Do small-aperture presbyopic corrections influence the visual field?

Purpose To explore the effect of small-aperture optics, designed to aid presbyopes by increasing ocular depth-of-focus, on measurements of the visual field. Methods Simple theoretical and ray-tracing models were used to predict the impact of different designs of small-aperture contact lenses or corneal inlays on the proportion of light passing through natural pupils of various diameters as a function of the direction in the visual field. The left eyes of five healthy volunteers were tested using three afocal, hand-painted opaque soft contact lenses (www.davidthomas.com). Two were opaque over a 10 mm diameter but had central clear circular apertures of 1.5 and 3.0 mm in diameter. The third had an annular opaque zone with inner and outer diameters of 1.5 and 4.0 mm, approximately simulating the geometry of the KAMRA inlay (www.acufocus.com). A fourth, clear lens was used for comparison purposes. Visual fields along the horizontal meridian were evaluated up to 50° eccentricity with static automated perimetry (Medmont M700, stimulus Goldmann-size III; www.medmont.com). Results According to ray-tracing, the two lenses with the circular apertures were expected to reduce the relative transmittance of the pupil to zero at specific field angles (around 60° for the conditions of the experimental measurements). In contrast, the annular stop had no effect on the absolute field but relative transmittance was reduced over the central area of the field, the exact effects depending upon the natural pupil diameter. Experimental results broadly agreed with these theoretical expectations. With the 1.5 and 3.0 mm pupils, only minor losses in sensitivity (around 2 dB) in comparison with the clear-lens case occurred across the central 10° radius of field. Beyond this angle, sensitivity losses increased, to reach about 7 dB at the edge of the measured field (50°). The field results with the annular stop showed at most only a slight loss in sensitivity (≤3 dB) across the measured field. Conclusion The present theoretical and experimental results support earlier clinical findings that KAMRA-type annular stops, unlike circular artificial pupils, have only minor effects on measurements of the visual field.

In response: UV–vis light transmittance through tinted contact lenses and the effect of color on values

In the study, we used the Agilent 8453 spectrophotometer (which is equipped with a limiting aperture that restricts the light beam to the central 5 mm of the contact lens), to measure the transmittance of various coloured contact lenses including the one Day Acuvue define manufactured by Johnson and Johnson which the authors represent. We measured the instrument baseline before the transmittance spectra of lenses were tested. The values of lens transmittances were thus the difference between baseline and lens measurement at each time. The transmittance measurements were obtained at 0.5 nm intervals, from 200 to 700 nm after a soak in saline to remove the influence of any surface active agents within the packaging products. The technique used in our study was not very different from how other research studies [2], [3], [4], [5] and [6] have measured the spectra transmittances of contact lenses...

Effect of third-order aberrations on dynamic accommodation

We investigate the potential for the third-order aberrations coma and trefoil to provide a signed cue to accommodation. It is first demonstrated theoretically (with some assumptions) that the point spread function is insensitive to the sign of spherical defocus in the presence of odd-order aberrations. In an experimental investigation, the accommodation response to a sinusoidal change in vergence (1–3 D, 0.2 Hz) of a monochromatic stimulus was obtained with a dynamic infrared optometer. Measurements were obtained in 10 young visually normal individuals with and without custom contact lenses that induced low and high values of r.m.s. trefoil (0.25, 1.03 μm) and coma (0.34, 0.94 μm). Despite variation between subjects, we did not find any statistically significant increase or decrease in the accommodative gain for low levels of trefoil and coma, although effects approached or reached significance for the high levels of trefoil and coma. Theoretical and experimental results indicate that the presence of Zernike third-order aberrations on the eye does not seem to play a crucial role in the dynamics of the accommodation response.

Effect of presbyopic vision corrections on perceptions of driving difficulty

Objectives: As the population ages, more people will be wearing presbyopic vision corrections when driving. However, little is known about the impact of these vision corrections on driving performance. This study aimed to determine the subjective driving difficulties experienced when wearing a range of common presbyopic contact lens and spectacle corrections.----- Methods: A questionnaire was developed and piloted that included a series of items regarding difficulties experienced while driving under daytime and night-time conditions (rated on five-point and seven-point Likert scales). Participants included 255 presbyopic patients recruited through local optometry practices. Participants were categorized into five age-matched groups; including those wearing no vision correction for driving (n = 50), bifocal spectacles (n = 54), progressive spectacles (n = 50), monovision contact lenses (n = 53), and multifocal contact lenses (n = 48).----- Results: Overall, ratings of satisfaction during daytime driving were relatively high for all correction types. However, multifocal contact lens wearers were significantly less satisfied with aspects of their vision during night-time than daytime driving, particularly regarding disturbances from glare and haloes. Progressive spectacle lens wearers noticed more distortion of peripheral vision, whereas bifocal spectacle wearers reported more difficulties with tasks requiring changes of focus and those who wore no optical correction for driving reported problems with intermediate and near tasks. Overall, satisfaction was significantly higher for progressive spectacles than bifocal spectacles for driving.----- Conclusions: Subjective visual experiences of different presbyopic vision corrections when driving vary depending on the vision tasks and lighting level. Eye-care practitioners should be aware of the driving-related difficulties experienced with each vision correction type and the need to select corrective types that match the driving needs of their patients.

Corneal topography with Scheimpflug imaging and videokeratography : comparative study of normal eyes

PURPOSE: To compare the repeatability within anterior corneal topography measurements and agreement between measurements with the Pentacam HR rotating Scheimpflug camera and with a previously validated Placido disk–based videokeratoscope (Medmont E300). ------ SETTING: Contact Lens and Visual Optics Laboratory, School of Optometry, Queensland University of Technology, Brisbane, Queensland, Australia. ----- METHODS: Normal eyes in 101 young adult subjects had corneal topography measured using the Scheimpflug camera (6 repeated measurements) and videokeratoscope (4 repeated measurements). The best-fitting axial power corneal spherocylinder was calculated and converted into power vectors. Corneal higher-order aberrations (HOAs) (up to the 8th Zernike order) were calculated using the corneal elevation data from each instrument. ----- RESULTS: Both instruments showed excellent repeatability for axial power spherocylinder measurements (repeatability coefficients <0.25 diopter; intraclass correlation coefficients >0.9) and good agreement for all power vectors. Agreement between the 2 instruments was closest when the mean of multiple measurements was used in analysis. For corneal HOAs, both instruments showed reasonable repeatability for most aberration terms and good correlation and agreement for many aberrations (eg, spherical aberration, coma, higher-order root mean square). For other aberrations (eg, trefoil and tetrafoil), the 2 instruments showed relatively poor agreement. ----- CONCLUSIONS: For normal corneas, the Scheimpflug system showed excellent repeatability and reasonable agreement with a previously validated videokeratoscope for the anterior corneal axial curvature best-fitting spherocylinder and several corneal HOAs. However, for certain aberrations with higher azimuthal frequencies, the Scheimpflug system had poor agreement with the videokeratoscope; thus, caution should be used when interpreting these corneal aberrations with the Scheimpflug system.

In vivo confocal microscopy of the bulbar conjunctiva

Background: The aim of this work is to develop a more complete qualitative and quantitative understanding of the in vivo histology of the human bulbar conjunctiva. Methods: Laser scanning confocal microscopy (LSCM) was used to observe and measure morphological characteristics of the bulbar conjunctiva of 11 healthy human volunteer subjects. Results: The superficial epithelial layer of the bulbar conjunctiva is seen as a mass of small cell nuclei. Cell borders are sometimes visible. The light grey borders of basal epithelial cells are clearly visible, but nuclei can not be seen. The conjunctival stroma is comprised of a dense meshwork of white fibres, through which traverse blood vessels containing cellular elements. Orifices at the epithelial surface may represent goblet cells that have opened and expelled their contents. Goblet cells are also observed in the deeper epithelial layers, as well as conjunctival microcysts and mature forms of Langerhans cells. The bulbar conjunctiva has a mean thickness of 32.9 1.1 mm, and a superficial and basal epithelial cell density of 2212 782 and 2368 741 cells/ mm2, respectively. Overall goblet and mature Langerhans cell densities are 111 58 and 23 25 cells/mm2, respectively. Conclusions: LSCM is a powerful technique for studying the human bulbar conjunctiva in vivo and quantifying key aspects of cell morphology. The observations presented here may serve as a useful marker against which changes in conjunctival morphology due to disease, surgery, drug therapy or contact lens wear can be assessed.

Robust estimation of tear film surface quality in lateral shearing interferometry

Interferometry is a sensitive technique for recording tear film surface irregularities in a noninvasive manner. At the same time, the technique is hindered by natural eye movements resulting in measurement noise. Estimating tear film surface quality from interferograms can be reduced to a spatial-average-localized weighted estimate of the first harmonic of the interference fringes. However, previously reported estimation techniques proved to perform poorly in cases where the pattern fringes were significantly disturbed. This can occur in cases of measuring tear film surface quality on a contact lens on the eye or in a dry eye. We present a new estimation technique for extracting the first harmonic from the interference fringes that combines the traditional spectral estimation techniques with morphological image processing techniques. The proposed technique proves to be more robust to changes in interference fringes caused by natural eye movements and the degree of dryness of the contact lens and corneal surfaces than its predecessors, resulting in tear film surface quality estimates that are less noisy

Eyelid pressure on the cornea

The eyelids play an important role in lubricating and protecting the surface of the eye. Each blink serves to spread fresh tears, remove debris and replenish the smooth optical surface of the eye. Yet little is known about how the eyelids contact the ocular surface and what pressure distribution exists between the eyelids and cornea. As the principal refractive component of the eye, the cornea is a major element of the eye’s optics. The optical properties of the cornea are known to be susceptible to the pressure exerted by the eyelids. Abnormal eyelids, due to disease, have altered pressure on the ocular surface due to changes in the shape, thickness or position of the eyelids. Normal eyelids also cause corneal distortions that are most often noticed when they are resting closer to the corneal centre (for example during reading). There were many reports of monocular diplopia after reading due to corneal distortion, but prior to videokeratoscopes these localised changes could not be measured. This thesis has measured the influence of eyelid pressure on the cornea after short-term near tasks and techniques were developed to quantify eyelid pressure and its distribution. The profile of the wave-like eyelid-induced corneal changes and the refractive effects of these distortions were investigated. Corneal topography changes due to both the upper and lower eyelids were measured for four tasks involving two angles of vertical downward gaze (20° and 40°) and two near work tasks (reading and steady fixation). After examining the depth and shape of the corneal changes, conclusions were reached regarding the magnitude and distribution of upper and lower eyelid pressure for these task conditions. The degree of downward gaze appears to alter the upper eyelid pressure on the cornea, with deeper changes occurring after greater angles of downward gaze. Although the lower eyelid was further from the corneal centre in large angles of downward gaze, its effect on the cornea was greater than that of the upper eyelid. Eyelid tilt, curvature, and position were found to be influential in the magnitude of eyelid-induced corneal changes. Refractively these corneal changes are clinically and optically significant with mean spherical and astigmatic changes of about 0.25 D after only 15 minutes of downward gaze (40° reading and steady fixation conditions). Due to the magnitude of these changes, eyelid pressure in downward gaze offers a possible explanation for some of the day-to-day variation observed in refraction. Considering the magnitude of these changes and previous work on their regression, it is recommended that sustained tasks performed in downward gaze should be avoided for at least 30 minutes before corneal and refractive assessment requiring high accuracy. Novel procedures were developed to use a thin (0.17 mm) tactile piezoresistive pressure sensor mounted on a rigid contact lens to measure eyelid pressure. A hydrostatic calibration system was constructed to convert raw digital output of the sensors to actual pressure units. Conditioning the sensor prior to use regulated the measurement response and sensor output was found to stabilise about 10 seconds after loading. The influences of various external factors on sensor output were studied. While the sensor output drifted slightly over several hours, it was not significant over the measurement time of 30 seconds used for eyelid pressure, as long as the length of the calibration and measurement recordings were matched. The error associated with calibrating at room temperature but measuring at ocular surface temperature led to a very small overestimation of pressure. To optimally position the sensor-contact lens combination under the eyelid margin, an in vivo measurement apparatus was constructed. Using this system, eyelid pressure increases were observed when the upper eyelid was placed on the sensor and a significant increase was apparent when the eyelid pressure was increased by pulling the upper eyelid tighter against the eye. For a group of young adult subjects, upper eyelid pressure was measured using this piezoresistive sensor system. Three models of contact between the eyelid and ocular surface were used to calibrate the pressure readings. The first model assumed contact between the eyelid and pressure sensor over more than the pressure cell width of 1.14 mm. Using thin pressure sensitive carbon paper placed under the eyelid, a contact imprint was measured and this width used for the second model of contact. Lastly as Marx’s line has been implicated as the region of contact with the ocular surface, its width was measured and used as the region of contact for the third model. The mean eyelid pressures calculated using these three models for the group of young subjects were 3.8 ± 0.7 mmHg (whole cell), 8.0 ± 3.4 mmHg (imprint width) and 55 ± 26 mmHg (Marx’s line). The carbon imprints using Pressurex-micro confirmed previous suggestions that a band of the eyelid margin has primary contact with the ocular surface and provided the best estimate of the contact region and hence eyelid pressure. Although it is difficult to directly compare the results with previous eyelid pressure measurement attempts, the eyelid pressure calculated using this model was slightly higher than previous manometer measurements but showed good agreement with the eyelid force estimated using an eyelid tensiometer. The work described in this thesis has shown that the eyelids have a significant influence on corneal shape, even after short-term tasks (15 minutes). Instrumentation was developed using piezoresistive sensors to measure eyelid pressure. Measurements for the upper eyelid combined with estimates of the contact region between the cornea and the eyelid enabled quantification of the upper eyelid pressure for a group of young adult subjects. These techniques will allow further investigation of the interaction between the eyelids and the surface of the eye.

Repeatability of measuring corneal subbasal nerve fiber length in individuals with Type 2 Diabetes

Purpose: To analyze the repeatability of measuring nerve fiber length (NFL) from images of the human corneal subbasal nerve plexus using semiautomated software. Methods: Images were captured from the corneas of 50 subjects with type 2 diabetes mellitus who showed varying severity of neuropathy, using the Heidelberg Retina Tomograph 3 with Rostock Corneal Module. Semiautomated nerve analysis software was independently used by two observers to determine NFL from images of the subbasal nerve plexus. This procedure was undertaken on two occasions, 3 days apart. Results: The intraclass correlation coefficient values were 0.95 (95% confidence intervals: 0.92–0.97) for individual subjects and 0.95 (95% confidence intervals: 0.74–1.00) for observer. Bland-Altman plots of the NFL values indicated a reduced spread of data with lower NFL values. The overall spread of data was less for (a) the observer who was more experienced at analyzing nerve fiber images and (b) the second measurement occasion. Conclusions: Semiautomated measurement of NFL in the subbasal nerve fiber layer is highly repeatable. Repeatability can be enhanced by using more experienced observers. It may be possible to markedly improve repeatability when measuring this anatomic structure using fully automated image analysis software.

Increased Langerhan cell density and corneal nerve damage in diabetic patients : role of immune mechanisms in human diabetic neuropathy

Aim/hypothesis Immune mechanisms have been proposed to play a role in the development of diabetic neuropathy. We employed in vivo corneal confocal microscopy (CCM) to quantify the presence and density of Langerhans cells (LCs) in relation to the extent of corneal nerve damage in Bowman's layer of the cornea in diabetic patients. Methods 128 diabetic patients aged 58±1 yrs with a differing severity of neuropathy based on Neuropathy Deficit Score (NDS—4.7±0.28) and 26 control subjects aged 53±3 yrs were examined. Subjects underwent a full neurological evaluation, evaluation of corneal sensation with non-contact corneal aesthesiometry (NCCA) and corneal nerve morphology using corneal confocal microscopy (CCM). Results The proportion of individuals with LCs was significantly increased in diabetic patients (73.8%) compared to control subjects (46.1%), P=0.001. Furthermore, LC density (no/mm2) was significantly increased in diabetic patients (17.73±1.45) compared to control subjects (6.94±1.58), P=0.001 and there was a significant correlation with age (r=0.162, P=0.047) and severity of neuropathy (r=−0.202, P=0.02). There was a progressive decrease in corneal sensation with increasing severity of neuropathy assessed using NDS in the diabetic patients (r=0.414, P=0.000). Corneal nerve fibre density (P<0.001), branch density (P<0.001) and length (P<0.001) were significantly decreased whilst tortuosity (P<0.01) was increased in diabetic patients with increasing severity of diabetic neuropathy. Conclusion Utilising in vivo corneal confocal microscopy we have demonstrated increased LCs in diabetic patients particularly in the earlier phases of corneal nerve damage suggestive of an immune mediated contribution to corneal nerve damage in diabetes.

How optometrists record corneal staining

Purpose: The aim of this study was to determine current approaches adopted by optometrists to the recording of corneal staining following fluorescein instillation. Methods: An anonymous ‘record-keeping task’ was sent to all 756 practitioners who are members of the Queensland Division of Optometrists Association Australia. This task comprised a form on which appeared a colour photograph depicting contact lens solution-induced corneal staining. Next to the photograph was an empty box, in which practitioners were asked to record their observations. Practitioners were also asked to indicate the level of severity of the condition at which treatment would be instigated. Results: Completed task forms were returned by 228 optometrists, representing a 30 per cent response rate. Ninety-two per cent of respondents offered a diagnosis. The most commonly used descriptive terms were ‘superficial punctate keratitis’ (36 per cent of respondents) and ‘punctate staining’ (29 per cent). The level of severity and location of corneal staining were noted by 69 and 68 per cent of respondents, respectively. A numerical grade was assigned by 44 per cent of respondents. Only three per cent nominated the grading scale used. The standard deviation of assigned grades was � 0.6. The condition was sketched by 35 per cent of respondents and two per cent stated that they would take a photograph of the eye. Ten per cent noted the eye in which the condition was being observed. Opinions of the level of severity at which treatment for corneal staining should be instigated varied considerably between practitioners, ranging from ‘any sign of corneal staining’ to ‘grade 4 staining’. Conclusion: Although most practitioners made a sensible note of the condition and properly recorded the location of corneal staining, serious deficiencies were evident regarding other aspects of record-keeping. Ongoing programs of professional optometric education should reinforce good practice in relation to clinical record-keeping.

Non-invasive assessment of tear film surface quality

The tear film plays an important role preserving the health of the ocular surface and maintaining the optimal refractive power of the cornea. Moreover dry eye syndrome is one of the most commonly reported eye health problems. This syndrome is caused by abnormalities in the properties of the tear film. Current clinical tools to assess the tear film properties have shown certain limitations. The traditional invasive methods for the assessment of tear film quality, which are used by most clinicians, have been criticized for the lack of reliability and/or repeatability. A range of non-invasive methods of tear assessment have been investigated, but also present limitations. Hence no “gold standard” test is currently available to assess the tear film integrity. Therefore, improving techniques for the assessment of the tear film quality is of clinical significance and the main motivation for the work described in this thesis. In this study the tear film surface quality (TFSQ) changes were investigated by means of high-speed videokeratoscopy (HSV). In this technique, a set of concentric rings formed in an illuminated cone or a bowl is projected on the anterior cornea and their reflection from the ocular surface imaged on a charge-coupled device (CCD). The reflection of the light is produced in the outer most layer of the cornea, the tear film. Hence, when the tear film is smooth the reflected image presents a well structure pattern. In contrast, when the tear film surface presents irregularities, the pattern also becomes irregular due to the light scatter and deviation of the reflected light. The videokeratoscope provides an estimate of the corneal topography associated with each Placido disk image. Topographical estimates, which have been used in the past to quantify tear film changes, may not always be suitable for the evaluation of all the dynamic phases of the tear film. However the Placido disk image itself, which contains the reflected pattern, may be more appropriate to assess the tear film dynamics. A set of novel routines have been purposely developed to quantify the changes of the reflected pattern and to extract a time series estimate of the TFSQ from the video recording. The routine extracts from each frame of the video recording a maximized area of analysis. In this area a metric of the TFSQ is calculated. Initially two metrics based on the Gabor filter and Gaussian gradient-based techniques, were used to quantify the consistency of the pattern’s local orientation as a metric of TFSQ. These metrics have helped to demonstrate the applicability of HSV to assess the tear film, and the influence of contact lens wear on TFSQ. The results suggest that the dynamic-area analysis method of HSV was able to distinguish and quantify the subtle, but systematic degradation of tear film surface quality in the inter-blink interval in contact lens wear. It was also able to clearly show a difference between bare eye and contact lens wearing conditions. Thus, the HSV method appears to be a useful technique for quantitatively investigating the effects of contact lens wear on the TFSQ. Subsequently a larger clinical study was conducted to perform a comparison between HSV and two other non-invasive techniques, lateral shearing interferometry (LSI) and dynamic wavefront sensing (DWS). Of these non-invasive techniques, the HSV appeared to be the most precise method for measuring TFSQ, by virtue of its lower coefficient of variation. While the LSI appears to be the most sensitive method for analyzing the tear build-up time (TBUT). The capability of each of the non-invasive methods to discriminate dry eye from normal subjects was also investigated. The receiver operating characteristic (ROC) curves were calculated to assess the ability of each method to predict dry eye syndrome. The LSI technique gave the best results under both natural blinking conditions and in suppressed blinking conditions, which was closely followed by HSV. The DWS did not perform as well as LSI or HSV. The main limitation of the HSV technique, which was identified during the former clinical study, was the lack of the sensitivity to quantify the build-up/formation phase of the tear film cycle. For that reason an extra metric based on image transformation and block processing was proposed. In this metric, the area of analysis was transformed from Cartesian to Polar coordinates, converting the concentric circles pattern into a quasi-straight lines image in which a block statistics value was extracted. This metric has shown better sensitivity under low pattern disturbance as well as has improved the performance of the ROC curves. Additionally a theoretical study, based on ray-tracing techniques and topographical models of the tear film, was proposed to fully comprehend the HSV measurement and the instrument’s potential limitations. Of special interested was the assessment of the instrument’s sensitivity under subtle topographic changes. The theoretical simulations have helped to provide some understanding on the tear film dynamics, for instance the model extracted for the build-up phase has helped to provide some insight into the dynamics during this initial phase. Finally some aspects of the mathematical modeling of TFSQ time series have been reported in this thesis. Over the years, different functions have been used to model the time series as well as to extract the key clinical parameters (i.e., timing). Unfortunately those techniques to model the tear film time series do not simultaneously consider the underlying physiological mechanism and the parameter extraction methods. A set of guidelines are proposed to meet both criteria. Special attention was given to a commonly used fit, the polynomial function, and considerations to select the appropriate model order to ensure the true derivative of the signal is accurately represented. The work described in this thesis has shown the potential of using high-speed videokeratoscopy to assess tear film surface quality. A set of novel image and signal processing techniques have been proposed to quantify different aspects of the tear film assessment, analysis and modeling. The dynamic-area HSV has shown good performance in a broad range of conditions (i.e., contact lens, normal and dry eye subjects). As a result, this technique could be a useful clinical tool to assess tear film surface quality in the future.

Precipitazioni sull'endotelio [Pigment Dispersion Syndrome]

Arguably, the most common patient seen in contact lens practice in our communities is the young adult white myope. The incidence of eye disease in this group of patients is very low, particularly if the genetically determined problems are excluded. However, there is one condition that should always be anticipated and searched for, especially in males. In fact, it affects 2-4% of these individuals and is known as pigment dispersion syndrome. This is important because 25-50% of these patients will get secondary or pigmentary glaucoma because of the pigment dispersion. It can be inherited as an autosomal dominant trait and has been mapped to chromosome 7. It is usually bilateral and is rarely encountered in patients of darker skin such as Asians and African-Americans.