Acknowledgement

Bausch & Lomb University

would like to thank
International Association of
Contact Lens Educators (IACLE)
for its valuable support
in form of literature review,
content & photographs from
IACLE Contact Lens Course.
Contents

Anatomy & Physiology of Eye......................................................................................... 1 - 10

Optics of Contact Lenses................................................................................................ 11 -12

History and Types of Contact Lens.................................................................................. 13 - 17

Parameters of Contact Lenses......................................................................................... 18 - 20

Contact Lens Materials and Manufacturing Techniques..................................................... 21 - 27

Instrumentation for Contact Lens Fitting......................................................................... 28 - 39

Preliminary Eye Examination.......................................................................................... 40 - 43

Soft Contact Lens Fitting................................................................................................. 44 - 49

Anatomy and Physiology of the Anterior Eye

The main structures of the anterior eye are as follow:

1. Cornea
2. Conjunctiva
3. Tear film
4. Eyelids
5. Sclera
6. Iris & Pupil
7. Ciliary body

Anatomy
and
Physiology 1. Cornea

of the Anatomy of the Cornea

Cornea is the most important structure of the eye. Cornea is unique in several ways.

Anterior Eye 1. It is highly transparent

There is no other tissue in the human body that is as or more transparent than the cornea.

2. It is avascular
Cornea has no blood vessel in its structure.

3. It has a very powerful refractive power

Cornea has a shape like a convex lens. It acts as a powerful lens to refract the light or seen objects to the retina.
It is stipulated that the cornea contributes approximately 70% of the refractive power of the whole eye.

4. The dimensions of the cornea are asymmetrical

Cornea is not round but actually ellipsoidal in shape. It's diameter is smaller vertically and wider horizontally.
Cornea is also thinner in the center and thicker in the periphery.

The average dimensions of the cornea is as follows:

Radius of corneal front surface : 7.80mm
Radius of corneal back surface : 6.70mm
Corneal centre thickness : 0.56mm
Corneal peripheral thickness : 1.00mm

1
The structures in the cornea
Surface cell layer
The cornea consists of 5 layers. The layers of the cornea are:
Wing cell layer
1. Epithelium Basal cell layer
2. Bowman's membrane (also known as the anterior limiting lamina)
3. Stroma
4. Descemet's membrane (also known as the posterior limiting lamina) The corneal epithelium consists of 5 layers. The 5 layers in the corneal epithelium are:-
5. Endothelium

a. Surface cell layer (2 layers)

Tears - Also known as the squamous cell layer
- Squamous cells are thin

C Epithelium

Bowman’s
membrane
- Squamous cell are in a variety of polygonal shapes (usually 6 sided)
- Outermost cell has microplicae or microvilli to increase area for mucin attachment to increase tear film
stability

O b. Wing cell layer (2 layers)

- Thicker than squamous cells

R
- Has protrusions to adhere to the basal cell layer to ensure they are tightly joined together

c. Basal cell layer (1 layer)

Stroma
- The deepest layer of the corneal epithelium

N - Basal cell are columnar in shape

- Basal cell will migrate to the surface when they divide (mitosis) to replace dead or dying cells. These
migrating cells will keep moving to the surface and then finally being shed into the tearfilm

E
(metabolism of epithelium).

2. Bowman's membrane
Descemet’s

A
- Second layer of the cornea
membrane - Mainly consists of collagen fibres and ground substance
Endothelium - Acellular (no cell is present in the Bowman's membrane)
Aqueous Humour - Actually considered to be a layer of differentiated anterior stroma

3. Stroma
1. Corneal Epithelium
- Third layer of the cornea
- Outermost layer in the cornea
- Thickest layer of the cornea (accounts for 90% of total corneal thickness)
- Epithelium cells are tightly packed together
- Mainly consists of collagen fibres (around 200 to 250 layers), keratocytes and ground substance
- Function is to prevent bacteria from entering the deeper layers of the cornea
- Collagen fibres in the stroma
- Damaged epithelial cells can regenerate (heal) in about 24 hours
- Similar in size with each other
- Epithelium is about 0.05mm thick and is attached to the Bowman's membrane
- Spaced evenly between each layer

2 3
- Runs parallel with each other Physiology of the Cornea
responsible for the transparency of the cornea (any disturbance to this layer will cause a change in
transparency) There is a constant metabolic activity in the cornea. This constant activity is to maintain the transparency, cell
- Keratocytes in the stroma reproduction and transport of tissue materials. The main nutrients needed for the metabolism activity are
- Located between layers of collagen fibres glucose, amino acids and oxygen.

- Ground substance
Aqueous humour provides glucose and amino acids but oxygen is derived from the atmosphere (which dissolve
- Hydrophilic structure that is responsible for the exact spacing of the collagen fibres in the tears).

4. Descemet's membrane The physiology of the cornea mainly involves 2 major activities. These are
- Fourth layer of the cornea
- Acts as a basement layer of the endothelium 1. Corneal epithelial repair
2. Maintaining corneal transparency
- Elastic and resistant to damage

5. Endothelium 1. Corneal epithelial repair

- Innermost layer of the cornea with direct contact to the aqueous humour
- A thin single-celled layer The corneal cells regenerate very quickly to cover for any defects on its surface.
- Cells have mainly hexagonal shape - If the wound is minor, then the neighbouring cells in the corneal epithelial layer will slide over (regenerate)
to cover the area of the wound.
- Does not regenerate {neighboring cells enlarge to cover areas of dead cell (polymegathism)}
- If the wound is big, then conjunctival and corneal cells will slide over (regenerate) to cover the defect.
- Nourished by the aqueous humor (the fluid behind the cornea)
- Endothelium acts like water pumps which maintain the balance of the fluid in the cornea to keep cornea
transparent 2. Maintaining corneal transparency

The cornea must maintain its transparency to ensure that the person can see well. Any loss to the transparency
to the cornea would affect the vision of the person.
Corneal sensitivity
The endothelium, which is the deepest layer in the cornea, is the main structure that works to maintain the
Approximately 70 sensory nerves innervate the cornea. transparency of the cornea.

The nerve that enters the cornea epithelium will lose its white coloured myelin sheath within 0.5mm of the
a. Due to osmosis, water from the aqueous humour (which provides nutrients to the uvea region) will always
limbus. The sensitivity of the cornea is greatest centrally and horizontally. be drawn into the cornea.
b. The endothelial cells' job is to then pump any additional water out of the cornea to maintain a correct
corneal thickness. The correct corneal thickness will ensure that the spacing between fibrils is adequate.
When the spacing is correct, the cornea stays transparent.

To ensure that the endothelial cells can consistently pump the additional water from the corneal layers, it must
have a consistent oxygen supply. Oxygen is needed to metabolise the nutrients (primarily glucose) by means of
glycolysis into sufficient energy to allow the waste product and lactic acid to diffuse quickly out of the tissue.

If there is a decrease in oxygen to the cornea (hypoxia), then the waste product and lactic acid can buildup in
the stroma, which will allow water to be drawn into the stroma faster than the endothelial cells to remove it.
This would result in thickening of the corneal layers, which will result in inconsistent spacing between fibril
layers in the stroma. The thickening of the corneal layers would result in a phenomenon called oedema.

4 5
2. Conjunctiva Conjunctival Sac

Anatomy of the conjunctiva

The conjunctiva is
Plica semilunaris
- A mucous membrane that contains a lot of cells
- A transparent layer (though it is not as transparent as the cornea)
- Comprised of 2 layers (epithelium and stroma)
- Divided into regional areas
- Palpebral conjunctiva (lines the tarsal plate of the eyelids) Caruncle
- Bulbar conjunctiva (which covers the anterior sclera)
- Conjunctival sac (conjunctival fornix)
- Plica semilunaris
- Caruncle
Diagram showing the frontal view of the conjunctiva

Even though the conjunctiva is transparent, it contains a lot of cells. The cells are
- Goblet cells (which secretes mucin, one of the layers in the tear film)
- Glands of Wolfring (which secretes the aqueous layer in the tear film)
- Glands of Krause (which secretes the the aqueous layer in the tear film)
- Crypts of Henle (contribute to mucin layer of the tear film)

Bulbar The conjunctival cells are actually closely linked with the cells in the cornea. There are 2 layers in the conjunctiva:-
Palpebral conjunctiva
1. Epithelium
conjunctiva
The conjunctival epithelium is actually a continuation of the corneal epithelium cells. The 5 layers of the corneal
epithelium cells become 10 layers of the conjunctival epithelium cells at the limbus.

2. Stroma
The stroma is the second layer in the conjunctiva. The conjunctival stroma is actually a continuation of the
Bowman's membrane in the cornea.
Conjunctival Sac
Eyelids
Palpebral conjunctiva
Eyelashes
Bulbar conjunctiva Tear Film

The tear film plays a very important function in the vision of an individual. The functions of the
tear film are:-

1. Optical
The tear film covers the whole cornea to create a smooth surface layer so that light is refracted towards
the retina.
Diagram showing the side view of the conjunctiva

6 7
2. Physiological Eyelid
Tear film
- Keeps the corneal surface moist Anatomy of the eyelid
- Acts as a lubricant for eyes and lids during blink
- Removes foreign bodies, like dust particles that has entered the eye The eyelid is actually a fold of skin that covers the eye. It contains 4 layers, which are
1. Skin (cutaneous layer)
3. Metabolic 2. Muscle layer (obicularis oculi muscle contributes approximately one-third of the eyelid thickness)
Tears contain a lot of metabolics and nutrients (oxygen) that the cells of the eye need to function properly. 3. Fibrous tissue layer (located behind the tarsal plate)
4. Mucosal layer
4. Protection
Tears contain protein (lysozyme and lactoferrin), which kills bacteria that it comes in contact with. Other extra structures connected to the eyelids are eyelashes, which is highly sensitive.
The tear film is approximately 7microns in thickness. 90% of the tear film volume is contained in the tear prism
along the lid margin. The eyelid's function is mainly to
1. Protect the eye from dust or other foreign bodies from entering the eye,
The tear film consists of 3 main layers. The layers in the tear film are:- 2. Protect the eye from high levels of light
1. Lipid layer 3. Help ensure even spreading of the tears over the anterior ocular structure during blinking action
2. Aqueous layer
3. Mucin layer There are also glands in the eyelid. They are
1. Zeis gland (which is a sebaceous glands which is closely associated with the lash follicle)
LAYER DIMENSION SOURCE FUNCTION 2. Moll's gland (which is a modified sweat gland)
Lipid layer - Meibomian gland - Prevents tear evaporation and 3. Meibomian Gland (which secretes the lipid which is a part of the tear film)
0.1 micron thick
tear overflow

Aqueous 7 microns thick - Lacrimal gland - Provides Nutrition to the

Other ocular structures
layer - Glands of Krause cornea
- Glands of Wolfring
The other important ocular structures are:-
Mucin layer 0.02 to 0.05 - Goblet cell - Ensures aqueous layer can
micron thick spread evenly over the cornea
Sclera

The tearfilm is spread by the action of blinking. The tearfilm exit the eye via the puncta to the nasolacrimal duct

Superior Puncta

Limbus

Inferior
Tears Puncta
Iris
There are a few tear function tests, which are:-
1. Tear Break Up Test (most commonly used by contact lens practitioners)
2. Schirmer Test
3. Phenol Red Thread Test
4. Rose Bengal Test

8 9
1. Sclera

The sclera is the white coloured structure that surrounds the whole eye. It is composed of collagen fibres (which
is not arranged in a regular pattern). The 6 extraocular muscles, which govern eye movement, are attached to
the sclera.

2. Limbus

The limbus is the area between the sclera and the cornea. The limbus consists mainly of the blood vessels and
nerve fibres.

3. Iris

The iris is a circular shaped diaphragm containing 2 sets of muscles to control the pupil size (circular & radial
muscles). The muscles react to light and govern the size of pupil. Both pupils should be equally big & round.
The diameter of the pupil will change when exposed to light & when the eye is accommodating.

Optics
The level of pigmentation on the iris will affect the colour of the iris. The more pigmentation on the iris, the
darker will be the colour of the iris.
Lot of pigments = 'brown eyes';
Less pigments = 'green eyes' or 'grey eyes';

of
Very little pigments = 'blue eyes'

4. Ciliary body

The ciliary body aids in accommodation of the eye. The sequence of accommodation is as follows:

a. Contraction of ring shape ciliary muscle causes the ciliary body to move anteriorly.
Contact Lenses
b. The size of the lumen decreases and this releases the tension of the zonules (suspensory ligament
linking the ciliary body with the lens).

c. The crystalline lens becomes thicker which will increase the total refractive power of the eye for near
vision. This process enables the person to look at near objects.

10
c. Amount of Accommodation
Contact Lens Optics
Myopic person would have to accommodate more when they see a near object when they switch from
An optical effect of a lens changes as the distance between the lens and eye changes. spectacles to contact lenses
Hyperopic person would accommodate less when they need to see a near object when they switch from
The prescription of the contact lens issued to the wearer depends on spectacles to contact lenses
1. Vertex distance
2. Tear lens power d. Amount of Convergence

1. Vertex distance Myopic person would have to converge more when they see a near object when they switch from spectacles
to contact lenses
The vertex distance is the distance between the back surface of the spectacle lens and the cornea Hyperopic person could converge less when they need to see a near object when they switch from spectacles
Vertex distance would affect the to contact lenses
a. Effective Back Vertex Power (BVP)
b. Magnification / minification 2. Tear lens power
c. Amount of accommodation
d. Amount of convergence Tear lens power is the difference between Spectacle BVP and Contact Lens BVP
Wherein, BVP = Back Vertex Power
a. Effects of Vertex distance on Back Vertex Power
Tear lens power is
Significant when greater than 4.00D - Not significant with soft contact lens (because soft contact lens follows the curvature of the cornea
Need compensation - Significant with RGP if the RGP is poorly fitted (fitting too loose or too tight)

Effects are opposite for: For example,

- A steep / tight fitting RGP lens would create a positive tear lens power
Minus lenses (myopes) - become less minus when changed from specs to CL - A flat / loose fitting RGP lens would create a negative tear lens power
Plus lenses (hyperopes) - become more plus when changed from specs to CL
A practitioner can actually have an idea about the fitting of RGP without the aid of fluorescein. All they need is
Difference in effective power depends on: to make sure that the contact lens power is the same as the spectacle BVP (after vertex distance compensation)
when they check for the over-refraction
BVP (bigger effect as power increases)
Vertex distance (bigger effect as VD increases) For example, if spectacle power is -2.50D, the contact lens power must also be
-2.50D. This would be a proof to the practitioner that the tear lens power is zero.
For example,
If the contact lens BVP is -3.00D If the contact lens power is -2.00D
-5.00D for spectacles -4.75D for contact lenses
and the spectacle BVP is -2.50D and the spectacle BVP is -2.50D
-7.00D for spectacles -6.50D for contact lenses
then the tear lens power is +0.50D then the tear lens power is -0.50D
+4.00 for spectacles +4.25D for contact lenses
Then the fitting of the lens is too steep. Then the fitting of the lens is too flat.
+9.00D for spectacles +10.00D for contact lenses
Change the flatter base curve Change to a steeper base curve
b. Magnification / Minification
Optical advantages of Contact Lenses: Optical disadvantages of Contact Lenses:
Minus lenses (for myopic people) tend to minimise the objects seen
1. No astigmatism of oblique rays 1. Lens decentration produces ghosting
- So a high powered myopic person would tend to see a larger object when they switch from spectacles to
2. No distortion 2. Moving lenses may produce visual disturbances
contact lenses
3. No chromatic aberration
Plus lenses (for hyperopic people) tend to magnify the objects seen
4. No limitations in the field of view
- So a high powered hyperpic person would tend to see a smaller object when they switch from spectacles
5. No spectacle frame diplopia
to contact lenses

11 12
Contact Lenses

History of contact lenses

1508 Leonardo Da Vinci described it

1938 Muller & Obrig developed first scleral contact lenses (PMMA)
1948 Kevin Touhy developed first corneal contact lenses (PMMA)
1950's Otto Wichterle developed first soft contact lenses (HEMA)
1980's RGP & Soft torics lenses introduced
1999 Silicone Hydrogel lenses introduced

First envisioned by Da Vinci

The theory behind a contact lens has been attributed to Leonardo da Vinci, who, in 1508, first described a lens
that would affect optics when placed against the eye.

History First used for eye protection

Over 300 years later, English astronomer John Herschel described a glass contact lens, which matched the shape
of the eye. In 1887, F.E. Muller fitted a blown glass lens for a patient whose eyelids had been surgically removed.

and
The lens was used to protect the eye and keep it moist. The patient wore this lens for 20 years.

Scleral lenses for vision correction

In 1888, A.E. Fick described the first contact lens for vision correction. These glass scleral lenses were 20 to 30mm

Types of
in diameter, and about 1- 2mm in thickness. Unfortunately, lens wear often caused corneal edema, resulting in
blurred vision and discomfort after only a few hours.

First corneal contact lens and first plastic scleral lens

Contact Lens Working independently of Fick, E. Kalt designed and fit the first glass corneal contact lenses, based upon the
measurement of the corneal curvature. In 1938, Muller and Obrig developed the first scleral contact lens made
entirely of plastic - a polymethyl methacrylate (PMMA) resin originally used in the production of aircraft canopies.

PMMA sets hard lens standard

Kevin Touhy developed the first plastic corneal lens in 1947, using PMMA. He established the need for tear
exchange under the lens for oxygen, setting the standard for hard lens fitting. PMMA lenses were widely
prescribed until the 70s, and are still fit in many countries today.

Development of HEMA and Bausch and Lomb acquires the rights

In the late 1950s, Otto Wichterle of Czechloslovakia developed the hydrogel polymer, hydroxyethyl methacrylate
(HEMA), which formed the basis for soft contact lenses. HEMA absorbs water to become soft and flexible, while
permitting the transmission of oxygen. In the 60s, Bausch & Lomb acquired the rights to HEMA as well as the
process of spincasting. In 1971, B&L became the first manufacturer to distribute and market soft contact lenses.

Early lenses and continued refinements

Early lenses were relatively thick and often caused visual distortion. Over the years, continual refinements in soft
contact lens design and manufacturing have led to improved comfort and performance. HEMA remains the basis
of most soft lens materials, although different manufacturers use several variations.

13
Soft lenses: Some improvements 1. Rigid Gas Permeable Contact Lenses
The first soft lenses were used to correct mild myopia and hyperopia in a limited range of powers. Today, they
also are prescribed to correct astigmatism and presbyopia, as well as enhance or change the color of the eye. Smaller in size than soft contact lenses
Soft contact lenses, which are considered medical devices by the FDA, can be used to correct medical conditions. Not as popular as soft contact lenses
For example, aphakic lenses for vision following cataract removal, bandage lenses are designed to protect the eye Not as comfortable, initially as soft contact lenses
and enhance healing, and some practitioners use hydrogel lenses to deliver drugs to the eye. Can “pop-out” if the lenses are not fitted well.
Usually used in special corneal conditions like keratoconus, high corneal astigmatism and irregular corneal
astigmatism.
Uses of Contact lenses
Advantages of RGP contact lenses
The 3 main uses for contact lenses are:- Crisp, consistent visual acuity
1. Optical Improved corneal physiology (higher oxygen transmission)
2. Therapeutic Ability to mask corneal astigmatism and can correct if fitted in a specific way.
3. Cosmetic Generally last longer than soft lenses
Lens care easy and economical (more durable and lower level of deposits)
1. Contact lenses for optical applications Excellent long-term comfort (minimal problems long term)
Contact lenses can be used to correct any form of ametropia, be it myopia, hyperopia, astigmatism, presbyopia
and aphakia. Contact lenses have many advantages over spectacles because they:- Disadvantages of RGP contact lenses
Provide wider field of peripheral vision Initial comfort is better with soft contact lenses
Provide distortion free vision Adaptation time is longer than for soft lenses (maybe up to 2 weeks or more)
More convenient for people with active lifestyle like sports Requires more time/expertise to fit in some cases
Are comfortable Initial cost per unit is higher/per unit cost is more than for soft lenses
Can correct most prescriptions including astigmatism
Can be worn for extended hours with high Dk/t lenses
2. Soft Contact Lenses
2. Contact lenses for therapeutic applications

Soft contact lenses are the most popular type of contact lenses worn nowadays.
Bandage contact lenses - high Dk/t (EW) used as a bandage over cornea to promote healing
Mostly used by Ophthalmologists or hospitals
Advantages of soft contact lenses
Better initial comfort
3. Contact lenses for cosmetic applications
Faster adaptation time
Enhanced natural appearance
Can be worn when participating in contact sports
Opaque / tinted lenses worn to change the colour of the eyes for cosmetic purpose
Can correct astigmatism. Spherical soft lenses can mask minimal astigmatism.
Toric soft contact lenses can correct significant amount of astigmatism.
Less chances of dust particles getting trapped between lens and cornea.
Disposable lens options available that are healthier & more hygienic
Classification of current contact lenses available in the market Less chair time (easier to fit)
Suitable for most patients
There are 2 main types of contact lenses available in the market. These are:-

1. Rigid Gas Permeable contact lenses Disadvantages of soft contact lens

2. Soft contact lenses (hydrogel and silicone hydrogel contact lenses) Care regimen very important
Lens dryness possible

14 15
Silicone hydrogel Contact Lenses 3. Disposable contact lenses: It refers to a schedule of weekly or fortnightly lens replacement while using a care
regimen, which does not usually include enzymatic cleaning.
Combination of silicone & hydrogel material together
Hydrogel lens characteristics: highly wettable, comfortable, adequate movement 4. Daily Disposable contact lenses: These lenses are discarded after each period of wear, usually one day. No lens
Silicone lens characteristics: high oxygen permeability care is required. These are true disposable lenses as they are single use products.
E.g. B&L Soflens Daily Disposable
Silicone hydrogel lenses differ from each other in the amount of silicone and hydrogel in their material.
Higher amount of silicone in the silicone hydrogel lenses would result in the lower amount of hydrogel content.
This would result in lower water content in the lens but this would increase the oxygen transmissibility (Dk/t) Advantages of Disposable contact lenses
of the Silicone hydrogel lens.
Less care regimen required
For example, Healthier & more hygienic
Water content of Purevision contact lenses is 36%, the Dk/t of the lens is 110 Comfortable and convenient
Water content of Acuvue Advance contact lenses is 47%, the Dk/t of the lens is 85.

Disadvantages of Disposable contact lenses

Wear Modalities of contact lenses Important to ensure that patients follow the recommended disposal period

The cornea requires sufficient amount of oxygen in order to maintain its normal physiological need. The oxygen
from the atmosphere dissolves into the tears and is consumed by the cornea. When a contact lens is worn, the
lens itself becomes a physical barrier blocking some of the oxygen supply to the cornea. As a result, it is
important that contact lens materials are permeable to oxygen.

The following are the most commonly used terminology in describing the permeability of the materials or
contact lenses to oxygen:

Daily Wear - Contact lenses are worn during the day and removed before sleeping

Flexible wear - Daily wear schedule interspersed with occasional overnight wear

Extended Wear - Contact lenses are worn uninterrupted upto 7 days and 6 nights before removal

Continous Wear - Contact lenses can be worn uninterrupted upto 30 days and 29 nights before removal

Classification of contact lenses based on replacement schedule

Based on their replacement schedule, contact lenses are classified as:-

1. Conventional lenses (Traditional lenses): These are lenses which are not replaced until their expected life span
has been reached or their usefulness has been terminated by damage or deposits. The lens replacement usually
happens at 12 months. Eg. B&L Optima 38, B/U/HO series

2. Frequent replacement (Planned replacement): It refers to a 1 to 3 month replacement schedule of lens

replacement using a complete care regimen. E.g. Soflens 38, Soflens 59

16 17
Oxygen requirement for contact lens wearing

The amount of oxygen transmitted by a contact lens is important for eye health. The amount of oxygen that
passes through a contact lens depends on the
1. Water content
2. Center thickness.

1. Water content

The water content of a lens is the amount of fluid taken up by a

contact lens material.

The current contact lens material has water content that ranges from 38% to 79%
Contact lenses with water content less than 50% is called low water content lenses. The contact lenses with
water content of more than 50% are called high water content lenses.

Higher water materials must be made thicker, for stability.

Parameters Higher water materials allow more oxygen through them than low water materials. The amount of oxygen
allowed through a material is called the material's Oxygen Permeability.

of 2. Centre thickness

Centre thickness is a feature of the lens design. The centre thickness of minus lenses typically ranges from
0.035mm to 0.14mm. Thickness of the lens is always given by the short abbreviation of t or L.

Contact Lenses Oxygen permeability (Dk)

Oxygen Permeability is termed as "Dk".

D = diffusion coefficient (measurement of how fast dissolved molecules of

oxygen move {diffuse} through the material)

k = solubility coefficient (measurement of oxygen molecules dissolved in the material)

Dk is a physical property of a contact lens material. It basically describes the ability of the material to
transfer oxygen.

Dk does not give you any idea of the actual oxygen flow through a real contact lens because the amount of
oxygen flow will also be determined by the thickness of the lens.

One specific material will have one specific Dk value at a given temperature. Increasing the water content of a
contact lens material will increase the Dk value. That is why higher water content hydrogel materials usually
have higher Dk value.

18
Oxygen transmissibility Lens Diameter / Total Diameter (LD / TD)
Overall lens diameter
Oxygen Transmissibility is termed as "Dk/t". More popular LD should be 14.00mm
Dk/t is the Dk of the material divided by the centre thickness (t) of the lens. This number is a more
meaningful indication of oxygen supply than Dk. Base Curve (BC)
The radii of curvature / base curve of the lens at the optic zone area
Oxygen Transmissibility of a contact lens represents the actual oxygen flow through a finished contact lens. Common base curve of a 14.00mm diameter lens is 8.60 and 8.70mm

Practitioners should also be aware that some researchers would use Dk/t while others will use Dk/L. Optic Zone Diameter (OZ)
Both mean the same thing. The section where all the power of the lens is situated (the size of the area for vision)
Most popular OZ size is around 8 - 10 mm
The value for Dk/t will decrease with increasing thickness of the lens. But Dk/t value will increase when the The optic zone should not be too small as this would hinder the vision when the pupil size increases during
thickness is decreased. low lighting condition
The optic zone should not be too big as the thickness of the higher-powered lens would affect the comfort
The thinner a lens, the more oxygen can pass through it. The flow of oxygen from the front to the back surface level of wear.
of a contact lens is called Oxygen Transmissibility.
Centre Thickness (c.t.)
Hence, to evaluate the oxygen performance of a lens, centre thickness and water content must be considered. Refers to the thickness of the lens at the geometric centre
That is why a thin low water lens may let the same amount of oxygen through (i.e. have the same Dk/L) as a Contact lens with center thickness of 0.035mm is regarded to be the thinnest lens in the world.
thick high water lens.

For daily wear, the recommended Dk / t of a contact lens is 24 (EOP > 9.9%). For extended wear, the
recommended Dk / t value of the contact lens is 87 (EOP > 17.9%). As most current hydrogel or soft contact
lenses has Dk / t of around 30, they are not recommended to be worn to sleep. For any contact lens user who
intent to sleep with their lenses, they would need to wear a contact lenses with a Dk/t of 87 and above.
For e.g. B&L Purevision contact lenses with Dk/t of 110.

Equivalent Oxygen Percentage (EOP) c.t.

Equivalent oxygen percentage refers to the concentration of oxygen at the surface of the cornea under a
LD
OZ BC
contact lens.

Oxygen Flux
Defined as the amount of oxygen that passes through a specified area of a contact lens per unit time
Unit: µl O2/cm2 x minute

Common Soft Contact Lens Parameters

The lens design refers to the shape, size, and thickness profile of the lens. These properties, in combination with
the lens material, must allow comfort, vision and health for the wearer.

Lens Design
Front Surface Design
Commonly Bicurve
Back surface design
Monocurve
Bicurve
Blended multiple spherical curve
Aspheric

19 20
Materials of soft contact lenses

Hydroxy-Ethyl Methacrylate (HEMA) or more popularly known as Polymacon was developed by Otto Wichterle
and Drahoslav Lim in 1950s. This material is actually very closely related to PMMA. The difference is that HEMA
has higher water content than PMMA, which results in Polymacon having a higher oxygen permeability (Dk)
than PMMA.

Various methods have been used to improve on the HEMA material. Among the ways to do so is to add various
materials to the HEMA material. The addition of new materials has changed HEMA in terms of

a. Water content
b. Ionicity
c. Oxygen permeability

Contact Lens The new material would usually have different physical characteristics. Some materials may be more susceptible
to the ocular and atmospheric environment.

Among the chemicals that has been added to improve HEMA include :

Materials a. Polyvinyl pyrrolidone (PVP) mainly to increase the water content

b. Methacrylic acid to make the lens more ionic

and Classification of soft contact lens material

The US FDA (United States Food and Drug Administration) classifies soft contact lenses materials into 4 main

Manufacturing groups.

The classification is based on the materials water content (low or high water content) and the ionicity (ionic
or non-ionic). Lenses from the same class of materials have similar properties.

Techniques Low water content soft contact lens material (less than 50% water content)

Adequate physiological response

Low protein deposition
High tensile strength
Compatible with all lens care systems
Can be manufactured using many methods like lathe-cut, RPIII, spincast or cast mold processes

High water content soft contact lens materials (more than 50% water content)

Moderate oxygen permeability

Lower tensile strength
Tend to absorb more protein deposit than low water content lenses
Greater dehydration potential
May discolor easier

21
Ionicity of soft contact lens materials Manufacturing Methods of Soft Contact Lens
Ionic lens surface is 'charged' (usually negative)
Four manufacturing methods are commonly used to produce soft lenses. Each produces lenses with slightly
Non - Ionic - lens surface is 'neutrally charged' or no charge
different performance characteristics.
The main reason to have an ionic surface contact lenses is to attract water into lens, thus older high water
1. Cast-Molding
content are ionic.
2. Reverse Process III
3. Spincast (Process I)
Advantage of having ionic lens 4. Lathe-Cut
- Easier to wet the contact lens

Disadvantage of having an ionic surface 1. Dry Cast Molding

- Deposits may adhere to the lens more readily

A lens is formed between two plastic molds. These molds

The groups and their features are listed in the table below: are manufactured with the precise dimensions and surface
geometry necessary to mold a lens without additional
lathing or polishing.
GROUP 1 GROUP 2 GROUP 3 GROUP 4
- Low Water - High Water - Low Water - High Water
- Non-Ionic - Non-Ionic - Ionic - Ionic
- Lowest Protein - Lower Protein - Lower Protein - Highest Protein
Cast Mold Manufacturing Process
deposition deposition deposition deposition
The four steps in the process include:
eg. eg. eg. eg.
B&L Soflens 38 B&L Soflens 59 B&L PureVision J&J Acuvue lenses 1. Mold production
B&L Optima 38 B&L Soflens Toric Ciba Vision Focus 2. Lens casting
B&L Soflens Daily lenses 3. Lens hydration,
Disposable 4. Lens inspection/packaging

The anterior and posterior molds are produced using high precision optical tools.

a. The anterior mold is injected with liquid monomer

Modulus of elasticity b. The anterior mold is then capped with the posterior mold.
c. The capped assembly then travels through a series of ultra-violet lights for the liquid monomers to
The modulus of elasticity shows a material’s ability to keep its shape while under stress; the higher the become harden.
value, the greater the resistance to stress. Materials with a high modulus of elasticity can be easier to d. Once the material hardens, the posterior mold is removed (decapped) and discarded.
handle. Materials with a low modulus of elasticity will quickly conform to the shape of the eye e. The anterior mold contains the hardened lens, which moves on to hydration.

Wettability The lens can be hydrated directly from the mold (polymacon), or dry released then hydrated (alphafilcon A).
The lenses are then inspected and packaged into a blister package. The lidstock on the blister will then be
Wettability is specified by the contact angle (also known as wetting angle) formed by a drop of water, labeled with the lot number, power, and expiration date of the lens.
saline solution or tears on the surface of the material. The more wettable surface has a smaller contact
angle (x<90°) so that the tears spread evenly over the lens surface to provide a stable tear film. The lenses are then autoclaved to ensure the product is sterilized.

Examples of cast mold lenses are B&L Soflens 59, B&L Soflens 38, B&L Soflens Toric, B&L Soflens MultiFocal
and B& L Purevision.

22 23
Advantages of Cast Molding d. The casting is transferred to a computerized lathe that cuts
the proper geometry for the posterior surface of the lens

- Produces finished lenses without the need to polish the lens (as in spincasting) or back surface polish e. The lens is then polished in a two-stage process to obtain a
(as in RPIII or double lathing). smooth central surface and rounded posterior edge following
the lathe-cut process
- Produces a high quality lens at a lower cost than any other process.
f. At this point, the lens is placed in a warm hydration chamber
- Has very consistent edges and smooth surface characteristics and removed from the mold.

- Produces a consistently high quality lens with excellent visual acuity and comfort. (Highest reproducability)
As with all Bausch & Lomb lenses, the Reverse Process III lens is
subjected to a series of quality assurance and sterilization
2. Reverse Process III procedures.

Bausch & Lomb has developed a unique process that combines the best of spincasting and lathe cutting called
Reverse Process III. With this process, the anterior surface of the lens is produced with spincast technique, and
lathe cutting produces the posterior surface of the lens. Advantages of Reverse Process III

- The spincast anterior lens surface is very smooth, giving the lens precise optical quality, excellent
Lathe-Tool comfort & an ideal edge profile.
Polisher

- The lathe-cut posterior surface gives optimal on-eye movement & centration.
Step Step Step

1 3 5 - Lathe cut allows better control of the lens thickness profiles, so the lens will be easier to handle
relative to spincast lens, especially in low lens powers.
Inject Lathe Polish
Monomer Posterior Edge
UV Surface

Polisher 3. Spincasting
Step
Step Step
6 Bausch & Lomb manufactured the world's first soft contact lens using spincasting. Spincasting is based on the
2 4 Finished
Lens simple concept of changing spinning liquid into a solid contact lenses. Example of a spincast lens is
B&L series (B,U & HO) and Optima 38 contact lenses.
Polymerize Polish Optic Zone

UV

Polisher
Reverse Process III Manufacturing Process

a. The mold is placed in a spinning cavity Finished

Lens
b. It is then injected with a liquid monomer
Monomer Edging
c. Using ultraviolet light, the material is Injection Polymerization
polymerized and hardened, and a
casting is produced

24 25
Spincast Manufacturing Process 4. Lathe Cutting

a. Lens production begins when liquid monomer is injected A diamond knife is used to cut both surface of the lens in order to get the final lens. Traditional PMMA and
into the spinning mold (lens geometry is determined by rigid gas permeable lenses, as well as some soft contact lenses, are produced using lathe cutting. This
spin speed and volume of material injected). process is often referred to as double lathing, since both lens surfaces undergo the cutting procedure.
Example of a lathe cut lens is B&L Optima Toric contact lenses.
Spin speed also determines the final lens power (the
faster the speed, the higher the minus power of the Lathe Cut Manufacturing Process
contact lenses).

The center thickness of the lens is determined by the a. Lathe-cut process begins with the material in the form of a
volume of monomer injected into the mold, the greater button (the button is typically made by molding liquid
the volume, the thicker the lens. monomer into a tube which is then cut into many buttons

b. The button is then placed in a diamond-tool lathe and rotated

b. After spinning, the lens form stabilizes and is polymerized at a very high speed.
(hardened) under a series of ultraviolet lights.
C. The diamond-tool cuts away the polymer and produces precise
lens surface curvatures and geometry. The concave surface of
c. Next, the periphery of the lens is buffed and polished to the lens is then polished.
produce a smooth surface
d. The lens is placed on another lathe, where the convex anterior
surface is cut and polished to the exact curvature required for
proper optical power
d. The lens is then hydrated in a sterile, hot water bath.
A polymacon (HEMA) lens absorbs about 38.6% of its e. Edge polishing is then performed using conventional hard lens
weight in water, and expands in volume techniques.
approximately 12%.
f. Once lathing is completed, the lens is hydrated in saline to make
it flexible. In its final form, the lens is measured and verified for accuracy, inspected for cosmetic defects,
labeled, sterilized, and tested for sterility.
Advantages of Spincasting
Advantages of Lathe Cutting
- Spincast lenses have tapered edge profiles and smooth surfaces that enhance comfort during lens wear.

- These lenses exhibit minimal lens movement on the eye because the back aspherical surface of the lens - Lathe-cut lens are usually thicker (when compared with spincast lenses) and therefore, they are relatively
matches well with the aspheric profile of the cornea, yet still produce dynamic tearfilm. easier to handle
- Lathe-cut lens has a better lens movement and centration when compared with spin-cast lens
- It is easy to fit because it has only one base curve.
Disadvantages of Lathe Cutting

Disadvantages of Spincasting - Compared with cast molding and spincasting, it is time consuming and labor intensive. It takes
approximately 30 minutes to complete the manufacturing process, resulting in lens production costs that
- In some patients, the spincast lens may decenter slightly. This does not affect visual acuity or physiological are four to ten times more expensive than spincasting.
performance because of the lens has a large optic zone. However, some practitioners consider this to be an - Lathe cut lenses are difficult to reproduce, because each lens is individually made. To minimize these
undesirable characteristic. variations most manufacturers use very simple designs, or introduce computerized procedures for lens
production.
- Because spincast lenses are thin and flexible, they can be more difficult to handle, especially in low powers. - Lathe-cut lens usually have more than 1 base curve and therefore, it would require trial fitting in order to
determine the final base curve during trial fitting.

26 27
Optometric Instruments

To fully understand the optometric work, one has to be familiar with the various instruments that are available
to the practitioner for use.

The instruments that are used in Optometry practice are:-

1. Retinoscope
2. Autorefractor
3. Phoropter
4. Trial Frame
5. Ophthalmoscope
6. Slit Lamp biomicroscope
7. Keratometer
8. Autokeratometer

Instrumentation
9. Radiuscope
10. Lensometer
11. Cornea Topographer
12. Other optometric instruments

for 1. Retinoscope (Objective Refraction)

The retinoscope is used to determine the refractive status of the eye during objective refraction.

Contact Lens 1. The practitioner's retinoscope must be at arm's length away from the eye

2. A red reflex is seen in the patient's pupil by the clinician when he shines the light towards the pupil (much

Fitting
like the "red-eye" seen in photographs taken with a flash)

3. By viewing the behaviour of this red reflex and altering the power of refractor lenses in front of the patient's
eye, the skilled practitioner can objectively determine the patient's refractive state. The evaluation is not
dependent on patient’s responses.

The retinoscope is an ideal instrument for prescribing correction in small children or babies, deaf patients, or
patients unable to verbally communicate. Practitioners can also use this instrument to detect deposits on the
surface of a contact lens or view the location of the near portion of a segmented bifocal contact lens in distance
and near gaze.

Advantages of using Retinoscope

A good starting point
Reasonably cheap and small
Can give information just by looking at reflex (amount of prescription / cataract)

Disadvantages of using Retinoscope

Skill required to master the instrument
Has to control fixation / accommodation of the patient
Working distance (distance between retinoscope and the patient's eyes) needs to be considered

28
2. Autorefractor (Objective Refraction) The refractor has plus and minus power spherical lenses for correction of simple hyperopia and myopia
respectively, as well as cylindrical lenses for the correction of astigmatism. The plus and minus power lenses are
This instrument automatically evaluates the patient's refractive error during objective refraction by electronically also used for performing an overrefraction during contact lens fittings.
assessing the reflection of light from the back of the eye.
A variety of prisms, filters, and other optical devices within the instrument assist the practitioner in assessing the
1. The practitioner can align the instrument by looking patient's vision.
at the mini monitor on the autorefractor.
Advantages of using a Phoropter
2. Once the eye is focused and centered on the screen, Convenient
the operator presses a button, and the readout Can provide multi-tests
displays the estimated prescription. Simple to use

3. An average of 3 readings are usually taken as a guide Disadvantages of using a Phoropter

before proceeding to subjective refraction. Must control patient position
Field of view is restricted
Most units have the capability to make the adjustment between contact lens prescriptions and spectacle Phoropter has to be cleaned and service periodically
prescriptions, compensating for different vertex distances (how far the lens is placed from the eye). This is an Quite expensive
objective evaluation, since the patient looks at a picture on the screen and is not required to responds verbally.

Disorders, such as corneal defects or cataracts, can lead to false readings, because these conditions affect the quality 4. Trial Frame
of the reflected image Instead of using the phoropter, most practitioners use the trial frame.

Advantages of using Autorefractor Advantages of using the Trial frame Disadvantages of using a Trial frame
A quick and easy starting point for objective refraction Small and cheap to use Less convenient than a phoropter
Fixation of the patients eye is enclosed Field of view is similar to spectacles Less comfortable specially if trial lenses are made of glass
Objective refraction Patient position is not important

Disadvantages of using Autorefractor

An expensive instrument that does take up some space 5. Ophthalmoscope
Calibration of the instrument extremely important and must be done periodically
Accommodation (of children) is a constant problem
Fixation could lead to accommodation

3. Refractor / Phoropter (Subjective Refraction)

The refractor (often referred to by the name phoropter)

provides a subjective assessment of the patient's
refractive error.

1. The phoropter is placed in front of the patient, centered over the patient's eyes.
The ophthalmoscope is used to view the retina and blood vessels of the eye, as well as other internal ocular
2. A variety of trial lenses are "dialed in" to determine the one, which provides the clearest vision, based on structures. It is similar to a retinoscope in that it allows the viewing of the red reflex from the retina, but rather
the subjective response of the patient. The procedure used in determining the best lenses is called refraction. than viewing the reflex from a distance, the ophthalmoscope is used as close to the eye as is physically possible,
and has a series of built-in lenses that allow the clinician to focus on the various internal structures of the eye.

29 30
Physicians through an ophthalmoscopic examination first observe many ocular and systemic diseases. Using the Slit Lamp
Conditions that affect the retina include hypertension, diabetes, AIDS, and kidney disease.
1. The practitioner must first setup the Slit Lamp, making sure that the instrument is in perfect working condition.
There are 2 types of ophthalmoscope There are locking devices on the Slit Lamp, which the practitioner must be aware of.
a. Direct Ophthalmoscope
b. Indirect Ophthalmoscope 2. The practitioner does adjustment of the pupillary distance of the observation system. The practitioner must
also ensure that the Slit Lamp’s illumination system is in focus.
a. Direct Ophthalmoscope
3. The practitioner will then ask the patient to put the chin on the chin rest. The practitioner can then align the
Direct Ophthalmoscopy involves the usage of a hand held ophthalmoscope. In the direct ophthalmoscope, outer canthi of the patient's eye with the marker line on the mechanical support.
practitioner can view the ocular structures.

Direct Ophthalmoscope
- requires no pupil dilation
- give a magnified view of the retina, optic disc and the blood vessels (which is useful in the examination of The outer canthi of
the macular and the optic nerve head) the eye is aligned to
- cannot examine the periphery of the retina the marker on the
Slit Lamp
b. Indirect Ophthalmoscope

Indirect Ophthalmoscope involves a usage of a head gear which contains the prisms . The practitioner would have
to hold a +13D lens in front of the patient's eye to view the retina.

Indirect Ophthalmoscope
- will require the pupil to be dilated
4. With one hand, practitioner holds the illumination
- will not give a magnified view of the retina
adjustment knob to control the width of the slit
- give a wider view of the retina (up to Ora Serrata)
beam. The other hand is to hold the handle of the
- able to provide a stereoscopic (3D) image
observation system to maneuver it. Practitioner
- extremely useful in thorough exam of the retina (esp in cases of retinal degeneration or detachment)
ensures that the illumination beam is approx.
600 temporal from the observation system.
8. Slit Lamp / Biomicroscope
5. Focus a slit or a section of light onto the cornea. The practitioner can then view through the observation
system using the lowest magnification available from the Slit Lamp. The practitioner can then change the
For the contact lens fitter, the Slit Lamp Biomicroscope, or Slit Lamp, is
width of the illumination by changing the width of the slit of the light in the illumination system and also
generally considered the most important instrument in the examination room.
the amount of magnification of the observation system.
The Slit Lamp Biomicroscope consists of 3 parts.
Various beam widths and types of illumination can be used to view different aspects of the ocular structures.
In addition, all slit lamps have color filters, which enhance the view of different eye structures.
1. The mechanical support (where the patient can rest his forehead in a
correct manner)
The cobalt blue illumination filter is used during fluorescein evaluation to help determine the health of the
epithelium and proper rigid contact lens fit. A yellow filter can be placed in front of the microscope to enhance
2. The illumination system (where the light illuminate the ocular structures)
the fluorescein image.
3. The observation system (where the practitioner can view the ocular
The Slit Lamp is suitable for viewing the anterior structures of the eye, including the lids, tearfilm, cornea, anterior
structures through various magnification)
chamber (angle), iris, and crystalline lens. Additional lenses are necessary for viewing of the retina, vitreous body,
or optic nerve.

31 32
B. Direct illumination
Illuminations that can be used with the Slit Lamp
Direct illumination is the second type of illumination that
There are various types of illumination that can be used with the Slit Lamp. This is usually done by altering the the practitioner uses to evaluate the eye.
amount of light falling on to the corneal structures and changing the magnification of the observation system.
Among the types of illumination that are usually used with the Slit Lamp are:- Direct illumination is usually used to view a certain section
of the eye that the practitioner wants to observe. Observation
a. Diffuse illumination & illumination systems are focused at the same point.
b. Direct illumination
c. Indirect illumination In direct illumination,
d. Retro illumination - The width of the slit beam of the illumination system
e. Sclerotic scatter is reduced
f. Specular reflection - The magnification of the observation system is then
g. Van Herick Method increased to the practitioner’s requirement
- Variation in the width and/or height of the light source
will give the following:-
a. Diffuse illumination a. Optic Section (narrow, focused light)
b. Parellelepiped (wider, focused light)
Diffuse illumination is usually the first step that c. Conical beam (small, circular light)
practitioners used to view the external structure
of the eye. Direct illumination (narrow slit) showing
RGP lens scratched surface
c. Indirect illumination

The indirect illumination is another type of Slit Lamp observation that the practitioner can use to evaluate the eye.
In diffuse illumination, In indirect illumination, the observation system and the illumination system is not focused on to the same point.
- The slit beam of the illumination system is usually large & combines with low magnification of the
observation system (450 angle between light and microscope). So instead of focusing the slit beam onto the structures of the eye that the practitioner wants to observe, the
- Variable illumination (low to high) practitioner would focus the beam on the other parts of the external eye while viewing another part of the eye
- The practitioner would view the whole eye to look for any interesting part of the eye. through the observation system.

Among the ocular problems that can be viewed with diffuse illumination are:- The practitioner can change the focus of the slit beam by decoupling or offsetting the slitbeam to focus on the
- Lid deformities pupil. The practitioner can change the width of slit and the magnification to view the ocular structures better.
- Lid margin problems/infection Indirect illumination is best used to observe any corneal epithelial defect and epithelial vesicle
- Tear prism
- Pterygium
- Pinguecala d. Retroillumination
- Conjunctivitis
- Cataract In Retro illumination the object of regard is illuminated by
- The surface quality of the reflected light.
contact lens Retro illumination is similar to indirect illumination as the
practitioner focuses the slit beam onto an area while
observing another specific area. The difference
between retro illumination and indirect illumination is the
Diffuse illumination showing a peripheral Diffuse illumination showing
corneal ulcer under fluorescein staining subconjunctival haemorrhage slit beam is focused on the iris in the retro while in indirect
and blue light of the Slit Lamp illumination; the slit beam is focused on the pupil.

33 34
Retro illumination is best used to observe 6. Keratometer
- Epithelial oedema
- Blood vessels on the cornea The function of a keratometer is to measure the
- Microcysts Central corneal curvature and toricity (amount of astigmatism of the cornea)
- Crystalline lens opacities Corneal shape
- Contact lens deposits Corneal apex position
Corneal regularity
Assess contact lens surface (wetting, deposits, flexure)
e. Sclerotic Scatter Lens verification (rigid lens BCOR)

In sclerotic scatter, a slit of light is focused on the limbus. The keratometer measures the radius of curvature over the
This will cause an internal reflection within the cornea. central three millimeters of the cornea (only 6% of the average
corneal area).
A normal cornea would appear to be dark with a ring of light
adjacent to it. The radius readings provided by a keratometer can be in
millimeters or in diopters.
Sclerotic scatter is especially useful in viewing for any opacity The image seen via a keratometer is called mire.
of the cornea, corneal oedema and foreign bodies in the cornea. Sclerotic scatter showing infiltrative keratitis
The keratometer also measures the amount of astigmatism or the corneal toricity.

f. Specular Reflection For example,

Readings from a keratometer 42.50D @ 180 (7.94mm @ 180)
In specular reflection, the angle of the incident light is equal to 44.00D @ 90 (7.67mm @ 90)
the angle of reflected light. Total amount of corneal astigmatism -1.50D @ 180 (0.27mm @ 180)

Specular reflection is particularly useful in viewing the endothelial The measurement of corneal radius provides information to the practitioner for
cell layer, crystalline lens layering, tearfilm debris and tearfilm - Types of contact lens to be prescribed
lipid layer. It is a monocular phenomenon. - Selection of the initial contact lens base curve to choose for the trial lens fitting.

G. Van Herick Method Specular reflection of surface of soft contact lens A. Types of contact lens to be chosen
a. If the corneal astigmatism is the SAME as the prescription astigmatism, then the practitioner can choose
The Van Herick method is used to view the anterior chamber angle. either Soft Toric contact lens or spherical RGP
b. If the corneal astigmatism is NOT THE SAME as the prescription astigmatism, then the practitioner can
A narrow slit of beam is initially focused on the limbus. choose either Soft Toric contact lens or toric RGP
The practitioner then moves the slit on to the cornea so
that a corneal section is seen. b. Selection of initial contact lenses
The practitioner must understand that the average corneal curvature flattens from the center to the periphery
A careful assessment of the angle of the anterior chamber is then of the cornea.
observed by looking at the ratio between the distance from the
iris to the back of the cornea and the thickness of the cornea. Keratometer readings are critical for the RGP lens fitter. The practitioner would usually choose the flatter meridian
as a starting point, especially when fitting RGP contact lenses.
If the ratio of the aqueous interval to corneal thickness is However, unlike RGP lenses which fit over the central 9mm of the cornea, soft lenses actually fit the entire cornea
1 : 1 (Grade 4) means that the angle is wide open Van Herick method showing small angle and over the limbal area.
1 : 2(1/2)(Grade 3) anterior chamber
1 : 3(1/3)(Grade 2) should b viewed with suspicion The keratometry information is, at best, only a guide for the soft lens fitter. To ensure a proper fit, final soft lens
1 : 4 (1/4)(Grade 1) extremely narrow anterior chamber angle selection is made on the basis of lens movement, centration, comfort, and vision.

35 36
c. Other uses of Keratometer 10. Lensometer / Focimeter

The practitioner can also use the keratometer to A lensometer is used to measure the power of a contact lens or a pair
- Assess corneal health (by evaluating the quality of the reflected images). of glasses. This instrument measures the power in sphere, cylinder,
- Measure of base curve of RGP lens. and axis form.
- Measure of base curve of soft contact lens
A trained observer can also use the lensometer to evaluate the optical
Assessment of Corneal Health quality of a lens by examining the quality of the focused image.
Any corneal distortion may indicate overwear of lenses, corneal swelling, or corneal disease. This instrument is also called a vertometer, or focimeter

If the mire image is clear, then it is indicative of

Good tear film quality (can be used as a Tear Break Up Time assessment)
Good optical qualities of the corneal surface and integrity 11. Corneal Topographer (Corneal Surface Mapping)

If the mire image is poor or distorted, then it is indicative of One of the drawbacks to using keratometry to measure corneal curvature is that it only provides information of
Poor tear film quality the central 3mm of the corneal surface. However, the shape of the entire corneal surface, including the limbal
Possible corneal surface irregularity (keratoconus) junction area, affects the fitting performance of soft contact lenses.
Deposits / non-wetting of the contact lenses
Corneal topographers also known as corneal mapping systems
Measurement of base curve of RGP lens provide information about the corneal shape over the central
With a special attachment of a prism to the keratometer, a measurement of RGP lens base curve can be obtained. 8 to 10mm of the corneal surface, and some of the newer
instruments can provide information out to the limbal
Measurement of base curve of soft contact lens region.
With a special attachment of a prism and wet cell containing saline, the keratometer can then be used to
measure the soft contact lens base curve.

Corneal Topographers
9. Radiuscope
- Use a series of ring targets to measure the curvature of the cornea at points over a large portion of the
The radisucope is an instrument commonly used to measure the base curve of the rigid gas permeable contact lens. corneal surface instantaneously, using the same optical concepts as the keratometer

The method of using the radiuscope to measure the center radius of the RGP lens is as follows: - A video-capture system linked to a desktop computer allows real-time analysis of this data.
a. A drop of saline or distilled water is added to the well of the radiuscope lens holder.
b. A clean dry RGP lens is then added to the lens holder - Corneal surface information is typically presented as corneal "maps", which look very similar to
c. Ensure the image of the instrument light is at the center topographical land maps used to show mountains and valleys.
d. Turn the measurement knob until the first spoke image is seen (press the
radiuscope knob to zero) - Colors on the corneal topographical maps represent corneal curvatures at those regions of the cornea, and
e. Then turn the knob until the second spoke image is seen (repeat this to get the clearly show changes in corneal shape due to astigmatism, or pathological conditions such as keratoconus.
average of base curve RGP lens)
- Although these systems are becoming more popular in optometric offices, they are not necessary for
The method of using the radiuscope to measure the peripheral radius of the RGP lens is the same as measurement successful contact lens fitting, and in fact, are most useful at detecting patients with corneal diseases such
of center radius. The difference is that the practitioner needs to tilt the lens to one side. as keratoconus, corneal dystrophies, or for determining how best to fit contact lenses to patients after
cornea surgery (RK, PRK, corneal grafts) or for assessment of the corneal change of Othro-K lenses fitting.
Other uses of the radiuscope include the measurement of
- Thickness of the RGP contact lenses
- Base curve of the soft contact lens as well (a soft contact lens immersed in saline in a wet cell)

37 38
12. Other optometric instrumentation

Other optometric instrumentation that are not commonly used are

a. V-gauge

V-gauge are used to measure the diameter of the RGP contact lenses

b. Dial thickness gauge

The thickness gauge is used to measure the center and peripheral thickness of the RGP contact lenses

c. Projection magnifier

This instrument, which gives a magnified image of the contact lens on a screen, can be used to measure
- Total diameter of the RGP and soft contact lenses
- Base curve of the soft contact lenses
- Thickness of soft contact lenses

d. Refractometer
Preliminary
Refractometer is used to measure the water content of soft contact lenses
Eye
Examination

39
b. Refraction
Preliminary Eye Examination
Procedures of Refraction
Eye examination is divided into a few areas of specialization. These are:-
Visual acuity measurement with Snellen Chart
- Measurements taken with or without current spectacles / contact lenses
1. Basic eye examination
2. Contact lens examination Objective refraction with Autorefractor / Retinoscope
3. Evaluating spectacles and contact lenses
4. Ophthalmic research Subjective refraction with Trial Frame or Phoropter
- To finetune the Rx obtained with autorefractor / retinoscope
1. Basic Eye Examination - Start by checking Distance Rx and then Near Rx
The basic eye examination consists of:- - For distant vision,
a. History taking Use Astigmatic Fan & Block chart / Cross Cylinder to check the cylinder power and axis
b. Refraction Check with Duochrome to make sure that Rx is not over-minus or over-plus
c. Slit Lamp Examination - For near vision
d. Ophthalmoscopy Use a reading chart which the patient should hold at their normal reading distance
Add the required plus power lenses until they can read well (make sure that the patient can read
2. Contact Lens Examination well at a range of distance)
The contact lens examination consists of:-
a. Keratometry
b. Other ocular measurements c. Slit Lamp Examination
c. Trial Fitting External eye examination with Slit Lamp
d. Over-refraction - Using all the required illumination to look at the external eye
e. Lens Delivery
f. Education on contact lens wear
g. Aftercare visit d. Ophthalmoscopy
Internal eye examination with Ophthalmoscope

1. Basic Eye Exam

2. Contact Lens Examination
a. History
Indications for contact lens wear
Current symptoms
- Any problems with current vision (distance or near / double vision / tired eyes) Contact lenses can be worn for the following ocular conditions:
- How old is present pair of spectacles / contact lenses? Myopia
- Headaches (when and during which situation / position of the headache on the head) Hyperopia
Astigmatism
General health Presbyopia
- Other questions that practitioner can ask the patient Aphakia
Family history (any known family history of hereditary problems like diabetes, hypertension etc) Keratoconus
Ocular history (any history of ocular problems) Astigmatism secondary to post-op/trauma
Medications (what medications are taken and for what reasons) Corneal protection
Allergies (any known allergies) Corneal healing
Occupational requirements

40 41
Contraindications for contact lens wear What was the type of previous lenses?
What was the exact problem with the old lenses?
Contact lenses cannot be worn in following conditions. Some of these are relative contraindications wherein What is the problem with the current lenses?
the patient can wear contact lenses after the condition subsides. Certain conditions may fall into relative and Does the patient want to change the lenses? Why?
absolute depending on the severity and duration of the condition. Some relative contra indications for regular
contact lenses can be fitted with bandage/therapeutic contact lenses. Regular follow up must be administered - General health condition
in all these cases. Does the patient have any general health problems?
If patient is diabetic, investigations must be performed with utmost care and a regular follow up should
Anterior segment inflammation or infection - Relative be maintained.
Chronic ocular allergy - Absolute / relative If patient has a history of systemic allergies, contact lenses can still be fitted but frequent aftercare is
Certain systemic diseases that affect the eye - Relative needed. Common antigens are dust, pollens, drugs etc. Asthmatic patients are generally allergic.
Ptosis - Absolute / relative There is a chance that these patient can be allergic to the lens care product too.
Corneal hyposensitivity - Absolute If patient is arthritic, then contact lenses can still be fitted but frequent aftercare is needed
Chronic dry eye Absolute / relative If a pregnant woman wants to opt for contact lenses, postpone fitting. Maximum changes in the eye are
Poor quality or inadequate tear film Absolute / relative expected in the third trimester. Existing wearers can still wear their lens if no problems are encountered.
Occupational incompatibility - Relative If patient is under medical treatment, then practitioner must check what those medications are (some
Noncompliant, unmotivated patient - Absolute medications like sinusitis medication may affect tear production)
Poor patient hygiene Absolute unless the hygiene is improved
- Ocular health condition
Practitioner must assess the anterior eye by using the slit-lamp
Questioning / Screening patients on Lids (colour and any abnormal growth)
Eyelashes (any irregular growth and hygiene)
- Reasons for wanting contact lenses Lid margin (redness and abnormal growth meibomitis, blepharits, stye, chalazia)
Patient's expectations Cornea (transparency, sensitivity, early signs of keratoconus)
Patients should be made aware of limitations as well as the benefit of contact lenses Conjunctiva (bulbar and palpebral conjunctiva)
Patient's motivation Tear volume and quality (by fluorescein staining and tear prism) (patients with abnormal tear
Patient will most likely not follow the practitioner's instructions regarding wearing schedule and care Production or quality may be unsuccessful with soft contact lenses)
regimens if they are unmotivated)
Patient's hygiene
Patients with poor personal hygiene have a higher risk of ocular infection when wearing contact lenses e. Keratometer
Patient's responsibility
Patients who are not responsible enough to properly take care of contact lenses and follow instructions - Measures only the central 3mm of the corneal radius (while this measurement provides an indication of which
are not suitable candidates for contact lenses. The patient should be able to understand the importance base curve of the RGP trial lens to fit)
of the care regimen. In case of children, the parents can be instructed about the car and maintenance of - Assessment of the mire reflex quality (poor mire reflex quality obtained with the keratometer usually indicate
contact lenses. poor tear film quality and / or poor corneal surface quality)
Patient's refractive error
Acceptable visual acuity must be achieved with contact lenses
Patient's occupation f. Other ocular measurements
The working environment in certain occupations presents a risk when using contact lenses. E.g. Patients - Measurement of the corneal diameter should be made and recorded
working in chemical laboratories may experience stinging and irritation when wearing soft contact lenses
due to permeation of chemical vapors through the lens. - HVID (horizontal visible iris diameter) is usually measured (this is to aid the practitioner in deciding which lens
- Contact lens history diameter to choose when fitting a contact lens on a patient)
Have the patient worn the contact lens before?
If they have, are they still wearing the lens?
How old are the present lenses?
Did they stop wearing contact lens? Why?

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Fitting of Soft Contact Lenses

Fitting of soft contact lenses differ from fitting of RGP lens. The biggest difference in fitting soft contact lenses
is that no fluorescein is used when assessing the lens fit. One of the reasons for not using fluorescein dye is that
it can stain the soft contact lens permanently.
Though fluorescein with high molecular weight can be used in conjunction with Soft Contact Lenses, its use in
the current practice is limited.

There are basically 2 methods of fitting soft contact lenses on patients. The methods are:-
1. Empirical fitting
2. Trial lens fitting

1. Empirical fitting

- The practitioner just needs to obtain the prescription, corneal curvature and diameter
- The practitioner doesn't fit any trial lens on the patient's eye hence the patient doesn't get the feel of

Soft the lens in the eye

- The practitioner orders the lens from the manufacturer and informs the patient when the lens arrives

Contact Lens 2. Trial lens fitting

- After performing measurements of corneal curvature (keratometry) and Horizontal Visible Iris Diameter
(HVID), the parameters of trial lens are selected

Fitting - The total diameter of the contact lens is selected based on the HVID. Add 2 mm to the HVID or follow
manufacturer's recommendation.
- The Back Optic Zone Radius (BOZR) or Base curve of the trial lens is selected depending upon the
keratometry readings.
- To get the base curve, add 0.8 mm to the flatter K, or 1.00 mm to the average K, or select 4 D flatter than
the average K.
- Select the BVP of the trial lens nearest to vertex corrected spectacle Rx (Preferably + 3.00 D)
- Best Vision Sphere (Spherical Equivalent)
If a patient has a low astigmatic refractive error (less than 0.50D cylinder), in addition to simple
myopia or hyperopia, the diagnostic soft lens is based on a calculation known as the "spherical
equivalent." The procedure determines the spherical lens power, which will most likely provide clear
vision for both the myope and hyperope, and also correct astigmatic refractive error. This procedure
works well for low amounts of astigmatism.
Spherical Equivalent = Sphere + 1/2 of Astigmatic Component

Example:
Patient Spectacle Prescription: -3.00 -0.50 x 180
Spherical Equivalent: -3.00 +(-0.50/2) = -3.25D
Spherical Equivalent: -3.25D

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- Full prescription Centration
In cases where higher amounts of astigmatism are present, other alternatives such as soft toric
lenses or rigid gas permeable lenses may be indicated. The Lens that centers well on the cornea is said to provide good centration.
- Vertex Distance Compensation Good centration of the soft contact lens is extremely important because it provides:
Patients with optical correction greater than +/- 4.00D, require an additional adjustment to provide - Good comfort (lens that centers well will ensure the edge is not resting on the limbal area)
accurate visual correction known as the vertex distance compensation. - Good vision (a lens that centers well will ensure that the patient is looking through the optic zone)
- Considering all the above-mentioned parameters, the trial lens is selected and then inserted in the
patient's eye.

Before trial lens insertion

- Always inform the patient before lens insertion that it is very normal if he has a mild lens sensation,
when the lens is worn
- Always inform patient to open both eyes when inserting the lenses (less trauma on the lids)
- Assure wearer that “lens sensation” will wear off after wearing the lens for a few days.

Fit assessment

The patient will usually be given a time of 5 to 15 minutes so that the patient can adapt to the trial lens.
Good lens centration Poor lens centration (lens riding high)
The trial lens can also settle down at the eye before the trial lens assessment is done

- In trial lens fitting, the practitioner needs to assess Lens movement

Lens coverage of the cornea
Centration of the soft contact lens The lens should exhibit perceptible movement with the blink. The practitioner must use the slit-lamp to observe
Movement of soft contact lens with blink and assess the lens movement.
Tightness of the lens
Comfort Directing fixation laterally can reveal tendency of the lens to decenter or for the lens position and movement to
Stability of vision lag behind that of the eye's movement (lateral gaze lag). Excessive decentration or lag may indicate the lens is
too loose or flat. No lag or decentration means the lens is too tight or steep. Lateral gaze lag upto 1.5 mm is
Corneal Coverage considerable acceptable.

All soft lenses must provide full corneal coverage, i.e. the soft contact lens must cover the entire cornea. The upgaze lag is assessed by instructing the patient to look up and maintain the eye position by not blinking. If
The lens must provide corneal coverage at all gaze positions. Assessment of the corneal coverage is done when the lens slides down upto 1.5 mm, it is most likely to be a well fitting lens. If the lens does not slide, it is a tight
patient is looking at fit and if it slides more than 1.5 mm, it is a flat or loose fit.
- Primary gaze position (eyes looking at straight ahead position)
- Upward gaze position (eyes looking up and down) The practitioner can assess the post blink lens movement by asking the patient blink at primary position.
- Lateral gaze (eyes looking at left or right) Similarly post blink movement can also be assessed in up gaze.

If the lens does not provide adequate corneal coverage, a steeper base curve or a larger diameter should be The optimal movement during blinking is 0.50 mm to 1.00 mm.
evaluated. - If movement is excessive, a steeper base curve or larger diameter should be used
- If the soft contact lens exhibits little or no movement, a flatter base curve or smaller diameter lens should
If this change does not provide adequate coverage, the patient should not be fitted with that design of be used
contact lens.
A lens that moves excessively during blink will usually
- Not center well (the lens will either sit too high or too low)
- Gives poor vision (as the eye is not looking through the optic zone)
- Be uncomfortable

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A lens that exhibits little or no lens movement during blink will usually Fitting Silicone hydrogel contact lenses
- Center very well
- Not move much even when practitioner performs the soft lens push up test Assessing the fitting of the Silicone hydrogel contact lenses is the same as assessing the fit of soft contact lenses.
- Give good vision immediately after blink
- Give dryness sensation The practitioner needs to assess
- Lens coverage of the cornea
Assessment of lens tightness is also done using the Lower lid push up test. The ease to displace the lens and the - Centration of the soft contact lens
lens returning to its original position after the lower lid push up can determine if the fit is optimal. The result of - Movement of soft contact lens with blink
this test is recorded as percentage of tightness: 100 % being an immobile lens and 0 % being a lens that does - Comfort
not stay on the eye. The desired tightness is between 40-60 %. - Stable vision

When assessing movement, it is important to use the following three criteria:

1. Does the patient have good comfort?
2. Does the patient have good, stable vision? Some potential soft contact lens fitting problems
3. Does the patient have full corneal coverage?
Complications can occur when lenses are poorly fitted. Problems are normally associated with lenses that move
If the answer to all three questions is yes, the lens movement is not excessive. too little or too much, or decenter sufficiently to expose the cornea.
If lens movement is non-existent when viewed by the slit lamp, particularly after several hours of wear, a flatter
base curve or smaller diameter should be evaluated.
Avoid Corneal Exposure
Comfort Practitioners should not fit soft lenses that leave the cornea partially exposed.
Lenses that decenter sufficiently to expose the corneal tissue under any position of gaze will lead to exposure
Lenses that move less may be comfortable than lenses that exhibit greater movement. corneal staining and the potential for corneal infection (ulcer).
If a patient reports discomfort, it may be necessary to evaluate a steeper base curve or larger diameter to
reduce lens/lid interaction.
Avoid Non-Moving Lens
Vision Equally important is the need to avoid a tight, non-moving lens. It is imperative that the tearfilm flows freely
behind the contact lens in order to flush out metabolic by-products. Any cellular debris that is allowed to
In steep fit lenses, the vision clears immediately after blink and then reverts to a lesser quality. In flat fit lenses accumulate behind the lens on the corneal epithelium may act as a toxin, resulting in inflammation.
the vision blurs immediately after blink and then reverts to better quality. A well-fitted lens will enable a
consistent and clear vision.
An over-refraction is then performed on the patient to obtain the best prescription. Practitioner must remember Avoid Excessive Lens Movement
to provide compensation for vertex distance for spherical prescription above -4.00D. Lenses, which move excessively, will uncover the cornea during blinking, leading to potential corneal exposure.
They will also provide unstable vision as the lens moves with each blink, and may be uncomfortable for the
patient.
Other methods of soft contact lens fitting assessment

Soft contact lens fit assessment can be done by looking at Lens Delivery
- Keratometric mire image reflex
This is usually done by using the keratometer to check the quality of the mire reflex when the patient - Education to the patient on lens handling (insertion & removal) and lens care
is still wearing the trial lens (a good mire reflex indicates a good fit but a poor mire reflex indicates a - Practitioner has to assure patient of normal adaptive symptoms (e.g. mild redness, dryness, lens awareness)
poor fit). - Recommend wearing time (if patient extremely sensitive, practitioner may want to build up wearing time
Tight fit - clear mire immediately after blink which then becomes distorted and blurry. over a period of time)
Loose fit - Mire distortion which becomes more distorted on blink - Practitioner to advise patient on replacement schedule (1 year for traditional soft contact lens,
- Retinoscopic reflex manufacturer’s recommendation for Planned Replacement / Disposable lenses)
A poor fitting soft contact lens will exhibit a poor retinoscopic reflex where the practitioner will see a - Advice the patient to have a spare pair of spectacles ready
poorly defined image

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- Other recommendations like wearing protective eyewear while riding or performing outdoor activities
- Strict instructions on the wear schedule. Patient should not sleep in the lenses unless he is on Silicone
hydrogels or high Dk lenses prescribed as extended wear lenses.
Acknowledgement
- Patients must be made to understand that they need to remove lenses and seek professional opinion if
they experience any problem

- Patients are advised to do daily self test (See good / Look good/ Feel good) Bausch & Lomb University
k. Aftercare visit would like to thank
- Must be done regularly for continued success of contact lens wear
- Recommended to be done on the first week, first month, third month and then once every six month after
lens dispensing
International Association of
- Follow up must be done on
Wearing condition (how long does the patient wear his lens each day)
Visual acuity (with contact lens on)
Contact Lens Educators (IACLE)
Lens fitting (assessing lens centration and movement)
Lens condition (assessing condition of lens surface)
Lens care condition (assessing how wearer cares for his lens)
for its valuable support
Lens care system used
Eye health condition (check the external eye by using the Slit Lamp)
in form of literature review,
content & photographs from
IACLE Contact Lens Course-Module3.

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