CONTACT LENS

Dr.Rajitha R.J.
• An artificial device whose front surface substitutes anterior corneal
surface
• Correct refractive errors and irregularities of front surface of cornea
CLASSIFICATION
DEPENDING ON ANATOMICAL POSITION
• Scleral contact lens
• Semiscleral
• Corneal contact lens
DEPENDING ON NATURE OF MATERIAL USED FOR MANUFACTURING
• Rigid non gas permeable-hard.eg:PMMA
• RGP lenses.eg:cellulose acetate butyrate and silicone lenses
• Soft contact lens or hydrogel.eg:HEMA
DEPENDING ON MODE OF WEAR
• Daily wear
• Extended wear
• Disposable
• Continuous wear
• Occasional wear
• Frequent replacement
DEPENDING ON WATER CONTENT
• Low water content-0 to 40%
• Medium water content-40 to 55%
• High water content->55%
TERMINOLOGY
SINGLE CUT LENS:
• Front surface is a single continuous curve
• Back surface has either has single curve,bicurve
or more than 2 curves

LENTICULAR CUT LENS

• Front surface has central optical portion and
peripheral carrier portion
• Carrier portion has radius of curvature flatter
than centre
BASE CURVE
• Central posterior curve
• Radius of curvature of central area of posterior surface of contact lens

PERIPHERAL AND INTERMEDIATE POSTERIOR CURVE

• On the back surface
• Series of curve which provides flattening from base curve to edge of lens.
• Reservoir of tears

CENTRAL ANTERIOR CURVE

• Determines power of contact lens

OPTIC ZONE
• Single cut lens-entire front surface of lens
• Lenticular cut-front surface minus carrier width
SAGITTAL DEPTH
• Perpendicular distance from central posterior portion of lens to the
diameter of lens
THICKNESS
• Distance between anterior and posterior surface measured at
geometric centre
POWER
• Difference between diopteric power of central anterior and posterior
curve
• Measured in terms of posterior vertex power in diopters
DIAMETER
• Dimension from one edge to the other
BLEND
• Smooth area of transition of radius of curvature from one curve to another

EDGE
• Blended union of peripheral posterior and anterior curve of lens
• Sharp edge-dig into cornea
• Thick edge-irritate the lids
• Z FACTOR-edge lift,extent to which curvature of most peripheral curve
differs from that of base curve radius

TINT
• Colour of the lens
LENS PROPERTIES
WETTABILITY
• Adherence of a liquid to a surface of solid
despite cohesive forces holding liquid
together
WATER CONTENT
• Percentage of contact lens constituted by
water
• Increase in water content increases oxygen
transmissibility, thickness of lens,
mechanical strength.
OXYGEN PERMEABILITY
• Property of polymeric material to transmit gaseous substances
• Expressed as coefficient of variable DK
• D-diffusion coefficient
• K-solubility coefficient

OXYGEN TRANSMISSIBILITY
• Oxygen permeability for a contact lens of given thickness
• DK/L, L is the thickness
• LIGHT TRANSMISSION-measure of optical property

• REFRACTIVE INDEX-depends on density

• HEAT RESISTANCE-depends on external factors

• FLEXURE-mechanical property
Contact lens materials
Focons
• Hydrophobic rigid contact lens
• PMMA, CAB, silicone and styrene
Filcons
• Hydrophilic non rigid gas material
• Hydrophobic silicone rubber elastomers
RIGID NON GAS PERMEABLE-PMMA
Advantage
• High optical quality, stability, light in weight, excellent molding, non
toxic-does not excite allergic reactions

Disadvantage
• Impermeable to Oxygen
• Hard-cause corneal abrasions
• Resist wetting
RGP LENSES
CAB
• Good wetting
• Easily scratched
• Tendency to warp
SILICONE
• High oxygen permeability
• Lack of wettability
STYRENE
• High oxygen permeability
• Surface durability and brittleness
SILICONE ACRYLATE
• Good wetting
• Oxygen permeability

FLUOROPOLYMERS
• High oxygen permeability
• Good surface characteristics
• Not prone to surface deposits
HYDROGEL LENS MATERIALS
HEMA
• Resistant to biodegradation
• Withstand chemical and thermal sterilization
HEMA-VP
• Maximum hydration
• Tendency to color with age
MMA-PVD lenses
made of hydrophilic polymer PVP,monomer VP,hydrophobic MMA
GLYCIDYL METHACRYLATE
SILICONE HYDROGEL
• High DK Value,low water content
OPTICS OF CONTACT LENS
• Thickness
• Surface curvature
• Converging power of liquid lens in air increases
by 0.12 D for 1mm increase in thickness
• Soft contact lens-tear lens have plano power
• RGP
• Plano power when base curve of CL=Corneal
curvature(K)
• Plus power tear lens when base curve of CL
steeper than K
• Minus power tear lens when base curve of
contact lens flatter than K
AFOCAL LENSES
• Correcting properties of optical system imparted by different
curvatures of surface of fluid lens
• Correction of ametropia is due to back vertex power of fluid lens in air

POWERED LENSES
• Correction of ametropia due to difference in curvature of anterior and
posterior surface of contact lens
POWER AND MAGNIFICATION
• Contact lens is placed at vertex plane ,spectacles 13mm in front of
vertex plane
• In hypermetropia, stronger contact lens required.
• Myopia, weaker lens required
• Power of contact lens can be calculated from spectacle correction
• Eg:+8.0 D spherical lens for spectacles
Focal length=1/8 = 0.125m =125mm
Contact lens is 13mm nearer back vertex distance
Focal length of contact lens= 125-13 =112mm
Power of contact lens= 1/f= 1/112= +8.93 D
• Retinal image size is influenced by vertex distance of a corrective lens.
• Contact lens have shorter vertex distance than spectacles, so image
size is changed less.
• Aphakia magnification is 22% with spectacles, 7% with contact lens.
EFFECT ON ACCOMODATION AND
CONVERGENCE DEMAND
• Contact lens increase the accommodative and convergence
requirements of myopic eyes, decrease those of hyperopic eyes
• Effect on the vergence of light rays as they pass through respective
lenses.
• Contact lens corrected eyes have accommodation equivalent to
emmetropic eyes.
INDICATIONS
OPTICAL INDICATIONS
• Anisometropia, unilateral aphakia, high myopia, keratoconus and irregular
astigmatism
Advantages over spectacles
• Can correct irregular corneal astigmatism
• Normal field of vision
• Lack of aberrations
• BSV in high anisometropia
• Rain and fog do not condense on lens
• Cosmetically acceptable
THERAPEUTIC INDICATIONS
• Corneal diseases-non healing ulcer, bullous keratopathy, filamentary
keratitis ,recurrent erosions
• Diseases of iris-aniridia, albinism, coloboma to avoid glare
• Glaucoma-drug delivery
• Amblyopia-opaque lens for occlusion
• Bandage soft contact lens-following keratoplasty, microcorneal
perforation
PREVENTIVE INDICATIONS
• Prevention of symblepharon and restoration of fornices in chemical burns,
exposure keratitis, trichiasis

DIAGNOSTIC INDICATIONS
• Gonioscopy,ERG,Examination of fundus in presence of irregular
astigmatism
• Fundus photo
• Goldmann three mirror examination

OPERATIVE
• Goniotomy,vitrectomy,endocular photocoagulation
COSMETIC INDICATIONS
• Unsightly corneal scars,cosmetic scleral lenses in phthisis bulbi

OCCUPATIONAL INDICATIONS
• Sports men,pilot,actors
CONTRAINDICATIONS
• Mental incompetence,poor motivation
• Chronic dacryocystitis
• Diseases of lids-stye,blepharitis
• Conjunctivitis
• Corneal dystrophies,degeneration
• Episcleritis,scleritis
• Iridocyclitis
• Seventh nerve palsy
• Inability to use hands
• Poor personal hygiene
• Dry eyes
FITTING PROCEDURE FOR RIGID CONTACT LENS

INITIAL PATIENT WORK UP

• History-exclude medical contraindications
• General ocular examination-congestion, infiltration, tear film, blink,
corneal and pupil diameter, palpebral width
• Refraction-Expressed in spherocylindrical notation
• Keratometry
 TRIAL LENS FITTING
1.DIAMETER- overall diameter of 9mm is appropriate
• 0.5 mm less or more may be selected if corneal diameter and palpebral
aperture are small or wide respectively

2.BASE CURVE RADIUS-derived from keratometry

• Usually fit the trial lens based on flatter K reading
In astigmatism base curve steeper than K may be chosen
Guidelines:
0.5 to 1 D- Base curve 0.25D steeper than K is chosen
1.0 to 2.0 D-Base curve 0.5D steeper than K is chosen
More than 2 D-One third toricity to be added to K
3.POWER OF TRIAL LENS
• Calculated from refraction
• Spectacle refraction determined in minus cylinder form
• Corrected for power at refracted vertex distance to a vertex distance
of zero

4.OPTIC ZONE
• Measure pupil diameter in bright and dim light.2mm greater than
pupillary diameter is chosen as the optic zone.
EVALUATION OF TRIAL LENS FIT
• Selected trial lens inserted into eye
• Adaptation period-15 to 30 minutes
• Evaluate using slit lamp biomicroscopy and fluorescein pattern
evaluation
• Position-optic zone must cover entire pupillary area in all gazes

Lens may ride high-upper edge of lens crosses upper limbus while
looking straight….cause and correction given below
Position of lower lid higher(reduce diameter)
Upper lid may be tight(make the edge thin)
Both factors above(use very small lens or prism ballast)
Marked with the rule astigmatism(make lens steep and small)
High minus lens(make edge thin or make plus carrier lenticular lens)
Lens may ride low
Lens may be heavy(make plain lenticular or minus carrier lenticular)
Small or flat lens(fit a large or steep lens)
Exophthalmic eyes(large or steep and small lens)
Horizontal decentring of lens
In corneal opacity,oblique or against the rule astigmatism(steep and
small lens)
Base curve determination
Check lens is flat,steep or ideal
 IDEAL FIT STEEP FIT FLAT FIT

CENTRATION WELL CENTERED WELL CENTERED DECENTERED

MOVEMENT 1.5 TO 2 MM LESS THAN 1 MM MORE THAN 2 MM

MOVEMENT TYPE SMOOTH AND AVERAGE FAST AND JERKY FAST AND EXCESSIVE

FLUORESCEIN CENTRAL LIGHT GREEN(APICAL CENTRAL BRIGHT GREEN CENTRAL BLACK AREA OVER
PATTERN CLEARANCE) CORNEAL APEX.
MID PERIPHERY BROAD BLACK
MID PERIPHERY DARK(TOUCH) AREA MID PERIPHERY AND
PERIPHERY:DIFFUSE GREEN
PERIPHERAL BRIGHT GREEN PERIPHERALBRIGHT GREEN BAND PATTERN
BAND(PERIPHERAL CLEARANCE)
FINALIZATION OF OVERALL
DIAMETER
• Diameter selected initially may
sometimes have to be changed
with change in base curve

• Large lens should have flat radius to

produce same effect as that of
small lens with steep radius
FINALIZATION OF POWER
• Carry out an over refraction
POST FITTING PATIENT MANAGEMENT
• ORDERING RIGID LENSES –specifying the variables(base curve radius,
optic zone diameter, peripheral curve radius, overall diameter, power
of lens.
• EXAMINATION OF ORDERED LENS
• Overall diameter –diameter gauge
• Central lens thickness-lens thickness gauge
• Base curve radius-radioscope
• Lens power-lensmeter
• Edges,peripheral curves and quality inspected
• EVALUATION OF ORDERED LENS FIT

1.LENS POSITION-well centered

2.Lens movements-1 to 2 mm smooth vertical or lateral excursion on
lateral or down gaze
3.Fluorescein pattern
4.Quality of vision-should match the best corrected vision with
glass,better and stable throughout blink
5.Comfort to be evaluated
6.Physiological response-any corneal disturbance
EDUCATING THE PATIENT
• Care of lenses
• Technique of insertion,removal,recentration
• Hygeine,wearing schedule

• Post fit follow up

After 24 hours,72 hours,week,month,3 months,6 months,yearly
RIGID LENS PROBLEMS
• 1.Blurred vision at distance
o Watering,incorrect power,residual astigmatism,scratched lens
o Warped lens and corneal edema
o Oil or mucus deposits

• 2.Blurred vision for near

o Defective power,decentered lens,decreased fluid
interchange,convergence insufficiency

• 3.Blurred vision when contact lens removed and spectacles

worn(spectacle blur)-corneal edema,induced curvature change
• Innevitable awareness of lens-edges damaged,flat base curve,thick large lens,foreign
matter on lens,low grade conjunctivitis
• Feeling of burn,hot and scratchy eyes
• Feeling of lens touching lids
• Uncomfortable feeling in the morning
• Tilting back of head
• Excessive blinking
• Milky fluid coating over lens in morning
• Swelling of lids after all day wear
• Difficulty in removing lens
• Feeling of dryness
• Pain
• Watering
• Photophobia
FITTING OF SOFT CONTACT LENS
• INITIAL WORK UP
1.History
2.General ocular examination
3.Refraction
4.Keratometry
5.Corneal diameter-HVID is noted to denote corneal diameter
TRIAL LENS FITTING TECHNIQUE
• Recommendations for soft contact lens fitting are provided in
brochures by manufacturers
• Maximum three choices of base curve and diameter
• SELECTING INITIAL TRIAL LENS
1.Overall diameter-1.5 to 2 mm larger than HVID
2.Base curve
• Initial base curve chosen is flatter than K
• How much flatter depends on overall diameter and water content of
lens
• Overall diameter of 13 mm,base curve of 0.3mm flatter than flattest K
chosen.
• 0.5 mm further increase in diameter,0.3mm increase in flattening
should be made
• High water content lens-needs slight steeper fit
3.Power of lens
• Spectacle refraction corrected for vertex distance
• Spherical equivalent of this gives contact lens power
EVALUATION OF TRIAL LENS FIT
• Appropriate lens inserted into eye
• Wait for 20 minutes-low water content lens,10 minutes for high water
content lens
• 1.Evaluation of base curve
Fluorescein is never used
 STEEP FIT FLAT FIT OPTIMAL FIT

CENTRATION WELL CENTERED CENTERS INFERIORLY WELL CENTERED

GOOD COVERAGE GOOD COVERAGE

PRIMARY GAZE LESS MOVEMENT >1MM MOVEMENT OPTIMAL MOVEMENT

0.1 TO 0.2 MM <0.5MM

UPGAZE LAG DOES NOT LAG LAGS 2 TO 3 MM LAGS 1MM DOWNWARDS

DOWNWARDS

PUSH UP TEST EXCESS PRESSURE MINIMAL PRESSURE 45-55% TIGHTNESS

APPLIED(>70%) APPLIED(0-40%)

EFFECT OF BLINK ON VISION CLEARS IMMEDIATELY AFTER BLURS ON BLINK CLEAR BEFORE AND AFTER
BLINK BLINK

RETINOSCOPIC REFLEX CLEAR IMMEDIATELY AFTER BLURS AFTER BLINK SHARP AND CRISP BEFORE
BLINK AND AFTER BLINK
• 2.Evaluation of diameter of lens-ideal should extend 1-1.5 mm over
the cornea
• 3.Evaluation of lens power-power of lens corresponds with calculated
power and patient seeing clearly, lens power is alright

• Guidelines for changing trial lens

1.centration improved by increasing overall diameter
2.edge compression diminished by flattening base curve
3.Steep fitting lens replaced by smaller overall diameter or flatter base
or both
4.Flat fitting lens replaced with larger overall diameter,steeper base or
both
POST FITTING PATIENT MANAGEMENT
• ORDERING SOFT LENSES-from manufacturer’s known series,specifying
the required power
• EXAMINATION OF ORDERED LENS AND EVALUATION OF FIT-Examined
for diameter,power,thickness and base curve
• HANDLING AND CARE
• WEARING SCHEDULE
• POST FIT FOLLOW UP AND PROBLEMS
 RIGID CL SOFT CL

QUALITY OF VISION BETTER VARIABLE DESPITE GOOD FIT

DURABILITY MORE DURABLE LESS DURABLE,NEEDS FREQUENT

REPLACEMENT
CORRECTION OF ASTIGMATISM CORRECT MODERATE TO HIGH DO NOT CORRECT ASTIGMATISM
ASTIGMATISM
DEPOSIT FORMATION DEPOSIT RESISTANT PRONE

INFECTION RISK LESS MORE

DRY EYE AND TEAR FILM ARE NOT CONTRAINDICATIONS NOT SUITABLE FOR THOSE WITH
IRREGULARITIES TEAR FILM ABNORMALITY
COST AND HANDLING LESS COST MORE COSTLY
HANDLING EASY DIFFICULT TO HANDLE
DISADVANTAGES ADVANTAGE

COMFORT LESS COMFORTABLE

WEARING PROBLEMS PEOBLEMS WITH IRREGULAR NOT MUCH

SCHEDULE
SPECTACLE BLUR OCCUR NOT KNOWN
 RIGID CL SOFT CL

LENS STABILITY DIFFICULTY IN ACHIEVING DISLODGED LESS FREQUENTLY

GLARE,PHOTOPHOBIA COMMON RARE

FITTING OF LENSES DIFFICULT EASY

SUITABILITY ON DUSTY POOR BETTER

ENVIRONMENT

PATIENTS WITH TIGHT LIDS DIFFICULT SUITABLE

PROBLEM OF IMAGE MOVEMENT RIGID LENS MOVE WITH BLINK- NOT MUCH KNOWN
CAUSING IMAGE MOVEMENT
EXTENDED WEAR LENSES
• Concept of continuous wear day and night for several days,weeks or
months without removal
• Hydrogel soft lenses and RGP lenses
Indications
• Elderly aphakic
• Younger patients to avoid frequent handling problems
• Not willing to comply with routine of DWLs.
• Profession –irregular waking shifts or working hours
• Habitual of falling asleep with lenses worn
• Habitual overwearers
DISPOSABLE CONTACT LENS
• Based on new concept with idea to replace lenses before a problem
develops
• Lenses can be worn on daily or extended wear basis and replaced
weekly,biweekly,monthly or quarterly
ADVANTAGES
• Problem of lens deposit reduced
• GPC incidence reduced
• Reduction of preservative related keratitis
• Convenience in care system
COMPLICATIONS
• Epithelial edema
• Epithelial microcysts
• Corneal abrasions
• Superficial punctate keratitis
• Corneal neovascularization
• 3 and 9 o clock staining Sterile corneal infiltrate
• Corneal warping
• Corneal endothelial changes
• Allergic conjunctivitis
• Giant papillary conjunctivitis
• Superior limbic keratoconjunctivitis

CONTACT LENS RELATED

• Physical damage to lens
• Discolouration
• Lens loss
• Lens deposits