Specialist contact lens fitting

What is meant by the term ‘specialist contact lens fitting’? Or put another way, what would be considered non-specialist contact lens fitting? Is there such a thing as routine contact lens fitting? Soft or silicone hydrogel fitting for daily wear would probably be considered as routine contact lens fitting, but would extended or flexible wear remain in the same category or would they be considered a specialist fit? Different eras will classify different products as being ‘specialist’. Certainly twenty years ago soft toric contact lenses were considered as being speciality lenses but today would be thought of as routine lenses. Conversely, gas permeable lenses were thought of as mainstream twenty years ago but now are considered as speciality lenses. Although this would not be the same globally, as in some countries (such as Netherlands, France and Japan) gas permeable lens fitting remains popular and is not on the decline as in other countries (Canada, Australia and Sweden) [1]. Bandage soft lenses applied after surface laser refractive procedures would be considered as therapeutic lenses but in reality they are just plano thin hydrogel lenses worn constantly for 3–4 days to allow the underlying epithelium to convalesce and are then removed [2]. Some patients find that wearing hydrogel lenses during periods when they suffer from seasonal allergies actually improves their ocular comfort as the contact lens acts as a barrier to the allergen [3] and [4]. Scleral lenses have long been considered speciality lenses, apart from a time when they were the only lenses available but at that time all contact lens work would have been considered speciality practice! Nowadays we see the advent of mini-scleral designs and we see large diameter gas permeable lenses too. It is possible that these lenses increase the popularity of gas permeable lenses again and they become more main stream. So it would seem that the lines between routine and speciality contact lens fitting are not clear. Whether a lens is classed a specialist fit or not would depend on the lens type, why it was fitted, where in the world the fitting was being done and even the era in which it was fitted. This begs the question as to what would be considered entry level knowledge in contact lens fitting. This may not be an issue for most BCLA members or CLAE readers but certainly would be for bodies such as the College of Optometrists (UK) or the Association of British Dispensing Opticians when they are planning the final registration examinations for budding practitioners or when planning the level of higher level qualifications such as College Certificates or Diplomas. Similarly for training institutions when they are planning their course content. This becomes even trickier when trying to devise a qualification that spans across many countries, like the European Diploma in Optometry and Optics. How do we know if the training and examination level is correct? One way would be to analyse things when they go wrong and if patterns of malpractice are seen then maybe that could be used as an indicator to more training being needed. There were 162 Fitness to Practice Hearing at the General Optical Council between 2001 and 2010. Forty-seven of these were clinically related case, 39 fraud related, and 76 others. Of the clinical ones only 3 were contact lens related. So it would appear that as whole, in the profession, contact lens clinical skills are not being questioned too often (although it seems a few of us can’t keep our hands out the cookie jar!).

Future of contact lens usage

I was recently part of a small committee looking at higher qualifications in contact lens practice and the discussion turned to future technologies. There was mention of different materials and different applications of contact lenses. Drug delivery with contact lenses was discussed as this has been talked about in the literature for a while. The first paper I could find that talked about using contact lenses for drug delivery dates back over 40 years. There was a review paper in CLAE in 2008 that looked specifically at this too [1]. However, where are these products? Why are we not seeing them in the market place? Maybe the technology is not quite there yet, or maybe patents are prohibiting usage or maybe the market is not big enough to develop such products? We do have lenses on the market with slow release of lubricating agents but not therapeutic agents used for ocular or systemic conditions. Contact lenses with pathogen detectors may be part of our contact lens armoury of the future and again we can already see papers in the literature that have trialled this technology for glucose monitoring in diabetics or lactate concentration in the tear film. Future contact lenses may incorporate better optics based on aberration control and we see this starting to emerge with aspheric designs designed to minimise spherical aberration. Irregular corneas can be fitted with topography based designs and again this technology exists and is being used by some manufacturers in their designs already. Moreover, the topography based fitting of irregular corneas is certainly something we see a lot of today and CLAE has seen many articles related to this over the last decade or so. What about further into the future? Well one interesting area must the 3-dimensional contact lenses, or contact lenses with electronic devices built in that simulate a display screen. A little like the virtual display spectacles that are already sold by electronics companies. It does not take much of a stretch of the imagination to see a large electronic company taking this technology on and making it viable. Will we see people on the train watching movies on these electronic virtual reality contact lenses? I think we will, but when is harder to know.

Tear protein composition and contact lens wear

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Evidence of lipid degradation during overnight contact lens wear:gas chromatography mass spectrometry as the diagnostic tool

Purpose. We investigated structural differences in the fatty acid profiles of lipids extracted from ex vivo contact lenses by using gas chromatography mass spectrometry (GCMS). Two lens materials (balafilcon A or lotrafilcon A) were worn on a daily or continuous wear schedule for 30 and 7 days. Methods. Lipids from subject-worn lenses were extracted using 1:1 chloroform: methanol and transmethylated using 5% sulfuric acid in methanol. Fatty acid methyl esters (FAMEs) were collected using hexane and water, and analyzed by GCMS (Varian 3800 GC, Saturn 2000 MS). Results. The gas chromatograms of lens extracts that were worn on a continuous wear schedule showed two predominant peaks, C16:0 and C18:0, both of which are saturated fatty acids. This was the case for balafilcon A and lotrafilcon A lenses. However, the gas chromatograms of lens extracts that were worn on a daily wear schedule showed saturated (C16:0, C18:0) and unsaturated (C16:1 and C18:1) fatty acids. Conclusions. Unsaturated fatty acids are degraded during sleep in contact lenses. Degradation occurred independently of lens material or subject-to-subject variability in lipid deposition. The consequences of lipid degradation are the production of oxidative products, which may be linked to contact lens discomfort. © 2014 The Association for Research in Vision and Ophthalmology, Inc.

Contact lens interactions with the tear film

Biochemical changes brought about by the influence of the contact lens on the tear film are conveniently split into two categories. Firstly, the lens can remove or reduce the levels of specific components in the tear film, and secondly, the lens can augment the tear film, by stimulating the influx of new components or increasing the level of existing components. The most obvious tear film components for study in this context are lipids, proteins, mucins and electrolytes. The interactions are affected by the properties of the lens, the characteristics of the individual wearer and the wear schedule. An additional complicating factor is the fact that the lens is many times thicker than the tear film and any immobilised tear components will be more extensively exposed to oxygen and UV radiation than is the case in the absence of a lens. It is arguably the lipoidal components that are most markedly affected by lens wear, since their immobilisation on the lens surface markedly increases their susceptibility to autoxidative degradation. The limited information that is available highlights the importance of subject specificity and suggests that lipid oxidation phenomena are potentially important in contributing to the 'end of day' discomfort of symptomatic contact lens patients. It is clear that tear lipids, although regarded as relatively inert for many years, are now seen as a reactive and potentially important family of compounds in the search for understanding of contact lens-induced discomfort. The influence of the lens on tear proteins shows the greatest range of complexity. Deposition and denaturation can stimulate immune response, lower molecular weight proteins can be extensively absorbed into the lens matrix and the lens can stimulate cascade or upregulation processes leading either to the generation of additional proteins and peptides or an increase in concentration of existing components. Added to this is the stimulating influence of the lens on vascular leakage leading to the influx of plasma proteins such as albumin. The evidence from studies of mucin expression in tears is not consistent and conclusive. This is in part because sample sources, lens materials and methods of analysis vary considerably, and in some cases the study population numbers are low. Expression levels show mucin and material specificity but clear patterns of behaviour are elusive. The electrolyte composition of tears is significantly different from that of other body fluids. Sodium and potassium dominate but potassium ion concentrations in tears are much higher than in serum levels. Calcium and magnesium concentrations in tears are lower than in serum but closer to interstitial fluids. The contact lens provides the potential for increased osmolarity through enhanced evaporation and differential electrolyte concentrations between the anterior and posterior tear films. Since the changes in ocular biochemistry consequent upon contact lens wear are known to be subject-dependent - as indeed is wearer response to the lens - pre-characterisation of individual participant tear chemistry in clinical studies would enhance understanding of these complex effects. © 2013 Elsevier Ltd.

Adverse events and discontinuations during 18 months of silicone hydrogel contact lens wear

PURPOSE. To report differences in the incidence of adverse events and discontinuations found in a group of neophyte contact wearers using two different silicone hydrogel contact lenses on a daily- and continuous-wear basis during an 18-month period. METHODS. Sixty-one subjects were initially examined, and 53 were eligible to participate in the study. Eligible subjects were randomly assigned to wear one of two silicone hydrogel materials: lotrafilcon A or balafilcon A lenses on a daily- or continuous-wear basis. After an initial screening, subjects were monitored weekly for the first month and then after 3, 6, 12, and 18 months. The incidence of adverse events, including corneal infiltrative events, superior epithelial arcuate lesions, and contact lens-induced papillary conjunctivitis, and discontinuations in each of the four contact lens groups were recorded. RESULTS. Twenty-two adverse events were found. A higher incidence of adverse events was found in subjects wearing lotrafilcon A lenses than in those wearing balafilcon A lenses (χ = 4.40, P=0.04). There were fewer adverse events in subjects wearing lenses on a daily-wear basis than in those wearing lenses on a continuous-wear basis (χ = 5.98, P=0.01). Eight subjects discontinued from the study as a result of recurrent corneal infiltrative events (one), vision problems (two), excessive ocular discomfort (one), relocation (one), noncompliance with the study protocol (one), and being lost to follow-up (two). No significant differences were found in the number of discontinuations between the two lens types (χ = 0.66, P=0.42) and wearing regimens (χ = 0.08, P=0.78). CONCLUSIONS. Lotrafilcon A lenses were associated with a higher incidence of adverse events than balafilcon A lenses were, and this difference is attributed to the difference in the incidence of corneal infiltrative events. Subjects wearing lenses on a daily-wear basis had fewer adverse events than did subjects wearing lenses on a continuous-wear basis. Both lens types and wearing regimens showed a similar incidence of discontinuations. © 2007 Lippincott Williams & Wilkins, Inc.

Changes in ocular physiology, tear film characteristics, and symptomatology with 18 months silicone hydrogel contact lens wear

Purpose. The purpose of this study was to evaluate the longitudinal changes in ocular physiology, tear film characteristics, and symptomatology experienced by neophyte silicone hydrogel (SiH) contact lens wearers in a daily-wear compared with a continuous-wear modality and with the different commercially available lenses over an 18-month period. Methods. Forty-five neophyte subjects were enrolled in the study and randomly assigned to wear one of two SiH materials: lotrafilcon A or balafilcon A lenses on either a daily- (LDW; BDW) or continuous-wear (LCW; BCW) basis. Additionally, a group of noncontact lens-wearing subjects (control group) was also recruited and followed over the same study period. Objective and subjective grading of ocular physiology were carried out together with tear meniscus height (TMH) and noninvasive tear breakup time (NITBUT). Subjects also subjectively rated symptoms and judgments with lens wear. After initial screening, subsequent measurements were taken after 1, 3, 6, 12, and 18 months. Results. Subjective and objective grading of ocular physiology revealed a small increase in bulbar, limbal, and palpebral hyperemia as well as corneal staining over time with both lens materials and regimes of wear (p < 0.05). No significant changes in NITBUT or TMH were found (p > 0.05). Subjective symptoms and judgment were not material- or modality-specific. Conclusions. Daily and continuous wear of SiH contact lenses induced small but statistically significant changes in ocular physiology and symptomatology. Clinical measures of tear film characteristics were unaffected by lens wear. Both materials and regimes of wear showed similar clinical performance. Long-term SiH contact lens wear is shown to be a successful option for patients. Copyright © 2006 American Academy of Optometry.

The effect of contact lens wear on dynamic ocular surface temperature

Aim: To determine the dynamic emitted temperature changes of the anterior eye during and immediately after wearing different materials and modalities of soft contact lenses. Method: A dynamic, non-contact infrared camera (Thermo-Tracer TH7102MX, NEC San-ei) was used to record the ocular surface temperature (OST) in 48 subjects (mean age 21.7 ± 1.9 years) wearing: lotrafilcon-A contact lenses on a daily wear (LDW; n = 8) or continuous wear (LCW; n = 8) basis; balafilcon-A contact lenses on a daily wear (BDW; n = 8) or continuous wear (BCW; n = 8) basis; etafilcon-A contact lenses on a daily disposable regimen (EDW; n = 8); and no lenses (controls; n = 8). OST was measured continuously five times, for 8 s after a blink, following a minimum of 2 h wear and immediately following lens removal. Absolute temperature, changes in temperature post-blink and the dynamics of temperature changes were calculated. Results: OST immediately following contact lens wear was significantly greater compared to non-lens wearers (37.1 ± 1.7 °C versus 35.0 ± 1.1 °C; p < 0.005), predominantly in the LCW group (38.6 ± 1.0 °C; p < 0.0001). Lens surface temperature was highly correlated (r = 0.97) to, but lower than OST (by -0.62 ± 0.3 °C). There was no difference with modality of wear (DW 37.5 ± 1.6 °C versus CW 37.8 ± 1.9 °C; p = 0.63), but significant differences were found between etafilcon A and silicone hydrogel lens materials (35.3 ± 1.1 °C versus 37.5 ± 1.5 °C; p < 0.0005). Ocular surface cooling following a blink was not significantly affected by contact lens wear with (p = 0.07) or without (p = 0.47) lenses in situ. Conclusions: Ocular surface temperature is greater with hydrogel and greater still with silicone hydrogel contact lenses in situ, regardless of modality of wear. The effect is likely to be due to the thermal transmission properties of a contact lens. © 2004 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.

Customer loyalty among daily disposable contact lens wearers

Background: Optometric practices offer contact lenses as cash sale items or as part of monthly payment plans. With the contact lens market becoming increasingly competitive, patients are opting to purchase lenses from supermarkets and Internet suppliers. Monthly payment plans are often implemented to improve loyalty. This study aimed to compare behavioural loyalty between monthly payment plan members and non-members. Methods: BBR Optometry Ltd offers a monthly payment plan (Eyelife™) to their contact lens wearers. A retrospective audit of 38 Eyelife™ members (mean. ±. SD: 42.7. ±. 15.0 years) and 30 non-members (mean. ±. SD: 40.8. ±. 16.7 years) was conducted. Revenue and profits generated, service uptake and product sales between the two groups were compared over a fixed period of 18 months. Results: Eyelife™ members generated significantly higher professional fee revenue ( P<. 0.001), £153.96 compared to £83.50, and profits ( P<. 0.001). Eyelife™ members had a higher uptake of eye examinations ( P<. 0.001). The 2 groups demonstrated no significant difference in spectacle sales by volume ( P= 0.790) or value ( P= 0.369). There were also no significant differences in contact lens revenue ( P= 0.337), although Eyelife™ members did receive a discount. The Eyelife™ group incurred higher contact lens costs ( P= 0.037), due to a greater volume of contact lens purchases, 986 units compared to 582. Conclusions: Monthly payment plans improve loyalty among contact lens wearers, particularly service uptake and volume of lens purchases. Additionally the greater professional fees generated, render monthly payment plans an attractive business model and practice builder.

BCLA Pioneers Lecture - evidence basis for patient selection:how to predict contact lens success

Editorial

Use of imaging technology to better understand soft contact lens fit dynamics

The principal theme of this thesis is the identification of additional factors affecting, and consequently to better allow, the prediction of soft contact lens fit. Various models have been put forward in an attempt to predict the parameters that influence soft contact lens fit dynamics; however, the factors that influence variation in soft lens fit are still not fully understood. The investigations in this body of work involved the use of a variety of different imaging techniques to both quantify the anterior ocular topography and assess lens fit. The use of Anterior-Segment Optical Coherence Tomography (AS-OCT) allowed for a more complete characterisation of the cornea and corneoscleral profile (CSP) than either conventional keratometry or videokeratoscopy alone, and for the collection of normative data relating to the CSP for a substantial sample size. The scleral face was identified as being rotationally asymmetric, the mean corneoscleral junction (CSJ) angle being sharpest nasally and becoming progressively flatter at the temporal, inferior and superior limbal junctions. Additionally, 77% of all CSJ angles were within ±50 of 1800, demonstrating an almost tangential extension of the cornea to form the paralimbal sclera. Use of AS-OCT allowed for a more robust determination of corneal diameter than that of white-to-white (WTW) measurement, which is highly variable and dependent on changes in peripheral corneal transparency. Significant differences in ocular topography were found between different ethnicities and sexes, most notably for corneal diameter and corneal sagittal height variables. Lens tightness was found to be significantly correlated with the difference between horizontal CSJ angles (r =+0.40, P =0.0086). Modelling of the CSP data gained allowed for prediction of up to 24% of the variance in contact lens fit; however, it was likely that stronger associations and an increase in the modelled prediction of variance in fit may have occurred had an objective method of lens fit assessment have been made. A subsequent investigation to determine the validity and repeatability of objective contact lens fit assessment using digital video capture showed no significant benefit over subjective evaluation. The technique, however, was employed in the ensuing investigation to show significant changes in lens fit between 8 hours (the longest duration of wear previously examined) and 16 hours, demonstrating that wearing time is an additional factor driving lens fit dynamics. The modelling of data from enhanced videokeratoscopy composite maps alone allowed for up to 77% of the variance in soft contact lens fit, and up to almost 90% to be predicted when used in conjunction with OCT. The investigations provided further insight into the ocular topography and factors affecting soft contact lens fit.

Immunoblotting and tear sampling techniques for the study of contact lens-induced variations in tear protein profiles

More information on the biochemical interactions taking place between the tear film and the contact lens is required to further our understanding of the causative mechanisms behind the symptoms of dryness and grittiness often experienced by contact lens wearers. These symptoms can often lead to an intolerance to contact lens wear.

The detection of kinin activity in contact lens wear

Many factors can be, and have been, attributed to the appearance of complications in lens wear, but the greatest is associated with deposition. Reduced acuity, irritation and inflammatory responses are often referred to as adverse reactions arising as a result of deposition. In this study, particular attention was paid to the potential role of adsorbed proteins in activating, mediating and/or stimulating a host immune response, i.e., the hypothesis that the adsorption of certain proteins from the tears and ocular surfaces may actively affect successful lens wear. In particular, the purpose of this study was to investigate the presence of a group of proteins previously undiscovered in the ocular environment. The intention was to target a family of proteins/glycoproteins that have become prominent recently in a variety of inflammatory responses and disorders at many other mucosal associated sites around the body, e.g. in nasal rhinitis and in joint inflammation. The protein cascade in question is the kinin family of inflammatory mediators. The aim was to investigate their presence in the ocular environment, specifically in relation to contact lens wear, and consequently assess the implications of their discovery. High molecular weight kininogen (HMWK), with its central role in kinin responses, was investigated initially as the marker of kinin activity, with subsequent members examined thereafter.

Optimal time following fluorescein instillation to evaluate rigid gas permeable contact lens fit

PURPOSE: To examine the optimum time at which fluorescein patterns of gas permeable lenses (GPs) should be evaluated. METHODS: Aligned, 0.2mm steep and 0.2mm flat GPs were fitted to 17 patients (aged 20.6±1.1 years, 10 male). Fluorescein was applied to their upper temporal bulbar conjunctiva with a moistened fluorescein strip. Digital slit lamp images (CSO, Italy) at 10× magnification of the fluorescein pattern viewed with blue light through a yellow filter were captured every 15s. Fluorescein intensity in central, mid peripheral and edge regions of the superior, inferior, temporal and nasal quadrants of the lens were graded subjectively using a +2 to -2 scale and using ImageJ software on the simultaneously captured images. RESULTS: Subjectively graded and objectively image analysed fluorescein intensity changed with time (p<0.001), lens region (centre, mid-periphery and edge: p<0.05) and there was interaction between lens region with lens fit (p<0.001). For edge band width, there was a significant effect of time (F=118.503, p<0.001) and lens fit (F=5.1249, p=0.012). The expected alignment, flat and steep fitting patterns could be seen from approximately after 30 to 180s subjectively and 15 to 105s in captured images. CONCLUSION: Although the stability of fluorescein intensity can start to decline in as little as 45s post fluorescein instillation, the diagnostic pattern of alignment, steep or flat fit is seen in each meridian by subjective observation from about 30s to 3min indicating this is the most appropriate time window to evaluate GP lenses in clinical practice.