Corneal sensitivity and slit scanning in vivo confocal microscopy of the subbasal nerve plexus of the normal central and peripheral human cornea

Purpose: To determine the subbasal nerve density and tortuosity at 5 corneal locations and to investigate whether these microstructural observations correlate with corneal sensitivity. Method: Sixty eyes of 60 normal human subjects were recruited into 1 of 3 age groups, group 1: aged ,35 years, group 2: aged 35–50 years, and group 3: aged .50 years. All eyes were examined using slit-lamp biomicroscopy, noncontact corneal esthesiometry, and slit scanning in vivo confocal microscopy. Results: The mean subbasal nerve density and the mean corneal sensitivity were greatest centrally (14,731 6 6056 mm/mm2 and 0.38 6 0.21 millibars, respectively) and lowest in the nasal mid periphery (7850 6 4947 mm/mm2 and 0.49 6 0.25 millibars, respectively). The mean subbasal nerve tortuosity coefficient was greatest in the temporal mid periphery (27.3 6 6.4) and lowest in the superior mid periphery (19.3 6 14.1). There was no significant difference in mean total subbasal nerve density between age groups. However, corneal sensation (P = 0.001) and subbasal nerve tortuosity (P = 0.004) demonstrated significant differences between age groups. Subbasal nerve density only showed significant correlations with corneal sensitivity threshold in the temporal cornea and with subbasal nerve tortuosity in the inferior and nasal cornea. However, these correlations were weak. Conclusions: This study quantitatively analyzes living human corneal nerve structure and an aspect of nerve function. There is no strong correlation between subbasal nerve density and corneal sensation. This study provides useful baseline data for the normal living human cornea at central and mid-peripheral locations

In vivo confocal microscopy of the palpebral conjunctiva and tarsal plate

Purpose The aim of this work is to develop a more complete understanding of the in vivo histology of the human palpebral conjunctiva and tarsal plate. Methods. The upper eyelids of 11 healthy human volunteer subjects were everted, and laser scanning confocal microscopy was used to examine the various tissue layers of the palpebral conjunctiva and tarsal plate. Results The superficial and basal epithelial layers are composed of cells with gray cytoplasm and thick, light gray borders.Nuclei can not be seen. The stroma has a varied appearance; fibrous tissue is sometimes observed, interspersed with dark,amorphous lacunae, and crevases. Numerous single white or gray cells populate this tissue, and fine blood vessels are seen traversing the field. Occasional conjunctival microcysts and Langerhans cells are observed. The tarsal plate is dark and amorphous, and meibomian gland acini with convoluted borders are clearly observed. Acini are composed of an outer lining of large cuboidal cells, and differentiated secretory cells can be seen within the acini lumen. Conclusions Laser scanning confocal microscopy is capable of studying the human palpebral conjunctiva, tarsal plate, and acini of meibomian glands in vivo. The observations presented here may provide useful supplementary anatomical information relating to the morphology of this tissue.

Corneal confocal microscopy : a novel noninvasive means to diagnose neuropathy in patients with Fabry disease

ABSTRACT: Neuropathy is a cause of significant disability in patients with Fabry disease, yet its diagnosis is difficult. In this study we compared the novel noninvasive techniques of corneal confocal microscopy (CCM) to quantify small-fiber pathology, and non-contact corneal esthesiometry (NCCA) to quantify loss of corneal sensation, with established tests of neuropathy in patients with Fabry disease. Ten heterozygous females with Fabry disease not on enzyme replacement therapy (ERT), 6 heterozygous females, 6 hemizygous males on ERT, and 14 age-matched, healthy volunteers underwent detailed quantification of neuropathic symptoms, neurological deficits, neurophysiology, quantitative sensory testing (QST), NCCA, and CCM. All patients with Fabry disease had significant neuropathic symptoms and an elevated Mainz score. Peroneal nerve amplitude was reduced in all patients and vibration perception threshold was elevated in both male and female patients on ERT. Cold sensation (CS) threshold was significantly reduced in both male and female patients on ERT (P < 0.02), but warm sensation (WS)and heat-induced pain (HIP) were only significantly increased in males onERT (P<0.01). However, corneal sensation assessed withNCCAwas significantly reduced in female (P < 0.02) and male (P < 0.04) patients on ERT compared with control subjects. According to CCM, corneal nerve fiber and branch density was significantly reduced in female (P < 0.03) and male (P < 0.02) patients on ERT compared with control subjects. Furthermore, the severity of neuropathic symptoms and the neurological component of the Mainz Severity Score Index correlated significantly with QSTand CCM. This study shows that CCM and NCCA provide a novel means to detect early nerve fiber damage and dysfunction, respectively, in patients with Fabry disease.

Factors influencing the prescribing of hydrogel contact lenses

Despite the current market popularity of silicone hydrogel contact lenses, conventional hydrogel lenses still represent a significant proportion of the overall contact lens market. Data gathered from annual UK contact lens fitting surveys over the past 13 years indicate that 64% of hydrogel lenses prescribed during this period were of low/medium water content (<60% water). Whereas, in the past, practitioners would choose the water content of a hydrogel lens to meet specific clinical needs, this choice appears today to be largely governed by product availability.

Aberrations and pupil location under corneal topography and Hartmann-Shack illumination conditions

PURPOSE. This study was conducted to determine the magnitude of pupil center shift between the illumination conditions provided by corneal topography measurement (photopic illuminance) and by Hartmann-Shack aberrometry (mesopic illuminance) and to investigate the importance of this shift when calculating corneal aberrations and for the success of wavefront-guided surgical procedures. METHODS. Sixty-two subjects with emmetropia underwent corneal topography and Hartmann-Shack aberrometry. Corneal limbus and pupil edges were detected, and the differences between their respective centers were determined for both procedures. Corneal aberrations were calculated using the pupil centers for corneal topography and for Hartmann-Shack aberrometry. Bland-Altmann plots and paired t-tests were used to analyze the differences between corneal aberrations referenced to the two pupil centers. RESULTS. The mean magnitude (modulus) of the displacement of the pupil with the change of the illumination conditions was 0.21 ± 0.11 mm. The effect of this pupillary shift was manifest for coma corneal aberrations for 5-mm pupils, but the two sets of aberrations calculated with the two pupil positions were not significantly different. Sixty-eight percent of the population had differences in coma smaller than 0.05 µm, and only 4% had differences larger than 0.1 µm. Pupil displacement was not large enough to significantly affect other higher-order Zernike modes. CONCLUSIONS. Estimated corneal aberrations changed slightly between photopic and mesopic illumination conditions given by corneal topography and Hartmann-Shack aberrometry. However, this systematic pupil shift, according to the published tolerances ranges, is enough to deteriorate the optical quality below the theoretically predicted diffraction limit of wavefront-guided corneal surgery.

Mathematical models for describing the shape of the in vitro unstretched human crystalline lens

We developed orthogonal least-squares techniques for fitting crystalline lens shapes, and used the bootstrap method to determine uncertainties associated with the estimated vertex radii of curvature and asphericities of five different models. Three existing models were investigated including one that uses two separate conics for the anterior and posterior surfaces, and two whole lens models based on a modulated hyperbolic cosine function and on a generalized conic function. Two new models were proposed including one that uses two interdependent conics and a polynomial based whole lens model. The models were used to describe the in vitro shape for a data set of twenty human lenses with ages 7–82 years. The two-conic-surface model (7 mm zone diameter) and the interdependent surfaces model had significantly lower merit functions than the other three models for the data set, indicating that most likely they can describe human lens shape over a wide age range better than the other models (although with the two-conic-surfaces model being unable to describe the lens equatorial region). Considerable differences were found between some models regarding estimates of radii of curvature and surface asphericities. The hyperbolic cosine model and the new polynomial based whole lens model had the best precision in determining the radii of curvature and surface asphericities across the five considered models. Most models found significant increase in anterior, but not posterior, radius of curvature with age. Most models found a wide scatter of asphericities, but with the asphericities usually being positive and not significantly related to age. As the interdependent surfaces model had lower merit function than three whole lens models, there is further scope to develop an accurate model of the complete shape of human lenses of all ages. The results highlight the continued difficulty in selecting an appropriate model for the crystalline lens shape.

Decentred optical axes and aberrations along principal visual field meridians

Suggestions that peripheral imagery may affect the development of refractive error have led to interest in the variation in refraction and aberration across the visual field. It is shown that, if the optical system of the eye is rotationally symmetric about an optical axis which does not coincide with the visual axis, measurements of refraction and aberration made along the horizontal and vertical meridians of the visual field will show asymmetry about the visual axis. The departures from symmetry are modelled for second-order aberrations, refractive components and third-order coma. These theoretical results are compared with practical measurements from the literature. The experimental data support the concept that departures from symmetry about the visual axis in the measurements of crossed-cylinder astigmatism J45 and J180 are largely explicable in terms of a decentred optical axis. Measurements of the mean sphere M suggest, however, that the retinal curvature must differ in the horizontal and vertical meridians.

Blur limits for defocus, astigmatism and trefoil

We investigated the limits at which blur due to defocus, crossed-cylinder astigmatism, and trefoil became noticeable, troublesome or objectionable. Black letter targets (0.1, 0.35 and 0.6 logMAR) were presented on white backgrounds. Subjects were cyclopleged and had effectively 5 mm pupils. Blur was induced with a deformable, adaptive-optics mirror operating under open-loop conditions. Mean defocus blur limits of six subjects with uncorrected intrinsic higher-order ocular aberrations ranged from 0.18 ± 0.08 D (noticeable blur criterion, 0.1 logMAR) to 1.01 ± 0.27 D (objectionable blur criterion, 0.6 logMAR. Crossed-cylinder astigmatic blur limits were approximately 90% of those for defocus, but with considerable meridional influences. In two of the subjects, the intrinsic aberrations of the eye were subsequently corrected before the defocus and astigmatic blur were added. This resulted in only minor reductions in their blur limits. When assessed with trefoil blur and corrected intrinsic ocular aberrations, the ratio of objectionable to noticeable blur limits in these two subjects was much higher for trefoil (3.5) than for defocus (2.5) and astigmatism (2.2).

Limits of spherical blur determined with an adaptive optics mirror

We extended an earlier study (Vision Research, 45, 1967–1974, 2005) in which we investigated limits at which induced blur of letter targets becomes noticeable, troublesome and objectionable. Here we used a deformable adaptive optics mirror to vary spherical defocus for conditions of a white background with correction of astigmatism; a white background with reduction of all aberrations other than defocus; and a monochromatic background with reduction of all aberrations other than defocus. We used seven cyclopleged subjects, lines of three high-contrast letters as targets, 3–6 mm artificial pupils, and 0.1–0.6 logMAR letter sizes. Subjects used a method of adjustment to control the defocus component of the mirror to set the 'just noticeable', 'just troublesome' and 'just objectionable' defocus levels. For the white-no adaptive optics condition combined with 0.1 logMAR letter size, mean 'noticeable' blur limits were ±0.30, ±0.24 and ±0.23 D at 3, 4 and 6 mm pupils, respectively. White-adaptive optics and monochromatic-adaptive optics conditions reduced blur limits by 8% and 20%, respectively. Increasing pupil size from 3–6 mm decreased blur limits by 29%, and increasing letter size increased blur limits by 79%. Ratios of troublesome to noticeable, and of objectionable to noticeable, blur limits were 1.9 and 2.7 times, respectively. The study shows that the deformable mirror can be used to vary defocus in vision experiments. Overall, the results of noticeable, troublesome and objectionable blur agreed well with those of the previous study. Attempting to reduce higher-order aberrations or chromatic aberrations, reduced blur limits to only a small extent.

Effect of orthokeratology on peripheral aberrations of the eye

Purpose: To investigate the effect of orthokeratology on peripheral aberrations in two myopic volunteers. Methods: The subjects wore reverse geometry orthokeratology lenses overnight and were monitored for 2 weeks of wear. They underwent corneal topography, peripheral refraction (out to ±34° along the horizontal visual field) and peripheral aberration measurements across the 42° × 32° central visual field using a modified Hartmann-Shack aberrometer. Results: Spherical equivalent refraction was corrected for the central 25° of the visual fields beyond which it gradually returned to its preorthokeratology values. There were increases in axial coma, spherical aberration, higher order root mean square aberrations, and total root-mean-squared aberrations (excluding defocus). The rates of change of vertical and horizontal coma across the field changed in sign. Total root mean square aberrations showed a quadratic rate of change across the visual field which was greater subsequent to orthokeratology. Conclusion: Although orthokeratology can correct peripheral relative hypermetropia it induces dramatic increases in higher-order aberrations across the field

The influence of oblique viewing on axial and peripheral refraction for emmetropes and myopes

Refraction may be affected by the forces of lids and extraocular muscles when eye direction and head direction are not aligned (oblique viewing) which might potentially influence past findings on peripheral refraction of the eye. We investigated the effect of oblique viewing on axial and peripheral refraction. In a first experiment, cycloplegic axial refractions were determined when subjects' heads were positioned to look straight-ahead through an open-view autorefractor and when the heads were rotated to the right or left by 30° with compensatory eye rotation (oblique viewing). Subjects were 16 young emmetropes (18–35 years), 22 young myopes (19–36 years) and 15 old emmetropes (45–60 years). In a second experiment, cycloplegic peripheral refraction measurements were taken out to ±34° horizontally from fixation while the subjects rotated their heads to match the peripheral refraction angles (eye in primary position with respect to the head) or the eyes were rotated with respect to the head (oblique viewing). Subjects were 10 emmetropes and 10 myopes. We did not find any significant changes in axial or peripheral refraction upon oblique viewing for any of the subject groups. In general for the range of horizontal angles used, it is not critical whether or not the eye is rotated with respect to the head during axial or peripheral refraction.

Influences of accommodation and myopia on the foveal Stiles-Crawford effect

We determined the foveal Stiles-Crawford effect (SCE) as a function of up to 8D accommodation stimulus in six young emmetropes and six young myopes using a psychophysical two-channel Maxwellian system in which the threshold luminance increment of a 1 mm spot entering through variable positions in the pupil was determined against a background formed by a 4 mm spot entering the pupil centrally. The SCE became steeper in both groups with increasing accommodation stimulus, but with no systematic shift of the peak. Combining the data of both groups gave significant increases in directionality of 15-20% in horizontal and vertical pupil meridians with 6D of accommodation. However, additional experiments indicated that much of this was an artefact of higher order aberrations and accommodative lag. Thus, there appears to be little changes in orientation or directionality in the SCE with accommodation stimulus levels up to 6 D, but it is possible that changes may occur at very high accommodation levels

Influence of presbyopic corrections on driving-related eye and head movements

Purpose: To investigate whether wearing different presbyopic vision corrections alters the pattern of eye and head movements when viewing and responding to driving-related traffic scenes. Methods: Participants included 20 presbyopes (mean age: 56.1 ± 5.7 years) who had no experience of wearing presbyopic vision corrections, apart from single vision (SV) reading spectacles. Each participant wore five different vision corrections: distance SV lenses, progressive addition spectacle lenses (PAL), bifocal spectacle lenses (BIF), monovision (MV) and multifocal contact lenses (MTF CL). For each visual condition, participants were required to view videotape recordings of traffic scenes, track a reference vehicle, and identify a series of peripherally presented targets. Digital numerical display panels were also included as near visual stimuli (simulating the visual displays of a vehicle speedometer and radio). Eye and head movements were measured, and the accuracy of target recognition was also recorded. Results: The path length of eye movements while viewing and responding to driving-related traffic scenes was significantly longer when wearing BIF and PAL than MV and MTF CL (both p ≤ 0.013). The path length of head movements was greater with SV, BIF, and PAL than MV and MTF CL (all p < 0.001). Target recognition and brake response times were not significantly affected by vision correction, whereas target recognition was less accurate when the near stimulus was located at eccentricities inferiorly and to the left, rather than directly below the primary position of gaze (p = 0.008), regardless of vision correction. Conclusions: Different presbyopic vision corrections alter eye and head movement patterns. The longer path length of eye and head movements and greater number of saccades associated with the spectacle presbyopic corrections may affect some aspects of driving performance.

A population survey of the penetrance of contact lens wear in Australia : rationale, methodology and results

Purpose: A population based, cross-sectional telephone survey was conducted to estimate the total penetrance of contact lens wear in Australia. Methods: A total of 42,749 households around Australia were randomly selected from the national electronic telephone directory based on postcode distribution. Before contact was attempted, letters of introduction were sent. The number of individuals and contact lens wearers in each household was ascertained and lens wearers were interviewed to determine details of lens type and mode of wear using a structured questionnaire. Results: Of households contacted, 59.2% (19,171/32,405) agreed to participate. Response rates were only marginally higher amongst households that first received a letter of introduction. In these households, 35,914 individuals were identified, of which, 1,798 were contact lens wearers. The penetrance of contact lens wear during the study period was 5.01% (95% CI: 4.78-5.24). Soft hydrogel lenses had the largest penetrance in the community, (66.7% of all wearers), however, their market share decreased significantly over the study period with increased uptake of newly introduced lens types. Conclusions: The penetrance of contact lens wear concurs with market estimates and equates to approximately 680,000 contact lens wearers aged between 15 and 64 years in Australia. The low response rate obtained in this study highlights the difficulty in contemporary use of telephone survey methodology

Low Vision

The care of low-vision patients is termed vision rehabilitation, and optometrists have an essential role to play in the provision of vision rehabilitation services. Ideally, if patients stay with one optometrist or practice, their low-vision care becomes part of a continuum of eye care, from the time when they had normal vision. If progressive vision loss occurs, the role of the optometrist changes from primary eye care only to one of monitoring vision loss and gradually introducing low-vision care, especially magnification and advice on lighting and contrast, in conjunction with other vision rehabilitation professionals.