The effect of presbyiopic vision corrections on nighttime driving performance

Purpose. To investigate the effect of various presbyopic vision corrections on nighttime driving performance on a closed-road driving circuit. Methods. Participants were 11 presbyopes (mean age, 57.3 ± 5.8 years), with a mean best sphere distance refractive error of R+0.23±1.53 DS and L+0.20±1.50 DS, whose only experience of wearing presbyopic vision correction was reading spectacles. The study involved a repeated-measures design by which a participant's nighttime driving performance was assessed on a closed-road circuit while wearing each of four power-matched vision corrections. These included single-vision distance lenses (SV), progressive-addition spectacle lenses (PAL), monovision contact lenses (MV), and multifocal contact lenses (MTF CL) worn in a randomized order. Measures included low-contrast road hazard detection and avoidance, road sign and near target recognition, lane-keeping, driving time, and legibility distance for street signs. Eye movement data (fixation duration and number of fixations) were also recorded. Results. Street sign legibility distances were shorter when wearing MV and MTF CL than SV and PAL (P < 0.001), and participants drove more slowly with MTF CL than with PALs (P = 0.048). Wearing SV resulted in more errors (P < 0.001) and in more (P = 0.002) and longer (P < 0.001) fixations when responding to near targets. Fixation duration was also longer when viewing distant signs with MTF CL than with PAL (P = 0.031). Conclusions. Presbyopic vision corrections worn by naive, unadapted wearers affected nighttime driving. Overall, spectacle corrections (PAL and SV) performed well for distance driving tasks, but SV negatively affected viewing near dashboard targets. MTF CL resulted in the shortest legibility distance for street signs and longer fixation times.

Confocal microscopy of the bulbar conjunctiva in contact lens wear

Purpose: The aim of this study was to investigate the capabilities of laser scanning confocal microscopy (LSCM) for undertaking qualitative and quantitative investigations of the response of the bulbar conjunctiva to contact lens wear. Methods: LSCM was used to observe and measure morphological characteristics of the bulbar conjunctiva of 11 asymptomatic soft contact lens wearers and 11 healthy volunteer subjects (controls). Results: The appearance of the bulbar conjunctiva is consistent with known histology of this tissue based on light and electron microscopy. The thickness of the bulbar conjunctival epithelium of lens wearers (30.9 ± 1.1 μm) was less than that of controls (32.9 ± 1.1 μm) (P < 0.0001). Superficial and basal bulbar conjunctival epithelial cell densities in contact lens wearers were 91% and 79% higher, respectively, than that in controls (P < 0.0001). No difference was observed in goblet and Langerhans cell density between lens wearers and controls. Conjunctival microcysts were observed in greater numbers, and were larger in size, in lens wearers compared with controls. Conclusions: The effects of contact lens wear on the human bulbar conjunctiva can be investigated effectively at a cellular level using LSCM. The observations in this study suggest that contact lens wear can induce changes in the bulbar conjunctiva such as epithelial thinning and accelerated formation and enlargement of microcysts, increased epithelial cell density, but has no impact on goblet or Langerhans cell density.

Corneal confocal microscopy : a novel noninvasive test to diagnose and stratify the severity of human diabetic neuropathy

OBJECTIVE: The accurate quantification of human diabetic neuropathy is important to define at-risk patients, anticipate deterioration, and assess new therapies. ---------- RESEARCH DESIGN AND METHODS: A total of 101 diabetic patients and 17 age-matched control subjects underwent neurological evaluation, neurophysiology tests, quantitative sensory testing, and evaluation of corneal sensation and corneal nerve morphology using corneal confocal microscopy (CCM). ---------- RESULTS: Corneal sensation decreased significantly (P = 0.0001) with increasing neuropathic severity and correlated with the neuropathy disability score (NDS) (r = 0.441, P < 0.0001). Corneal nerve fiber density (NFD) (P < 0.0001), nerve fiber length (NFL), (P < 0.0001), and nerve branch density (NBD) (P < 0.0001) decreased significantly with increasing neuropathic severity and correlated with NDS (NFD r = −0.475, P < 0.0001; NBD r = −0.511, P < 0.0001; and NFL r = −0.581, P < 0.0001). NBD and NFL demonstrated a significant and progressive reduction with worsening heat pain thresholds (P = 0.01). Receiver operating characteristic curve analysis for the diagnosis of neuropathy (NDS >3) defined an NFD of <27.8/mm2 with a sensitivity of 0.82 (95% CI 0.68–0.92) and specificity of 0.52 (0.40–0.64) and for detecting patients at risk of foot ulceration (NDS >6) defined a NFD cutoff of <20.8/mm2 with a sensitivity of 0.71 (0.42–0.92) and specificity of 0.64 (0.54–0.74). ---------- CONCLUSIONS: CCM is a noninvasive clinical technique that may be used to detect early nerve damage and stratify diabetic patients with increasing neuropathic severity. Established diabetic neuropathy leads to pain and foot ulceration. Detecting neuropathy early may allow intervention with treatments to slow or reverse this condition (1). Recent studies suggested that small unmyelinated C-fibers are damaged early in diabetic neuropathy (2–4) but can only be detected using invasive procedures such as sural nerve biopsy (4,5) or skin-punch biopsy (6–8). Our studies have shown that corneal confocal microscopy (CCM) can identify early small nerve fiber damage and accurately quantify the severity of diabetic neuropathy (9–11). We have also shown that CCM relates to intraepidermal nerve fiber loss (12) and a reduction in corneal sensitivity (13) and detects early nerve fiber regeneration after pancreas transplantation (14). Recently we have also shown that CCM detects nerve fiber damage in patients with Fabry disease (15) and idiopathic small fiber neuropathy (16) when results of electrophysiology tests and quantitative sensory testing (QST) are normal. In this study we assessed corneal sensitivity and corneal nerve morphology using CCM in diabetic patients stratified for the severity of diabetic neuropathy using neurological evaluation, electrophysiology tests, and QST. This enabled us to compare CCM and corneal esthesiometry with established tests of diabetic neuropathy and define their sensitivity and specificity to detect diabetic patients with early neuropathy and those at risk of foot ulceration.

Using biological motion to enhance the conspicuity of roadway workers

This study examined whether the conspicuity of road workers at night can be enhanced by distributing retroreflective strips across the body to present a pattern of biological motion (biomotion). Twenty visually normal drivers (mean age = 40.3 years) participated in an experiment conducted at two open-road work sites (one suburban and one freeway) at night-time. At each site, four road workers walked in place wearing a standard road worker night vest either (a) alone, (b) with additional retroreflective strips on thighs, (c) with additional retroreflective strips on ankles and knees, or (d) with additional retroreflective strips on eight moveable joints (full biomotion). Participants, seated in stationary vehicles at three different distances (80 m, 160 m, 240 m), rated the relative conspicuity of the four road workers. Road worker conspicuity was maximized by the full biomotion configuration at all distances and at both sites. The addition of ankle and knee markings also provided significant benefits relative to the standard vest alone. The effects of clothing configuration were more evident at the freeway site and at shorter distances. Overall, the full biomotion configuration was ranked to be most conspicuous and the vest least conspicuous. These data provide the first evidence that biomotion effectively enhances conspicuity of road workers at open-road work sites.

In vivo performance of melimine as an antimicrobial coating for contact lenses in models of CLARE and CLPU

Purpose: One strategy to minimize bacteria-associated adverse responses such as microbial keratitis, contact lens–induced acute red eye (CLARE), and contact lens induced peripheral ulcers (CLPUs) that occur with contact lens wear is the development of an antimicrobial or antiadhesive contact lens. Cationic peptides represent a novel approach for the development of antimicrobial lenses.---------- Methods: A novel cationic peptide, melimine, was covalently incorporated into silicone hydrogel lenses. Confirmation tests to determine the presence of peptide and anti-microbial activity were performed. Cationic lenses were then tested for their ability to prevent CLPU in the Staphylococcus aureus rabbit model and CLARE in the Pseudomonas aeruginosa guinea pig model. ---------- Results: In the rabbit model of CLPU, melimine-coated lenses resulted in significant reductions in ocular symptom scores and in the extent of corneal infiltration (P < 0.05). Evaluation of the performance of melimine lenses in the CLARE model showed significant improvement in all ocular response parameters measured, including the percentage of eyes with corneal infiltrates, compared with those observed in the eyes fitted with the control lens (P ≤ 0.05). ---------- Conclusions: Cationic coating of contact lenses with the peptide melimine may represent a novel method of prevention of bacterial growth on contact lenses and consequently result in reduction of the incidence and severity of adverse responses due to Gram-positive and -negative bacteria during lens wear.

Visual field size criteria for mobility rehabilitation referral

Purpose. To investigate evidence-based visual field size criteria for referral of low-vision (LV) patients for mobility rehabilitation. Methods. One hundred and nine participants with LV and 41 age-matched participants with normal sight (NS) were recruited. The LV group was heterogeneous with diverse causes of visual impairment. We measured binocular kinetic visual fields with the Humphrey Field Analyzer and mobility performance on an obstacle-rich, indoor course. Mobility was assessed as percent preferred walking speed (PPWS) and number of obstacle-contact errors. The weighted kappa coefficient of association (κr) was used to discriminate LV participants with both unsafe and inefficient mobility from those with adequate mobility on the basis of their visual field size for the full sample and for subgroups according to type of visual field loss and whether or not the participants had previously received orientation and mobility training. Results. LV participants with both PPWS <38% and errors >6 on our course were classified as having inadequate (inefficient and unsafe) mobility compared with NS participants. Mobility appeared to be first compromised when the visual field was less than about 1.2 steradians (sr; solid angle of a circular visual field of about 70° diameter). Visual fields <0.23 and 0.63 sr (31 to 52° diameter) discriminated patients with at-risk mobility for the full sample and across the two subgroups. A visual field of 0.05 sr (15° diameter) discriminated those with critical mobility. Conclusions. Our study suggests that: practitioners should be alert to potential mobility difficulties when the visual field is less than about 1.2 sr (70° diameter); assessment for mobility rehabilitation may be warranted when the visual field is constricted to about 0.23 to 0.63 sr (31 to 52° diameter) depending on the nature of their visual field loss and previous history (at risk); and mobility rehabilitation should be conducted before the visual field is constricted to 0.05 sr (15° diameter; critical).

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.

Simulated visual impairment leads to cognitive slowing in older adults

PURPOSE: To investigate the impact of different levels of simulated visual impairment on the cognitive test performance of older adults and to compare this with previous findings in younger adults. METHODS.: Cognitive performance was assessed in 30 visually normal, community-dwelling older adults (mean = 70.2 ± 3.9 years). Four standard cognitive tests were used including the Digit Symbol Substitution Test, Trail Making Tests A and B, and the Stroop Color Word Test under three visual conditions: normal baseline vision and two levels of cataract simulating filters (Vistech), which were administered in a random order. Distance high-contrast visual acuity and Pelli-Robson letter contrast sensitivity were also assessed for all three visual conditions. RESULTS.: Simulated cataract significantly impaired performance across all cognitive test performance measures. In addition, the impact of simulated cataract was significantly greater in this older cohort than in a younger cohort previously investigated. Individual differences in contrast sensitivity better predicted cognitive test performance than did visual acuity. CONCLUSIONS.: Visual impairment can lead to slowing of cognitive performance in older adults; these effects are greater than those observed in younger participants. This has important implications for neuropsychological testing of older populations who have a high prevalence of cataract.

An international survey of contact lens prescribing for presbyopia

Purpose: The aim was to determine world-wide patterns of fitting contact lenses for the correction of presbyopia. Methods: Up to 1,000 survey forms were sent to contact lens fitters in each of 38 countries between January and March every year over five consecutive years (2005 to 2009). Practitioners were asked to record data relating to the first 10 contact lens fittings or refittings performed after receiving the survey form. Results: Data were received relating to 16,680 presbyopic (age 45 years or older) and 84,202 pre-presbyopic (15 to 44 years) contact lens wearers. Females are over-represented in presbyopic versus pre-presbyopic groups, possibly reflecting a stronger desire for the cosmetic benefits of contact lenses among older women. The extent to which multifocal and monovision lenses are prescribed for presbyopes varies considerably among nations, ranging from 79 per cent of all soft lenses in Portugal to zero in Singapore. There appears to be significant under-prescribing of contact lenses for the correction of presbyopia, although for those who do receive such corrections, three times more multifocal lenses are fitted compared with monovision fittings. Presbyopic corrections are most frequently prescribed for full-time wear and monthly replacement. Conclusions: Despite apparent improvements in multifocal design and an increase in available multifocal options in recent years, practitioners are still under-prescribing with respect to the provision of appropriate contact lenses for the correction of presbyopia. Training of contact lens practitioners in presbyopic contact lens fitting should be accelerated and clinical and laboratory research in this field should be intensified to enhance the prospects of meeting the needs of presbyopic contact lens wearers more fully.

Corneal sensitivity as an ophthalmic marker of diabetic neuropathy

Purpose. The objective of this study was to explore the discriminative capacity of non-contact corneal esthesiometry (NCCE) when compared with the neuropathy disability score (NDS) score—a validated, standard method of diagnosing clinically significant diabetic neuropathy. Methods. Eighty-one participants with type 2 diabetes, no history of ocular disease, trauma, or surgery and no history of systemic disease that may affect the cornea were enrolled. Participants were ineligible if there was history of neuropathy due to non-diabetic cause or current diabetic foot ulcer or infection. Corneal sensitivity threshold was measured on the eye of dominant hand side at a distance of 10 mm from the center of the cornea using a stimulus duration of 0.9 s. The NDS was measured producing a score ranging from 0 to 10. To determine the optimal cutoff point of corneal sensitivity that identified the presence of neuropathy (diagnosed by NDS), the Youden index and “closest-to-(0,1)” criteria were used. Results. The receiver-operator characteristic curve for NCCE for the presence of neuropathy (NDS ≥3) had an area under the curve of 0.73 (p = 0.001) and, for the presence of moderate neuropathy (NDS ≥6), area of 0.71 (p = 0.003). By using the Youden index, for an NDS ≥3, the sensitivity of NCCE was 70% and specificity was 75%, and a corneal sensitivity threshold of 0.66 mbar or higher indicated the presence of neuropathy. When NDS ≥6 (indicating risk of foot ulceration) was applied, the sensitivity was 52% with a specificity of 85%. Conclusions. NCCE is a sensitive test for the diagnosis of minimal and more advanced diabetic neuropathy and may serve as a useful surrogate marker for diabetic and perhaps other neuropathies.

Clinical investigation of asmofilcon A silicone hydrogel lenses

Purpose. To investigate the clinical and subjective performance of asmofilcon A, a new third generation silicone hydrogel contact lens during 6-night extended wear (EW) over 6 months. Methods. A prospective, randomized, single-masked study was conducted. Sixty experienced daily wear soft contact lens wearers were randomly assigned to wear either asmofilcon A or senofilcon A contact lenses bilaterally for 6 months on an EW basis. Evaluations were conducted at contact lens delivery and after 1 week, 4 weeks, 3 and 6 months of EW. Results. Fifty subjects (83%) successfully completed the study. Two subjects experienced adverse events; one unilateral red eye with asmofilcon A and one asymptomatic infiltrate with senofilcon A. There were no significant differences in high or low contrast distance visual acuity between asmofilcon A and senofilcon A; however, low contrast distance visual acuity decreased significantly over time with both contact lens types (p < 0.05). The two lens types did not vary significantly with respect to any of the objective and subjective measures assessed (p > 0.05). Superior palpebral conjunctival injection showed a statistically significant increase over time with both lens types (p < 0.05). Both lens types were rated highly with respect to overall comfort, with subjects reporting 14 or 15 h of comfortable lens wearing time per day at each of the study visits (p > 0.05). Overall satisfaction ratings were also very high at all visits, with median scores of 95 (86 to 99) for asmofilcon A and 90 (85 to 96) for senofilcon A at 6 months (p > 0.05). Conclusions. Over 6 months of EW, the asmofilcon A contact lens performed in a similar manner to senofilcon A with respect to visual acuity, ocular health, and contact lens performance measures. Longer-term EW studies are required to investigate the changes over time observed with both lens types.

Model-order selection in Zernike polynomial expansion of corneal surfaces using the efficient detection criterion

Corneal-height data are typically measured with videokeratoscopes and modeled using a set of orthogonal Zernike polynomials. We address the estimation of the number of Zernike polynomials, which is formalized as a model-order selection problem in linear regression. Classical information-theoretic criteria tend to overestimate the corneal surface due to the weakness of their penalty functions, while bootstrap-based techniques tend to underestimate the surface or require extensive processing. In this paper, we propose to use the efficient detection criterion (EDC), which has the same general form of information-theoretic-based criteria, as an alternative to estimating the optimal number of Zernike polynomials. We first show, via simulations, that the EDC outperforms a large number of information-theoretic criteria and resampling-based techniques. We then illustrate that using the EDC for real corneas results in models that are in closer agreement with clinical expectations and provides means for distinguishing normal corneal surfaces from astigmatic and keratoconic surfaces.

Lateral shearing interferometry for analysis of tear film surface kinetics

Purpose: To date, there have been no measuring techniques available that could clearly identify all phases of tear film surface kinetics in one interblink interval. ----- ----- Methods: Using a series of cases, we show that lateral shearing interferometry equipped with a set of robust parameter estimation techniques is able to characterize up to five different phases of tear film surface kinetics that include: (i) initial fast tear film build-up phase, (ii) further slower tear film build-up phase, (iii) tear film stability, (iv) tear film thinning, and (v), after a detected break-up, subsequent tear film deterioration. ----- ----- Results: Several representative examples are given for estimating tear film surface kinetics in measurements in which the subjects were asked to blink and keep their eyes open as long as they could. ----- ----- Conclusions: Lateral shearing interferometry is a noninvasive technique that provides means for temporal characterization of tear film surface kinetics and the opportunity for the analysis of the two-step tear film build-up process.

Ability of silver-impregnated contact lenses to control microbial growth and colonisation

Purpose: To examine the ability of silver nano-particles to prevent the growth of Pseudomonas aeruginosa and Staphylococcus aureus in solution or when adsorbed into contact lenses. To examine the ability of silver nano-particles to prevent the growth of Acanthamoeba castellanii. ----- ----- Methods: Etafilcon A lenses were soaked in various concentrations of silver nano-particles. Bacterial cells were then exposed to these lenses, and numbers of viable cells on lens surface or in solution compared to etafilcon A lenses not soaked in silver. Acanthamoeba trophozoites were exposed to silver nano-particles and their ability to form tracks was examined. ----- ----- Results: Silver nano-particle containing lenses reduced bacterial viability and adhesion. There was a dose-dependent response curve, with 10 ppm or 20 ppm silver showing > 5 log reduction in bacterial viability in solution or on the lens surface. For Acanthamoeba, 20 ppm silver reduced the ability to form tracks by approximately 1 log unit. ----- ----- Conclusions: Silver nanoparticles are effective antimicrobial agents, and can reduce the ability of viable bacterial cells to colonise contact lenses once incorporated into the lens.----- ----- Resumen: Objetivos: Examinar la capacidad de las nanopartículas de plata para prevenir el crecimiento de Pseudomonas aeruginosa y Staphylococcus aureus en soluciones para lentes de contacto o cuando éstas las adsorben. Examinar la capacidad de las nanopartículas de plata para prevenir el crecimiento de Acanthamoeba castellanii.----- ----- Métodos: Se sumergieron lentes etafilcon A en diversas concentraciones de nanopartículas de plata. Las células bacterianas fueron posteriormente expuestas a dichas lentes, y se compararon cantidades de células viables en la superficie de la lente o en la solución con las presentes en lentes etafilcon A que no habían sido sumergidas en plata. Trofozoítos de Acanthamoeba fueron expuestos a nanopartículas de plata y se examinó su capacidad para formar quistes.----- ----- Resultados: Las lentes que contienen nanopartículas de plata redujeron la viabilidad bacteriana y la adhesión. Hubo una curva de respuesta dependiente de la dosis, en la que 10 ppm o 20 ppm de plata mostró una reducción logarítmica > 5 en la viabilidad bacteriana tanto en la solución como en la superficie de la lente. Para Acanthamoeba, 20 ppm de plata redujeron la capacidad de formar quistes en aproximadamente 1 unidad logarítmica.----- ----- Conclusiones: Las nanopartículas de plata son agentes antimicrobianos eficaces y pueden reducir la capacidad de células bacterianas viables para colonizar las lentes de contacto una vez que se han incorporado en la lente.