantation
Contact lenses are worth considering for

anisometropia. Anisometropia is an impediment
to the development of binocular vision. The child
prefers to use the eye with better visual acuity
(VA). Therefore, the eye with poor VA will go
through stages of suppression, amblyopia, and
perhaps strabismus. With glasses, there is a
prismatic effect in both the horizontal and vertical
meridians that increases demand on vergence
or causes a vertical displacement. Contact lens
reduces the unwanted prismatic differences
between the eyes, especially in vertical gaze,
which exists when anisometroic spectacles lenses
are used. The child cannot overcome the condition and sees double. Contact lenses eliminate
this problem since they move with the eye.
Young children with low myopia usually do not

require contact lenses. Their VA is usually sufficient
for their short viewing-distance requirements.
Contact lenses can provide remarkable
improvements of vision in high myopes, and they
provide satisfactory means of correction for
unilateral high myopes. Results of myopic
photorefractive keratectomy (PRK) in pediatric
eyes with amblyopia resulting from anisometropia have been encouraging over short followup intervals.17 Stromal haze had occurred in some
children 3 to 6 months postopertively. Recently,
Agarwal et al18 reported a study on laser in situ
keratomileusis (LASIK) to correct myopia in
children. According to the authors, LASIK for
uniocular high myopia in pediatric eyes provided
encouraging results in the management of select
cases of anisometroic amblyopia when other
measures failed. However, according to the same
authors, larger studies with longer follow-up are
necessary to determine the long-term effects.
Patients with high myopia may also require
spectacles for additional minus power and/or
cylindrical power to correct astigmatism, but the
spectacle lenses will be cosmetically acceptable
and have average thickness. Contact lenses often
improve vision two to three lines above the
childs VA with glasses, and babies fitted with
contact lenses for high myopia show increased
awareness of their surroundings and improved
fixation. In contrast to sensitivity testing, the visual
performance of highly myopic patients is better
with contact lenses than with spectacles.19
There have been a number of reports
claiming that hard lenses have a stabilizing or
retarding effect on the progression of myopia.
(Morrison, 1956; Nolan, 1964; Baldwin, 1969;
Kelly, 1975; Stone, 1976, Khoo CY, 1999).20-24
Anisometropia
Myopia
Section
offers a potentially more effective means of

optically correcting these children since the lens
is located within the eye and is providing a
constant visual input. It is well known that
the majority of the eyes axial growth occurs
during the first two years of life. This rapid growth
makes selection of an IOL power for an infant
difficult. Despite these complexities, IOLs are
being implanted in infants with increasing
frequency. A multicenter clinical trial, the Infant
Aphakia Treatment Study (IATS), is being organized in the United States to critically compare
IOL and contact lens correction for infantile
aphakia.
Piggyback IOL implantation has also been
used successfully to overcome the problem of
changing refraction in infantile eyes.16 This later
procedure was named as temporary polypseudophakia and it may help in the prevention
and treatment of amblyopia by avoiding residual
hyperopia.
211
212
Section
The controlled clinical trial carried out by Stone

over a five-year period involved a contact lens
wearing group fitted with polymethyl methacrylate (PMMA) lenses just steeper than the
flattest keratometry reading, and a control group
of spectacles wearers. Stone concluded that the
effects of the contact lenses on the progression
of myopia could not be accounted for entirely
by corneal flattening, and suggested that the
contact lenses might have a retarding effect on
the axial elongation of the eye. Hard gaspermeable contact lenses may give some degree
of myopia control according to Grosvenors25
study. In his two-year study, the authors found
an increase of 0.28 Diopter (D) in the contact
lens wearers and 0.8 D in the control group.
They measured the axial length of the eye and
found increase of only 0.1 mm in those wearing
contact lenses but 0.6 mm in the spectacle
wearers.
Accommodative Esotropia
Young children with uncorrected hyperopia may
develop accommodative esotropia. Full optical
correction will allow for binocularity. Spectacles
are most often prescribed for hyperopia associated with accommodative esotropia. However,
contact lenses may be used to improve cosmesis,
decrease the weight of the spectacle correction,
and improve optics through minimization of
distortion and magnification. Optometrists have
noted, moreover, that the hyperopic patients
using contact lenses instead of spectacles may
enhance power acceptance.26
Astigmatism
In children normal degrees of astigmatism are
most easily treated with spectacles. This is not
true, however when astigmatism is extreme or

irregular, as in cases of trauma, disease, or
surgery. Occasionally, very young children may
present to the clinician with irregular corneas
secondary to penetrating wounds or infections.
Often, simple spherical rigid contact lens will
dramatically improve VA, eliminating the need
for surgical intervention. In high astigmatism, VA
is usually far better with contact lenses than with
spectacles. Most conventional hard lenses and
cellulose acetate butyrate (CAB) contact lenses
are adequate for high residual astigmatism, or
the child can wear soft contact lenses combined
with simple spectacles. Other more sophisticated
contact lenses may also be considered when
indications suggest their use. Such lenses include
spherical power effect, cylindrical power effect,
front surface toric rigid lenses and toric hydrogel
lenses.
Keratoconus
Although keratoconus rarely affects young
children, it can appear in teenagers. Hard
corneal lenses are required and sometimes are
the only solution for obtaining reasonable VA.
Gas permeable (CAB) lenses are superior to
traditional hard PMMA lenses. A piggyback
technique, i.e. fitting a large diameter soft lens
with a smaller diameter hard lens over it, has
been used with some success.27
COSMETIC
Aniridia, Albinism and Nystagmus28
Patients with congenital structural abnormalities
of the eye may also benefit from the use of
specialized types of contact lenses. Albinism and
aniridia may be associated with extreme light
213

Ocular Disfigurement
Many conditions may disfigure an eye.

Congenital microcorneas can be easily noticed.
Inoperable cataract can produce leucokoria.
Trauma can lead to obvious corneal scar or
lesions in the iris-pupil plane. Restoration of a
normal appearance can dramatically improve
the childs social situation and self-image.
Early methods involved scleral lenses, which
were often difficult to tolerate for long periods
of time and were quite expensive, owing to the
art and skill involved in fitting them. Most children
do not tolerate the fitting and wearing of a scleral
contact lens.
Section
sensitivity. Darkly tinted contact lenses or those

with an opaque periphery and small central clear
zone may be of great benefits to such patients.
Furthermore, since large refractive error may also
be associated with both conditions, the contact
lens can incorporate the appropriate refractive
correction. They can help correct vision and the
tinted lenses can block out light and give the iris
a natural appearance. However, according to
authors experience, albinism in children
responds better with tinted glasses. Aniridia
patients develop more corneal pannus in
authors experience and therefore may not
continue using contact lenses for long term.
Contact lens correction is believed by some to
provide improved VA for nystagmic patients with
usable vision by centering the optic of the
refracting lens over the pupil, thus reducing prism
and spectacle distortion encounter during eye
movements behind spectacles. Although this is
interesting in theory, we have not found it to be
helpful. Patients with nystagmus may have
difficulty in insertion and removal of the contact
lenses.
Use of cosmetic soft contact lenses (Narcissus
Foundation, Daly City, California) in eyes with
albinism has been reported in the literature.
Wesley-Jessen (Chicago, II) commercially stocks
lenses that use an opaque map-dot matrix
pattern, coloring areas of the underlying iris with
transparent spaces interspersed between opaque
areas. The W-J Durasoft colors and
multipackaged Fresh Look Colors have the dotmatrix design. Illusion lenses by Ciba (Atlanta,
GA) have an opaque white iris material deeper
in the lens matrix covered by a transparent tint.
PBH (Pilkington Barnes Hind, Sunnyvale, Calif)
offers a dark peripheral ring in addition to the
iris pattern in their natural touch lenses.
B
FIGURES 15.2A and B: (A) Corneal scarring, right eye,
which is cosmetically unacceptable. (B) Much improved
cosmetic appearance with prosthetic contact lens in place
214
Before considering the child for any

prosthetic lenses, the potential for vision in the
childs eye has to be considered as the clinical
goals are vision primarily and cosmesis
secondarily. If, on the other hand, the eye is
blind, the clinician can consider the use of a
totally prosthetic lens (Figures 15.2A and B).
THERAPEUTIC USES
Amblyopia and Occlusion
Section
Patching an eye to manage amblyopia is a

common part of pediatric ophthalmic practice.
Children often object to this treatment, in the
younger age group because it reduces their
vision in the better eye and in the older more
peer pressure-conscious group because of
cosmesis. Contact lens patches are more difficult
for a younger child to learn to remove and more
acceptable cosmetically for an older child to
tolerate, so ideally they should improve
compliance in both groups. When traditional
patching fails because of patch dermatitis or
because the child refuses to wear it, a high plus
soft contact lens or a black soft lens (Narcissus
Foundation, Daly City, California) can be worn
to fog or occlude the better eye. High plus soft
lens is satisfactory for mild to moderate cases
and the black soft lens is better for dense
amblyopia. Cosmetic soft contact lenses with an
occluded pupil are also available, so the childs
eye can be made to appear close to normal.
It has been said that failure of occlusion is
the failure to totally occlude, so the only patches
expected to be really effective would be those
that occlude all light transmission in the optical
zone. It has been determined clinically that for
occlusion to occur the diameter of the occluding
optical zone must be quite large (10 to 11 mm),
thus effectively eliminating the potential use of

rigid lenses, which are commonly less than 10
mm in overall diameter. Tinted American and
European hydrogels contact lenses are available
that allow for this application.
On the other hand, clear lenses offer some
distinct advantages. High plus, and possibly high
minus lenses may blur the retinal image enough
to function as a patch. Advantages include ease
of application (they are even easier to prescribe
than normal lenses as power does not need not
be precise), decreased expenses (when
compared to blackened custom hydrogel), and
improved availability. Rigid lenses or hydrogel
lenses may be used. The mechanical fit and
physiologic tolerance may be clinically assessed
with normal techniques. Finally, but perhaps
most important, cosmesis is substantially enhanced as the eye under treatment appears normal
rather than blackened. A clear high-power occluder should be considered before a total (black)
occluder lens for the reasons stated above. Some
authors have reported that amblyopic patients
showed definite VA improvements in the
amblyopic eye while using such a clear lens to
occlude the nonamblyopic eye.
Amblyopia therapy with a contact lens has
potentially greater success.29 It follows the childs
gaze and prevents peeking above or below the
occluder. Furthermore, there may be positive
psychological advantages when the child does
not appear to be wearing a patch.
Corneal Ulceration
Literature has reported successful use of
therapeutic contact lenses in the treatment of
corneal ulceration. According to authors,30 best
results were obtained using the contact lens
215
Table 15.2: Pros and cons of different materials used for contact lens
Cons
PMMA
Availability even in extreme

prescriptions.
Can be customized in regards
to power and base curve.
Relatively inexpensive.
Good optical performance.
(in most cases neutralizing
astigmatic and spherical
components of refractive error)
More durable and easy to handle.
Occasional lens breakage and loss.

Some initial discomfort for the
child.
Must be removed daily.
Soft
Comfort
Frequent and rapid lens loss.

Poor correction of residual
refractive astigmatism.
Difficulty in insertion.
Silicone
Easy to handle, durable.

Relatively low loss rate.
Can be fitted using either
measurements or trial techniques.
Superior corneal oxygenation.
Cost.
Inability to obtain full optical
correction as manufactured in
limited number of powers.
Occasional corneal abrasion.
(Table prepared by Abhay R Vasavada, MD FRCS, Rupal H Trivedi, MD)
(RGP) lenses, the hydrogel extended wear or

daily wear lens, and the silicone lens. Pros and
cons of different materials used for contact lenses
are shown in Table 15.2.
early, during the first days of treatment. Contact

lenses caused decreasing of pain and reduced
application of medicine and were a good
protection for injured cornea and fasten the
healing period.
HARD CONTACT LENSES

MISCELLANEOUS USES
Efficacy of quadraspheric contact lens for slit
lamp laser photocoagulation in cases of retinopathy of prematurity has been recently described
in the literature.31 It helps visualization of all the
structures to be treated with very low rate of
complication. Mactier et al32 have reported the
feasibility of using contact lens electrode to record
electroretinogram (ERG) in preterm infants.
The use of contact lens for the visual rehabilitation

of a pediatric patient was first reported in 1959,33
the lens used was PMMA. RGP lenses are
commonly used in children (Figure 15.3). They
correct astigmatism better than softer lenses and
can be custom fit at lower cost. Infection and
ulceration risks are lower, but they must be
removed daily.
SOFT CONTACT LENSES
SELECTING CONTACT LENS TYPE

There are three choices of contact lens: the hard
lens, including PMMA and rigid gas-permeable
Section
Pros
The hydrogel or soft contact lens has comfort as

its main advantage. It has been used as an
extended wear contact lens (EWCL) in the
216
Section
FIGURE 15.3: Use of rigid gas-permeable (RGP) contact lens

for aphakic correction after surgery for traumatic cataracts
in a 9-year-old child. Note the traumatic corneal scar
inferonasally extending from 7 o clock to 1 oclock and a large
sector iridectomy from 4 oclock to 10 oclock. The visual acuity
of the eye was 20/40 with the RGP contact lens (Courtesy:
Ashok Sharma, MD, Cornea and External Ocular Disease
Section, Postgraduate Institute, Chandigarh, India)
pediatric population.34 These lenses are tolerated

in a wide range of base curvatures and thus they
are easily fitted. Lens centration and movement
can be observed using standard methods, or
aided by the use of a hand-held slit lamp or
penlight. The literature has reported successful
use of extended wear poly HEMA lenses for
children with unilateral aphakia.
A disadvantage of this lens is that fluorescein
technique cannot be used to assess fit, so there is
a tendency to obtain a flatter fit, leading to higher
loss rates. Its large diameter and tendency to fold
makes the hydrogel lens difficult to handle and
insert. Insertion difficulties coupled with instability
and fragility of this lens lead to a high damage
and loss rate. Given the high loss rate, it is important
for the family to have backup lenses.
SILICONE CONTACT LENSES
The silicone lens (Figures 15.4 A to C) has been
used in infants and children since the late 1970s.35
Silicone contact lenses (SilSoft, Bausch & Lomb,
C
FIGURES 15.4A to C: (A) Unilateral aphakia corrected
with a silicone (SilSoft) contact lens. (B) Unilateral aphakia
in a toddler. A SilSoft contact lens is well tolerated to the
child. The parents remove, clean and replace the contact
lens weekly. (C) A six-month-old child with unilateral cataract
operated at 2 weeks of age. Patching and SilSoft contact
lens are tolerated well
corneal decompensation called the sucked-on

syndrome which is reversible in children, has
been associated with previous silicone lenses. This
problem has been overcome, for the most part,
by changing the lens design, aiming for a flat fit,
prophylactic use of lubricating agents, and
replacing lenses.
DAILY WEAR V/S EXTENDED WEAR
Several authors have reported use of extended

wear contact lens (EWCL) in pediatric population.35,40,41 Most clinician and parents agree that
EWCL would be ideal for children with aphakia.
However, owing to the increased incidence of
severe complications (e.g. acute red eye reaction,
giant papillary conjunctivitis, neovascularization,
abrasion, infective keratitis) associated with use
of current contact lens designs and material for
extended wear, daily wear is theoretically
recommended for all lens types at present.
However, the majority of pediatric ophthalmologist in the US use SilSoft lenses extended wear
in children under age of 6 years with a high
degree of safety. According to some authors, the
use of EWCL improves the quality of vision and
this in turn makes the effort justifiable.34 The use
of EWCL on young children in a practical
preposition and produces rewarding result.
Section
Rochester, NY) combine the best features of hard

and soft lenses. They are reported to mask up
to 2 D of astigmatism in the adult. Like the hard
lenses, they are easy to handle, have a relatively
low loss rate, and can be fitted using either
measurement or trial techniques. Most children
under the age of one year can be fitted with a
lens of 7.50 base curve. Older children are most
often fit with a base curve of 7.70. A fluorescein
pattern may be used during the fitting sequence
as needed. Lens movement with blinking is the
most critical and important factor to evaluate
during fitting. If too much movement is seen, a
steeper lens can be tried. If little or no movement
is seen, a flatter lens is indicated. Literature36-38
has reported the performance of silicone lenses
in pediatric eyes with aphakia.
SilSoft super plus kids manufactured by
Bausch & Lomb are available in base curve 7.5,
7.7 and 7.9 mm. Diameter remains 11.3 mm.
Power varies from 23 to 32 D (at 3 D increment).
Aasuri et al38 have reported that they are safe,
provide satisfactory optical correction, and are
easy to handle. Limited availability and the
financial cost associated with frequent lens
replacement are limitations in developing
countries.
A disadvantage of silicone contact lenses is
that in older children and adults they may be
initially uncomfortable. Other disadvantages are
their hydrophobicity and adhesion effects. Since
infants have more watery tear layers and
produce less mucus, the drying and discomfort
of the silicone elastomer lens, noted with adult
wearers is not as common with children. They
also have a tendency to acquire deposits when
drying alters the surface characteristics or by an
inappropriate lens care regimen. A type of
217
FITTING TECHNIQUE
Most children are initially examined under
anesthesia (EUA). Ketamine anesthesia is
preferred in infants. If the practitioner decides
to fit in his office the child can be sited on the
mothers (or accompanying adults) lap for the
examination. If necessary, each step of the
procedure can first be done on the mother and
218
then on the child. When the child seems ready,

a contact lens practitioner may demonstrate
placing lens on his or her own eye. If the child
becomes apprehensive, it is good idea to
reschedule the visit a few days later. However,
visits should not be scheduled too far apart,
because the initial efforts may be forgotten
quickly.
The pupil should be fully dilated with 0.5%
atropine. A complete ophthalmologic examination should be conducted under anesthesia
to gain as much information as possible. This
includes external examination, corneal measurements; examination of media and retina, careful
accurate keratometry (especially if hard lenses
are going to be fitted) and a refraction by retinoscopy. Authors have reported using a keratometer mounted on the operating microscope
arm.35 Although keratometry is revealing in
many cases, it usually is not essential for fitting
soft contact lenses. Final contact power for the
infant and young child is most easily determined
by retinoscopy through a trial contact lens. For
contact lens fitting, it may be easier to use a set
of trial hard contact lenses (all 10 mm in
diameter) with base curves varying from 7.2 mm
to 8.2 mm in 0.1 mm steps. For the hard and
CAB lenses, a study of the fluorescein pattern is
made and the lens changed if indicated. A
method using trial soft lenses and observing
under the operating microscope the pressure
exerted by them upon the limbal vessels has also
been reported in the literature.39 Fluorescein
evaluation with these template lenses in situ
allows an experienced observer to determine the
lens that best aligns with the underlying cornea.
A steep lens produces distinct central pooling
of fluorescent tears perhaps with bubbles, a flat
lens produces an absence of fluorescence
Section

centrally, and a lens in alignment with corneal
curvature produces a uniform distribution of dye.
The major problem with fitting young children
is stability. To overcome displacement due to the
small size of the eye and high tonicity of the lids,
it is necessary to fit a lens that is both tight and
relatively large in comparison with fitting criteria
for an adult eye. It was found necessary to fit as
steep as 0.1 mm flatter than the flattest corneal
reading, with an overall diameter 2-3 mm greater
than the horizontal diameter.40 Aphakic lenses
in children should be fitted flat so that there is
adequate movement. Small lenses must be
custom ordered so that they may be inserted
into the narrow palpebral tissues. If there is a
frequent lens loss in infants, the lenses ordered
should be 15 to 16 mm in diameter.
Infants who are aphakic should be fitted with
contact lenses, preferably immediately after the
surgery. Otherwise, they should be fitted as early
in the postoperative course as possible. Strict
hygiene is important for any contact lens use,
but it is especially important with recent surgery.
If the child is to undergo cataract extraction, only
quantification of corneal curvature is made, and
the initial diameter and power of the contact
lens is selected by knowledge of age norms or
from keratometry reading and perhaps axial
length measurements made during surgery.
Many practitioners overcorrect aphakic
infants, subscribing to the theory that the infants
world is close at hand, and distance acuity can
be sacrificed for near point clarity. Infants
younger than 18 months can be overcorrected
by +2.5 D. Children between 18 months and 3
years of age can be overcorrected by +2 D.
Older children should not be overcorrected.
Additional near reading correction is supplied
in a spectacle form.

INSERTION AND REMOVAL
Under 2 years of age: Insertion in this age group

is easily managed, as there is a minimum of
Between 2 and 5 years: A struggle might occur.

Insertion may be easier if the child is laid on a
bed and his head held between the arms of a
parent, whose hands are also holding down the
childs shoulders and hands. It is often the father
who learns to hold the child and the mother
who learns to insert the lenses. With time, no
holding is required and eventually the lenses can
be inserted whilst the child is sitting in the
consulting room chair.
Above 5 years: It may be possible to encourage
the children to begin to manage insertion and
removal themselves. Insertion is not always so
easily achieved and so initially help is required
from parents to hold the lids or guide the
childs finger. Once the child has gained
confidence and appreciates the advantages of
being independent, his insertion technique
improves, enabling him to handle the lenses
without any assistance. Children then become
remarkably responsible in looking after and
handling their lenses, although some supervision
of the cleaning regimen is wise. Children may
find hard lenses easier to insert than soft lenses
because of size, but they may find them difficult
to remove.
INSERTION
struggle. The practitioner should pull up the

babys upper lid and insert the lens under it,
then pull the lower lid over the lower edge of
the lens. The contact lens should then be checked
to ensure that it has not folded during insertion.
Section
Generally, babies are very easy to handle. Little

communication is required other than
pacification, which is best done by the mother.
The babies attention may be gained by using
lights and noise. Once infancy is attained, then
the practitioner may use appropriate actions and
speech to keep the attention of the young patient
during such procedures as retinoscopy and lens
evaluation. Insertion and removal of a contact
lens can be a struggle at this age. As the child
gets older, he or she will learn to trust the
practitioner, especially when shown care and
patience over a period of time. Nevertheless,
even after a few years of wear, insertion and
removal of contact lenses may still be traumatic
for pediatric patients.
For the new patient who presents at five or
six years of age, fear of the unknown proves to
be the most difficult problem for the child to
overcome. Patience and kindness will eventually
enable a lens to be inserted, and once this has
been experienced the child will gain confidence.
Managing the patient become progressively
easier. Topical anesthetics are never used to
facilitate either the evaluation of the fitting of
contact lenses or the teaching of insertion and
removal techniques. The greatest obstacle to the
insertion of contact lenses is the childs fear.
Topical anesthetics have little effect on this critical
problem, and they also give a false impression
as to what the child will experience when the
lenses are inserted at home.
219
REMOVAL
Below 2 years: To remove soft contact lenses in
a child, the lids are pulled apart as much as
possible and gentle pressure is put on the
superior and inferior lens edges; this produces a
220
break of the suction allowing the lens to be lifted

out by the lids.
Between 2 and 5 years: As the child grows, the
same method may be employed, although in
some cases it may be necessary to hold the childs
head. If there is struggling, the lids may be
squeezed tightly shut and this may actually help
ejection of the lens as the practitioner pulls the
lids apart. Once the child is old enough, the lens
can be pinched off in the conventional way.
Above 5 years: Children may pitch soft contact

lenses from their corneas without any prompting,
and indeed the younger child may remove his
lenses frequently in order to impress his mother,
which can prove to be a nuisance.
Section
FOLLOW-UP
Initially, the child should be seen twice weekly

for 2 to 3 weeks, then once weekly for 3 to 4
weeks, followed by visits every 2 to 3 months
for the first year. Frequent visits are advisable
initially for pediatric patients in order to monitor
corneal physiology and contact lens integrity and
to supervise hygienic care of the lenses. The
cooperation of both parents and patients is
needed for successful fitting of a child. Questions
should be directed at the care regimenany
difficulties handling the lens, lens loss, any
irritation of the eyes, and behavioral visual
progress.
Excessive blinking, photophobia, tearing,
conjunctival injection or discharge may indicate
the possible presence of conjunctival or corneal
pathology. Careful slit lamp examination after
contact lens removal, without and with
fluorescein staining, is essential. Parents should
be asked about any untoward reaction. Wearing

time is gradually increased starting with a few
hours at first. Follow-up keratometry should be
practiced by anyone fitting contact lenses. The
corneal radius and diameter change very rapidly
over the first few years. The possibility therefore
exists that, if an extended wear lens is
deliberately fitted tight and is left in situ for too
long the cornea will grow beneath it and the fit
becomes tighter still, leading to complications.
Such a tight lens will cause corneal edema and
conjunctival chemosis which, in turn, causes
embarrassment of the limbal capillaries. If regular
follow-up is maintained, little difficulty arises.
Changes in corneal curvature require a
change in the lens, and special attention must
be paid to this possibility. During the first year of
life, the eye grows rapidly, from an axial length
of approximately 16.8 mm at birth to almost 20
mm by 1 year of age. As the eye grows, the
aphakic power requirements decrease. An
assessment of retinoscopy in these young children
has shown a decrease of approximately 10 D
over the first year of life. The most rapid ocular
growth phase is during the first 18 months of
life. Also, during the first 18 months of life, the
cornea rapidly changes by increasing its overall
diameter and decreasing the radius of curvature.
Thus, the importance of frequent early visits
cannot be overemphasized. When corneal
changes are found, wearing should be stopped
and keratometric measurements are taken
weekly until the values stabilize. Measurements
that stabilize at a curvature other than the original
require refitting of the lens. Sometimes, minor
corrections are possible on hard contact lenses
but not on soft lenses.
221

CONSIDERATIONS
GENERAL
Age of the Child
Parents are patients as much as the child. The

management of the pediatric patients cannot be
discussed without consideration of the parents.
Ocular conditions that manifest themselves in
the first few weeks or months of life are usually
psychologically traumatic to the parents. In these
situations, the practitioner needs to spend time
discussing with the parents the importance of
contact lenses for their baby and to give them
B
FIGURES 15.5A and B: Insertion of contact lens.
(A) Teaching mom to insert a silicone contact lens. (B) Parents
successfully insert silicone contact lens in the office
Training Parents
Section
When contact lenses are indicated, the age of

the child often cannot be a determining
consideration. However, the parents ability to
care for the young childs lenses is a reality that
the responsible surgeon must consider. When
there are options for vision correction or when
the child is older, the age at which a youngster
can be fitted is very much an individual
consideration. Generally, 7- or 8-year-olds can
handle their own lenses; however, there are
reports on 4- and 5-year olds who have
mastered the application and care of their lenses
successfully. Schwartz et al 41 have suggested that
a child be at least 11.3 years of age before
contact lenses are recommended as an
alternative to wearing glasses. But even with the
older child, it is essential for the parents to
understand the importance of wearing schedules
and cleanliness. An up-to-date pair of spectacles
must be maintained and worn instead of contact
lens whenever the eye becomes red or the
contact lenses feel uncomfortable.
explanations and reassurance concerning the

future management of their child.
The success of the contact lens fitting and
ultimately of the childs vision often depends on
the training and understanding of parents or
others who will be responsible for the childs eyes
and lenses. The parent who is going to take the
most responsibility for wearing schedule,
insertion (Figures 15.5A and B), removal
(Figures 15.6A and B), storing and disinfection
of the lens should be encouraged to attend the
clinics as much as possible so as to learn these
techniques and to develop a relationship with
the practitioner, thus aiding communication
222
Section
B
FIGURES 15.6A and B: Removing a silicone contact lens.
(A) The eyelids are gently pulled apart. (B) Pressure is
applied on the superior and inferior lens edge as the thumbs
are brought together. The lens lifts out onto the skin
should any problems arise in the future. From

the outset, parents should always be present and
included in such procedures as insertion and
removal of a contact lens. In this way, they learn
as much as possible about the handling of the
contact lens and their responsibilities towards
their childs contact lens treatment. Each step
should be practiced in the office under
supervision. It is the physicians responsibility not
only to make sure the parents learn to apply,
remove, and care for the lenses but also to help
them make these activities a simple, daily routine.
Because training is of the utmost importance to
the success of the fitting, high quality staff are
needed to train the parents.
Furthermore, it is the parents who must

scrutinize the child daily and report any change
at the earliest possible moments. Written
instruction on the fundamentals of hygiene,
handling, insertion and removal of the lenses
should be given to reinforce oral instructions.
The clinician tells the parents what to observe in
terms of steep lens (nonmoving, which may
induce injection or a sectorial or complete
compression ring indentation in the sclera if
hydrogel) or loose lens (which produces some
edge lift, increased lens excursions, and poor
centering). The parents are also told that the
child should be quiet quickly after contact lens
insertion; but if the child continues to cry more
than about 5 minutes, the lens may be torn,
chipped, cracked or inside-out or there may be
a foreign body underneath. If the child continues
to be uncomfortable, the lens should be
removed and inspected.
Friendly and associates42 reported that contact
lens wearing in 4 of 23 infants with cataract (30
eyes) was discontinued because of the parents
inability to insert the soft contact lenses. This was
the most frequent reason for treatment failure
in that study. When the clinician is convinced
that the parents can adequately care for the lens,
they can be given a wearing schedule (usually 6
hours/day for the first week) and a return
appointment. Wearing time is rapidly increased
to all waking hours if no particular problems are
encountered. In general, any sleeping or
napping with the lens in place is discouraged.
However, child may sleep for a short nap with
the contact lens according to some authors.
Parents should be certain that the lenses are
always adequately cleaned and disinfected
before reinsertion.

OTHER CONSIDERATIONS
Emotional Factor
Before the advent of comfortable soft contact
lenses, it was frequently said that it was better to
have a one-eyed child or one with poor vision
than a neurotic child. Certainly, this advise should
still be considered for some patients; however,
for all practical purposes, the situation is reversed
today to the extent that not providing contact
lenses can hamper visual development and
emotional development as well.
Lens Loss
Noncompliance of both the parents and the child

is the major obstacle in contact lens practice.
Loss of contact lenses, conjunctival erythema and
poor fit were reasons for noncompliance in
pediatric patients.
Prescription Changes
Frequent follow-up is needed as the power
COMPLICATIONS
Minor infections occur from time to time,
especially if the child is on soft lens extended
wear. The parents must always be carefully
briefed on the removal of a lens if they see the
slightest redness of the bulbar conjunctiva. If at
this stage they are unable to handle the lens,
then they must get ophthalmic help. If the infant
is a bilateral aphake, removal of both lenses is
advisable as amblyopia can quickly develop in
the eye without the lens. Aphakic spectacles
should then be worn until refitting of the contact
lens can occur.
Corneal vascularization due to various
degrees of anoxia was reported by Morris and
Taylor44 in about 25% of patients attending the
pediatric contact lens clinic of Moorfields who
were wearing soft lenses. A child on extended
wear must be refitted with a daily wear lens; and
if on daily wear soft lenses, then hard gas-permeable lenses are needed. Otherwise, spectacles
are often the preferred choice. This is also true
for contact lens induced giant papillary
conjunctivitis.
Problems of contact lens use, more commonly
encountered in developing country patients, who
often come from rural communities with poor
socioeconomic and educational background,
include infectious keratitis, corneal vascularization,
hypoxic corneal ulceration and red eye without
ulcerations.
Noncompliance
changes very rapidly. Younger the child more

frequent the follow-up.
Section
Authors have reported43 average loss of nine

lenses in the first year and then 2.4 lenses a year
thereafter. The major loss was by the one to two
years old, but babies of a few months easily rub
the lenses out during sleep. The authors34 have
reported that one mother even attempted to
recover a lens from an infant who was seen to
remove it and then swallow it; unfortunately,
her efforts were unrewarded. For continued
optical correction to prevent amblyopia, a spare
set of lenses needs to be in store in the clinic,
and with the parents. Once on daily wear, the
problem decreases and eventually lens deterioration is the major cause of lens replacements of
about six months.
223
CONCLUSION
Young children often cannot articulate problems.
Thus, much contact lens care becomes the
224
responsibility of the parents or guardians, and

this can become a burden. Furthermore,
childrens eyes change rapidly with growth, both
in refractive error and corneal topography,
necessitating more frequent professional
evaluation and contact lens changes for both fit
and power, which may involve some expenses.
If children do not return for professional care, a
contact lens may become inappropriate in
power, fit or both. However, end results of
making all the efforts to fit the contact lens in
children makes it worthwhile.
REFERENCES
Section
1. Dutton JJ, Baker JD et al. Visual rehabilitation of

aphakic children. Surv Ophthalmol 1990; 34:365384.
2. Moore BD. Contact lens problems and management
in infant, toddlers and preschool children. Probl
Optom 1990;2(3):365-393.
3. Stein RM, Cohen EJ, et al. Corneal birth trauma
managed with a contact lens. Am J Ophthalmol
1987; 103:596-598.
4. Hodur NR. Vision care with contact lenses for infants
and children. CL Forum 1987; Aug: 38-40.
5. Kanpolat A, Ciftci OU. The use of rigid gas permeable
contact lenses in scared corneas. CLAO J 1995;
21(1):64-66.
6. Tsubota K, Yamada M. Treatment of amblyopia by
extended-wear occlusion soft contact lenses.
Ophthalmologica 1994; 208:214-215.
7. Rich LS, Glusman M. Tangent streak RGP bifocal
contact lenses in the treatment of accommodative
esotropia with high AC/A ratio. CLAO J 1992;
18(1):56-58.
8. Enoch JM. Fitting parameters which need to be
considered when designing soft contact lenses for
the neonate. Contact Lens J 1979;5(2):31-37.
9. Foster A, Gilbert C, Rahi J Epidemiology of cataract
in childhood: A global perspective. J Cataract Refract
Surg 1997; 23: 601-604.
10. Birch EE, Stager DR. The critical period for surgical
treatment of dense congenital unilateral cataract.
Invest Ophthalmol Vis Sci 1996; 37:1532-1538.
11. Taylor D: The Doyne Lecture Congenital Cataract:
The history, the nature, and the practice. Eye 12:936,1998.
12. Brown SM, Arsher S, Del Monte. Stereopsis and

binocular vision after surgery of unilateral infantile
cataract. J AAPOS 1999: 3(2): 109-113.
13. BenEzra D, Cohen E, Rose. Traumatic cataract in
children: correction of aphakia by contact lens or
intraocular lens.1997;123(6):773-782.
14. Lambert SR, Lynn M, Drews-Botsch C et al. A
comparison of grating visual acuity, strabismus,
and reoperation outcomes among children with
aphakia and pseudophakia after unilateral cataract
surgery during the first six months of life. J AAPOS
2001; 5(2):70-75.
15. Mittelviefhaus H, Mittelviefhaus K, Gerling J. Etiology
of contact lens failure in pediatric aphakia.
Ophthalmologe 1998;95(4):207-212.
16. Wilson ME, Peterseim MW, Englert JA et al.
Pseudophakia and polypseudophakia in the first
year of life. J Am Ass Pediatr Ophthalmol Strabismus
2001 (in press).
17. Alio JL, Artola A, Claramonte P et al. Photorefractive
keratectomy for pediatric myopic anisometropia. J
Cataract Refract Surg 1998; 24:327-330.
18. Agarwal A, Agarwal A, Agarwal A et al. Results of
pediatric laser in situ keratomileusis. J Cataract
Refract Surg 2000; 26:684-689.
19. Collins JW, Carney LG. Visual performance in high
myopia. Curr Eye Res 1990; 9:217-223.
20. Morrison RJ. Contact lens and the progression of
myopia. Optom Wkly 1956; 47:1487-1488.
21. Nolan JA. Progress of myopia and contact lenses.
Contacto 1964; 8(1):25-26.
22. Kelly TS, Chatfield C, Canustin G. Clinical
assessment of the arrest of myopia. Brit J Ophthal
1975; 59:529-538 .
23. Stone J. The possible influence of contact lenses on
myopia. British J Physiol Optics 1976; 31:89-114.
24. Khoo CY, Chong J, Rajan U. A 3 year study on the
effect of RGP contact lenses on myopic children.
Singapore Med J 1999; 40(4): 230-237.
25. Grosvenor T, Perrigin J, Perrigin D. Use of siliconeacrylate contact lenses for the control of myopia:
Results after two years of lens wear. Optom & Vis
Sci 1989;66(1):41-47.
26. Robertson DM, Ogle KN, Dyer JA. Influence of
contact lenses on accommodation. Am J Ophthalmol
1967;64:860.
27. Tsubota K, Mashima Y, Murata H et al. A piggyback
contact lens for the correction of irregular astigmatism
in keratoconus. Ophthalmology 1994;101(1):134.
28. Allen ED, Davies PD. Role of contact lenses in the
management of congenital nystagmus. Br J
Ophthalmol 1983;67:834-836.
36. Harris M, Caputo A. Use of continuos wear silicone

lenses in aphakic children. Contact Intraocular Lens
Med J 1979; 5:155-159.
37. Harris M. Correction of pediatric aphakia with
silicone contact lenses. CLAO J 1985; 11(4) 343-347.
38. Aasuri MK, Venkata N, Preetam P et al. Management
of pediatric aphakia with SilSoft contact lenses.
CLAO J 1999; 25(4):209-212.
39. Arnaud B, Zeris J, Alcayde M. Constant wear in children under 3 (?) months. Proc ECLSO (Ghent), 1977.
40. Ellis P. The use of permanent wear contact lenses on
young aphakic children. Contact lens J 1977;5(8):23.
41. Schwartz CA. At what age? CL forum 1990;20.
42. Friendly DS, Brurner BS, Frey T et al. Use of the high
plus Bausch & Lomb SofLens in the management of
aphakia in infants and children. Medical Annals of
the District of Columbia 1974; 43(7):359-66.
43. Morris F. Pediatric contact lens practice. Pediatric
eye care. Science Oxford; Cambridge, Mass.:
Blackwell Science, 1996;312-323.
44. Morris JA, Taylor D. In M Ruben, M Guillon (Eds):
Contact lenses for children. Contact lens practice.
London: Chapman and Hall, 1994.
Section
29. Eustis HS, Chamberlain D. Treatment for amblyopia:

results using occlusive contact lens. Journal of
Pediatric Ophthalmology & Strabismus 1996;
33(6):319-22.
30. Koraszewska-Matuszewska B, SamochowiecDonocik E, Lange E. Therapeutic contact lenses in
infant corneal ulceration. Klin Oczena 1999;
101(2):119-121.
31. Zavalia UJ, Zavalia UE, Iros M. Slit-lamp laser
photocoagulation with a quadraspheric contact lens
for the treatment of retinopathy of prematurity. J Fr
Ophthalmol 2000;23(4):361-363.
32. Mactier H, Hamilton R, Bradnam MS et al. Contact
lens electroretinography in preterm infants from 32
weeks after conception: a development in current
methodology. Arch Dis Child Fetal Neonatal 2000;
82(3): 233-236 .
33. Sato T, Satio N. Contact lenses for babies and children.
Contacto 1959;56:419-424.
34. Ellis P. Extended wear contact lenses in pediatric
ophthalmology. CLAO J 1983; 9:317-321.
35. Gurland JE. Use of silicone lenses in infant and
children. Ophthalmology 86:1599-1604.
225
Chapter
16
Acanthaemoeba
Keratitis
N Venkatesh Prajna
INTRODUCTION
MICROBIOLOGY
Acanthamoeba is a free-living genus of

Amoebae that is abundant in the environment.
Until Culbertson and co-workers demonstrated
the pathogenicity of this organism in 1959, these
species were considered harmless. Since this
organism is present almost everywhere, human
contact with this organism is very frequent and
inevitable. In a study based on sampling of air
both inside and outside a building, it was
estimated that a human inhales on average two
Acanthamoeba organisms per day.1 It has
tremendous capacity to survive in diverse
conditions and has been isolated from soil and
dust,2,3 fresh water,4 sea water5 and air. In contrast
to many other pathogenic amoebae, this
organism is not naturally parasitic and does not
require a host. In humans, these species are the
causative agents in three relatively rare infections:
keratitis, granulomatous encephalitis, and
fulminant meningoencephalitis. The appearance
of either form of systemic disease simultaneously
with keratitis is extremely rare.
Order: Amoebida
Suborder: Acanthopodina
Family: Acanthamoebidae
Originally placed in the genus Hartmanella,
they were later reclassified as belonging to the
newly created genus Acanthamoeba. They form
thin spiny pseudopods called acanthopodia. The
species causing keratitis are A. castellani,
A. polyphaga and A. culbertsoni.
Acanthamoeba exists in two different forms.
Trophozoite
This is the active form of the organism and is 25
to 40 microns in length. It has a central
cytoplasmic contractile vacuole, the function of
which is to expel water. The trophozoite is slowly
motile and tends to track in straight lines when
placed in agar. It preferentially engulfs gramnegative enteric bacilli, but some species can
survive on gram-positive bacteria, yeasts or
algae. It reproduces by mitosis, during which
the nuclear membrane and nucleolus disappear.
230
During adverse conditions like extremes of

temperature, inadequate food supply, pH
changes, the trophozoite transforms to a highly
resistant cyst form.
Cyst
Section
The cyst varies from 15 to 28 microns in size.

The ability of Acanthamoeba to encyst protects
this organism and is also the precise reason for
the ineffectiveness of the antiamoebic treatment,
since the drugs are ineffective against the cysts.
The cysts are stable and highly resistant to
desiccation, heat, cold, pH extremes and
chemotherapy. It is slightly smaller than the
trophozoite and has a double wall, which is joined
in places, giving rise to a polygonal structure.
The cyst may remain for many years until it is
exposed to a food source, where it again
assumes the trophozoite form.6 Exposure to
favorable environmental conditions can trigger
excystation within 3 days.
experience that, in our settings the prevalence

of Acanthamoeba keratitis is far higher in noncontact lens wearers than in contact lens wearing
population.
Though the organism has been reported in
conjunction with almost all types of contact
lenses,8,9 some of the observed increases in cases
can be explained by changes in patterns of
contact lens use. In the USA, the increase seen
in the 1980s was attributed to a rise in the
number of contact lens wearers in the population
and to the use of home-made saline for rinsing
lenses,10 and more recently the use of certain
chlorine release tablets for disinfection.
Humans may also come into contact with
amoebas while swimming in pools, which have
been
found
too
frequently
contain
Acanthamoeba. Another source is domestic tap
water,11 where the incidence of contamination
appears to be greater when lime scale is present,
which may account for geographic variation in
the incidence of Acanthamoeba keratitis.12
PATHOGENESIS
Acanthamoeba has not been known to invade
the normal epithelium. An important prerequisite is epithelial denudation. The cause of this
denudation is different in different settings.
Western literature consistently report that
improper use of contact lenses are the prime
predisposing factor in the causation of
Acanthamoeba keratitis, while our experience is
different. Investigations from our institute had
reported the prevalence of Acanthamoeba
keratitis in noncontact lens wearers.7 In our study,
the common predisposing factors were trauma,
especially with vegetable matter and exposure
to contaminated brackish water. It has been our
CLINICAL FEATURES
The pain in Acanthamoeba keratitis is commonly
described to be particularly severe and seemingly
disproportionate to the signs, but we feel that
pain is not different than any suppurative
bacterial and fungal keratitis. In fact, the earlier
symptoms may be photophobia and defective
vision, in which case it is often confused with a
viral stromal keratitis. However, once established,
the disease runs a long indolent and relentless
course. Early in the course of the disease, the
symptoms and signs may wax and wane, giving
an erroneous information about the status of
the infection.
Acanthamoeba Keratitis
231
Anterior Segment
FIGURE 16.1: Overlying epithelial defect
cannot be considered as an initial

manifestation of the disease. The delay
in most of these cases may be due to the
relatively slow rate of division of
Acanthamoeba compared with other
pathogens. Although initially the epithelium within the ring may be intact, in
longstanding cases, a central defect, which
is often associated with stromal thinning
and hypopyon may occur (Figure 16.2).
The ring may be incomplete or
occasionally double and concentric.18 This
can be confused with either a viral
Section
The anterior segment and most frequently the

cornea is the most common structure to be
affected by this organism. Within the cornea,
the various layers can be afflicted in the different
stages of the disease.
1. Corneal changes
a. Epithelial changes: The earliest signs are
seemingly nonspecific and take the form
of epithelial microerosions, irregularities,
and opacities or microcystic edema, often
with patchy anterior stromal infiltrates.13
An unhealthy looking sick epithelium may
be the initial presenting sign. Commonly
there is a dendriform keratitis that is often
initially treated as herpes simplex keratitis.14 A high index of suspicion is called
for in contact lens wearers who develop
dendriform keratitis, especially when it
fails to resolve with standard antiviral
therapies.
b. Perineural changes: A pattern of perineural infiltrates that occurs in a radial distribution (radial keratoneuritis) is virtually
pathognomonic for Acanthamoeba keratitis.15 Investigators using confocal microscopy have identified typical perineural
infiltrates virtually acting as cuffs around
the nerves. During this stage, pain is most
severe. Diminished corneal sensation may
occur as a result.16
c. Stromal infiltrates: A ring infiltrate, usually
with an overlying epithelial defect is
commonly seen (Figure 16.1).17 The
feature has been reported as early as 4
days and as late as 21 months after the
onset of symptoms, but more commonly
occurs after the first month. Hence, this
FIGURE 16.2: Stromal thinning
232
immune ring or the ring infiltration caused

by gram-negative organisms. The viral
immune ring is often associated with very
minimal infiltration and conjunctival congestion, slow progression and responds
to topical steroid therapy. In contrast, the
ring infiltration in gram-negative keratitis
is fulminant, typically occurs 2-3 days after
the onset of symptoms and worsens
rapidly if treatment is not started
immediately. Another reported feature is
the occurrence of multiple scattered
subepithelial infiltrates that appear to
respond to topical steroid therapy and
may be a reaction to the presence of
antigen released from killed amoebae. At
this stage, this lesion can be confused with
the nummular keratitis lesion caused by
Herpes simplex viruses. Advanced stages
of the infection are characterized by
central corneal epithelial loss and marked
stromal opacity. Vascularization may
occur, but it is not usually marked unless
secondary bacterial infection has
occurred.
2. Scleral changes
Very often the sclera is not involved with this
disease. In advanced cases of acanthamoebic
stromal keratitis, contiguous nodular scleritis
may develop. The development of nodular
scleritis indicates a poor prognosis for the
survival of the eye. Isolated scleral involvement has not been reported.
3. Limbitis
It has been reported to be a frequent
accompaniment, especially in ulcers extending close to the corneal periphery and is
characterized by areas of limbal hyperemia
and edema.
Section

4. Miscellaneous
Other anterior segment findings, which can
be associated, include hypopyon and
glaucoma.19
Posterior Segment
Involvement of the posterior segment is
extremely rare, although occasional reports exist
of optic nerve edema, optic neuropathy and
optic atrophy, retinal detachment, choroidal
inflammation and macular scar.
PATHOLOGY
Both trophozoites and cysts are seen in histologic
sections of infected corneal tissue. Rarely, the
parasite has been found in the iris and ciliary
body. Evidence of inflammatory response is
usually minimal in areas of trophozoite invasion.
DIAGNOSIS
Early diagnosis of Acanthamoeba is important
to limit the relentless progression of the disease.
The clinical characteristics that help distinguish
Acanthamoeba keratitis from other causes of
keratitis are:
a. Ring infiltrate
b. Radial keratoneuritis
c. Pain out of proportion of the clinical findings
d. Elevated epithelial lines
e. Unhealthy, sick looking epithelium with
microerosions
f. Relative lack of vascularization in light of the
chronicity and severity of the disease.
g. History of contact lens use.
DIFFERENTIAL DIAGNOSIS
Acanthamoeba keratitis is often confused with
viral keratitis since they share a lot of clinical
233
features. In the initial stages, it may mimic

dendritic keratitis and in later stages it may
typically mimic viral stromal keratitis and immune
ring formation. Like viral stromal keratitis, it may
respond to topical steroid therapy initially.
LABORATORY DIAGNOSIS
FIGURE 16.3: Cytoplasmic granularity
Smears can also be examined using the

chemofluorescent dyes such as calcofluor white,
and Concanayalin A viewed with a fluorescent
microscope.20 Cysts measuring 10 to 25 mm in
diameter appear bright green, and trophozoite
measuring 15-20 mm in diameter appears bright
orange. Viewed with an ultraviolet light, the
chemofluorescent dye appears white. Enzymatic
digestion of the background stroma enhances
visualization. The method requires a fluorescent
microscope and an individual skilled in the
identification of Acanthamoeba species, because
calcofluor also stains the cell wall of fungi.
The ideal method to be used for growing
Acanthamoeba organism is to culture the
specimen on a confluent lawn of Escherichia coli
(monoaxonic culture) plated on nutrient agar.21
The enteric gram-negative bacteria such as E.coli
are a food source for Acanthamoeba. In this
technique, Acanthamoeba trophozoites now
tracks through the lawn of the bacteria. The
bacteria will not fill in these paths, because the
bacteria are plated in non-nutrient agar. The
trailing should be demonstrated on at least one
serial plating transfer to be suggestive of
Acanthamoeba. Macrophages and polymorpho-
Section
Once the clinical suspicion of Acanthamoeba

keratitis has been raised, laboratory confirmation
of the disease should take place prior to starting
treatment. The clinically involved epithelium and
stroma are scraped vigorously with a sharpened
Kimura spatula or a No 15 Bard Parker blade.
Too superficial scrapings may be a reason for
non-identification of the organism in smears. If
there is deep stromal infiltrate, then a corneal
biopsy may be preferred in some cases.
Commonly, the cysts and rarely the trophozoites can be identified in corneal scrapings or
smears by staining with Gram and Giemsa and
potassium hydroxide stain. It has been our
experience that Gram staining and potassium
hydroxide wet mount preparation are very
specific and sensitive for the rapid identification
of the organism and may be the only stains
required for smear examination. These two
smears also show a high correlation with positive
cultures. In the potassium hydroxide mount, the
cysts stand out as having a double cell wall with
cytoplasmic granularity (Figure 16.3) and the
Gram stain reveals the double cell-walled nature
of these cysts. Trophozoites and cysts stain purple
with Giemsa-Wright staining. The trophozoite is
characterized by a large single nucleus and spindle
like pseudopodia. It is much easier to recognize
the cysts, which are double walled, with the inner
wall having a variety of polygonal shapes.
234
Section
nuclear cells can also produce trails after initial

plating (pseudotrails), but leukocytes will not
replicate these trails on serial transfer. Two plates
are prepared for incubation at 25C and 37C,
since some species do not grow at higher
temperatures. Trophozoites can be identified
under the microscope for the presence of
contractile vacuoles.
Species identification is based on cyst
morphology, immunofluorescent identification,
isoenzyme profile, lectin reaction and DNA
analysis.
Tandem scanning confocal microscopy has
been used in the diagnosis and managing
Acanthamoeba keratitis because of the ability to
detect the organism on cornea in vivo.22 More
recently, a study demonstrated that polymerase
chain reaction (PCR) analysis of epithelial biopsy
specimens could provide definitive verification
of the confocal microscopic and histologic identification of Acanthamoeba organisms associated
with keratitis.23
TREATMENT
MEDICAL
The initial treatment of choice is using a variety
of medical therapies. The various agents described as being helpful in this condition include:
1. Aromatic diamidines [0.1% propamidine
isethionate drops and 0.15% dibromopropamidine ointment (Brolene), pentamidine
(0.05%):24 The diamidines are frequently
used in the treatment regimen. These drops
may be started at every half-hour intervals
during the day and tapered. Lack of adequate amoebic activity, poor bioavailability,
acquired resistance and induced encystment
from subcysticidal drug levels are possible
reasons for treatment failure.

2. Aminoglycosides (Neomycin): Aminoglycosides with antiamoebic activity include
neomycin and paromomycin. Neomycin is
commercially available and can be prepared
as 8 mg/ml or fortified up to 20 mg/ml.
3. Imidazoles and triazole antifungals (Clotrimazole 1%, Miconazole, Ketoconazole, Itraconazole): Imidazole compounds such as miconazole and clotrimazole can be used topically
as a 1-2 percent suspension. Oral therapy with
ketoconazole, fluconazole or itraconazole may
play an important adjunctive role.
4. Polymyxins.
5. Cationic antiseptics (Polyhexamethylbiguanide and chlorhexidine):25 Polymeric biguanides are available as a contact lens
disinfectant at a low (0.00005%) concentration and as a swimming pool supplement at
a high concentration (20%). These biocides
interfere with cytoplasmic membrane integrity and inhibit essential respiratory enzymes
of multiple microbes. A diluted concentration
of PHMB (0.02%) appears clinically useful
in the anterior chamber.
At our institute, we commence treatment
using 0.02 percent PHMB drops as monotherapy, hourly for the first 15 days and titrate
following host response. The treatment is
continued at reduced intervals for at least three
months after the ulcer has clinically healed.
Often, the treatment schedules take place for a
minimum period of 6 months. The chronic use
of PHMB induces severe stromal vascularization,
which disappears over a period of time after
discontinuation of the drug. Supplementary
therapy includes cycloplegics for the treatment
of associated uveal inflammation and antiglaucoma medication in cases of increased
intraocular pressure. Pain management is an
important aspect in the later part of the disease.
Sulindac has been found to be of some benefit
in the treatment of pain by some investigators.
Topical Corticosteroids
They are used in the early cases of undiagnosed
Acanthamoeba keratitis, however, their use is
controversial. Although steroids may partially
suppress the inflammation associated with
Acanthamoeba species infection, inhibiting the
host response may ultimately prolong the course
of the disease.
Penetrating Keratoplasty
1. Kingston D, Warhorst DC. Isolation of amoeba from

the air. J Med Microbiol 1969;2: 27-36.
2. Culberton CG. The pathogenicity of soil amoeba.
Ann Rev Microbiol 1971;25:231-54.
3. Page FC. Taxonomic and ecological distribution of
potentially pathogenic free living amoebas. J Parasitol
1970;56 (Suppl): 257.
4. Kyle DE, Noblet GP. Seasonal distributions of
thermoloterant free living amoebas. I Willards Pond.
J Protozool 1986;33: 422-34.
5. Sawyer TK, Visvesvara GS, Harke BA. Pathogenic
amoebas from brackish and ocean sediments. Science
1977;196: 1324-25.
6. Mazor T, Hadas E, Jwanika I. The duration of the cyst
stage and the viability and violence of Acanthamoeba
isolates. Trop Med Parasitol 1995;46: 106-08.
7. Sharma S, Srinivasan M, George C. Acanthamoeba
keratitis in non-contact lens wearers. Arch
Ophthalmol 1990;108: 676-78.
8. Stetir Green JK, Bailey TM, Visvesvara GS. The
epidemiology of Acanthamoeba keratitis in the Unites
States. Am J Ophthalmol 1989;107: 331-36.
REFERENCES
9. Radford CF, Bacon AS, Part JKG et al. Risk factors

for Acanthamoeba keratitis in contact lens usersa
case control study. BMJ 1995;310: 1567-70.
10. Stetir-Green JK, Bailey TM, Brandt FH et al.
Acanthamoeba keratitis in soft contact lens wearers
a case control study. JAMA 1987;258: 57-60.
11. Kilvington S, Larkin DFP, White DG et al. Laboratory
investigation of Acanthamoeba keratitis. J Clin
Microbiol 1990;28: 2722-25.
12. Seal D, Staphleton F, Dart J. Possible environmental
sources of Acanthamoeba sp in contact lens wearers.
Br J Ophthalmol 1992;76: 424-27.
13. Berger ST, Mondino BJ, Hoft RH et al. Successful
medical management of Acanthamoeba keratitis.
Am J Ophthalmol 1990;110: 395-403.
14. Johns KJ, ODay DM, Head WS et al. Herpes simplex
masquerade syndrome: Acanthamoeba keratitis.
Curr Eye Res 1987;6: 207-12.
15. Moore MB, McCulley JP, Kaufman HE et al. Radial
keratoneuritis as a presenting sign in Acanthamoeba
keratitis.
16. Perry HD, Donnenfeld ED, Foulks GN et al. Decreased
corneal sensation as an initial feature of
Acanthamoeba keratitis. Ophthalmol 1995; 102:
1565-68.
17. Theodore FH, Jakobiec FA, Juechter KB et al.
Diagnostic value of a ring infiltrates in Acanthamoeba
keratitis. Ophthalmol 1985;92: 1471-79.
18. Hirst LW, Green WR, Merz W et al. Management of
Acanthamoeba keratitisa case report and review
of the literature. Ophthalmol 1984;91: 1105-11.
19. Bacon AS, Frazen DG, Dart JKG et al. A review of 72
consecutive cases of Acanthamoeba keratitis 19841992. Eye 1993;7: 719-25.
20. Wilhelmus KR, Osato MS, Font et al. Rapid diagnosis
of Acanthamoeba keratitis using calcofluor white.
Arch Ophthalmol 1986;104: 1309.
21. Ma P, Visvesvara GS, Martine AJ et al. Naegleria
and Acanthamoeba infections: Review. Rev Infect
Dis 1990;12: 490.
22. Cavanagh HD, Patroll WM, Alizadeh H et al. Clinical
and diagnostic use of in vivo confocal microscopy in
patients with corneal disease. Ophthalmol 1993;100
(10): 1444.
23. Mandell GL, Bennett JE, Dolin R: In Mandell, Douglas
and Bennetts (Eds): Principles and Practice of
Infectious Diseases (4th edn). New York: Churchill
Livingstonen 1997;1118.
24. Mathers WD, Nelson SE, Lane JL et al. Confirmation
of confocal microscopy diagnosis of Acanthamoeba
keratitis using polymerase chain reaction analysis.
Arch Ophthalmol 2000;118: 178-83.
25. Wright P, Warhorst D, Jones BR: Acanthamoeba
keratitis successfully treated medically. Br J
Ophthalmol 1985;69: 778.
Section
The timing and indications for penetrating

keratoplasty are not established. Some authors
advocate debulking the cornea while the
infection is limited. Successful cases with surgery
alone have been reported. Others prefer first to
treat medically and eradicate the infection.
235
236
Chapter
17
Visual Acuity with

Contact Lenses versus
LASIK in Myopia
Section
Melania Cigales
Fernando Rodriguez-Mier
Marta Marsan
Jairo E Hoyos
INTRODUCTION
There are several options to consider for

correcting refractive errorsspectacles, contact
lenses or refractive surgery. All of these options,
starting with spectacles which were already
recommended by Daza de Valds1 in 1623,
through contact lenses2,3 and finally surgical
correction by means of refractive surgery,4,5 are
all valid for the correction of refractive errors;
but should always be considered bearing in mind
the knowledge, practice and experience of the
ophthalmologist and the best optical and visual
benefit for the patient. Many medical and
surgical factors influence the selection of one
therapeutic option over another, including
complications from the use and abuse of contact
lenses, the potential complications of the
refractive surgery, the difficulty of wearing
spectacles in certain jobs or leisure activities, or
the psychological rejection to their use.
In this study we will only present the results

of our comparisons of visual outcomes with
contact lenses and refractive surgery, in reference
to myopic patients who underwent LASIK
surgery. Visual differences between contact lenses
and refractive surgery with LASIK will be
explained on the basis of the optical analysis of
image size, visual field and the chromatic quality
of the images obtained with corrective spectacles.
The analysis was performed using charts based
on the principles of optics, thickness factors,
distance from the eye and lens powers.
OPTICAL PHYSIOLOGY
Visual acuity is the ability of the eye to perceive
the details of a shape or form. The minimum
separable is the minimum distance at which two
points may be perceived as separate.
The majority of myopic patients report better
visual quality and acuity with contact lenses than
Visual Acuity with Contact Lenses versus LASIK in Myopia

with glasses. Let us consider some aspects related
to vision which change depending on whether
the refractive error is corrected with spectacles
or with contact lenses.
Ocular Accommodation
With spectacles, the vergence of the object
changes as it passes through the glasses, which
is not the case with contact lenses because of
their close contact with the cornea. The range
of accommodation of a myopic patient using
contact lenses will be much larger than with
spectacles, and the higher the myopia, the larger
the range of accommodation.6 Patients with high
myopia complain of problems with near vision
during the first few days of contact lens wear.
Magnification of the Retinal Image

The retinal image is the image of an object
formed on the retina and may be focused or
unfocused depending on whether it coincides
with the optical image or not (Figure 17.1).
Optical correction of a refractive error is
achieved when the image focus of the corrective
lens is made to coincide with the focal point of
the ametropic eye, in this case the myopic eye.
When spectacles are used for correcting myopia,

the optic centers on the spectacles are centered
for distant vision giving rise to a nasal prism effect
in near vision which, in turn, creates a smaller
convergence than would exist with the naked
eye.7 Convergence in the patient corrected with
contact lenses will be greater than in the patient
corrected with spectacles, since correction will
move together with the movement of the eye
without creating the prism effect.
(due to lens geometry) occur with spectacles

because the curvature and power of the glasses
cannot be the same throughout the entire
surface; for this reason, when the eye is not
looking through the optical center of the
spectacles, visual quality diminishes. For one
material, the distortion effect of the lens is greater
the longer the passage through it and the greater
the angle at which light hits and leaves the surface.
Therefore, lens aberration will be greater the
higher its power and the farther away it is from
the cornea.9 Contact lenses, because of their
smaller size and their ability to rotate with the
eye, give rise to much smaller aberrations.
Visual Field
The visual field for the contact-lens wearer is the
same as would exist with the naked eye. The
field shrinks with the use of spectacles depending
on the vertex distance, the diameter of the
glasses, the frame, etc.8
Optical Aberrations
Chromatic aberrations (induced by the nature
of the material) as well as geometric aberrations
Section
Ocular Convergence
237
FIGURE 17.1: Myopes image with and without correction.

Image formation of an object O located to the left. No use of
optical correction is depicted below. When the minus lens is
used, the object forms a smaller image (I2) which is located
further back
238
Therefore, the power of the corrective lens will

vary depending on the distance at which it is
placed from the eye. In myopic patients, the
farther away from the eye, the greater the lens
power required for correcting the same refractive
defect and vice versa and, in each case, the lensinduced vertex magnification will be different.
Vertex magnification is the relationship
between the retinal image of the compensated
eye and the retinal image of the noncompensated eye.10
Vertex magnification = 1/(1Vd Sp) = Y/Y
Section
Where
Vd = Vertex distance of the spectacles
Sp = Spectacle power
Y = Retinal image through the glasses
(sharp image)
Y = Uncorrected retinal image (blurred
image)
The formula implies that the greater the
power of the spectacles in a myopic patient (Sp),
or the greater the vertex distance (Vd), the
smaller the retinal image seen through the
spectacles (Y) (Figures 17.2 and 17.3).
FIGURE 17.2: Lens power and magnification. Lenses of

lower and greater power, respectively, are depicted above
and below. Both are located at the same distance from the
eye. The image (I) formed by the higher power lens is
formed farther away and it is smaller than the other image
(I2)
FIGURE 17.3:
Considering two
different distance
eye, the greater
images size
Vertex distance and magnification.

lenses of equal power but placed at a
from the eye, the closer the lens is to the
the corrective effect and the larger the
The same formula can be used to compare the

size of the retinal image which would be theoretically obtained in an emmetropic patient and in
a myopic patient wearing 5.00 D spectacles, both
of them with a visual acuity of 0.8 (using the letter
E on the Snellen chart at 3 meters).
The following formula is used to calculate the
size of the letter (Y):
4
Y = d u (rad) = d u 2.9 10 = (d 2.9 10 )/VA
Where
Y = Object size in meters
d = Distance between the object and the
eye in meters
u = Angle in radians formed by object
height and distance in relation to the
eye
u = 1 rad
VA = Visual acuity on the Snellen decimal
scale
Thus, the size of the object (Y) seen by a
patient with 0.8 visual acuity from a 3 meter
distance (d) will be: Y = (3 2.9 104 )/0.8
= 1.09 103 meters (Figure 17.4).
239
Y= 3.63 104 [(1 + 12 103 0)/

(0 + 60)]
6
= 6.05 10 meters
RETINAL IMAGE FOR A MYOPE
The following is the calculation of the retinal image
(Y) in a myopic patient wearing 5.00 D spectacles who is capable of seeing the same object.
Considering that it is an axial myopia, Ep =
60 D, the refraction value is calculated on the
corneal plane (r):
FIGURE 17.4: Objects size and visual acuity. The minimun
separable is the minimum value at which two close points
are seen as separate
RETINAL IMAGE FOR AN EMMETROPE
u = Y/X
Where
Y = Retinal image in meters
u = Angle in radians formed by the height
and distance of the object in relation
to the eye
Vd = Spectacle vertex distance = 12 mm
R = Spectacle power at the cornea = 0 D
(emmetropic patient)
Ep = Eye power (theoretical eye = 60 D)
Y = Object size in meters
X = Distance in meters between the object
and the eye.
Thus, the retinal image (Y) for the emmetrope will be as follows:
Y = u [(1+ Vd R)/(R + Ep)]
Sp = Spectacle power = 5.00 D

Vd = Vertex distance = 12 mm.
If the patient has a 5.00 D myopia, then
R = 4.72 D and the retinal image will be:
Y = 3.63 104 [(1 + 12 103
4.72)/( 4.72 + 60)]
= 6.19 106 meters.
The image will be blurred because the object
is farther away from the remote point for the
myopic eye and larger in size than the one
obtained on the retina of the emmetropic eye
(6.05 106 m). Now let us consider the vertex
magnification of the retinal image when the
patient looks at the same object through
spectacles:
Section
Let us now calculate the size of the retinal image

in an emmetropic patient capable of distinguishing an object 1.09 103 meters in size.
Our theoretical eye has only one 60 diopter
lens, and the formula is then applied as follows:
R = Sp/(1 Vd Sp)
Vertex amplification = Y/Y = 1/(1 Vd Sp)
Where
Vd = Vertex distance = 12 mm
Sp = Spectacle power = 5.00 D
Y = Myopic retinal image without spectacles
Y = Myopic retinal image with spectacles
Y = 0.94 Y = 5.82 106 meters
Therefore, for the same visual acuity (0.8),
the size of the retinal image through the spectacles
of a myopic patient (Y= 5.82 106) will be
240
FIGURE 17.5: Magnification and visual quality. The table

shows the magnification calculations for different myopic
ametropias. VA* is the theoretical visual acuity that would
achieve the patient wearing contact lenses
Section
significantly smaller than the one in the

emmetropic eye (Y= 6.05 106). This means
that the discrimination ability in this patient is
greater because he or she is able to see a much
smaller image.
Now let us calculate the visual acuity of an
emmetropic eye which is capable of discriminating the size of the retinal image of the
5.00 D myope through his or her spectacles
(Y = 5.82 106):
Y = u [(1 + Vd R)/R + Sp]
= u (1/Sp)
u = Y Sp = 5.82 106 60
= 3.49 104 meters
u = Y/X;Y = u X = 3.49 104 3
= 1.05 103 meters
VA*= (d 2.9 104)/Y
= (3 2.9 104 )/(1.05 103)
= 0.83
Therefore, a 5.00 D myopic patient wearing
spectacles, with a visual acuity of 0.8, when fitted
with contact lenses would achieve a theoretical
visual acuity (VA*) of 0.83.
We will use the same procedure described
above to calculate image amplification in other
myopic patients, all of them with a visual acuity
of 0.8 (measured with the letter E of the
Snellen chart at 3 meters), wearing 10.00 D,
15.00 D and 20.00 D spectacles, respectively
(Figure 17.5).
These results show why high myopes
improve their visual acuity with contact lenses,
since the magnification effect of the retinal image
disappears. When comparing a common
spectacle lens with a contact lens of equivalent
power in the myopic patient, the image size
obtained with the spectacle lens is smaller than
the one obtained through the contact lens
FIGURE 17.6: Contact lens and magnification. A lens of

8.87 D placed on the cornea (vertex distance = 0 mm)
produces a larger image at the same focal distance as a
lens with the equivalent power (10.00 D) placed at a vertex
distance of 12 mm
(Figure 17.6). The higher the myopia, the

greater this difference will be.
The purpose of the following study is to
determine what happens to the visual acuity of
this myopic patient who is a contact lens wearer
and decides to undergo refractive surgery. We
will also assess whether the vision achieved after
LASIK is the same as the one achieved with
contact lenses, considering that surgery also
eliminates the magnification effect produced by
the spectacles, or whether there are other factors
which might prevent this from happening.

MATERIALS AND METHODS
Refraction was performed under cycloplegia

and surgery was planned for cycloplegic
refraction. A computerized corneal topography
was performed (TMS-1, Computed Anatomy
Inc., software release 1.61, New York, NY) and
the simulated keratoscope reading (Sim K) was
used to analyze the pre- and postoperative
corneal curvatures.
Contact lens wear was discontinued before
surgery, for a period of 2 weeks for soft lens
wearers and 4 weeks for RGP lens wearers. All
of the patients signed an informed consent
before surgery.
All of the interventions were performed by
the same surgeon (JH) at the Instituto
Oftalmolgico de Sabadell (Barcelona, Spain).
The intervention was myopic LASIK using the
Automated Corneal Shaper microkeratome
(Chiron Vision, Claremont, CA) to create a flap
8.5 mm in diameter and 160 mm in thickness.
The myopic ablation was performed with the
broad-beam excimer Apollo laser (Apollo Vision
Inc, California, CA), using a 193 nm wavelength,
a 260 to 290 mJ/cm2 fluency energy, a 10 Hz
repetition frequency and a cut rate of 0.25
microns per pulse. The patient was asked to fix
the eye on a helium-neon light and the ablation
was centered on the visual axis. The surgery was
planned to the cycloplegic refraction correction
expressed in terms of a negative cylinder, and
the astigmatism was treated by flattening the
steepest meridian.
RESULTS
FIGURE 17.7: Types of contact lenses. The table shows

the relationship between refraction, contact lenses and
patients
Section
A total of 100 myopic eyes wearing contact

lenses to correct myopia or myopic astigmatism
were studied: 55 eyes soft contact lens wearers,
34 eyes rigid gas-permeable (RGP) contact lens
wearers, and 11 eyes toric-soft contact lens
wearers.
The eyes were divided into four groups on
the basis of the spherical equivalent (Figure
17.7):
Group A: Up to 5.00 diopters (23 eyes)
Group B: From 5.25 to 10.00 diopters (39
eyes)
Group C: From 10.25 to 15.00 diopters
(22 eyes)
Group D: More than 15 diopters (16 eyes).
All patients underwent a thorough ophthalmological examination. Corrected visual acuities
for distance and near were measured. Visual
acuity data were collected and analyzed in
decimal fraction units. Visual acuity was assessed
in all cases with the contact lenses worn by the
patients before surgery, and it was compared
with the visual acuity obtained after LASIK
surgery, using the Snellen decimal scale.
241
The following was observed when comparing

visual acuity with contact lenses in the 100 eyes
studied with the visual acuity without optical
correction achieved after LASIK (Figure 17.8).
242
FIGURE 17.8: Visual acuity without correction. The graph

shows the visual results obtained in the 100 eyes studied
comparing the visual acuity with contact lenses before LASIK
and the uncorrected visual acuity (UCVA) achieved after
LASIK
Section
Visual acuity diminished (from 1 to 5 lines of

vision) in 41 percent of eyes
Visual acuity improved (from 1 to 6 lines of
vision) in 34 percent of eyes
Visual acuity maintained the same in 25
percent of eyes.
Visual acuity remained the same or improved
in the majority of eyes (59%) after LASIK. The
analysis of the reasons for improved visual acuity
after LASIK revealed that 70 percent were using
undercorrected contact lenses and 12 percent
had contact lenses in bad condition. The main
cause for diminished visual acuity after LASIK
was undercorrection after surgery (55%), but
undercorrection was intentional in 30 percent
of these cases because of their presbyopic age.
When analyzing these visual results for the
different groups of myopia (Figure 17.9), we
find that myopias up to 10.00 D (groups A
and B) showed the best improvement after
LASIK surgery, whereas myopias greater than
10.00 D (groups C and D) showed the greatest
reduction of visual acuity after surgery. This is
FIGURE 17.9: Visual acuity without correction. The table

shows the visual results obtained in each group comparing
the visual acuity with contact lenses before LASIK and the
uncorrected visual acuity (UCVA) achieved after LASIK
explained by the poor predictability of LASIK in

high myopias.
Over-refraction was performed with contact
lenses in order to determine the best preoperative visual acuity, which was then compared
with the best-corrected visual acuity (BCVA) after
LASIK. The results were as follows (Figure
17.10):
52 percent maintained the same visual acuity.
FIGURE 17.10: Visual acuity with correction. The graph

shows the visual results obtained in the 100 eyes studied
comparing the preoperative best-corrected visual with
contact lenses with the best-corrected visual acuity (BCVA)
after LASIK

30 percent gained visual acuity after LASIK
(from 1 to 5 lines of vision)
18 percent lost visual acuity after LASIK (15
eyes lost one line of vision and 3 eyes lost
two lines)
The majority of eyes (82%) maintained or
gained visual acuity after LASIK. The analysis of
these results according to myopia groups (Figure
17.11) showed that the group which gained most
visual acuity after LASIK was group A with less
than 5.00 D (52%), while the group with the
greatest loss was group D with more than
15.00 D (44%).
243
Section
acuity obtained with contact lenses, and where

the eyes that showed loss of vision (13%) lost
only one line.
The group with myopia greater than 15.00
D (group D) showed the greatest loss of visual
acuity after LASIK as compared with the
preoperative visual acuity with contact lenses
(44%). However, this was not associated with a
surgical complication, considering that the cases
selected for this visual assessment had no complications during or after LASIK. It was found that
71 percent of the patients with more than 15.00
D who lost vision were rigid gas-permeable
(RGP) contact lens wearers with a preoperative
visual acuity with contact lenses ranging between
0.6 and 0.8, which is higher than expected in
these high myopias.
No association was found between loss of
visual acuity and post-LASIK keratotomy studied
with topography (Sim K). Similar Sim K values
were found both in eyes that lost vision as well
as in eyes which maintained the same vision after
LASIK.
We believe that the loss of visual acuity found
in the group with more than 15.00 D myopia
could be associated with the small optical zones
used for LASIK correction in these high myopes.
Optical zones greater than 5 mm were used in
groups A, B and C; but in group D (> 15.00
D), 5 mm optical zone was used and these
patients reported splitting of the image edges
which prevented clear vision. This might be the
cause for visual acuity loss in these eyes which
were able to see very small images before
surgery and which saw split images difficult to
decipher after surgery as a result of the
interference with the edge of the optical zone.
FIGURE 17.11: Visual acuity with correction. The table

shows the visual results obtained in each group comparing
the preoperative best-corrected visual with contact lenses
with the best-corrected visual acuity (BCVA) after LASIK
The expected theoretical result would have

been that in the majority of eyes, the BCVA after
LASIK should have been the same as with
contact lenses before surgery and would have
been even better, considering that in some cases
the lenses were soiled and did not allow for good
visual quality. This theoretical outcome was
obtained for the groups with less than 15.00 D
myopia (groups A, B and C), where 87 percent
of the eyes maintained or improved the visual
244
CONCLUSION
Section
Refractive surgery has a number of ophthalmological and psychological connotations.

LASIK is a refractive technique used to solve a
refractive error which, in many cases, had been
solved totally or partially by contact lens wear.
Therefore, it is mandatory to assess patients
expectations regarding this form of surgery.
We have observed that the higher the
myopia, the greater the degree of patient
satisfaction after LASIK, since there is no longer
a need to depend on the optical correction.
However, there is also a greater possibility of
undercorrection and of inducing glare and halos
in night vision as a result of the optical zone
diameter and corneal shaping used for correcting
the refractive error.
REFERENCES
1. Daza de Valds. Uso de los anteojos. In Sevilla (Ed)
Madrid: Garsi 1982;1623.
2. Mann IC. History of contact lenses. Trans Soc UK
1938;58: 109.
3. Ridley F. Clinical significance of contact lenses. Br
Ortho 1954;J 10: 10.
4. Trokel S, Srinivasan R, Braren B. Excimer laser surgery
of the cornea. Am J Ophthalmol 1983;94: 125.
5. Buratto L, Ferrari M, Rama P. Excimer laser
intraestromal keratomileusis. Am J Ophthalmol
1992;113: 291-95.
6. Optics, Refraction and Contact lenses. Basic and
Clinical Science Course Section 3. American
Academy of Ophthalmology: San Francisco 1997.
7. Belmonte N: Refraccin Ocular. Ediciones Doyma,
S.A. Barcelona 1989.
8. Duke-Elder S, Abrams D. Ophthalmic optics and
refraction. In Duke-Elder S (Ed): System of
Ophthalmology Kimpton: London 5: 1970.
9. Welford WT. Aberrations of the Symmetrical Optical
Systems Academic Press, 1974.
10. Yves Le Grand. Optique physiologique. Ed. Revue
dOptique, Paris, 1964.
Chapter
18
The Use of Contact Lenses

in the Athletic World
Michael R Spinell
Section
If one were to look at the athletic spectrum of

accomplishments over the last 100 years, it would
not take very long to appreciate the tremendous
improvement in all aspects of sports. In some
cases, it is due simply to athletes training harder.
In other cases, it is due to technological changes
which have influenced training methods and
routines. In most cases, it is due to an
accumulation of changes which have enabled
athletes to perform at higher levels. This includes
associated things such as a better understanding
of nutrition which enables athletes to train harder
and the importance of understanding the causes
of many athletic injuries. These concepts all are
related since they have one common goal; giving
the athlete a better chance to scientifically train,
have a faster and more complete recovery
period and thereby have a better chance of
raising the level of achievement to a higher and
more impressive level. Paralleling these things
has been the widespread use of computers.
These devices can analyze an athletes progress,
track numerous components in training routines
and even analyze a given athletes mechanics
relative to his/her body structure and the specific

maneuvers that person is trying to perform.
Depending on the activity, routine training
methods have usually centered on the athletes
spending countless hours running and/ or doing
aerobics, lifting weights or working with
mechanical resistance machines and generally
engaging in all sorts of stressful training activities
in the hope of gaining some advantage and
thereby, improve their athletic performance.
Frequently, the visual system, easily one of
the most important systems in the body, is
conveniently overlooked. The reasons for this
vary. In some cases, it is due to the coaches,
trainers and the athlete being somewhat naive.
In many cases, it is due to the fact that most
people do not feel comfortable giving advise
about the eyes and their various functions. This
could be due to age old fears concerning the
bodys most delicate and important organ or it
could be due to a variety of other reasons. The
point that should be made, however, is that it is
generally agreed that about 80% of the
information coming into the brain comes by way
of the visual system. Consequently, many
246
problems or difficulties that may occur during

athletic activities could be attributed to a visual
problem.
Naturally, different athletic activities have
different requirements. For example, in some
cases, the participants are involved in activities
that are very dynamic. Frequently, a fast moving
object is involved and often the participant is
also moving at high speeds. Since visual
information is the trigger mechanism for an
athletes first movement, it would seem obvious,
that everything should be done to ensure that
all athletes have clear, comfortable, crisp and
stable vision. Naturally, different sports have
different requirements. In fact, in a sport like
American football, different positions have
different physical and visual requirements.
Interior linemen are usually involved in close
proximity gross movement since they work so
closely to defensive players. Little time is available
for them to visually analyze a situation. In
contrast, a quarterback or defensive back must
continuously analyze visual information and
utilize these visual cues in order to decide what
physical action they should make.
Tennis (Figure 18.1) nicely illustrates a sport
where all aspects of the visual system are
challenged. This can be broken down into specific
categories involving clear vision, ocular movements, stereo acuity, visual fatigue and even color
vision. In this example, most people can easily
relate to the different aspects of the game and
how the different aspects of the visual system
might relate. However, this is not always the case.
For example, Track and Field (Figures 18.2
to 18.7) nicely illustrates many different activities.
Some events have a lot in common, while other
events have totally different visual requirements.
It is extremely important that everyone has a
Section
Tennis is one of the most visually demanding sports since

good sharp vision and long-term concentration are frequently
required and many times the game is played under extremely
hot and humid conditions
FIGURE 18.1: Shows a tennis player following the flight of
the ball
good working knowledge of each activity since

many times what seems like a simple valid fact
can be incorrect. Distance runners may not
initially seem like they have great need for seeing
clearly since they are moving relatively slow and
are not trying to catch or hit a fast moving
projectile. However, they still may have need to
see a distant clock; or if they are running on
streets or grass, they must see objects or subtle
holes in the ground before they land incorrectly
and get hurt. Sprinters are known for their
incredible ability to move quickly. Yet, it is not
uncommon to see sprinters and hurdlers take
off their glasses before a race since they do not
want to have them bounce off while running.
This may initially seem like a prudent thing to
do. However, in good competition, short distance
races are frequently won by leaning at the finish
where the upper torso actually cheats forward
8 to 12. Even though this may not seem like a
great amount of distance, in good competition,
it may be the difference between the winner and
the 4th place runner! Knowing precisely when
The Use of Contact Lenses in the Athletic World
247
FIGURE 18.4: Shows a runners view of the finish in a short

sprint. In approximately 10 seconds of dynamic vision,
sprinters will cover this distance and then have to precisely
judge the location of the finish line so they can lean at
precisely the right moment. If one leans properly, a gain of
about one foot occurs. If one leans too early, deceleration
actually occurs
Section
to lean is a visual cue that relies on a runners

ability to see the finish and lean at precisely the
correct moment. Leaning too soon will cause
the runner to actually decelerate and leaning
too late will simply be useless. Consequently,
being able to see clearly under extremely
dynamic conditions and then to utilize this
information properly is mandatory and the key
to the whole process is the visual clarity at the
finish line.
It is often difficult to describe the different
FIGURES 18.2 and 18.3: A long distance runner may seem

like they do not require good vision since they are moving
relatively slow compared to a sprinter. However, they still
must be able to see the terrain over which they are running
in order to avoid dangerous obstacles in their path. This is
illustrated in Figures 18.2 and 18.3 where a runners foot is
about to land on a sharp rock and a banana
FIGURE 18.5: Shows the finish of the 100 meter dash.

Note that the runner in lane four has not leaned at all
types of athletes and what attributes they have

and require to accomplish their specific goals.
Usually, an athlete is described as a person who
is well coordinated, fast, strong, has developed
endurance for the event he/she is doing.
Frequently some mention is made to the athletes
strong motivational qualities. Occasionally,
mention is made to the fact that some athletes
have good eyes. With the exception of eye
248
Section
FIGURE 18.6: Shows a hammer thrower in action. Even

though good vision is nice to have, it is not an absolute
necessity in this event
FIGURE 18.7: In some cases, blurry vision can be an asset

as well as a problem. This is illustrated in figure where a
presbyopic nearsighted target shooter is able to see the
front sight of his pistol quite well, but unable to see the target
clearly. If he was to wear corrective lenses, the target may
now be clear, but the front sight now blurry
doctors, most people consider good eyes as

simply relating to the ability to read letters on a
vision chart that might be smaller than the
average person can read. Sometimes, a television announcer will comment on somebodys
good peripheral vision. Healthcare and eye care
practitioners who engage in the athletic world
quickly realize that there is much more to vision
than the things that have been mentioned above.
However, almost everything begins with ones

ability to see clearly and without unnecessary
stress. If a particular athlete has a problem not
seeing well, almost all eye doctors are able to
improve things with the use of some form of
visual correction either in the form of glasses or
some form of contact lens.
It is the intent of this chapter to present the
topic of designing contact lenses for athletes as
completely as possible. It is not the intent to make
this topic more complex and confusing than
necessary. One will quickly realize that many
common well-established contact lens principles
will apply throughout. However, many times
some subtle things will be mentioned that could
easily make a difference in an athlete getting the
best and most current help possible.
One must remember that athletes are
normal people. However, the demands of their
sport often make them do things that are not
normal. As illustrated before, this could be due
to speeding object or colliding with an opposing
athlete. A mild contact lens problem can become
a significant distraction that could adversely effect
athletic performance since both the visual and
mental aspects of the visual system are involved.
A superficial review of the current contact
lens literature might lead one to think that there
have not been too many advances lately in the
field. Basically, there are soft hydrophilic-type
lenses and rigid or hard lenses that are now
almost exclusively made out of some form of gas
or oxygen-permeable material. Even though the
actual design of most soft lenses has not changed
much recently, the widespread popularity of
disposable or planned replacement lenses
has provided definite advantages to athletes. A
similar situation also occurs with rigid lenses since

GENERAL ADVANTAGES OF
CONTACT LENSES
There are several important advantages for

athletes to wear contact lenses. For one, there is
an increase in the peripheral fields of view of
about 15%. There is also no outline of a frame
to obstruct or hinder vision. This can become
especially annoying in athletic activities where
there are sudden changes in direction of gaze. A
third baseman in baseball may have to field a
ground ball on one play, dive into a shadow for
a line drive on another and then look up into a
bright dazzling sun shortly afterwards.
A goalie in hockey (Figure 18.8) must be
able to maintain a tremendous amount of
concentration at all times. He/she must be able
Section
there have been a few significant lens design

changes, yet some of the new materials may
provide some definite advantages to many
athletes where constancy of sharp acuity is vital.
It is also important to keep an open mind to
future changes. Sometimes what may now seem
like a real problem may shortly be improved.
For example, scleral lenses were used years ago
by athletes, but lost favor due to physiological
problems. These lenses are now available in gaspermeable materials and may prove helpful in
some sports such as swimming.
The recent popularity of refractive surgery,
especially LASIK (laser-assisted in situ keratomileusis) has added another dimension to the
options available to athletes. There is no doubt
that many athletes are helped by this procedure.
However, it is important for all athletes to realize
that there are disadvantages to this procedure,
as well. Below is a list of some of the concerns
athletes should have when deciding on this
surgical procedure. The reader is advised to
investigate this topic, where it is discussed in
detail.
1. This procedure is permanent. Once it is done,
the recipient cannot change his/her mind and
go back to the presurgical situation.
2. Not all people get results consistent with their
visual needs as an athlete.
3. Large pupils can create flare or ghosting
that can be very annoying. This can occur
even in situations where they are able to read
the 20/20 line.
4. The present or future presbyopic needs of
the athlete must be understood by the person
involved.
5. Refinements or further procedures to solve
any future refractive changes may be
necessary.
249
FIGURE 18.8: Shows the incredible concentration that

hockey goalies must have. This is one of the most visually
demanding positions in any sport. If they are experiencing
any type of contact lens problem, their visual concentration
will be affected which will then affect their ability to perform
250
Section
to anticipate the puck changing direction due to

ricochets or being temporarily screened by an
opposing player. Any other obstructions in the
field of view would be devastating.
A tennis player often has to be out on a court
for hours under extremely hot and humid
conditions. It is still important to be able to
appreciate the spin of the ball coming off of the
opposing players racquet, as well as, the precise
location of the other player(s) and the foul lines
demarcating the field of play.
Contact lenses are also advantageous since
they do not fog up as glasses often do during
hot and humid conditions. They also do not spot
up during competition in the rain. They seldom,
if ever, get dislodged. These comments are based
on the supposition that the lenses being used
have been properly designed, manufactured and
cared for.
All of these examples illustrate the need for
clear, constant and efficient vision. If athletes do
not have confidence in their visual system, they
will not be able to focus 100% of their attention
on their real objective. In good competition, this
will eventually affect their performance and
possibly the results of the game.
DISADVANTAGES OF CONTACT
LENSES
As one might anticipate, any device placed on
an eye, no matter how scientifically designed,
could still have certain disadvantages. An obvious
example would be the possibility that contact
lenses might not provide suitable protection from
a blow to the anterior segment of the eye. It is
quite possible that the lens could rip or shatter
and create some rather devastating situations.
There are instances where fast moving foreign
bodies have hit the cornea and then bounced

off causing no real injury to the eye.
Throughout this chapter, it will be
continuously mentioned that if a lens design is
chosen that does not take into consideration
certain important things, a lens intended to help
an athlete might actually create distractions that
could adversely affect athletic performance.
Consequently, one should pay attention to many
of the subtle suggestions being made in regard
to things like pupil size, the use of lenses during
contact or aquatic sports, and the designing of a
lens that provides not only the clearest of vision
but also the most efficient vision possible.
EXTERNAL MEASUREMENTS OF
THE EYE
It is important when designing any contact lens
to take into consideration several basic measurements and utilize this information in the choice
of lens. Some practitioners do not formally write
down this information, others have it as part of
their usual fitting form. Such things as horizontal
visible iris diameter (HVID), pupil size, palpebral
aperture, lid tension and position may get
overlooked. On some lens wearers, this may not
make any difference. However, there are
situations where this information can be
extremely important. For example, suppose a
practitioner has decided to use some large
athletic lens on a patient who has small
apertures and very tight lids. It might become
quickly apparent that the lens wearer is unable
to handle these big, flimsy lenses. The situation
could even become further complicated if the
patient requires a low minus or even hyperopic
power that is even more difficult to handle.
Consequently, it is important for the contact lens
251
practitioner to continuously keep in mind all of

the basic contact lens edits and relate them to
the activity the lens wearer will be doing.
PUPIL SIZE
Pupil size (Figures 18.9 to 18.11) has always
been of concern since early rigid lenses were
purposely kept small so that as much of the
cornea was exposed to atmospheric oxygen as
possible. This necessitated the use of small
posterior optic zones which often created the
well-known phenomenon of flare from
extraneous lights. The many advancements that
have been made in gas-permeable materials
FIGURE 18.11: Shows how lights might look if a large pupil

caused flare or ghost images from light reflecting off of the
optic zone/peripheral curve juncture
FIGURE 18.9: Shows an eye with a very large pupil
FIGURE 18.10: Shows how overhead lights would look in

sharp focus
LID STRUCTURE AND LID ACTION
Section
have greatly improved this situation since much

larger lenses with larger optic zones can now be
used with little concern about physiological
problems. However, big pupils can still create
some problems that will be continuously
discussed throughout this chapter.
The role of the eyelids and the action of the lids

during a blink are often ignored (Figure 18.12).
However, during the fitting of contact lenses, lid
structure, lid position and lid action all become
significant factors in determining the overall
success. For example, with rigid gas-permeable
(RGP) lenses, a high upper lid might not pick
up some lens designs. A tight upper lid may drag
up some lenses or even knock down others.
They could also cause ultra-thin lenses to flex
during a blink and create a momentary loss of
sharp vision which could create a dangerous
situation.
Soft lenses have their own idiosyncrasies. A
lens wearer who does not blink sufficiently could
cause a lens to dehydrate slightly resulting in
252
FIGURE 18.12: The composite picture in figure illustrates

how some lenses do not deform from lid pressure as much
as other lenses. This enables athletes to appreciate more
constant vision. Soft lenses that contain methylmethacrylate
usually are slightly stiffer and deform less
Section
smudgy vision. This problem has continuously

plagued routine contact lens wearers for years.
As one will shortly see, there is now a lens
material available that clinically seems to address
this problem better than most other lens
materials. A person who has a very forceful blink
or one who must have incredibly sharp and
consistent acuity at all times may be better off
with a lens material that contains methylmethacrylate to make it stiffer and less apt to
deformation from lid action during a blink.
PRESCRIPTION OF THE LENS

Fortunately, most low to moderate lens powers
do not create any significant problems. However,
patients who require very high powered lenses
can experience some problems due to the
required lens design. For example, if a patient
needs a 12.00 D RGP lens, most lens
practitioners would order the lens in a plus edge
lenticular carrier design to minimize the thickness
of the edge. This would also make the lens more
comfortable, increase oxygen transmissitivity
(since the overall thickness of the lens would be

less) and reduce the affect of the lids since a
much thinner edge would be present. This type
of lens design, however, creates an anterior optic
zone (cap) that can, itself, create flare from
lights, especially if the lens wearer has large pupils
or the lens moves a lot.
Soft lenses are much larger than RGP lens
designs, so lenticularization is automatically
incorporated in the design during the manufacturing process. Almost all soft lens
manufacturers seem to have the anterior optic
zone in high power lenses at about 8 mm or
greater. Thus, a high myope with large pupils
could easily experience ghost images from light
hitting off of the anterior optic zone boundaries.
This is different than the problems that occurred
with small nonoxygen-permeable PMMA lenses
used years ago when it was the light hitting off
of the posterior optic zone boundaries that
created the problem. One might think that a
good solution for this situation would be to have
the soft lens manufacturers simply make the
anterior optic zone larger. Even if this was
possible, the end result might be a situation
where flare was only reduced. Also, the lens
would probably now be extremely uncomfortable due to the thicker edge and peripheral
edema or limbal plexus engorgement might also
become a concern.
CORNEAL CURVATURE
Historically, the keratometer has been the
instrument most practitioners used to determine
the curvature of the cornea. This information
was then used to determine the base curve or
back curve of the contact lens. In the past 10 or
so years, modern-day computerized topograp-
This topic constitutes one of the most important

concepts in contact lenses since it helps in
predicting how a lens wearer will see with various
lens designs. Sometimes, there is an obvious
advantage to using one lens design over another.
Other times, many different lens types could all
be considered acceptable. As mentioned above,
the interrelationship between the central keratometric reading, especially corneal astigmatism
THE INTERRELATIONSHIP
BETWEEN CORNEAL ASTIGMATISM
AND REFRACTIVE ASTIGMATISM
and the patients refractive error, especially

refractive astigmatism, frequently narrows down
the alternatives.
A discussion of this type becomes quite
complex since it involves a number of variables
such as the amount of corneal astigmatism, the
amount of internal or physiological astigmatism,
the spherical correction and the sensitivity and
visual needs of the individual. As one will see,
the lens design being used and the characteristics
of the various lens materials are all involved.
Consequently, the following discussion should
be considered an overview. The prudent practitioner often considers the theoretical implications
of a situation that could become a problem, but
answers the question by clinically trying good
lens designs and evaluating them.
1. The simplest situation involves a spherical
cornea and a patient whose refractive error
has little or no astigmatism. This could be a 3
diopter myope whose K reading is a 44.00
D sphere. The implication here is that there is
no physiological (usually lenticular) astigmatism present. A rigid lens would usually
have to be fit so that the back curve was flatter
than the curvature of the central cornea in
order to encourage good tear exchange under
the lens. A soft lens would also be very
advantageous since the lens would be able to
take the shape of the underlying cornea, which
in this case is spherical.
2. The second type of relationship that could
occur would be one in which there is some
corneal astigmatism, but it is insignificant in
magnitude or it is negated by physiological
astigmatism. An example of this would be
one in which the refractive error was;
2.75 = 0.50 cx 180 and the keratometric
reading was: 0.75 cx 180 flat meridian
Section
hical instruments have been developed which

give more sophisticated information. For
example, it is now easier to precisely locate the
apex of the cornea. One can also determine
information on the eccentricity value (manner
of flattening) of the various quadrants of the
cornea. It is also a very valuable instrument in
determining the shape of the cornea and how
this shape might relate to other normal or
abnormally shaped corneas such as occur with
keratoconus. This additional information
frequently helps explain why a certain lens design
may have performed differently than expected.
Flat corneas are usually larger in size and
require larger lenses. Gravity also works against
these eyes since lenses are more apt to slip
inferiorly. Steeper corneas are usually smaller in
size and because of the location of the center of
gravity (further in), lenses usually position better.
Knowing the shape of the cornea and the
difference in curvature between various
meridians of the cornea (corneal astigmatism) is
pertinent in determining what type of lens to
use on an individual in order to maximize visual
results.
253
254
43.00 D. In this example, there is about 0.25

D of against-the-rule physiological astigmatism. If a rigid lens is placed on this cornea,
a new spherical front surface for the eye
would be present. This would leave, however,
0.25 D of uncorrected physiological astigmatism. This would be clinically insignificant
and not affect vision.
3. In the following situations, the amount of
astigmatism will be increased which could
affect the choice of lens to use. If, for
example, the refractive error was: 4.00 =
0.50 cx 180 and the keratometric reading
was 1.75 cx 180 flat meridian 45.00 D and
a rigid lens was placed on the eye, there
would be approximately 1.25 D of uncorrected physiological astigmatism present. It
would be anticipated that this would reduce
vision unless something was done to address
the uncorrected astigmatism.
The simplest method to try and improve
acuity would be to use a Panofocal front
surface lens. This lens design resembles a
regular gas-permeable lens except that the
front curve of the lens is aspheric and
designed to reduce aberrations to the point
that acuity would be improved. It does not
correct the astigmatic component, it really
improves ones ability to see by reducing
aberrations. It seems to work about 80% of
the time and is quite useful in cases where
the uncorrected residual astigmatism is 1.25
D or less.
A more complex method of improving the
visual response of the lens wearer is to use a
front toric lens and simply correct the one
and a quarter diopters of uncorrected
physiological astigmatism. However, there are
Section

several problems associated with this design.
For one, it is necessary to incorporate prism
and/or truncation in order to keep the lens
in the proper position. Furthermore, the
lenses tend to torque nasally from lid action
during a blink. Thus, sharp vision could be
interrupted as the lens wearer blinks. The
thicker prism could also cause the lens to get
flicked out of the eye at times, such as
during high-speed ocular excursions.
In this example, if a soft lens was used, the
lens would again wrap on the cornea allowing
the with-the-rule corneal astigmatism to
come through. This would, however, be
negated almost completely by the 1.25 D
of against-the-rule physiological astigmatism.
The end result of this would be that a basic
spherical soft lens might provide excellent
acuity.
4. The fourth type of astigmatism that could occur
would involve a person who had a significant
amount of refractive astigmatism. This could
be a person who has 2.00 D of corneal
astigmatism and perhaps a refractive error of
1.50 = 1.75 cx 180. If a rigid lens was
utilized, good vision would be expected since
the front surface of the contact lens would
cover the 2.00 D of corneal astigmatism
leaving only a tiny 0.25 D of uncorrected
physiological astigmatism. If a spherical soft
lens was placed on this eye, vision would be
poor. The lens would again take the shape of
the astigmatic cornea. The 0.25 D of
physiological astigmatism would not be
sufficient to reduce the refractive astigmatism
so the end result would be a significant amount
of uncorrected astigmatism being present. The
only way this lens wearer could see properly
Even though there are many ways to classify

contact lenses, there are basically two distinct
types of lenses that are being used to any great
extent. There are also two other unique lens
types that have some advantages for use with
athletes. One of the two main lens types that
will be described in detail is the RGP hard lens.
The other lens type is hydrophilic and often
referred to as a soft lens. There is also a
combination lens that consists of RGP central
area and a soft hydrophilic peripheral skirt.
Lately, there has been a resurgence in the haptic
or scleral lens design, but, now it is being made
RIGID GAS-PERMEABLE LENSES

Rigid gas-permeable lenses can be described or
classified in several ways. It is sometimes
convenient to think of them according to their
specific design or in regard to the material that
they are made from.
LENS MATERIAL
Most of the gas-permeable lenses made now
consist of some combination of methylmethacrylate and an oxygen-permeable component
such as some form of silicone or fluorine. For
daily wear lenses, most seem to provide the
cornea with an acceptable amount of oxygen.
The thick central portion of a plus lens creates
some problem with oxygen transmissitivity so it
is best to use a material that has a higher dK
value.
Often times, knowing the subtle differences
between the various materials can be helpful in
avoiding potential problems. For example, some
materials have a tendency to gunk up if they
come in contact with an oily environment such
as grease, Vaseline, eye black or hand lotions.
The lens surface actually gets greasy and creates
all sorts of problems to the lens wearer who is
trying to maintain clear, constant and comfortable
acuity.
Some materials also scratch easier than
others. Thus, it is a good idea to emphasize to
all lens wearers the importance of carefully
cleaning their lenses using good quality care
LENS TYPES
from a gas-permeable material. This lens was

one of the first lens types ever used on eyes. As
will be discussed, it has some good advantages
in certain athletic situations.
Section
with a soft lens would be to use a toric soft lens

that specifically corrected the astigmatic
portion of the refractive error.
5. A fifth type of astigmatic problem is one in
which there is a great deal of corneal
astigmatism. This situation usually requires
the use of back or bi-toric rigid lenses to
stabilize and properly position the rigid lens.
Good quality high powered custom soft toric
lenses are now available from several
manufacturers. One must remember that
even though these lenses frequently relate
well to the cornea, a few degrees
misaligmment reduces vision significantly.
As one can see, the topic of astigmatism is
rather complex. The previous examples only
illustrate some of the situations that can occur.
What should be gleaned from this discussion
is an appreciation of some of these situations
and an understanding that practitioners should
carefully discuss any possible problems with
their patients so that realistic goals are understood.
255
256
systems and oil-free hands. Sometimes, a person

will actually rub contaminants into the lens
surface while they are attempting to clean the
lens.
Many RGP materials tend to flex on the eye
during routine blinks. This causes the lens wearer
to experience momentary periods when vision
suddenly becomes blurred or interrupted. This
can create some frustrating distractions when the
lens wearer is trying to hit a baseball or return a
fast moving serve in tennis. These lens wearers
might find themselves subconsciously holding or
timing their blinks at a critical time in order to
avoid a momentary loss of clear vision.
Flexing can be reduced or eliminated by
making the center thickness of the lens thicker
(0.16-0.18 mm) or by making the lens out of a
material that is known to resist flexure. One of
the earliest RGP materials, Polycon II, does not
flex very much. Unfortunately, this material has
a much lower dK value than many of the other
materials presently available, so it has lost much
of its previous popularity. The fluoropolymers
with dKs around 30 seem to have a very good
combination of good permeability, low flexure
and good wettability. Recently, a new material
called Boston ES has become available. This
material is a modification of the Polymer
Technologys Boston 7 material and can be used
in fabricating true ultra-thin lenses.
A recent addition to the list of RGP materials
is the SportSight GP from Paragon Vision
Sciences. This material is available in gray and
said to enhance perceived visual acuity and
improve visual comfort by controlling the
quantity and quality of light reaching the eye.
The lens selectively filters blue light and blocks
more than 99% of UVA and UVB lights. This
should improve the optics and contrast sensitivity.
Section

LENS DESIGNS
A BASIC RGP LENS DESIGN
This type of lens design is one that traditionally
is composed of a posterior optic zone and a series
of blended peripheral curves that collectively
make up the overall diameter of the lens.
Depending upon how much corneal astigmatism
the patient has, the base curve of the lens is
usually fit within + or 0.50 D of the flattest
corneal meridian as determined by keratometer.
Over the years, the overall diameter of the lenses
has increased since sufficient oxygen is being
supplied through the lens matrix. For years,
relatively smaller lenses had physiological
advantages since more cornea was exposed to
atmospheric oxygen. Oxygenated tears from the
peripheral curve reservoir had less distance to
travel to reach the underlying cornea, especially
under the apex of the lens. Now larger lenses
with larger optic zones can be used which are
more comfortable, resist ejection to some extent
and can reduce the possibility of annoying flare.
The future may have still larger lenses with
modifications in fitting principles that may be still
more comfortable and resist lens ejection as well
as soft lenses now do.
A LID-ATTACHMENT LENS DESIGN
This is a lens design that encourages the lens to
attach to the superior lid by utilizing a
modification in the anterior periphery of the lens.
These designs are sometimes referred to as
Korb lenses or Korb-type lenses or minus
edge lenticular carrier lenses. When performing
properly, the lens rides high and moves with the
lid upon each blink. These lenses are traditionally
larger than basic multicurve lenses and have
larger optic zones. Due to these characteristics,

some people feel that they may have advantages
when used on athletes.
ULTRA-THIN LENS DESIGNS
Years ago, when only firm lenses were available,

practitioners tried all sorts of modifications in the
design of lenses in order to improve lens
adherence to the eye. These athletic lenses
were usually fit much steeper than conventional
lenses. They also had larger diameters and a
ASPHERIC LENS DESIGNS

These lenses are designed with posterior curves
that flatten out as one proceeds from the center
or apex of the lens toward the periphery of the
lens. The base curve is described in a similar
manner as with spherical back curve lenses. Thus,
an aspheric lens could still be described as a lens
with a base curve of 7.85 mm or 43.00 D. The
difference is that the aspheric lens only has the
back curve radius for a very small area in contrast
to a regular lens in which the back curve radius
would extend out for the entire area of the optic
zone.
Aspheric lenses can vary as to how quickly
the peripheral areas flatten. This is referred to as
the eccentricity value (e value) of the lens. The
higher the e value, the faster the lens flattens.
Thus, two aspheric lenses of identical diameter
and same base curve could have different
eccentricities and perform quite differently on
the eye. The lens with the higher e value would
have a smaller sagittal value and, therefore, fit
looser than the other lens. Consequently, lenses
are usually fit with base curves that are quite
ATHLETIC LENS DESIGNS
steeper system of peripheral curves. The basic

concept behind all of these changes was to try
and make the lens tighter, so it would be less apt
to get knocked out of the eye when used in
sports. Though all of these changes are
theoretically correct, the question always
remained whether the lenses really would stay
on the eye after somebodys elbow struck the
lid or adnexa and what would happen after the
lens wearer got involved in a real collision. It
was also important to carefully monitor wearing
time since these lenses were made from PMMA
material and tear exchange was going to be
significantly sacrificed.
Section
These lenses are usually small in size and are

manufactured with center thicknesses around
0.08 mm to 0.11 mm. They adhere to the
cornea by both the customary vector forces and
by capillary attraction. They are also
manufactured with very thin edges which aid in
comfort and also make the lens less apt to get
ejected from the eye during extreme ocular
excursions or a blow to the head.
This lens design, though very popular, has
several definite disadvantages. For example,
most RGP lens materials cannot be machined in
the above thicknesses because the lenses would
warp or break quite easily. The lens also has to
be kept relatively small since large diameters
would encourage poor dimensional stability and
result in flexure, fluctuations in vision and
probably warpage and breakage. Thus, athletes
with large pupils might experience flare or ghost
images as the line of sight approaches the optic
zone/secondary curve juncture.
An interesting situation now occurs with the
introduction of the Boston ES material. Lenses
can now be machined with very thin centers.
This would allow these ultra-thin lenses to be
made relatively larger than before and still not
have them lose their dimensional stability.
257
258
Section
steep compared to a spherical lens design.

However, this steepness is only for a remarkably
small area of space. The fluorescein pattern
usually shows a small area of central pooling that
disappears as one observes the paracentral area
adjacent to the corneal apex. Thus, a lens that is
said to be fit 3 diopters steeper than the flat
meridian should not be thought of in the same
manner as a spherical lens that is fit than steep.
The advantage of these lenses for athletes is
that they have no peripheral curves that
resemble the peripheral curve system of a
spherical lens. Thus, these lenses could be
advantageous to use for an athlete who has large
pupils and might be bothered from flare from
lights.
There are several disadvantages of this type
of lens design. Good centration is very
important. It is very difficult to make any
modifications in the lens. The laboratory cost is
higher and the lenses are usually thicker. It is
also possible that this type of lens design might
help a particular problem, but, not completely
eliminate it.
RIGID GAS-PERMEABLE LENS

EVALUATION
Regardless of the type of lens that has been used,
all lenses must perform adequately according to
the basic contact lens rules. This involves an
assessment of lens position, movement, vision,
comfort, fluorescein pattern and postwear health
of the eye. Even though these things will be
discussed individually, it is important to note that
these things are all inter-related.
For example, if a rigid lens positions inferiorly
and does not get picked up by the action of the
superior lid upon blinking, there is a good chance
that not all of the criteria for success will be met.

The lens may provide acceptable acuity though
there is a chance that the poor positioning may
cause the optic zone to splice the pupillary area
causing flare or ghost images. Since the lens is
essentially not moving, there could be physiological problems since adequate tear exchange
may not occur. The fluorescein pattern may show
some central pooling that has to be considered
relative to the lens malpositioning. Comfort could
be good, however, if the superior lid bumps into
the top of the lens edge with each blink, there is
a strong possibility that this lens would be
uncomfortable, as well.
LENS POSITION
Most RGP lenses should position very close to
the center of the cornea. In actuality, they usually
position slightly higher than the true centered
position due to the effect of the superior lid
during a blink. During this action, the lens is
picked up by the lid and then should gently
gravitate down to the near centered position
again. This sequence is slightly different for lidattachment lens designs. In these cases, the lens
moves down with the lid and then moves back
up as the blink is concluded.
The end result of either of these actions is to
pump fresh oxygenated tears under the lens and
flush out the old tears and any debris that might
be behind the lens. If a lens is not positioning
properly, corrective measures must be made.
For example, in the above case, where the lens
was positioning inferiorly, changes in lens design
such as increasing lens diameter to encourage
superior lid grab could be helpful. An
accompanying flattening of the base curve might
also be helpful. If the lens still does not position

properly, the practitioner would have to decide
whether a further increase in diameter was to
be tried or whether a totally different approach
was necessary. This could include a change to a
minus edge lenticular carrier design to emphasize
lid grab or a change to a totally different
philosophy such as to an ultra-thin design that
de-emphasizes lid action. Naturally, if this lens
wearer had large 8 mm pupils, changing to a
small ultra-thin lens with small optic zone would
not be prudent.
In a similar manner, if a lens is riding too
high, it might be lowered by tapering the anterior
edge, steepening the base curve or even
decreasing the overall lens size, if appropriate.
VISION
From the previous discussion, it is probably

apparent that it is very difficult to discuss lens
position without discussing lens movement since
it is a change in lens positioning that constitutes
movement.
It is also important to consider the speed in
which the lens moves since that can create other
problems. If a lens is moving too fast, there is
usually a great deal of lens awareness and vision
is usually inconsistent. This can create all sorts of
problems in any sport, especially dynamic ones,
in which both the athlete and an object are
moving. If lights are also involved, the chance
of flare further complicating the situation also
occurs.
Consequently, it is important that athletes be
fit with lenses that not only move but also move
in a way that is consistent with them being able
to maintain their concentration. If a lens is
moving too much, normal contact lens rules
indicate a steeper base curve, thinner lens
increasing capillary attraction or some change

in lens diameter.
Ironically, changing to either a larger or
smaller diameter may be helpful depending on
the specific situation. Going larger in diameter,
though perhaps accentuating lid grab, may also
be more stable on the eye. Changing to a smaller
diameter may reduce lid grab and, therefore,
lens movement. However, there are times when
this might even increase the movement since lid
control is reduced. Consequently, it is sometimes
necessary to put lenses on and evaluate them.
The important thing is not to create another
problem while you are solving the first one. For
example, if one was trying to decrease movement
by going steeper, it would be important to make
sure that this was not being done at the expense
of tear exchange. Consequently, it would be
important to monitor the fluorescein pattern and
postwear physiology of the eye.
Section
LENS MOVEMENT
259
It is important to remember that vision must be

clear and consistent. Any deviation from this will
put the athlete under stress that could easily affect
athletic performance. This is especially true in
athletic contests that involve long-term or intense
concentration such as in a tennis match, hitting
a baseball or driving a race car. As mentioned
before, any form of residual astigmatism that is
significant enough to affect acuity must be
considered by the practitioner when designing
a lens. This problem is not new and not relegated
to only RGP-type lenses.
However, there are some situations that occur
that are definitely attributable to the characteristics
of the materials being used to fabricate these
lenses. This was especially true with some of the
earlier lens material which contained significant
260
Section
FIGURE 18.13: Shows the front surface of a lens that is

not wetting well
FIGURE 18.14: Shows a basketball player preparing to

shoot a foul shot. Consider the problems that might occur of
this was her lens and she was trying to concentrate and
could not clear her vision. Suppose this was actually
happening in a close game to decide a championship
amounts of silicone or derivatives of silicone.

Some of these lenses developed wetting problems
(Figures 18.13 and 18.14). This could be seen
by focusing the slit lamp beam on the front surface
of the lens and asking the lens wearer to blink
and then to hold their blink. A haze or greasy film
would be observed on the front surface usually

traveling in an upward direction. At times, this
could be so significant that it would appear like
Vaseline on the front of the lens. Needless to say,
it could drive lens wearers crazy since both vision
and comfort were affected.
Frequently, the causative agent could be
attributed to products like Vaseline Intensive
Care for dry hands. Though this product, as well
as, products like it, are excellent for dry skin, the
lens wearers often would rub residual lotion into
the lens surfaces, while they were ironically trying
to clean their lenses. Sometimes, the problem
could be attributed to residual Vaseline on the
lashes and lid margins put there by the lens
wearer, while they were removing their own eye
make up. Lens wearers frequently would
complain that their vision was inconsistent or not
sharp or simply that it was smudgy.
This problem, though very annoying, can
often be solved by cleaning the lens with one of
the excellent professional cleaners that are
available. This would include products such as
the Boston Laboratory Lens Cleaner and
Miraflow which contains isopropyl alcohol.
Sometimes, both professional cleaning and
polishing are necessary. On occasion, brand new
lenses may actually have to be returned to the
fabricating laboratory for some special cleaning
or polishing due to residual polishing compound
being on the lens surfaces. Athletes who use
eyeblack to reduce reflections may also
experience this.
A few years ago, a few new materials started
appearing that reduced the amount of silicone
in the formulation by substituting a fluorinated
component. These materials have become the
workhorses in the contact lens arsenal since they
provide many characteristics that both the
After adaptation, a well-fit RGP lens is usually

quite comfortable. It is wise to inform new lens
wearers before the initial fitting period that they
will experience a progressive improvement in
comfort. Usually, the lenses start to feel better
within the first 10 minutes. After about 30
minutes, there is another increase in comfort as
there is after the first few days. The use of a
topical short-term anesthetic is becoming much
more acceptable now. For years, this was
LENS COMFORT
frowned upon since there was some concern

that the cornea would soften. However, the
immediate advantages of being able to better
assess the overall fit of the lenses on a new lens
wearer far outweighs whatever minor corneal
changes might occur. There is also a reduction
in tearing which reduces lens movement which
also makes the lens more comfortable and easier
to evaluate.
Lens awareness can also be due to a poorly
finished edge which does not permit the lid to
glide over it comfortably. A poorly wetting lens
will also cause lens awareness. If a patient has a
large palpebral aperture, it may not be possible
for a lens to position under the superior lid.
Consequently, every time the lens wearer blinks,
the superior lid bumps the edge of the lens. This
frequently causes the lens wearer to blink less
which then causes 3 and 9 oclock peripheral
staining from drying due to the lid gap that is
created. Interpalpebral lens designs are not
recommended for most athletes because the lens
could get easily ejected from the eye from the
force of the superior lid during a high-speed
ocular excursion.
Even though ultra-thin lenses often fit
between the lids, dissication problems are not
often seen since the highly tapered design of
the edges usually enables the superior lid to
comfortably glide over it. These lenses usually
have steeper peripheral curves than regular
lenses, so less lid gap is present. The end result
of all of this is that lens wearers usually do not
adversely alter their blinking habits and the
peripheral cornea usually stays wet.
Finally, one should remember that there are
always some individuals who are just too sensitive
to wear RGP-type lenses.
Section
manufacturers and the practitioners find

favorable.
Occasionally, a practitioner may have to
replace a lens for a perfectly satisfied lens wearer
who is wearing one of the older materials. It
sometimes becomes a minor dilemma whether
to replace the lens in one of the newer materials.
Even though this may seem like a step in a better
direction, sometimes perceptive lens wearers
become aware of a change in comfort or in the
manner that their lids may glide over the front
lens surfaces.
It is also important to carefully consider lens
thickness so a lens is not ordered in a design
that causes flexure. This could easily cause an
inconsistency in vision that could be a real
distraction during an athletic contest. For
example, a third baseman in baseball may have
to time his/her blink to coincide with the pitchers
release of the ball so no drop in sharpness of
acuity ever occurs at a crucial time. This same
situation occurs with a hockey goalie who needs
sharp acuity at all times. In cases where lens
flexure is a potential problem, one should
consider the Boston ES material or any other
material that reduces flexure.
261
262
FLUORESCEIN PATTERNS
Section
It is important in any discussion of RGP lenses

to mention fluorescein patterns since they are
used to evaluate the relationship of the back of
the lens to the front of the eye and to observe
the critical flushing action that occurs with each
blink. Traditionally, fluorescein patterns are
viewed with a UV Burton lamp. However, the
use of the biomicroscope is suggested since it
provides much better resolution. This topic is
very complex and the actual patterns seen are
influenced by many factors: corneal topography,
corneal astigmatism, blinking habits, lens design,
lens position, UV source and tearing. Ironically,
this topic is not overly pertinent to RGP lenses
relative to their use in athletics. Perhaps, this
entire topic can be summarized by stating that
the proper fluorescein pattern, consistent with
the lens design being utilized, should be present
and that good tear flushing action should occur
upon a blink. There should also be no significant
binding areas present indicating a potential for
physiological problems.
POSTWEAR PHYSIOLOGY
This topic is very important since it involves an
assessment of whether any health problems are
occurring or have the potential to occur. This
will be discussed later. For now, it is important to
realize that a lens design should never be altered
in a manner that may be helpful in one way,
but create a potential for future health problems
to occur.
SIGNIFICANT POINTS
The following guidelines are being suggested as
a summary for the discussion on the fitting of
RGP lenses on athletes.
1. Avoid RGP lenses in water sports unless good

quality goggles are to be worn.
2. Avoid RGP lenses in sports where collisions
occur or the area around the eyes could get
struck.
3. Try to use larger size lenses with diameters
around 9.6 mm.
4. Try to use lenses with optic zones that consider
the lens wearers pupillary size so that flare
and ghost images are less likely to be a
problem.
5. Use a material that is known to wet well.
6. Use a material that will provide the necessary
oxygen to ensure good corneal physiology
relative to the center thickness of the lens as
determined by the required power.
7. Use base curves that are biased in the flat
direction since lens flexure will be minimized.
This will also avoid steep and tight-fitting
lenses since the larger optic zones will be
extending out in the periphery where the
cornea is progressively flatter.
8. Use heavy blends for blending the peripheral
curves since less binding will occur and some
reduction in ghost images might take place.
9. Give adequate instructions in the care of RGP
lenses to avoid athletes getting contaminants
on the lens surfaces that cause the lens to
gunk up.
SOFT LENSES
When soft lenses were first introduced, practitioners were able to give all sorts of reasons that
supported the idea that soft lenses were much
better to wear. However, with the introduction of
good gas-permeable rigid lens materials and lens
designs, many of these reasons are not as true.
FIGURE 18.15: Trying to find a lost lens was a common

thing before soft lenses were developed as illustrated in
figure where two players are trying to find a lens that has
just got ejected from the eye by an accidental elbow to the
orbital region
263
FIGURE 18.17: Ladys field hockey is also supposed to be

a non-contact sport. However, figure shows a player who
has just got knocked down barely surviving a possible hit in
the face when her teammate just happened to interfere with
the direction of the ball
Section
They also are initially more comfortable to wear

so adaptation is easy and they can be worn for
occasional use. There are now a large number
of lens materials and lens designs available. Most
lenses have a great deal in common. However,
there are some different lenses that either due
to their design or the material they are made of,
have distinct advantages to use in certain
situations.
LENS MATERIAL
FIGURE 18.16: Soccer is said to be a non-contact sport
yet it is quite common to see collisions like this occur. It is
important that an athlete who is fit with contact lenses has
lenses that will be stable on the eyes
Ironically, the few remaining advantages that

soft lenses have over RGP lenses are very
significant in regard to their use in athletics. The
main advantage soft lenses have is that they
seldom, if ever, get dislodged from the eye
(Figures 18.15 to 18.17). It is true that on rare
occasion a lens does seem to get knocked out of
the eye, but the instances are rare and frequently
it is due to a lens having dehydrated on the eye.
Soft lenses are available in a variety of materials.

Almost all have a common ingredient hydroxyethylmethacrylate (HEMA) as the backbone of
their matrix. Various additives or cross linking
agents are used to change certain characteristics.
For example, N-vinylpyrrolidone is used to
increase the water content in some lenses and
methylmethacrylate is used in some lenses to
give the lens more dimensional stability.
Often times, a practitioner will take this topic
for granted when a little intuitive thinking could
have suggested the use of a material that would
have provided greater benefits for a particular
264
situation. For example, lenses made from

materials that are high in water content suggest
more oxygen permeability thereby offering a lens
wearer physiological advantages. However, high
water content lenses are usually more fragile so
frequently are manufactured with greater center
thicknesses. This immediately lowers the oxygen
transmissitivity. These materials may still have
advantages when used on hyperopes since the
center thickness of these lenses would be greater
anyway. Also, many routine high water content
lenses are ionic (charged) so attract deposits and
would, therefore, be a contraindication for a lens
wearer who had a past history of surface
disposition problems. If for some reason, it was
necessary to fit this type of lens, it would definitely
be important to stress lens hygiene to these lens
wearers and, if possible, use a high water content
lens that was available in disposable or planned
replacement designs.
Over the years, a number of soft lens wearers
have been bothered by varying amounts of lens
dehydration. This usually causes vision to get
smudgy and often times makes the lenses less
comfortable. Various theories on lens design and
material have been suggested over the years
including the use of re-wetters which are still
suggested for the temporary resolution of this
annoying problem. A recent addition to the soft
lens armamentarium is a material called Omafilcon A used in the Proclear lens. This material
contains a new type wetter called phosphorycholine (PC). It is unique in that it clinically
appears to reduce dehydration problems on
many people. It does not seem to be as helpful
for those individuals who are unfortunate
enough to have severe dry eye.
As mentioned before, lenses containing
Section

methylmethacrylate often are stiffer and may be
advantageous in enabling some lens wearers to
see more efficiently. This may seem like a very
subtle comment; but, when high-speed sporting
activities are taking place and the participant
must maintain periods of intense concentration,
any annoyance or unusual stress that occurs will
eventually start to affect their performance.
SOFT LENS DESIGN
There are many components that make up a
soft lens. Some are more important than others
in regard to lenses worn by athletes. This discussion will limit itself to the more important things.
DIAMETER
The vast majority of soft lenses measure between
13.8 mm and 14.5 mm. With the exception of
people who have either very small corneas
(microcornea or pediatrics) or very large corneas
(megacornea), these diameters have clinically
proven to be very acceptable.
Some practitioners feel that athletes would
benefit more if they wore soft lenses that were
slightly larger or with diameters about 15.0 mm.
These lenses would position further under both
superior and inferior lids which would improve
adherence and help maintain centration,
especially during high-speed ocular movements.
This could also be advantageous for swimmers
since the pressure of both lids against the lens
on the eye could be helpful in reducing the
chances of a lens floating away. Whether this
idea is true for all athletes or not may be a point
of personal opinion. However, over the years,
some manufacturers have designed lenses
specifically for athletes with this idea in mind.

ANTERIOR OPTIC ZONE
Most minus powered soft lenses are manufactured with center thicknesses between 0.03
and 0.06 mm. Modern lens design are much
easier to handle in thinner designs now,
especially in low minus and plus power
prescriptions since the paracentral areas have
CENTER THICKNESS
been built up in a way that increases dimensional

stability. However, many lenses still exist that
create all sorts of challenges to the lens wearer
so should be avoided if better alternatives are
available. If practitioners find that they are
having problems handling a particular lens, they
should realize that the athlete may not have the
desire or dexterity to spend a great deal of time
learning how to handle that lens.
The advantage of using thinner lenses is
simply due to the physiological advantages they
afford the cornea. However, if an athlete
continues to have a problem handling the
thinner lenses. There are some lenses available
that are around 0.10 mm thick at the center
and may be helpful. Even though less oxygen is
being transmitted through the lens matrix, it is
still sufficient for a lens that is to be worn on a
daily wear basis. It is suggested that the
practitioners refer to a local publication such as
in the United States (Tylers Quarterly, Review
of Optometry - November issue) where data are
compiled so that the best lens design is selected.
Section
Due to the relatively large diameter of soft lenses,

the edge thickness of most lenses would be quite
thick unless they were designed with an anterior
lenticular cut. This lens design feature has several
advantages. It makes the lens more comfortable
and allows more oxygen through. It also
simultaneously creates an anterior optic zone or
cap portion. If a potential lens wearer has large
pupils, it is advisable to try to use a lens that has
a large anterior optic zone as possible in order
to minimize future problems with flare and glare.
This can become a real problem with high
powered lenses, especially minus powered lenses
since the cap portion would become
progressively smaller as the amount of minus
power increased.
Most lens designs seem to have a cap or
anterior optic zone no smaller than 8.0 mm cap.
Usually, athletes do not have extremely high
prescriptions. However, if they do, and they also
have large pupils, they could have problems with
lights. One might think that it could be possible
to custom order a lens with a larger cap size.
Even if this was routinely possible and practical,
the lens wearer might have less glare, but, now
may have a thicker, less comfortable lens that
was less stable on the eye and might even get
ejected easier from lid interaction. The net result
would be a useless lens.
265
ASTIGMATISM
It is very important that practitioners keep in
mind that athletes involved in dynamic sports
must have as sharp acuity as possible. In situations
where there is only a small amount of refractive
astigmatism, it could be possible that almost any
lens will provide sufficient acuity. However, there
are situations where the use of a lens that contains
methylmethacrylate may be very advantageous.
As previously mentioned, these lenses can be
stiffer and resist the influence of the superior lid
that causes surface deformation during a blink.
This component appears in lenses made from
tetrafilcon A and crofilcon A materials.
266
There are many occasions where the amount

of refractive astigmatism is great enough that a
toric soft lens may be used. There are now many
lens designs available that provide the
practitioner with quite a few options. However,
not all soft toric lenses are created equal. It is
important for the practitioner accurately assess
the needs of the patient and then determine what
lens is available to address those needs. For
example, many toric lenses come in very specific
cylindrical powers and not every axis. Some
lenses come in ten degree axis increments,
others, five degree increments and some even
come in virtually any axis. It is quite possible
that a lens that only comes in ten degree
increments could be five degrees misaligned. In
a low cylindrical power, this probably will not be
a problem. In higher cylindrical powers, it will
definitely cause a reduction in visual quality. Even
though it is always dangerous to generalize, there
are some common rules that do apply to the
fitting of soft toric lenses.
1. They require more time and expertise to fit.
2. The relationship between the location of the
astigmatic error and the location of the
corrective cylinder is critical and must be
perfect so that a resultant cylinder does not
occur which degrades vision.
3. As the power of the correcting cylinder
becomes greater, the importance of proper
alignment becomes greater.
4. Most practitioners feel it is a good idea to
undercorrect the cylindrical power in toric
fits. The exact amount would be determined
by the specific circumstances and the
sensitivity of the lens wearer.
5. One should consider the effect that compensating for vertex allowance has on the
cylindrical power. For example, if a patients
Section

prescription is: 6.50 = 2.00 cx 180. If one
was to consider the power of each meridian
at the corneal plane, the contact lens power
would now be: 6.00 = 1.75 cx 180. This
does not constitute an undercorrection yet.
It simply is the power at the corneal plane. A
further reduction in cylindrical component
could still be made such as: 6.00 =1.50
cx 180.
6. Different toric lens designs are available that
utilize different means to stabilize the lens.
Some are more comfortable than others. If
a patient requires only a cylindrical correction
in one eye, it may be advisable to use a toric
lens design that incorporates thin zones in
the design since these lenses are usually more
comfortable than a lens that has, for example,
a prism to help stabilize the cylindrical
correction.
7. Some lenses are stronger than others. If a
patient seems to rip lenses, it would be wise
to make sure that either planned replacement/disposable lenses are used next, or a
toric lens with a reputation for durability be
substituted.
8. Sometimes, difficult situations exist such as
with high cylinders or oblique axes. It is
important that patients have realistic goals.
An example of this would be somebody who
has a very low spherical component and a
significant cylindrical component that could
even be oblique (0.25 = 3.50 cx 140).
This situation could be difficult since the power
of the spherical component is so low compared to the power of the cylindrical
component. Some lenses may not even
come in the expected axis. The cylinder is
quite high so even if the practitioner undercorrected the cylindrical power by one-half

diopter, a significant oblique cylinder still is
required.
SOFT LENS EVALUATION

Soft lenses are essentially evaluated in a similar
manner as RGP lenses except that fluorescein
patterns are not considered useful. Thus, lens
movement, position, comfort, vision and postwear health of the eye are all important. It is
again important to remember that though we
tend to think of these as individual components,
they are very much inter-related.
LENS POSITION
can easily develop that can affect the health of

the eye. For example, limbal compression can
occur which can be a precursor to limbal plexus
engorgement that can then lead to
neovascularization of the cornea. Also, various
forms of debris can accumulate under the lens
and not get washed out. This can lead to
irritation, epithelial breakdown and an increased
chance of an infection or even a dreaded ulcer.
Lens movement, though as slight as it may be,
also helps to keep the cornea wet.
One should be familiar with the characteristics
of the lens being used in order to evaluate it
relative to the acceptable criteria for that type of
lens. For example, a spincast lens displays very
subtle movement, especially on primary gaze in
the temporal area. Lathe cut lenses tend to move
more obviously. Toric lenses that correct for
astigmatism can be designed in several ways.
Lenses that are stabilized utilizing a prism should
display a good to 1 mm of movement with
the blink. However, rotation during a blink
should be minimal so vision will be constant.
One should remember to evaluate lens
movement not only in the primary gaze but also
LENS MOVEMENT
It is very important that all soft lenses display
some movement (Figure 18.18). It may at first
appear that lens movement is not all that
necessary since only about a 1% tear exchange
takes place with each blink. This is in contrast to
about a 20% tear exchange that takes place with
a well-fit RGP lens. However, if the lens does
not display some movement, several problems
Section
Soft lenses are designed to cover the cornea and

extend out onto the sclera about 0.5 mm to 2
mm with 1 mm being very common. If a lens is
decentered leaving an exposed area, some form
of lens design change is required to get the lens
better centered. With rare exception, soft lenses
usually position behind both the superior and
inferior lids. This has several advantages,
especially to athletes. First, it makes the lens rather
comfortable. Second, it is helpful in securing the
lens onto the eye, so it is less likely to get ejected
if the lens wearer suffers a severe blow to the
head. This is why, many of the past and present
athletic soft lenses are relatively large in size.
267
FIGURE 18.18: It is a good idea to have a lens wearer

practice extreme ocular movements in office, as illustrated
in figure, in order to see if the lenses remain stable on the
eyes
268
Section
when the lens wearer is looking to each side and

upwards, as well as, downwards. It may also be
wise to have the lens wearer simulate high speed
and dramatic ocular movements since that is
what the patients will often be doing when they
are competing.
The larger sports lenses may have some
advantages in this regard since they will probably
be quite stable on the eye, display good
movement and not cause any inconsistency in
vision.
If a lens moves too much, vision will often
be affected and the lens will be less comfortable.
This can easily affect ones concentration which
could then result in poorer performance. Sometimes, a lens that has been worn successfully for
a long time suddenly starts to stick to the superior
lid and gets dragged up with a blink. This is often
accompanied by an increase in mucus production and a progressive drop in wearing time. If
this occurs, one should evert the superior lid and
check for giant papillary conjunctivitis (GPC)
(Figure 18.19). This kind of problem is a real
nuisance. It actually is a self-immunilogical
response to a patients own protein which is
Giant papillary conjunctivitis is a real problem to contact

lens wearers since a lens can suddenly become attached
to the superior lid and alter vision
FIGURE 18.19: Shows a classic Figure of GPC
usually caked on the surfaces of the lens. There

is also some mechanical chafing that occurs. Up
until recently, there were virtually no really good
medical treatments for this condition. Sometimes, the best suggestion to the patient was to
avoid wearing lenses for a period of time until
the condition cleared up by itself. This often times
was not a very popular option for wellestablished soft lens wearers. Sometimes, medical
treatment with steroids was tried in an attempt
to reduce the inflammatory response. This also
necessitated the need to reduce or eliminate
contact lens wearing time which was also a very
unpopular treatment. For years, a mast cell
stabilizer was suggested since it would reduce
the subjective symptoms. This, however, was a
very slow and not always effective treatment.
Now, a combination drug called Patanol is
available which combines an antihistamine with
a mast cell stabilizer. Patients who use this, get
relief by both the immediate therapy involving
the antihistamine and the long-term effects of
the mast cell stabilizer.
In the last few years, excessive lens
movement caused by GPC could be helped with
the use of planned replacement or disposable
lenses. These are lenses that will be replaced after
a specific time period. The advantages are many.
In most cases, they help the GPC situation by
making sure the lens is replaced before surface
protein has a chance to attach to the lens matrix
and create all sorts of scenerios.
A lens that is not moving enough, must also
be changed. This can be done by either flattening
the base curve or making the lens smaller. Patients
usually have vague comments to make if a lens
is too tight and not moving properly. Initially,
the lens is comfortable but starts to feel dry after
it has been on for a while. Other vague

symptoms also can be described by the lens
wearer. After several days of this, the lens wearer
usually starts to get increasingly symptomatic. If
the lens is not replaced, neovascularization and
other undesirable physiological problems can
occur. Loosening a lens by going smaller in
diameter (instead of flatter in base curve) is not
the best solution when fitting athletes since the
larger size has the before mentioned advantages.
VISION
As lenses get older, surface deposits become

important considerations (Figures 18.20 and
18.21). It is not uncommon to have a patient
complain that they do not see as well as they
want, yet they read the 20/20 line on the Snellen
chart and do not require any adjustment in lens
power. These people usually will show a drop in
contrast sensitivity (Figures 18.22 to 18.24) which
can often be related to real-world situations such
as when driving a car at twilight or when following
a white baseball on an overcast day. It is very
Section
It should be apparent that the topic of vision

has continuously been discussed throughout this
chapter. It is virtually impossible to discuss some
topics without describing its relevancy to the lens
wearers vision. Thus, one should keep in mind
the significance of astigmatism as it relates to
visual potential, the effect of excessive lens
movement on vision and what happens when a
lens flexes as the superior lid presses down over
the lens during a blink.
One should also keep in mind the
phenomenon of dehydration. This occurs when
a lens loses a certain amount of water from its
matrix and vision becomes smudgy or blurry. If
one was to do an over K on this eye, the
keratometer mires would look out of focus. This
is sometimes due to a tear problem where
insufficient tears are being produced or it could
be due to poor tear quality where some of the
tear components are not being produced
properly. Occasionally, it is due to a lens wearer
subconsciously blinking less than required so the
lens dehydrates. It is also possible that a low
humidity environment or one where air
conditioning is significant is drying the lens. The
end result of this is that vision is reduced and
during an athletic contest, this can be a
devastating problem.
269
FIGURE 18.20: Shows cholesterol or jelly bumps on the

lens surface which can cause discomfort and interfere with
vision
FIGURE 18.21: Shows protein deposits on the lens surface

which can lead to a variety of problems including reduced
vision and giant papillary conjunctivitis
270
Contrast sensitivity is another method to check ones ability

to see. A dirty lens will cause contrast sensitivity to go down
even though the lens wearer might still be reading the 20/20
line
Section
FIGURE 18.22: Shows a typical contrast sensitivity chart
FIGURES 18.23 and 18.24: Show a real world illustration of

contrast sensitivity. In the first picture, the ball is dirty and
much more difficult for the infielder to see especially if this
ball is traveling around 100 mile per hour. This could become
even more of a problem if the player is wearing lenses that
are not clean. In the second picture, a clean ball is being
used and is much easier to see
important for athletes to practice good hygiene

and try to prevent this problem rather than try
some heroic cleaning techniques that sometimes
improve things for only a short period of time.
This type of problem can usually be helped with
disposable type lenses.
Recently, a very interesting innovation in lens
availability occurred with the introduction of the
Wesley Jessen PROSOFT lens. This teal colored
lens is said to provide visual advantages to tennis
players by muting background colors and
enhancing the optical yellow color of the tennis
ball. Athletes feel that the ball jumps out or
appears more three dimensional. The lens also
contains a UV filter.
COMFORT
Soft lenses are characteristically very comfortable. If a lens is not comfortable, it is important
to determine and correct the situation in order
to avoid further more involved problems.
It is usually important to consider the age of
an uncomfortable lens. If a lens is brand new,
many of the surface deposit problems that have
been already mentioned, can probably be
eliminated. It is possible that the lens may have
some foreign matter behind it. Swishing the lens
down onto the inferior sclera and then up,
sometimes referred to as the scleral swish
frequently helps. If this is unsuccessful twice, it is
wise to remove the lens, clean it and then try it
again. If it is still uncomfortable and seems to be
moving properly, one might assume that this
could be one of the rare poor quality lenses we
see from time to time. However, occasionally,
a patient will describe a new lens as: feeling like
they have a lash in their eyes. The lens appears
to be performing perfectly. Sometimes, this is
due to transient edge standoff where the very
If an uncomfortable lens is older, other causes

become possible. Physical rips and surface
deposits now become more definite possibilities.
Lens dehydration associated or unassociated with
deposits can occur. This can sometimes be
temporarily helped with the use of rewetting
agents or lubricants. It is probably best to try
these lubricants prior to dehydration rather than
after the problem has been manifested.
Regardless, these are only stop-gap solutions.
The best suggestion is to refit the lens wearer
with a low water content nonionic disposable
lens or a disposable-type lens that gets replaced
quite frequently.
One should remember that while trying to
investigate a problem, it is important to consider
all related aspects of the situation. One does not
want to go through the rigors of refitting a lens
wearer with another lens type only to learn later
that the patients problem would only have been
temporary and was due to the fact they were
taking antihistamines for either an allergy or cold
at the time they came in to see you with their
related contact lens problem.
Occasionally, a veteran lens wearer will relate
the signs and symptoms of GPC. Consequently,
it is strongly suggested to listen carefully to the
patient, keep an open mind and evert the
superior lids and examine the tarsal plate
carefully.
It is quite possible for contact lens wearers to
get afflictions that occur quite commonly in the
general population. For some reason, contact
lens wearers and practitioners often forget this.
Consequently, it is important to remember that
viral, allergic and bacterial conjunctivitis are all
possible causative problems, and not necessarily
the contact lens. The symptoms of itchy and
watery eyes would have occurred even if that
Section
peripheral edge is flipping up but only at certain

times. Sometimes, having the patients hold their
blink may initiate this. Changing to a slightly
tighter fitting lens usually solves the problem.
A lens that is relatively new can still have
physical defects (Figure 18.25). Sometimes,
scanning the lens surface and edge will reveal a
tiny edge or surface rip that causes subjective
symptoms as the lid glides over the area. It is
helpful to use direct or retroillumination when
using the biomicroscope for this observation.
Tiny rips can grow into large rips which not only
cause more discomfort but can also cause the
lens to get ejected out of the eye during a blink.
This can have devastating consequences in some
sporting activities such as in race car driving or
in bull fighting.
Occasionally, when working with a new or
relatively new lens that is causing awareness, a
differential test may become helpful. One simply
271
FIGURE 18.25: A small rip like the one in figure can be very
distracting to an athlete. The rip can also enlarge, cause the
lens to decenter or get ejected from the eye and influence
the outcome of a play
tries another identical lens on that eye to see if

the problem magically resolves. If it does, it is
probably due to a poor lens, the exact reason
of which, may never be realized. If it does not,
then one has to search further.
272
person had never worn lenses.

In summary, the contact lens practitioner
must frequently play detective to find the cause
of a problem since any discomfort experienced
by an athlete will affect their concentration, which
will affect their performance.
POSTWEAR PHYSIOLOGY
This topic will be discussed shortly relative to all
of the various lens types that will be mentioned.
THE COMBINATION LENS
Section
This lens design (Figure 18.26) has a rigid central

portion and a soft hydrophilic peripheral skirt.
Many practitioners feel this lens design is ideal
for athletes since it seldom gets dislodged from
the eye and affords the lens wearer excellent
visual acuity through the hard cap portion. It
could also have real advantages with athletes,
especially those who have large amounts of
corneal astigmatism since lens rotation and
aligning the refractive axis with the lens axis is
usually not important. The one notable

exception being a person who has large amounts
of internal residual astigmatism. This would be a
similar situation to an RGP wearer with significant
residual astigmatism.
Ths SoftPerm lens now available through
Wesley Jessen is an example of this lens design.
The lens is 14.3 mm in diameter. It has a rigid
zone that measures 8.0 mm in diameter and a
hydrophilic skirt composed of a material with a
25% water content.
Clinically, the lenses center well. Movement
is subtle which sometimes worries practitioners
who are not experienced with this lens design.
Even though this lens seems to have advantages
very related to use with athletes, it has not made
a big impact in that direction. This could be due
to the higher laboratory costs associated with
the higher production costs or practitioners are
pleased with the present arsenal of lens types.
There is also a possibility of the lens separating
at the juncture of the two materials.
SCLERAL LENS DESIGNS
The SoftPerm lens is a combination lens with a gaspermeable center area and a soft peripheral skirt. It appears
ideal for athletes even though it has not been used as much
as might be expected
FIGURE 18.26: Illustrates the unique lens design
SoftPerm lens
Scleral or haptic lenses have been used on

athletes for many years. In fact, before the
appearance of soft hydrophilic lenses, they were
considered by many practitioners to be the lens
design of choice. Historically, they were fit in one
of two different methods. Some lenses were prefabricated with certain specific zones and curves.
Trial lenses were used to determine the proper
cross section of lens parameters. It was then
hoped that the ordered lens would give decent
results. Sometimes, a few in-house modifications
were required. The other system was the cast
molding system. In this method, a shell was
placed on an anesthetized cornea and moldite
was injected through a syringe under the shell.
which has a dK value of about 127. It is lathe cut

and like other scleral lenses, it measures about
the size of a quarter or around 23 mm in diameter.
Though other size diameters are also available, a
fitting set of preformed trial lenses is suggested.
LENSES FOR COLOR DEFICIENCIES
Most people take routine things for granted until

a change occurs and they realize what they have
just lost. In other cases, a person may have a
congenital problem and may never appreciate
the things others take for granted. A good
example of this occurs with color discrimination
where about 0.5% of the female population and
about 8% of the male population are affected.
There are various forms of color vision problems.
The end result is that some people are unable
to distinguish certain colors, especially when the
brightness of certain objects is reduced.
Many people with this problem learn to adapt
by avoiding certain situations or by asking for
help from color normal individuals. Color vision
problems can affect athletes. In some sports,
opposing teams may be wearing uniforms that
are confusing, especially under adverse conditions such as in low illumination or fog. This
could be devastating for any athlete who has
to quickly utilize visual information and in a
fraction of a second decide on a course of
action. Simple things like a goalie slapping a shot
towards a person he confuses as a teammate or
a quarterback in football who has trouble
differentiating offensive and defensive players
since to him, they appear similar. These
individuals may have some advantages in
wearing a special contact lens.
The original idea for a lens to help color
deficient people was developed by Dr Harry I
Zeltzer who published a paper on his XCHROM
Section
This produced a negative impression of the

anterior surface of the eye. A dental stone/water
mixture was then poured into the negative
producing a hard positive cast of the anterior
surface of the eye. This mold was then sent to
the fabricating laboratory where it was used as a
template for the actual lens.
The main advantage in using these lenses now
is that they are almost impossible to dislodge.
They are, therefore, very useful in sports where
there is high probability of getting hit around
the eyes such as in rugby or in water sports such
as in water polo or kayaking. They could also
be useful in soccer where athletes may be less
apprehensive about heading a ball knowing
that their lenses would remain secure.
Vision is quite good since both spherical and
astigmatic components of the prescription can
be incorporated in the lens. Also, since no lens
rotation occurs, visual quality is constant.
The reason these lenses are so stable is due
to their large size and the fact that they position
well under both the superior and inferior lids
which hold them in place. Their unusual size may
lead one to believe that they are quite
uncomfortable, when in reality, they are quite
comfortable and do not cause any annoying lid
bump.
The disadvantage of these lenses is that a few
practitioners now have any experience of fitting
them and that a few laboratories are still available
to fabricate them. Thus, they have become a
real custom or specialty item and are quite
expensive. Due to the fact that they cover so
much of the ocular surface, anoxia can easily
occur, so wearing time is limited.
Lately, a gas-permeable version of the scleral
lens has been developed. It is called the Boston
Scleral Lens and is made from Equalens II material
273
274
lens in 1971. Basically, it involves wearing a special

red contact lens on one eye, usually on the nondominant eye. This lens transmits light in the 590
mu to 700 mu range. It seems to work best on
anomalous trichromats who have color
deficiencies with red and green. It does not cure
the problem, but seems to enhance color
perception. Patients who wear this lens frequently
comment on the fact that things appear more
vivid or vibrant and that their appreciation of
depth seems to be better.
The exact mechanism seems to be a mystery.
A popular theory is that in binocular patients
the brain is now receiving new and confusing
information from the two eyes. Possibly, by
alternating this information between the two eyes
through the process of retinal rivalry, a new
perception of color occurs. It is not advisable to
wear this lens during periods of reduced
illumination or at night. Thus, driving a car at
night could be a problem.
Cosmetically, the lens is difficult to see on
brown or dark brown irides. However, on light
irides, it is quite noticeable and appears
somewhat like an anisocoria. This slight cosmetic
disadvantage should not be considered a
deterrent for athletes if it provides them with
other advantages.
Lens designs in both RGP version and as a
soft lens are now available though they may
not be considered actual XCHROM lenses. The
RGP version of this lens is made from a material
called Transaire EX, Amsilfocon and is available
from different rigid lens laboratories. Fitting
these rigid lenses is generally the same as
fitting any rigid lens using the same criteria for
proper lens performance. Many lens wearers do
not wear their lenses all day but use them for
times when they feel they have a definite need
Section

to distinguish colors better. Lens thickness is
important since a lens that is too thick will
cut down the amount of light entering the eye
and thereby reduce the overall improvement in
color perception. Thus, rigid lens fitters must
consider overall lens thickness in a different
manner. In some instances, especially with plus
powers, it may be important to switch to
lenticular designs to minimize the center
thickness. Because these lenses are red, the lens
wearer may take 0.50 D more plus (or 0.50 D
less minus) than expected.
Soft lens versions of this lens are also
available. The actual fitting of these lenses is
slightly different in that a well-fitting soft lens is
usually sent to a company who dyes contact
lenses. These companies must know the exact
color that is desired and the size or diameter of
the red area. It is important to make the dyed
area slightly larger than the pupil size so that the
entire pupillary area will be covered. This is to
account for different levels of illumination and
to account for the fact that the lens may not
symmetrically center on the eye. If peripheral
light rays sneak into the pupillary area, the total
effect of the tint will be lessened and the
improvement in color perception altered.
Very recently, ColorMax Technologies Inc. has
introduced the ColorMax lens which is said to
help color blind people by shifting the wavelengths of light entering the eye towards the
longer end of the visible spectrum. This is claimed
to enhance contrast between colors making it
easier to distinguish warm colors such as reds,
yellows and oranges. It is said to also help with
the shorter wavelengths, as well.
An interesting thing that often occurs when
people try these lenses is that they often do not
place an order for the lens even though

acceptable results may have occurred. One also
learns that not everyone appreciates improvement. However, in the fast moving and
confusing world of the athlete, the improvement
these lenses may provide could be significant
and make a difference.
DISPOSABLE OR PLANNED
REPLACEMENT LENS SYSTEMS
FIGURE 18.27: Illustrates some of the well-known planned

replacement/disposable lens types that are available
Planned replacement or disposable lenses have proven to

offer almost all contact lens wearers many advantages.
They also have many advantages to athletes
powers and axes. This has greatly expanded the

use of disposable lenses since many complex
problems can now be solved.
There are many advantages for athletes to
use this system. For one, there will almost always
be an emergency spare replacement lens readily
available. All contact lens practitioners can relate
stories where their patients lost a lens and needed
a replacement lens yesterday. Most lens
wearers survive these temporary inconveniences. However, with athletes, the consequences
of not having a lens can be much greater since
so many other people are relying on their ability
to see properly and perform at a high level of
skill. An excuse such as, I lost my right lens
may gain some minor sympathy but does not
really solve the problem that exists. Another
advantage is that a clean lens will almost always
be available for use since old lenses will be
discarded before they cause problems. This will
also be helpful in providing the athlete with the
best vision possible even under low contrast
situations where precise judgment is critical. Also,
if proper lens care is not practiced, the chances
of a real problem occurring are reduced. It is
still advisable for the athlete to make sure that at
least one pair of emergency lenses is available
for use before the final lenses are used. Some
people hold on to the next to last pair just in
case something happens to one of the last lenses.
These lenses are basically fit and evaluated
in the same way as traditional soft lenses. The
real decision is to determine exactly how many
lenses would be best for each individual. In the
past few years, what has to be considered the
ultimate in disposable lenses has been
introduced. These are the daily disposable lenses
which are thrown away after only one use. Even
Section
As eluded to before, the introduction of

disposable or planned replacement lenses
(Figures 18.27) seems to be a tremendous idea
for athletes. These lenses are not much different
in design than the lenses that have been used
for years in the classical manner of each lens
wearer having one right and one left lens. What
has enabled this concept to flourish are
technological innovations enabling lenses to be
manufactured by molding or casting rather than
the much more time consuming and costly
method of lathe cutting. Recently, high quality
toric lenses in planned replacement designs have
become available in a large cross section of
275
276
though the initial cost may seem relatively high,

patients will have to consider that virtually no
solutions or enzyme systems will have to be
purchased so the final yearly cost will become
dramatically different. An athlete traveling for a
ten-day road trip would simply bring ten or
twelve lenses along to ensure good results.
CONTACT LENSES IN THE

AQUATIC ENVIRONMENT
Section
Over the years, many people have worn contact

lenses while engaged in water sports. This could
be in conjunction with competitive swimmers
who are in the water for long periods to lens
wearers who have been abruptly thrown into a
pool while attending a party. There are several
important considerations. The first is whether a
lens worn in that type of environment is safe for
the eye. The other consideration is whether a
lens will get easily lost and create both economic
and practical inconveniences to the lens wearer.
There is no doubt that an RGP lens will easily
float off of the cornea in an aquatic environment
unless the lens wearer squints rather dramatically
or wears special swim goggles. If swim goggles have
to be worn, then it may be prudent to simply put
the prescription in the goggles so that contact
lenses are not even required.
Some people may even question whether
swimmers really need sharp acuity, especially
since objects seen through the water are
enlarged. The answer probably relates to exactly
what that persons visual needs are while they
are in the water and how well they see without
any correction. A one diopter myope definitely
has usable vision without correction. A six diopter
myope might have trouble finding the right
blanket on a crowded beach unless some form
of visual correction was worn. Some questions

also arise as to whether competitive swimmers
need any correction since they swim in lined and
marked lanes.
The best way to answer this is to consider
that in good competition the margin of victory
is sometimes thousandths of a second. There
are numerous places in a race where an error in
judgment could be the deciding factor. For
competitive swimmers, judging precisely when
to begin their high speed turns is critical. If the
turn is started either too early or too late, a poor
kick against the side of the pool occurs. This
actually means that speed is affected and time is
lost. The decision on when to begin these turns
is based on visual information. If this information
is not accurate due to an inability of the swimmer
to see the marks clearly, compounded by the
excitement and stresses of the competition itself,
performance will be adversely effected.
The exact rate of lost lenses varies greatly
depending upon which study you choose to read
and how you interpret the results. The main thing
to consider is that for a person who has only
one pair of lenses, any loss is critical. If a person
has some form of frequent replacement lens
system, losses are much less significant. Thus,
there could be a tremendous advantage to
having daily disposable lenses. Theoretically, if a
lens is in a fresh water environment (hypotonic),
the lens should imbibe water, loosen and float
off of the cornea. If a lens is in a salt water
environment (hypertonic), it should lose water,
tighten and may be more difficult to remove.
Actually, both situations result in lenses sticking
or clinging to the eye. Of interest is the fact that
ocular irritation such as a chemical keratitis from
the water does not seem to have as much of an
adverse effect on the ocular tissues as feared.
It is at these great depths that nitrogen is

dissolved in body tissue. As the diver descends,
nitrogen is released which can get trapped
behind a rigid lens causing dry spots and dimple
veiling. The diver will experience transient
fogging of vision and some discomfort. Soft
lenses will also cause this problem but to a lesser
degree. Even though these problems only last
about 20 minutes and are not vision threatening,
practitioners should still try to minimize the effect
of these bubbles by doing everything possible
to fit lenses as loose as possible to encourage
good tear exchange. Scuba divers should be
continuously reminded that since they are in a
very humid environment their blink reflex is
diminished. Thus, it is important for them to blink
as much as possible upon ascending. This will
help keep their eyes wet and to facilitate bubble
removal.
POSTWEAR OCULAR HEALTH
Regardless of the type of lens being worn by the

athlete, it is important that all lenses provide not
only the necessary vision required by the athlete
but also fit properly so that no short-term or longterm physiological problems occur. This is why,
routine progress evaluation check-up visits should
be scheduled according to the customarily accepted intervals and about every 6 months afterwards.
Needless to say, some patients will adhere to the
proper routines while others will come in when
they perceive a problem or reason. A good
practice management tip would be to continuously remind athletes during all visits to your
office of the importance of their eyes relative to
them performing optimally when they compete.
They should think of their lenses as their most
important piece of athletic equipment.
Section
The risk of ocular infection from wearing

contact lenses in aquatic environments must be
considered since it is higher than for individuals
who do not wear their lenses in these situations.
This is especially true now since a great deal of
attention has recently been given to Acanthamoeba keratitis infections. Even though the risk
of any infection is still remarkably low, it can be
even further reduced if a few simple rules are
followed:
1. Swimmers should keep their eyes closed until
they hit the water.
2. Swimmers should squint while either in or
under the water. See below.
3. Swimmers should try to avoid looking to the
sides.
4. Upon surfacing, swimmers should wipe away
any excess water that is in the vicinity of their
eyes.
5. Once out of the water, swimmers should
irrigate their eyes with saline solution to
equilibrate their lenses.
6. Each lens wearer should be very careful when
removing each lens since they can still stick
to the eye and cause a loss of epithelium if
too much effort is exerted.
7. Competitive swimmers must be careful that
they do not squint in a manner that causes
their facial muscles to tighten which may
affect their shoulder muscles which then
affect their strokes.
8. Very nearsighted competitive swimmers
should practice their high speed turns days
before their first competition to get used to
their new way of seeing and judging distances.
Scuba divers present a slightly different
situation since they are wearing a face mask and
can also be wearing their lenses at great depths.
277
278
Section
The introduction of the thin soft lens and

oxygen-permeable rigid lens has greatly reduced
significant postwar problems in the daily wear
population. The recent availability of extended
wear soft lenses with a silicone base that enables
oxygen transmissitivity to be very high, may
reduce the incidence of extended wear
complications that were experienced 12 to 15
years ago. However, at this time, these lenses
have not been around long enough to see if
they really do provide significant physiological
advantages to the extended wear population.
There is no doubt that increasing oxygen
transmission has advantages. The next question
is whether these new lenses will also pump out
cellular debris and metabolites from behind the
lens and thereby improve another problem
associated with extended wear.
It is very advisable to recommend to patients
that if their eyes do not: look good, feel good,
or see good, (Yamanes), they are to remove
their lenses and call their doctors office for advice.
There simply is no substitute for a thorough
professional check-up utilizing the highly
sophisticated instrumentation that is available.
HYGIENE AND SAFETY AND THE

ROLE OF THE ATHLETIC TRAINER
Regardless of what type of contact lens is being
used, athletes should be thoroughly advised as
to the need for good conscientious care of their
eyes and lenses (Figures 18.28 and 18.29). This
sometimes becomes a real problem when
working with some of the highly paid professional athletes who often take their relatively
inexpensive lenses for granted until a real crisis
situation occurs.
Many athletes who participate in outdoor sports frequently

use eyeblack. However, it is important that the lens wearer
realizes that they have to be careful when handling their
lenses around their eyes since eyeblack is essentially a
grease that can easily get onto the lens surface
FIGURE 18.28: Illustrates an athlete wearing eyeblack
It also is a good idea to print up a special

set of instructions for athletes which emphasizes
proper hygiene and the consequences of doing
things incorrectly. It would be wise to remind
athletes that since their hands are often
contaminated with such things as resin, dirt, eyeblack, and analgesic muscle ointments, that they
must be very careful when handling their lenses
so that they do not get residual contaminants
on their lenses which could ruin them, and also
irritate their eyes. This could cause them to miss
some valuable time practicing or even miss a
game. It is sometimes helpful if the practitioner
can reinforce this point by having the athlete
read several newspaper articles that appear from
time to time, describing how this very thing
happened to somebody else. The better known
the athletes in the article are, usually the easier it
is to get your point across.
Contact lens practitioners should develop a
good friendly professional relationship with
FIGURE 18.29: Athletes who wear contact lenses have to

be very careful that they do not have any residual analgesic
muscle ointment on their fingers and hands when they touch
their eyes or lenses. Contact lenses and ointments should
be stored separately from each other and not like Figure
which shows a patients lenses being stored near muscle
ointments as well as other things that could irritate the eye if
they were to get near the lens or lens case
reason, a substitute lens could be immediately

provided. Proper provisions would have to be
made accessible so that either the trainer or the
athlete (with clean hands) was able to hygienically
handle the new lens and place it on the eye.
Though this suggestion may seem like a minor
thing, consider the possibility of a key athlete
playing a skill position being forced to go back to
a distant locker room to get a spare lens or being
forced to continue play wearing only one lens. If
this was to occur early in an athletic event, it may
not be significant, but consider the possible
consequences if it was to occur late in the athletic
contest and a trip to the Rose Bowl or Final Four
Basketball Championship was at stake. A modern
version of this situation occurred at the National
Basketball Association All Star Game (2000) when
one of the premier players sat out the entire
second half since he had lost a contact lens and
had no spare lens with him!
Many athletic events take place in hot or hot
and humid environments. It is quite common
for sweat to run into an athletes eyes which not
only burns but adversely affects vision and ones
ability to concentrate. Sometimes, a simple
suggestion to wear a fresh sweat band on their
forehead and/or wrists can be critical in
preventing problems and enabling the athlete
to continue play at a high level (Figure 18.30).
It is not uncommon to see tennis players use a
dozen of these wrist bands in one match.
The question whether it is safe for an athlete
to wear contact lenses relative to injury has been
frequently discussed. Obviously, contact lenses
should not be worn by boxers since a direct blow
to the eye or orbital area is quite possible.
However, in many other sports, the situation
becomes much more difficult to discuss. There
have been numerous articles written that
Section
athletic trainers. These people are usually very

much aware of what is happening on a team
and usually have developed a very trustworthy
relationship with the athletes. They are able to
monitor many situations and offer sound advice
to the athlete so many problems never develop
or escalate. Sometimes, something as simple as
suggesting to a player that a lost or troublesome
lens should be immediately evaluated by the
team doctor, could end up being one of the most
important bits of advice ever given to that athlete.
Athletic trainers should also be responsible
for making sure that an emergency supply of the
various contact lens solutions is available near
the playing field. It is important to check these
solutions so that expired bottles are replaced. A
list of what players wear contact lenses should
also be there. It would also be an excellent idea
if a special supply of spare lenses was made part
of the trainers equipment. Each player would
provide the trainer with a labeled spare lens for
each eye. If a lens had to be replaced for any
279
280
A contact lens wearers performance can be greatly affected

if sweat gets into the eyes causing irritation and blurry vision.
A simple suggestion such as to wear sweat bands on their
wrists and forehead can make a big difference in enabling
an athlete to perform without unnecessary obstacles
Section
FIGURE 18.30: Illustrates a tennis player using her

sweat bands
illustrate how contact lenses have protected eyes

from injury from flying objects. However, there
are also many instances that illustrate how contact
lenses cracked or ripped and created problems
of their own. Consequently, it is very difficult to
accurately evaluate safety as it relates to contact
lenses and ocular injury since so many different
variables are involved.
What is easy to evaluate is the absolute
necessity for any individual engaged in squash
or racquetball to wear adequate protective
goggles whether they choose to wear contact
lenses or not. These sports involve extremely
fast moving balls that measure about 58 mm in
diameter and fit nicely into the orbital opening
where they can cause devastating damage to
the eye.
Recently, a great deal of concern has been
made about the role of ultraviolet light and its
effect on the health of the eye. This is especially
important since many sporting events take place
outdoors where exposure to excessive levels of
ultraviolet radiation is quite possible. This could

be especially dangerous to high altitude skiers.
Several contact lens manufacturers have
incorporated UV absorbers in their lenses. This
will be quite beneficial to the tissues that are
covered but will still leave other ocular areas
exposed. It is, therefore, advisable to have these
people consider wearing UV absorbing goggles
to ensure complete protection. It will be interesting
to see how many other lens manufacturers
incorporate these types of filters in their materials
in the years to come.
CONCLUDING REMARKS
The fitting of contact lenses to athletes is actually
an extension of routine contact lens care. The
contact lens practitioner must understand the
visual demands of each athlete and relate those
demands to the choice of lens design that will
be best for that particular person. If it is
anticipated that a particular athlete may not take
the wearing of contact lenses seriously, then it is
important to provide that athletes with the most
convenient, safest lens system available and do
what is reasonable to ensure that they follow
the proper directions.
Few people ever have the opportunity to
distinguish themselves at some significant level
in the athletic world. Also, a few modern-day
athletes would be able to reach any level of
success without the help of others. One of the
most gratifying things a practitioner may ever
do is to offer some professional help to an athlete
and know that what you may have said or done,
regardless of how minor it may seem, may have
made a difference!
For most athletes, what is involved is basic
and routine contact lens care. However, from

the practitioners perspective, what you may do
can be very gratifying especially when you realize
that an athlete or team may have achieved some
high level of accomplishment because of a
contribution or suggestion that you made.
FURTHER READING
11. Legerton JA. Large diameter contact lenses for

dynamic water sports. Sports Vision 1990;6(1):1213.
12. Naylor D, Fischer B. Contact under the sea. Contact
Lens Forum 1980;5(10):15-19.
13. Nowozyckyl A, Carney LG, Efron N. Effect of
hydrogel lens wear on contrast sensitivity. Am J
Optom Physiol Opt 1988;65:263-271.
14. Personal Communication. Wesley Jessen Corp.
ProSoft Lens, Summer 2000.
15. Personal Communication. Paragon Vision Sciences.
SportSight GP Lens, Summer 2000.
16. Philadephia County Optometric Digest, August
2000.
17. Rengstorff RH, Black CJ. Eye protection from contact
lenses. J Am Optom Assoc 1974;45:270-276.
18. Robinson, Lorin. Contact lenses are eye savers, Source
Unknown.
19. Solomon J. Swimming with soft lenses. Contact Lens
Forum 1977;2:13-15.
20. Spinell MR. Contact lenses for athletes. Optometry
Clinics 1993;3(1)}:57-76.
21. Spinell MR. Contact lens designs and considerations
in the athletic environment. Sports Vision 1996;
(3)12:6-27.
22. Spinell MR. Sports vision, what does this actually
mean? NASV 15(1) Winter 99:6-22.
23. Vinger PF. Sports eye injuries: A preventative disease.
Am Acad of Ophth 1981;88:108-113.
24. Vinger PF. Sports medicine and the eye care
professional. NASV 15(2) Spring 99:18-34.
25. Yarwood RA. The use of contact lenses in all kinds of
sports. J Am Optom Assoc 1960;31:633-635.
26. Walker JS. SoftPerm for athletes. Contact Lens
Spectrum 1990;5(3):55-57.
27. Zeltzer H. The X-CHROM lens. J Am Optom Assoc
1971;42:933.
Section
1. Allensmith MR, Korb DR, Grenier JV et al. Giant

papillary conjunctivitis in contact lens wearers. Am
J Ophthalmol 1977;83:697-708.
2. Banks LD, Edward G. To swim or not to swim. A
remedy for patients prone to losing lenses while
taking a dip. Contact Lens Spectrum 1987;6:46-48.
3. Bennet ES. Rigid gas permeable contact lenses for
the athlete. NASV Sports Vision Newsletter 1989;
5{3}:30-34.
4. Cotter JM. Personal communications. The Boston
Scleral Lens Foundation for Vision Rehabilitation.
5. Davis RA, Morris JE. Contact lens considerations for
the athletes. NASV Sports Vision Newsletter
1989;5(3):24-28.
6. Davis RA. Disposable contact lenses and the athlete.
Contact Lens Forum 1990;15:24.
7. Filderman I, White P. Contact lens practice and
patient management. 1969;277-280.
8. Grey CP. Changes in contrast sensitivity when
wearing low, medium and high water content soft
lenses. J Br Contact Lens Assoc 1986;9:21-25.
9. Holland R. Rigid contact lenses for scuba diving
sports vision 1993;9:13-21.
10. Lee PN. Contact lens compliance and the athlete.
Sports Vision 1993;9-29.
281
282
Chapter
19
Therapeutics of Contact
Lens Care System
Ashok Garg
INTRODUCTION
Section
The use of contact lenses has increased sharply

in last decade specially in developing countries.
People have become more aware of usefulness
of contact lenses and prefer it in place of
spectacles (both from cosmetic angle and better
vision). Contact lenses offer patients a natural
appearance, increased visual performance and
convenience. They can successfully correct most
refractive errors such as myopia, hyperopia and
astigmatism. Now focal contact lenses are
available for the presbyopic patients. A variety
of new lens materials and designs are available
commercially. The number of contact lens care
products have also increased dramatically. With
new contact lens products and patient education,
we can expect that contact lens use should
continue to increase in 21st century.
Successful wear is dependent upon patient
compliance in caring of their contact lenses.
Research studies have shown that 50 percent of
the patient using soft contact lenses harbor
potentially pathogenic microorganisms in their
care system. Noncompliance specially inadequate cleaning can lead to lens discoloration and
lens surface build-up of protein, lipids, minerals

and other environmental contaminants which
can cause giant papillary conjunctivitis (GPC),
superficial punctate keratitis (SPK) and corneal
abrasions. Irregular contact lens disinfection can
lead to severe ocular infection.
Compliance must meet following criteria:
The patient should always wash hands before
lens manipulation.
The patient should use recommended lens
care system in an appropriate manner.
The patient should wear lenses only on a daily
wear schedule unless the lenses are approved
for extended wear.
All contact lens solutions should be free of
bacterial contamination.
Various types of contact lenses and materials
available for commercial use are dicussed below
in brief.
HARD CONTACT LENSES

Hard contact lenses are made from polymethylmethacrylate (PMMA) and are either lathed or
molded. They are relatively rigid and durable
and are easy to clean and may be stored wet or
Therapeutics of Contact Lens Care System

dry. These lenses provide satisfactory correction
of vision for the vast majority of the patients.
Oxygen permeability of hard contact lens
(PMMA) is minimal. Hard contact lenses can
cause chronic corneal edema, spectacle blur,
polymegathism, corneal abrasions, overwearing
syndrome and infectious ulcerative keratitis.
Because of these ocular complications, hard
lenses are now seldom the lens of choice. Less
than 1 percent of the contact lens population
wear heard contact lenses.
RIGID GAS PERMEABLE (RGP)

LENSES
283
feature of retaining a large volume of water but

sill retains their shape. The water content which
may vary from 30 to 85 percent with different
polymers makes them relatively comfortable,
easy to adapt and useful for intermittent wear.
In some soft lenses, HEMA is combined with
polyvinylpyrolidone (PVP) which increases the
hydration of methylmethacrylate (MMA) and
enhances the lens firmness. Daily wear soft
contact lenses are designed to be worn all day
(12-14 hours) but should be removed at night.
Since these lenses are larger and tend to move
less than hard lenses they are less apt to be displaced on the eye and fall out only occasionally.
They are difficult to handle and more fragile.
These lenses are approved for upto 30 days of

continuous wear but ophthalmologists recommend a maximum wearing period of 3 to 6
days. The lenses must then be removed
overnight for cleaning and disinfection. The
major advantage of extended wear lenses is
convenience. However with extended wear
lenses there are increased chances of infection.
Materials used to manufacture contact lenses
with these characteristics fall into three categories.
55-80 percent high water content soft lenses
CAB or PMMA silicone copolymer rigid lenses
Semisoft pure silicone lenses.
DAILY WEAR SOFT CONTACT

LENSES
DISPOSABLE SOFT CONTACT

LENSES
Soft contact lenses are made of hydroxyethylmethacrylate (HEMA) or related polymers

which are compounds that have the unique
Disposable soft lenses are extended wear soft

lenses designed for maximum convenience. The
concept is to totally eliminate lens cleaning and
EXTENDED WEAR CONTACT

LENSES
Section
About 20 percent of contact lens patients wear

rigid gas-permeable (RGP) lenses. The major
advantage of these lenses over hard lenses is
that they are oxygen permeable. Several new
lens polymers with a high degree of oxygen
permeability are available commercially for
extended wear. RGP lenses provide patient good
vision and easy care but these RGP lenses are
suspectible to lens deposits and vulnerable to
scratching and breaking. Recently new materials
such as cellulose acetate butyrate (CAB), silicone,
silicone crosslinked with PMMA and other have
been used for contact lens manufacturing. These
material exhibit varying degree of oxygen permeability and interfere less with corneal epithelial
metabolism. They result in little or no corneal
edema and rarely over wearing syndrome.
284
disinfection. Standard recommendation is to

discard these lenses after one week of continuous
wear and then replace them with a new lens.
Main advantages of these lenses include comfort,
less lens tightening and minimized proteinaceous
and other deposits. Reduced deposits reduce the
incidence of giant papillary conjunctivitis and red
eye.
TORIC SOFT LENSES
Section
Toric soft lenses have been developed in an

attempt to correct astigmatism problem for soft
lenses. Truncation or ballast is used alone or in
combination to design soft lenses that will not
rotate on the cornea. Truncation results in an
asymmetric shape and ballast results in asymmetric weight distribution. These lenses work best
for low to moderate degrees of astigmation that
are oriented near the 90 to 180 degree
meridians. Replacement costs for these lenses
are significantly higher.
BIFOCAL CONTACT LENSES

Previously bifocal contact lenses were tried only
in hard contact lenses with very limited success.
Soft bifocal lenses have recently been
introduced. Bifocal contact lenses are based on
two designs: one design has a central area to
correct far vision and peripheral concentric area
to correct near vision, and the second design
has an annular or semicircular area along one
edge with the near correction similar to bifocal
spectacles. The latter design utilizes truncation
or ballast to stabilize the lens and to maintain
proper orientation of the bifocal segment. The
major problem with both type of bifocal lenses
is stability of vision and maintaining the proper
position of the lens for the virtual task at hand
since blinking and eye movement alter the

relationship of the visual axis and the different
optical zones of the lens. Replacement costs of
these lenses is significantly higher.
CONTACT LENS CARE PRODUCTS

Products for use with contact lenses should be
sterile, isotonic and free of particulate matter.
Different types of lens materials requires a
unique lens care program. In selecting
appropriate lens care solutions, it is mandatory
to correctly identify the type of lens the patient
is using.
HARD AND RIGID GAS

PERMEABLE LENSES
Similar lens care is indicated for the hard and
RGP lenses. Products include wetting/soaking/
disinfection solutions, cleaning agents, lubricants
and rewetting solutions.
When a rigid contact lens is removed from
the eye, it may be covered with lipids, proteins
and other debris. After removal the lens should
immediately be cleaned with a surfactant cleaner.
Improper cleaning of lens can interfere with
vision and can cause corneal irritation. Rigid
lenses should be soaked overnight in a wetting/
soaking/disinfecting solution. This solution has
four major functions.
To enhance the lens surface wettability
To maintain the lens hydration
Lens disinfection
To act as a mechanical buffer between the
lens and cornea.
Patients wearing rigid lenses experience
dryness after several hours of wear because of
hydrophobic nature of the lens material.
Lubricating drops provide temporary relief by

rinsing debris off the lens surface and rewetting
the eye and the lens.
Ophthalmologists recommended the weekly
use of an enzyme cleaner (papain) with RGP
lenses. This weekly cleaning process is very
effective in removing protein deposits from the
lens surface. However a protein film on an RGP
lens can decrease vision and cause GPC.
HARD (PMMA) CONTACT LENS

PRODUCTS
STORAGE/SOAKING SOLUTIONS
WETTING SOLUTIONS
Wetting solutions contain surfactants to facilitate
hydration of the hydrophobic hard lens surface.
These solutions include methylcellulose and
derivatives, polyvinyl alcohol, povidone and
Storage/soaking solutions maintains the lens in

a state of hydration, prevent growth of microbial
contamination and possibly removes debris from
the lens surface through chelation or salvation.
Discard used soaking solutions and replace with
fresh solution daily. Soaking storage solutions
available commercially are:
Solution containing 0.01 percent benzalkonium chloride and 0.01 percent EDTA or
0.25 percent EDTA.
Solution containing polyvinyl alcohol with
0.01 percent benzalkonium chloride and 0.2
percent EDTA.
other new polymers, preservatives and buffering

agents. These agents increase solution viscosity
and act as physical cushioning agent between
lens and cornea. Various wetting solutions
Solution containing hydroxypropylmethylcellulose, polyvinyl alcohol, 0.004 percent
benzalkonium chloride and 0.025 percent
EDTA.
Solution containing polyvinyl alcohol with
hydroxyethylcellulose, benzalkonium chloride and EDTA.
Solution containing hydroxypropylmethylcellulose, NaCl, KCl, polyvinyl alcohol, 0.004
percent benzalkonium chloride, and EDTA.
Sterile buffer solution with 0.1 percent EDTA
and 0.01 percent benzalkonium chloride.
Solution containing polyvinyl alcohol,
hydroxyethylcellulose, povidone, NaCl, KCl
sodium carbonate, 0.01 percent benzalkonium chloride and 0.025 percent EDTA.
Wetting agents with 0.004 percent thiomersal
and 0.1 percent EDTA with buffering agents.
Section
Conventional hard lenses are made of a rigid

hydrophobic polymer PMMA. For optimal
comfort and to minimize problems, these lenses
require care with separate wetting, cleaning and
soaking solutions.
285
CLEANING, SOAKING AND WETTING

SOLUTIONS (HARD LENSES)
Solution containing hydroxypropylmethylcellulose, boric acid, nonoxynol-15, 0.01
percent benzalkonium chloride and 0.01
percent EDTA.
CLEANING SOLUTIONS AND GELS (HARD
LENSES)
Cleaning solutions and gels contain surfactant
cleaners to facilitate removal of oleaginous,
proteinaceous and other debris from lens surface.
For better cleaning, physically rub lens with
solution or gel and rinse with water or sterile
286
Section
saline solution. Various cleaning solutions

Solution with anionic sulfate surfactant with
friction-enhancing agents and NaCl.
Cleaning agent with 0.02 percent benzalkonium chloride and 0.1 percent EDTA.
Cleaning agent with 0.001 percent thiomersal
and EDTA.
Solution with 20 percent isopropyl alcohol,
poloxamer 407 and amphoteric 10.
Solution with polysorbate 21 and polymeric
cleaning beads with 0.004 percent thiomersal
and 0.1 percent EDTA.
Isotonic polymeric cleaning agent, hydroxyethylcellulose, polysorbate 21, 0.1 percent
EDTA and 0.01 percent polyquaternium-1.
Nonionic surfactant with 0.004 percent
thiomersal.
Solution with hydrophilic, polyelectrolyte,
polyvinyl alcohol, hydroxyethyl cellulose with
chlorhexidine gluconate and EDTA.
Solution with cleaning agents with lauramide
DEA, nonoxynol-15, poloxamer 188, NaCl,
sodium borate, boric acid, 0.02 percent benzalkonium chloride and 0.1 percent EDTA.
Solution with poloxamer 188 with 0.013
percent benzalkonium chloride and 0.25
percent EDTA.
RIGID GAS PERMEABLE CONTACT

LENS PRODUCT
Cellulose acetate butyrate (CAB) and silicon
containing polymers are used in gas permeable
hard contact lenses (RGP). Lens care regimens
include use of a surfactant cleaner and storage
in a chemical disinfecting solution. However
these lenses are predisposed to dehydration and
accumulating protein and lipid deposits.
DISINFECTING/WETTING/SOAKING
SOLUTIONS (RGP LENSES)
Isotonic solution with polyvinyl alcohol,
0.003 percent chlorhexidine gluconate, and
0.002 percent EDTA.
Solution with polyvinyl alcohol, hydroxyethylcellulose with chlorhexidine gluconate
and EDTA.
Isotonic buffered solution of polyvinyl alcohol
with 0.004 percent benzalkonium chloride
and EDTA.
CLEANING/SOAKING SOLUTIONS (RGP
LENSES)
Solution containing, hydrophilic polyelectrolyte, polyvinyl alcohol, hydroxyethylcellulose with chlorhexidine gluconate and
EDTA.
Solution with cocoamphocarboxyglycinate,
NaCl, sodium lauryl sulfate, sodium
phosphate, hexylene glycol and EDTA.
Nonionic cleaning agents with 0.004 percent
thiomersal and 2 percent EDTA.
Tablet containing papain, NaCl, sodium
carbonate, sodium borate and EDTA. To
make a solution for soaking when diluted in
distilled water.
SOFT (HYDROGEL) CONTACT

LENS PRODUCTS
Soft contact lenses are made of a hydrophilic
polymer HEMA. Hydrogel lenses must be
maintained in a hydrated state in physiological
saline to prevent them from becoming brittle.
These lenses must be disinfected either by
heating or by soaking in a chemical solution.
Soft lens solutions are specially formulated to
be compatible with and to meet the special needs
of soft contact lenses.
The original chemical soft contact lens system

used thiomersal with either chlorhexidine or a
quaternary ammonium compound. These
systems had a high incidence of sensitivity
reactions. Hydrogen peroxide disinfection system
SOFT LENS REWETTING SOLUTIONS
CHEMICAL (COLD) SYSTEM
has become a lens care system of choice for soft

contact lenses.
Hydrogen peroxide (3%) is a very effective
and can be used with all soft lens polymers. Few
hydrogen peroxide systems require two steps to
achieve disinfection and hydrogen peroxide
neutralization. While other systems combine disinfection and neutralization in one step. Hydrogen peroxide care system is expensive and
complex. AIDS virus and herpes viruses are
effectively killed by heat and disinfecting systems
using hydrogen peroxide (3%), chlorhexidine
(0.005% with edetate, thiomersal 0.001-0.004%
or benzalkonium chloride 0.005 percent.
Recently two new soft lens care systems have
been available commercially. These are:
Poly quad (polyquaternium-1)
Dymed (polyammopropyl biguanide)
These disinfection agents are used in soft lens
care system. These systems are simple to use
and therefore increase patient compliance.
Section
Soft lens contact lens care systems are

designed to clean, disinfect and rewet the lenses.
The first step is proper cleaning. Cleaning the
lens gently in the palm of the hand with a daily
surfactant cleaner or recently available multipurpose solution (MP solution) will remove fresh
lipids, oils and other environmental debris.
After cleaning the lens, it should be
thoroughly rinsed with a soft lens rinsing/storage
solution. All rinsing/storage solutions contain 0.9
percent saline. Enzymatic cleaners are generally
used on a weekly basis. They are more effective
in removing protein deposits than surfactant
cleaners because they contain proteolytic
enzymes (papain, pancreatin or subtilisin). Most
enzymes are dissolved directly in saline or MP
solution but a newer enzyme (subtilisin) tablet
can be dissolved in a hydrogen peroxide
disinfectant solution. Soft lens disinfection is the
most important step in soft lens care. Disinfection
is achieved by using a thermal (heat) or chemical
(cold) system.
Thermal disinfection was the first system
approved for soft contact lenses. A heat unit
specially designed for soft lenses is used for
10 minutes at 80C. This procedure kills most
of microorganisms. Acanthamoeba keratitis
is of great concern. Heat disinfection is the
only procedure that successfully kill acanthamoeba. However, continued use of heat can
shorten the life of soft lens.
287
These solutions permit the lubrication of the soft

lens.
Rinsing/Storage Solutions (Soft Lenses)
Use these solutions for rinsing and storage of
hydrogel lenses in conjunction with heat
disinfection.
Preservative free solutions are available for
patient intolerant to preservatives. Various
solutions available commercially are:
Solution containing NaCl, sodium hexametaphosphate, sodium hydroxide, boric acid,
sodium borate, 0.001 percent EDTA and
0.001 percent thiomersal.
288
Section
Isotonic buffered solution of NaCl monobasic

monohydrate sodium phosphate, dibasic
anhydrous sodium phosphate, sodium
hydroxide or hydrochloric acid with 0.001
percent thiomersal and 0.1 percent EDTA.
Isotonic solution of NaCl, borate buffer, 0.1
percent EDTA with 0.001 percent polyquaternium.
Isotonic buffered solution of NaCl, boric acid,
0.0003 percent polyaminopropyl biguanide
and EDTA.
Isotonic buffered solution of NaCl sodium
hexametaphosphate, sodium borate, boric
acid with 0.1 percent sorbic acid.
Isotonic solution with 0.9 percent NaCl
(preservative free).
Buffered isotonic solution with NaCl and
EDTA or NaCl with boric acid and sodium
borate (preservative free).
Salt tablets for normal saline (soft lenses):
Reconstitute tablets in purified water. Distilled
water can also be used. These solutions are not
sterile and are intended only for use in
conjunction with heat disinfection regimens. Salt
tablets are available in strength of 135 mg and
250 mg.
Surfactant Cleaning Solutions (Soft
Lenses)
Cleaning solutions are used for daily prophylactic
cleaning to prevent the accumulation of
proteinaceous deposits and to remove other
debris.
These solutions are:
Isotonic solution with NaCl, sodium phosphate, tyloxapol, hydroxyethylcellulose,
polyvinyl alcohol with 0.004 percent
thiomersal and 0.2 percent EDTA.
Solution with cocoamphocarboxyglucinate,

sodium lauryl sulfate, hexylene glycol with
EDTA 0.2 percent and sorbic acid 0.1
percent.
Hypertonic solution with salt buffers,
detergents, 0.004 percent thiomersal and 0.1
percent EDTA.
Cleaning agent with 0.001 percent thiomersal
and EDTA.
Solution with 20 percent isopropyl alcohol,
poloxamer 407 and amphoteric 10.
Hypertonic solution of salt buffers, block
copolymers of ethylene and propylene oxide,
lauryl sulfate, salt of imidazole, sodium
bisulfite 0.1 percent, sorbic acid 0.1 percent
with trisodium EDTA.
Isotonic polymeric cleaning agent, hydroxyethylcellulose, polysorbate 21, 0.1 percent
EDTA and 0.01 percent polyquaternium-1.
Solution with NaCl, KCl, poloxamer 407,
0.25 percent sorbic acid and 0.5 percent
EDTA.
Isotonic solution with NaCl, oxyethylene,
hydroxyethylcellulose with 0.13 percent
potassium sorbate and 0.2 percent EDTA.
One hydra-mat II cleaning until and soft mate
weekly solution (cleaning agents) combined
with 0.001 percent thiomersal and 0.1
percent EDTA.
Enzymatic Cleaners
Enzymatic cleaning by soaking in a solution
prepared from enzyme tablets is recommended
once weekly. This is intended to remove proteins
and other lens deposits.
Single step protein removal tablet enzymatically cleans and disinfects simultaneously right
in the lens case. It is a convenient single step

process which enhances patient comfort and
extends lens life.
Various
enzymatic
tablets
available
commercially are:
Tablet containing papain, NaCl, sodium
carbonate, sodium borate and EDTAto
make solution for soaking when diluted in
distilled water or MP solution.
Tablet containing subtilisin, polyethylene
glycol, sodium carbonate, NaCl and tartaric
acid.
Subtilising A, effervescing buffering and
tabling agents.
To make solution for soaking when diluted
in 3 percent hydrogen peroxide disinfecting
solution.
Chemical Disinfection Systems (Soft

Lenses)
Chemical disinfection is an alternative to heat.
Two solution systems use separate disinfecting
and rinsing solutions, while one solution system
uses the same solution for rinsing and storage.
Care should be taken that lenses must not be
disinfected by heating when using these
solutions.
Various commercial preparations available
are:
Solution containing 0.013 percent tris tallow
ammonium chloride, 0.002 percent
thiomersal, bis tallow ammonium chloride,
sodium bicarbonate, dibasic, monobasic and
anhydrous sodium phosphate, hydrochloric
acid, propylene glycol, polysorbate 80 and
special soluble poly-hema.
Solution with 3 percent hydrogen peroxide,
0.85 percent NaCl, sodium stannate, sodium
nitrate and phosphate buffer (thiomersal
free).
These solutions can be used directly in the eye

during contact lens wearing to rehydrate and
improve comfort for hydrogel lenses. These
solutions contain a chemically neutral buffer that
ensures the solution pH as close to natural tears.
These rewetting solutions give relief from the
irritation, blurring and itching caused by high
pollution levels (dryness, dust and smoke). It can
be used any time anywhere for day long
comfort. It can be used four times a day
depending upon the patient need.
Various rewetting solutions available
commercially are:
Hypertonic solution with hydroxyethyl
cellulose, sodium borate, poloxamer 407,
sorbic acid, 0.001 percent thiomersal and 0.1
percent EDTA.
Isotonic solution with polyhexamethylene
biguanide 0.001 percent, tromethamine 12
mg/ml, tyloxapol and disodium edetate.
Isotonic solution with NaCl, borate buffer,

carbamide, poloxamer 407, 0.2 percent
EDTA and 0.15 percent sorbic acid.
Isotonic solution with povidone and other
water soluble polymers, 0.004 percent
thiomersal and 0.1 percent EDTA.
Isotonic solution with polyvinyl alcohol,
0.002 percent thiomersal and 0.01 percent
EDTA.
Isotonic solution with NaCl, 0.13 percent
potassium sorbate and 0.025 percent EDTA
(thiomersal free).
Isotonic solution with NaCl and boric acid
(thiomersal and preservative free).
Section
Rewetting Solutions (Soft Lenses)
289
290
Solution with NaCl, sodium borate, boric acid

0.005 percent chlorhexidine gluconate and
0.1 percent EDTA, 0.001 thiomersal.
Section
Two solution systems available are:

Disinfecting solution: microfiltered hydrogen
peroxide 3 percent with sodium stannate,
sodium nitrate and phosphate buffers.
Neutralizing and rinsing spray: (i) buffered
isotonic solution with NaCl, sodium borate,
decahydrate, boric acid, bovine catalase with
sorbic acid and EDTA (ii) isotonic solution of
0.5 percent sodium thiosulfate, NaCl and
borate buffers.
Multiaction disinfecting solution containing
isotonic solution with NaCl, sodium borate,
boric acid, poloxamine, 0.0005 percent
polyaminopropyl biguanide and EDTA.
Disinfecting solution with NaCl, povidone,
octylphenoxyethanol, 0.005 percent chlorhexidine gluconate and 0.1 percent EDTA
(thiomersal free).
RECENT ADVANCES IN SOFT

CONTACT LENS CARE SYSTEM
Patients usually feel a lot of inconvenience, due
to separate soaking, cleaning, wetting and
enzymatic cleaning, solutions. For past few years,
multinational companies have come up with a
single multipurpose soft contact lens care
solution (for cleaning, soaking, rinsing, wetting
and enzymatic cleaning), improving the patient
compliance many fold. As we know that protein
deposits begin to build up after only minutes or
hours of lens wear, if left untreated protein
deposits can compromise visual acuity and lens
comfort. Various multipurpose (MP solutions)
for soft contact lenses available commercially
are:
Multipurpose solution (ReNu) containing

sterile isotonic solution with boric acid,
disodium edetate, sodium borate and sodium
chloride.
Active gradients are dymed (polyaminopropyl biguanide) 0.001 percent and
hydranate (hydroxyalkylphosphonate) 0.03
percent, poloxamine 1 percent. This
multipurpose solution with hydranate protein
remover has long lasting comfort.
It can be used for cleaning, rinsing, disinfecting, lubricating and storing the soft contact
lenses. It cleans, disinfects and removes protein
everyday. It contains hydranate, a unique agent
that removes protein daily to inhibit protein
build-up (Figure 19.1). It also contains
performance prove poloxamine and dymed
which work effectively to remove lipid and
environmental debris (Figure 19.1). No adverse
reaction has been reported even on prolonged
use of this solution.
MP solution containing
Polyhexamethylene 0.001 percent
biguanide (PHMB)
Tyloxapol
0.025 percent
Tromethamine
1.2 percent
Edetate disodium
0.05 percent
This MP all in one solution does not contain
chlorhexidine, thiomersal or other mercury
containing ingradients.
Polyhexamethylene biguanide (PHMB) is a
polymeric compound and acts as disinfectant.
It is a biocide with a wide spectrum of
antimicrobial activity and is more compatible
with lenses as the large size of the molecule
minimizes lens uptake or accumulation in the
soft lens matrix (Figure 19.2).
Tyloxapol acts both as surfactant and a
lubricant. It is a substituted polymeric phenol
291
Section
FIGURE 19.1: Multipurpose solution with hydranate and poloxamine and their mechanisms of action
292
Section
FIGURE 19.2: Molecular structure of PHMB

(polyhexamethylene biguanide)
FIGURE 19.3: Molecular structure of tyloxapol
and is compatible with other solution

components (Figure 19.3). It is hydrophobic
and tends to attach to other hydrophobic
surfaces such as lipid, protein, mascara and

other tear debris. Its water attracting
component carries away the debris that binds
to the hydrophobic component. These
surfactant qualities help tyloxapol surround
debris particles making them more likely to
be washed away.
Tyloxapol acts as lubricant or rewetter by
coating the surface of the lens with multiple
layers. It contributes to lens cleaning by reducing
the friction that normally exists between the
fingers and the lenses. Tyloxapol coats the lens
but does not concentrate in the matrix, thereby
avoiding irritation of ocular tissues.
Tromethamine is a well accepted biological
buffer (TRIS). It is chemically nonreactive in the
medium in which it is used. It helps to maintain
the solution pH in the range most favorable for
the hydrolysis of protein films on lens surfaces
effecting rapid removal of such films.
This multipurpose solution is used for
disinfection, cleaning, soaking, rinsing and
rewetting of soft contact lenses. It has low toxicity
as well as minimal lens uptake resulting in
increased comfort to patients.
Appendix 1
VERTEX DISTANCE CORRECTION
Vertex Distance (mm)
10
11
12
13
10
11
12
13
CONTACT LENS POWER

Spectacle
Power (D)
4.00
4.50
5.00
5.50
6.00
6.50
7.00
7.50
8.00
8.50
9.00
9.50
10.00
10.50
11.00
11.50
12.00
12.50
13.00
13.50
14.00
14.50
15.00
15.50
16.00
16.50
17.00
17.50
18.00
18.50
19.00
Minus Lenses
3.87
4.25
4.75
5.25
5.62
6.12
6.50
7.00
7.37
7.87
8.25
8.62
9.12
9.50
9.87
10.37
10.75
11.12
11.50
11.87
12.25
12.62
13.00
13.50
13.75
14.12
14.50
14.87
15.25
15.62
16.00
3.87
4.25
4.75
5.12
5.62
6.00
6.50
6.87
7.37
7.75
8.25
8.62
9.00
9.37
9.75
10.25
10.62
11.00
11.37
11.75
12.12
12.50
12.87
13.25
13.62
14.00
14.25
14.75
15.00
15.37
15.75
3.87
4.25
4.75
5.12
5.62
6.00
6.50
6.87
7.25
7.75
8.12
8.50
8.87
9.37
9.75
10.12
10.50
10.87
11.25
11.62
12.00
12.37
12.75
13.00
13.50
13.75
14.12
14.50
14.75
15.12
15.50
Plus Lenses
3.75
4.25
4.75
5.12
5.50
6.00
6.37
6.87
7.25
7.62
8.00
8.50
8.87
9.25
9.62
10.00
10.37
10.75
11.12
11.50
11.87
12.25
12.50
12.87
13.25
13.62
14.00
14.25
14.62
14.87
15.25
4.12
4.75
5.25
5.75
6.37
7.00
7.50
8.12
8.75
9.25
9.87
10.50
11.12
11.75
12.37
13.00
13.62
14.25
15.00
15.62
16.25
17.00
17.75
18.25
19.00
19.75
20.50
21.25
22.00
22.75
23.50
4.12
4.75
5.25
5.87
6.37
7.00
7.62
8.12
8.75
9.37
10.00
10.62
11.25
11.87
12.50
13.12
13.87
14.50
15.25
15.87
16.50
17.25
18.00
18.75
19.37
20.25
21.00
21.75
22.50
23.25
24.00
4.25
4.75
5.25
5.87
6.50
7.00
7.62
8.25
8.87
9.50
10.12
10.75
11.37
12.00
12.75
13.37
14.00
14.75
15.50
16.12
16.75
17.50
18.25
19.00
19.75
20.50
21.50
22.25
23.00
23.75
24.75
4.25
4.75
5.37
5.87
6.50
7.12
7.75
8.25
8.87
9.50
10.25
10.87
11.50
12.12
12.87
13.50
14.25
15.00
15.62
16.37
17.12
17.87
18.62
19.37
20.25
21.00
22.00
22.75
23.50
24.50
25.25
Index
295
Index
A
Abnormalities involving, iris and pupil
172-179
amblyopia 179
aniridia 175
anisocoria 172
diplopia 179
heterochromia 177
iris coloboma 173
photophobia 179
polycoria 174
problems associated with the lens
178
pupillary block lens 178
Acanthamoeba keratitis 44,229-234
clinical features 230
cyst 230
diagnosis 232
pathogenesis 230
pathology 232
treatment 234
trophozoite 229
Advanced orthokeratology 74
Amino acid composition, human tear
lysozyme 20
Anatomical factors, corneal
transparency 9
Antimicrobial factors, tears 25
Antiproteinasis concentration, tear and
plasma 24
Artificial tear substitutes 45
Astigmatic lenses 121
Astigmatism 193
B
Bandage contact lenses 204
Basement membrane, corneal
epithelium 4
Best-corrected visual acuity (BCVA)
after LASIK 242, 243
Bifocal (or multifocal) contact lenses
50
Bifocal contact lenses 284
Bitoric RGP lens 200
Blepharitis 39
Bowmans layer 5
C
CAB (cellulose compounded with
acetic and butyric acids) 54
Central steepening 85
Charcteristics of hydrogel materials
141-147
critical Dk/t values 145
dehydration 147
ionic charge 146
major hydrogel lens materials
categories 142
material chemistry 141
oxygen transmissibility (Dkt) 145
soft lens thickness and Dk/ts 144
thickness 143
water content 143
Chemical (cold) system 287
Chemical composition, tear fluid 20
Chemical disinfection systems (soft
lenses) 289
Choice of soft lens modality 147
Choosing lenses for patients 151-155
astigmatism 153
high myopia 152
hypermetropia 153
low to moderate myopia 153
part-time wearer 155
presbyopia 153
steep curvature cornea 154
Cleaning solutions and gels (hard
lenses) 285
Cleaning, soaking and wetting
solutions (hard lenses) 285
Cleaning/soaking solutions (RGP
lenses) 286
Color deficiency 180
Common causes, incomplete tear film
distribution 36
Common methods, tear film evaluation
36
Conjunctival lymphatic cysts 40
Contact lens associated red eye
(CLARE) 127
Contact lens care 51

Contact lens care products 284
Contact lens correction of astigmatism
194
Contact lens fitting 188-190
before LASIK surgery 189
in LASIK surgery 188
in post-LASIK phase 190
Contact lens fitting after photorefractive
keratectomy 187
indications 187
Contact lens fitting after radial
keratotomy 184-187
choice of RGP trial lenses 185
fitting procedure 185
fitting technique 186
indications 184
post fitting complications and
failures 187
Contact lens induced changes, tear film
35
Contact lens maintenance 45
Contact lens properties 55
Contact lens-induced topographical
abnormalities, cornea 57
Contact lenses and glaucoma patients
45
Contact lenses and ointments 46
Contact lenses for children 207
Contact lenses in the aquatic
environment 276
Contacts and air conditioning 41
Contacts and computer vision
syndrome 42
Contacts and dry eye syndrome 38
Cornea 3
Corneal curvature 252
Corneal distortion 84
Corneal endothelium 6
Corneal epithelium 3
Corneal erosion of infection 85
Corneal indetation 85
Corneal problems 167-171
arcus senilis or juvenilis 167
micro-cornea 171
scarred corneas 168
Corneal scars 37
Corneal stroma 5
296
Corneal topography assessment 75-77

corneal topography maps 76
corneal topography principles 76
keratometry limitations 75
sources of error 77
Corneal transparency 9
Corneal vidokeratography 37
Correction of presbyopia 123
D
Daily disposable lenses 50
Daily wear soft contact lenses 283
Daily wear v/s extended wear, contact
lens 217
Descemets membrane 6
Diagnostic tests and drug assays, tears 29
Diagnostic tests, tear hyposecretions 29
biopsy of the conjunctiva 31
lysozyme assay 30
Schimers test 29
tear film break-up time (BUT) 29
tear globulin assay 30
tear osmolarity 30
vital dye staining 30
Difference topographic plot 82
topography-central distortion 83
topography-central flattening 82
Different components, film layer 36
Disadvantages, contact lenses, atheletes
250
Disinfecting/wetting/soaking solutions
(RGP lenses) 286
Dispensing and follow-up care, toric
lenses 199
Disposable or planned replacement
lens systems 275
Disposable soft contact lenses 283
Drugs excreted in tears 28
E
Early orthokeratology fitting techniques
70
Elements that comprise lens
performance 161-163
lens comfort 162
lens movement 162
lens position 162
natural appearance 162
ocular health 163
vision 163
Endothelial pump 11
Enzymatic cleaners 288
Enzymes of energy producing
metabolisms 27
Evaluation, soft lens fit 138

Extended wear contact lenses 50, 283
Extended wear soft lenses 124
External measurements of the eye 250
Eye bandage lenses 47
F
FDA classification, hydrogel materials 55
Fitting keratoconus 103
Fitting of bandage contact lens 205
Fitting of RGP lenses on athletes 262
Fitting penetrating keratoplasty 106
Fitting postrefractive surgery 110
Fitting technique, children 217
Fitting toric corneas 102
Fluorescein patterns, lenses used for
orthokeratology 72
Fluoropolymer lenses 55
Front surface toric RGP lens 200-203
G
Gas-permeable (RGP) lenses 90-101
calculations 94
fluorescein patterns 96
PMMA rehabilitation 90
RGP designs 92
RGP materials 91
RGPs for presbyopia 98
rigid lens care systems 101
troubleshooting 94
General advantages, contact lenses,
atheletes 249
General features, soft lenses 136
Glaucoma filtering blebs 46
Graft topography, initial lens selection
108,109
asymmetric astigmatism 108
keratoconic type of topography 109
mixed prolate oblate pattern 108
oblate pattern 108
prolate pattern 108
steep to flat pattern 109
H
Hard (PMMA) contact lens products 285
Hard and rigid gas permeable lenses 284
Hard contact lenses 282
Human limbal epithelium 7
Human tear electrolytes 26
Human tear lysozyme 20-22, 27, 40
Hygiene and safety, role of the athletic
trainer 278
Hypersecretion, tears 28, 31
I
Imbibition pressure 10, 11
Immunoglobulin levels, tear and serum
22
Impression cytology mapping 17
Indications for contact lenses in
children 208-214
accommodative esotropia 212
albinism 212
amblyopia and occlusion 214
aniridia 212
anisometropia 211
aphakia 208
astigmatism 212
corneal ulceration 214
keratoconus 212
myopia 211
nystagmic patients 213
ocular disfigurement 213
Indications of BCL 204
Internet addresses, contact lens and
lens care companies 156
Interrelationship, corneal astigmatism
and refractive astigmatism
253
Intraocular pressure 11,12
Irregular contact lens disinfection 282
K
Keratoconjuctivitis sicca 39
L
Lacrimal gland 27
Lactoferrin 40
Lagophthalmos 38
LASIK (laserassisted in situ
keratomileusis) 48
Left add, right subtract approach 121
Lens configurations 165
pupillary block lens 167
semi-stock prosthetic lenses 167
solid opaque iris imagery lens with
clear or black pupil 166
solid translucent or opaque annulus
lens 166
solid translucent or opaque lens 165
Lens designs, atheletes 256
aspheric lens designs 257
athletic lens designs 257
basic RGP lens design 256
LID-attachment lens design 256
ultra-thin lens designs 257
Lens material, atheletes 255
297
Index
Lens types 255
LID structure and LID action 251
Limbal zone 7
Limitations of early orthokeratology 71
Lubrication, different types of contact
lenses 49
Lysosomal enzymes 27
M
Magnification of the retinal image 237
Materials used, contact lenses 54
Measuring the tear break-up time
(BUT) 37
Mechanism, tear film brak up 17
Medline articles on orthokeratology 72
Modified Schirmer test 29
Multipurpose solution (ReNu) 290
color Doppler scanography 33

fluorescein dye disappearance test 32
intubation dacryocystography 33
Jones I (primary) test 31
Jones II (secondary irrigation) test 32
scintillography (radionuclide
testing) 33
Physiological factors, corneal
transparency 10
Pinguecula 37, 39
PMMA lenses 49, 54
Polyhexamethylene biguanide 290,292
Postwear ocular health 277
Prescription of the lens 252
Principles of therapeutic efficacy 205
Pterygium 37
Pupil size 251
R
N
Non-hema materials 55
Normal tear drainage 18
Normal tear film 35
O
Occluded meibomian gland orifices 39
Ocular accommodation 237
Ocular convergence 237
Ocular measurements and
observations 163-164
corneal curvature 163
horizontal visible iris diameter 163
iris color and architecture 164
pupillary diameter 164
Ocular tear film 35
Optical aberrations 237
Optical physiology 236
Orthokeratology 69
Orthokeratology fitting techniques,
reverse geometry lenses 73
Osmotic pressure, tears 19
P
Parametric descriptors, corneal
topography 58
simulated keratoscope reading
(sim K) 59
surface asymmetry index (SAI) 59
surface regularity index (SRI) 59
Photorefractive keratectomy 48
Physical properties, tears 18
Physiological diagnostic test,
hypersecretions 31
Radial keratotomy 48
Recent advances, soft contact lens care
system 290
Referactive surgery, contact lens
wearers 58
Retinal image for a myope 239
Retinal image for an emmetrope 239
Reverse geometry lenses 71, 111
Rewetting solutions (soft lenses) 289
RGP contact lens-induced corneal
warpage 63
RGP lens-induced corneal changes 62
Rigid gas permeable (RGP) lenses 283
Rigid gas permeable contact lens
product 286
Rigid gas-permeable lens evaluation
258-262
fluorescein patterns 262
lens comfort 261
lens movement 259
lens position 258
postwear physiology 262
vision 259
Rigid gas-permeable lenses 49, 255
Rigid lens materials 54
Rigid toric contact lens 199
Rinsing/storage solutions (soft lenses) 287
S
Sagittal height fitting method 77-82
lens designs 78
lens materials 81
sagittal height formulae 78
tear reservoir depth 81
troubleshooting 82
Sclera 8
Selecting contact lens type, pediatric
patient 215
hard contact lenses 215
silicone contact lenses 216
soft contact lenses 215
Selection, lens parameters for fitting 137
Signs of contact lens-induced corneal
warpage 57
Silicone acrylate 54
Silicone resin lenses 54
Soft (hydrogel) contact lens products 286
Soft contact lens-induced corneal
warpage 60
Soft contact lenses 50
Soft lens 116
basic fitting concepts 117
history, materials and design 116
replacement frequency 118
Soft lens care 132
Soft lens complications 126
Soft lens evaluation 267-273
combination lens 272
comfort 270
lens movement 267
lens position 267
lenses for color deficiencies 273
postwear physiology 272
scleral lens designs 272
vision 269
Soft lens materials 55
Soft lens rewetting solutions 287
Soft lens-induced corneal changes 59
Soft lenses, atheletes 262-265
anterior optic zone 265
astigmatism 265
center thickness 265
diameter 264
introductory comments 262
lens material 263
soft lens design 264
Spherical soft lenses 119
Spreadsheet for calculating tear layer
profile in orthokeratology
79
Storage/soaking solutions 285
Stromal swelling pressure 10
Surface asymmetry and irregularity 85
Surfactant cleaning solutions (soft
lenses) 288
Symptoms of dryness 155
T
Tear abnormalities 39
Tear albumin 21
298
Tear base 39
Tear composition 18
Tear drainage system 14
Tear film 13
Tear film and blinking effects on fitting 140
Tear film formation dynamics 16
Tear film layers 14
Tear film physiology 15
Tear film, contact lens wearer 35
Tear layer profile for orthokeratology
lens 80
Tear lipids 39
Tear surfacing 39
Tear volume 38
Tear wetting 39
Test, dry eye evaluation 36
Thera Tears, lubricant 49
Therapeutic contact lenses 47
Therapeutic lenses 204

Tight lens syndrome 127
Tinted contact lenses 51
Toric contact lenses 50, 193
Toric lenses 122, 200
Toric lens fitting 197
Toric lens stabilization method 195-197
dynamic stabilization 197
periballasting 196
prism ballasting 195
truncation 196
Toric soft contact lens fitting 197
Toric soft lenses 284
Trichiasis 37
Tromethamine 292
Tyloxapol 292
Types of astigmatism 193
Types of toric lenses 193
U
Ultrasound pachymetry 58
Uncorrected visual acuity (UCVA) 242
Use contacts after refractive surgery 48
Useful tips, toric lens fitting 199
V
Vertex magnification 238
Visual acuity 236, 242
Visual field 237
W
Waffled appearance of epithelial
edema 127
Wetting solutions, hard lens 285
Wide parallelopiped topographic view,
radial keratotomy scars 49

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Dr Agarwals

Dr Agarwals Group of Eye Hospitals

MS FRCS FRC Ophth

Dr Agarwals Group of Eye Hospitals

This book is dedicated to

Textbook on Contact Lenses

Ashok Garg MS PhD

Dra Sarabel Simon-Castellvi

Dra Cristina Simon-Castellvi

Section 2: Contact Lens Designs

Textbook on Contact Lenses

8. Rigid Gas-Permeable Contact Lenses .......................................................... 90

Anatomy of the Cornea,

FIGURE 1.1: Corneal epithelium of human eye. Corneal

(Figure 1.1). The second layer, wing cells, consists

Textbook on Contact Lenses

and superficial cells. The content of the glycogen

FIGURE 1.2: High magnification of superficial cells of the

Anatomy of the Cornea, Limbus and Sclera

FIGURE 1.3: Basal cells of the corneal epithelium. Adhesion

The corneal stroma is located between the

Bowmans layer is a uniform layer, 8 to 14 m

FIGURE 1.4: High magnification of human corneal stroma.

The arrangement of the collagen fibers is

Textbook on Contact Lenses

Descemets membrane is divided into two

Descemets membrane is a homogenous layer,

Corneal endothelium is a monolayer of hexagonally shaped cells resting on the Descemets

ability of the cornea to scatter 98 percent of the

FIGURE 1.5: Corneal endothelium and Descemets

Anatomy of the Cornea, Limbus and Sclera

48 kDa keratin expressed in hyperproliferative

with aqueous humor, thus facilitating the pump

FIGURE 1.6: Human limbal epithelium. Some of the basal

Clinically, limbal epithelium is damaged in

Textbook on Contact Lenses

corneal epithelium is gradually replaced by

The sclera is the main part of the outer wall of

FIGURE 1.7: High magnification of human sclera. The

fibroblasts. It serves to maintain the shape of

The factors that maintain corneal transparency

The cornea is avascular except for the capillary

If one has to see clearly, the cornea has to be

Absence of Blood Vessels and

Textbook on Contact Lenses

might result in destructive interference of all

FIGURE 2.2: Factors controlling corneal hydration

1. Stromal Swelling Pressure

FIGURE 2.1: Cross-sectional view of fibrils

The endothelium is very permeable. It prevents

Normally, the swelling pressure is equal to the

FIGURE 2.3: Pressure relations in the cornea

1. PASSIVE INGRESS OF H2O

The endothelium has an active pump which is

Textbook on Contact Lenses

oxygen, glucose and carbohydrate metabolism

= Swelling Pressure (50) and

If the intraocular pressure increases, corneal

Tear Film Physiology

Tear Film Physiology

The exposed part of the ocular globethe

FIGURE 3.1: Cross-section of eye showing tear film (blue)

by the act of blinking and a drainage system