Edward S. Bennett, OD, MSEd, And Milton M. Hom, OD (Eds.) - Manual of Gas Permeable Contact Lenses (2004)

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MANUAL OF GAS PERMEABLE CONTACT LENSES ISBN 0-7506-7335-4

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Contributors
EDWARD S. BENNETT, OD, MSED ROBERT M. GROHE, OD

Director of Student Services Assistant Professor of Clinical
Co-Chief of the Contact Lens Service Ophthalmology
University of Missouri St. Louis Department of Ophthalmology,
College of Optometry Director, Contact Lens Service
St. Louis, Missouri Northwestern University Medical
School
ADRIAN S. BRUCE, BSCOPTOM, PHD Chicago, Illinois
Senior Fellow
Department of Optometry and Vision DAVID HANSEN, OD
Sciences Private Practice
The University of Melbourne; Des Moines, Iowa
Senior Optometrist
Clinical Vision Research VINITA ALLEE HENRY, OD
Victorian College of Optometry Clinical Associate Professor
Melbourne, Victoria, Australia Director of Residencies
Co-Chief of the Contact Lens Service
HELEN J. CHANDOHA, OD University of Missouri St. Louis
Staff Optometrist College of Optometry
Cornea and Refractive Surgery St. Louis, Missouri
Department
Northeastern Eye Institute MILTON M. HOM, OD
Scranton, Pennsylvania Private Practice
Azusa, California
SHELLEY CUTLER, OD
Adjunct Faculty URSULA LOTZKAT
Contact Lenses Granger, Indiana
Pennsylvania College of Optometry
Elkins Park, Pennsylvania BELINDA MING WAI LUK, BSC, OD
Private Practice
MICHAEL D. DEPAOLIS, OD Columbia, Missouri
Clinical Associate
Department of Ophthalmology BRUCE W. MORGAN, OD
University of Rochester Medical Chief of Cornea and Contact Lens
Center Service
Rochester, New York Michigan College of Optometry
Ferris State University
Big Rapids, Michigan
v
vi CONTRIBUTORS
JOHN M. RINEHART, OD LORETTA B. SZCZOTKA-FLYNN, OD, MS

Private Practice Associate Professor
Peoria, Arizona Department of Ophthalmology
Case Western Reserve University;
JOSEPH P. SHOVLIN, OD Director, Contact Lens Service
Director of Contact Lens Services University Ophthalmologists, Inc.
Senior Optometrist University Hospitals of Cleveland
Northeastern Eye Institute Cleveland, Ohio
Scranton, Pennsylvania
JEFFREY J. WALLINE, OD, MS
IVETTA SIEDLECKI, OD Research Scientist
Assistant Professor The Ohio State University
Cornea and Contact Lens Service College of Optometry
University of Missouri St. Louis Columbus, Ohio
College of Optometry
St. Louis, Missouri
Preface
G as permeable (GP) lenses are an important and underutilized

contact lens option in eye care practices today. The benefits of
good quality of vision, astigmatic correction, bifocal designs,
irregular cornea management, and myopia control make them a
“must use” modality in today’s practice if patients are to receive the
best possible vision management. However, for several reasons GP
lenses are not prescribed for a large percentage of those patients who
would benefit most from them. Certainly, the initial comfort issue is
an important concern. The ease of fitting disposable lenses makes
them a simple option to use. In addition, many practitioners do not
feel confident in their GP fitting and problem-solving skills.
The goals of this text are to address all of the aforementioned con-
cerns and describe a management strategy to optimize the initial com-
fort while emphasizing the ease of fitting both spherical and specialty
designs. This text is clinical in nature and will help the practitioner
understand the basics of material selection, fitting, and problem-solv-
ing GP lenses, with the assistance of the video images on the accom-
panying CD-ROM. Contemporary presbyopic management with
GPs—a much underutilized corrective option—is emphasized as well.
With the current interest in corneal reshaping as an alternative to
refractive surgery with myopic patients, the accompanying chapter on
this topic provides a “How to” approach for the successful incorpora-
tion of this modality into contact lens practice. In addition, manage-
ment of young people, keratoconus, and postsurgical patients with GP
lenses is provided.
The authors would like to acknowledge the contributors to this text
including: Adrian Bruce, Shelley Cutler, Dave Hansen, Vinita Henry,
Ursula Lotzkat, Belinda Luk, Bruce Morgan, John Rinehart, Joe
Shovlin, Loretta Szczotka-Flynn, and Jeff Walline. We would also like
to acknowledge the contributions of Bob Grohe to this and the first edi-
tion as well as a lifelong friendship with the first author. The assistance
provided by Maria Taylor via inputting information is also appreciated.
The support provided by Elsevier was essential to the publication of
this manuscript. We would like to especially thank Karen Oberheim,
former medical publisher for Butterworth-Heinemann, for her sup-
port and enthusiasm. This book would not exist today if it were not for
her. Also, Managing Editor Christie Hart’s persistence in seeing
the project completed is greatly appreciated. Likewise, the editorial
vii
viii PREFACE
assistance provided by Project Manager David Stein was invaluable in

improving the quality of this text. The assistance of Managing Editor
Kathy Falk and Editorial Assistant Colin Odell was also appreciated.
The authors would like to thank Drs. John Mountford and Rajni Singh
for their review of sections of this text.
It is our sincere belief that, in every practice that prescribes contact
lenses, GP lenses should be an important part of the practitioner’s fit-
ting regimen. We hope this text will be a valuable guide in both moti-
vating practitioners to fit GP lenses on a regular basis and increasing
their knowledge about the many beneficial applications of this modality.
Edward S. Bennett
Milton M. Hom
1
Corneal Physiological Response and
Consequences of Hypoxia
ADRIAN S. BRUCE
S ome 50 years ago, Smelser et al1,2 demonstrated that oxygen is

necessary for normal corneal function. They showed that con-
tact lenses made from oxygen-impermeable polymethyl-
methacrylate (PMMA) led to marked structural and optical changes in
the cornea. Thirty-four years later, when the first edition of this text
was published in 1986, Andrasko and Bennett3 commented:
“In order to predict whether a prospective contact lens wearer will
achieve success or failure, the practitioner must have a thorough under-
standing of corneal physiology. Specifically, the practitioner must
understand corneal metabolism and its effect on corneal hydration, oxy-
gen demand and waste production under both normal and adverse
conditions.”
Today, it is pleasing to see that the technological advances of rigid lens

materials have greatly decreased the physiologic impact of daily (open-
eye) rigid lens wear. Most patients wearing rigid lenses for daily wear
show minimal or no corneal signs that could be attributed to hypoxia.
For certain hydrogel lens designs, such as higher refractive errors and
toric prescriptions, rigid lenses can offer markedly superior gas
exchange characteristics.
Despite these advances, it remains important for the clinician to
have knowledge of corneal physiology in relation to hypoxia. There are
still some patients wearing older, low-oxygen permeability materials,
and it is important to detect corneal changes when they are present to
form a basis for refitting. There are still some patients needing refit-
ting from the oxygen-impermeable PMMA lenses.
Another situation is patients who may wear their lenses on an
extended-wear basis. Suitable rigid lens materials for extended wear
did not exist 15 years ago; however, with the remarkable advances in
material biochemistry, there are now a number of suitable materials.
However, if suitable materials have not been prescribed or if the
2
Chapter 1 Corneal Physiological Response and Consequences of Hypoxia 3
patients have themselves chosen to wear their lenses overnight, then

hypoxic corneal changes may occur.
Ocular changes related to hypoxia and hypercapnia tend to affect only
the cornea, and there are few associated symptoms, unlike those related
to other causes.4 Thus it is essential for the patient to have a compre-
hensive slit-lamp examination at aftercare visits, including evaluation of
epithelial integrity, stromal transparency, and endothelial regularity.
HOW MUCH OXYGEN IS NEEDED

A decreased availability of oxygen (hypoxia) and an increase in carbon
dioxide (hypercapnia) may occur during contact lens wear. Normally
there is a flow of oxygen (O2) into the anterior corneal surface and an
efflux of carbon dioxide (CO2). The partial pressure gradients for O2
and CO2 are the key to gas movement across the cornea (Table 1-1 and
Figure 1-1). When the eyelid is closed during sleep, the palpebral tarsal
vascular supply becomes the site of gas exchange.
More than 10 to 15 years ago there was agreement among
researchers regarding the precorneal partial pressure of O2 required to
avoid corneal edema. Approximately 10% O2 is required to avoid stro-
mal edema during lens wear.5,6
However, the consensus regarding the O2 transmissibility of rigid
lens materials has been slower in coming, with agreement in pub-
lished values of a larger range of lenses occurring only in recent
years.7-11 Published values for rigid lens materials by these authors,
using Fatt’s ISO/DIS 8321-2 method, are shown in Table 1-2.
O2 transmissibility (Dk/t) of a contact lens material is directly pro-
portional to the O2 permeability of the lens material (Dk, Barrer) and
inversely related to the lens thickness (t, cm). The Dk unit Barrer,
(cm2/sec)(mlO2/[ml × mm Hg]) × 10−11, is also known as Fatt units.12 If
metric units are desired, using hectopascals rather than mm Hg and
then multiplying the Barrer/Fatt unit values by 0.75006 will give the
appropriate value.13
Table 1-1 Oxygen and Carbon Dioxide Partial Pressures

Oxygen Partial Carbon Dioxide Partial
Pressure (PO2 ) Pressure (Pco2 )
Corneal surface, open eye 155 mm Hg ~ 0 mmHg
Corneal surface, closed eye 55 mm Hg 40 mm Hg
Anterior chamber (open 55 mm Hg 40 mm Hg
and closed eye)
4 SECTION I INTRODUCTION
160
Stroma
140
120
Endothelium
Oxygen tension (mm Hg)
100
Open
80 Epithelium
60
Closed
40
20 Anoxic
Covered
0.10 0.20 0.30 0.40 0.50

Distance from aqueous humor (mm)
Figure 1-1. Oxygen tension profiles for various conditions at the epithelial surface.
(From Fatt I: Steady-state distribution of oxygen and carbon dioxide in the in vivo
cornea, Exp Eye Res 7(3):413-430, 1968.)
CO2 transmissibility is directly related to the O2 transmissibility for

rigid lenses, being numerically seven times greater for gas permeable
(GP) lenses.14 Therefore, if a lens has acceptable O2 transmissibility,
then the CO2 transmissibility will also usually be sufficient. However,
the CO2 efflux from the eye is substantially greater than the ingress
of O2 (Figure 1-2).
Lenses with a Dk/t of 22 to 24 × 10−9 Barrer/cm should meet the
corneal O2 requirement when worn in open-eye conditions.6,15,16 This
corresponds to a rigid lens material of Dk = 35, for a lens thickness of
0.15 mm. Holden and Mertz15 found an ideal Dk/t value for extended
wear to be 87 × 10−9 Barrer/cm, although a clinically acceptable value
was suggested to be 34 × 10−9 Barrer/cm.
Table 1-2 Oxygen Permeability (Dk) of Rigid Lens Materials*
Polymer
Chapter 1
Holden et al Fatt & Ruben Tranoudis & Benjamin Technology

Type Manufacturer† (1990) (1993) Efron (1995) (1998) Corp (1998)
Zero Dk
PMMA A all 0 0
Low Dk (<15)
Polycon II S/A 5 10 7 10 8
Optacryl 60 S/A 2 8 8
Paraperm O2 S/A 2 12 10 12
Alberta S/A 12
Boston II S/A 1 12
Medium Dk (15-30)
Boston ES F-S/A 1 18
Boston IV S/A 1 19
Boston RXD F-S/A 1 23 24
Fluoroperm 30 F-S/A 2 28 24 26 24
Fluorex 500 F-S/A 3 25
High Dk (31-60)
Paraperm EW S/A 2 39 30 39
Quantum 1 F-S/A 1 36
Fluoroperm 60 F-S/A 2 38 38
Corneal Physiological Response and Consequences of Hypoxia
Continued
5
6
Table 1-2 Oxygen Permeability (Dk) of Rigid Lens Materials*—cont’d

Polymer
Holden et al Fatt & Ruben Tranoudis & Benjamin Technology
Type Manufacturer† (1990) (1993) Efron (1995) (1998) Corp (1998)
Paragon HDS F-S/A 2 41
SECTION I
Equalens I F-S/A 1 49 48 51 47
Boston 7 F-S/A 1 49
Boston EO F-S/A 1 58 58
Super Dk (61-100)
Menicon EX F-S/A 4 64 62 58
Fluoroperm 92 F-S/A 2 57 64 63 61
Fluoroperm 151 F-S/A 2 74 88
INTRODUCTION
Equalens II F-S/A 1 85
Quantum 2 F-S/A 1 99 93 95
Boston XO F-S/A 1 100
Hyper Dk (>100)
Menicon SF-P F-S/A 4 126 134 125
Menicon Z F-S/A 4 163
*
Measured using ISO/Fatt (ISO/DIS 8321-2) method and categorized according to the criteria listed by Benjamin (1996). In the ISO/Fatt (ISO/DIS
8321-2) method, oxygen transmissibility (Dk/t) of a contact lens is directly proportional to the oxygen permeability of the lens material (Dk, Barrer) and
inversely related to the lens average thickness (L, cm). For comparison with corneal critical oxygen values, use nominal center thickness of 0.15 mm (e.g.,
divide by 1.5 to obtain Dk/t value; need Dk >18 × 10−11 Barrer, for Dk/t >12 × 10−9 Barrer/cm).
†
Manufacturers:
1, Polymer Technology Corporation, Bausch & Lomb; 2, Paragon Optical, USA; 3, GT Laboratories, Illinois; 4, Menicon, Japan; 5, Wesley-
Jessen/CibaVision.
S/A, Silicone/acrylate; F-S/A, fluoro-silicone/acrylate.
O2
1 cm2 CO2
mm3 mm3
Oxygen Carbon dioxide

5 mm3 cm2 hour 21 mm3 cm2 hour
O2 cornea CO2 cornea
Figure 1-2. Volume of oxygen entering and carbon dioxide leaving, 1 cm2 of corneal surface per
hour. (From Hill RM: The physiology of soft contact lens systems. In Ruben M, editor: Soft
contact lenses, New York, 1978, John Wiley & Sons.)
A different way to consider the required Dk/t for corneal health is

via the categories given by Benjamin,13,17 which relate the Dk/t of
lenses in terms of the equivalent O2 percentage received by the healthy
eye during various conditions:
●
Low (Dk/t <12): corneal oxygenation less than that available in
the healthy closed eye
●
Moderate (Dk/t = 12 to 25): corneal oxygenation similar to that in
the healthy closed eye
●
High (Dk/t = 26 to 50): corneal oxygenation significantly more
than that available in the healthy closed eye, although can be
significantly affected by lens design
●
Super (Dk/t = 51 to 80): corneal oxygenation significantly more
than that available in the healthy closed eye, with lens design
having reduced effect, but substantially less than that received by
the central cornea of the open eye
●
Hyper (Dk/t >80): corneal oxygenation just below that received
by the central cornea of the open eye, with minimal effect of lens
design. Even hyper-Dk/t lenses reduce corneal O2 availability
during closed-eye wear, although whether there are clinically
significant effects is unproven.18
The Dk/t of a lens can be related to the equivalent O2 percentage (EOP)
under the lens on the eye. The O2 tension of ambient air is approxi-
mately 21% of barometric pressure (760 mm Hg at sea level), and
the palpebral O2 tension is approximately 7%.19 Figure 1-3 shows the
relationship between the EOP and Dk/t for open- and closed-eye situ-
ations. Lenses of medium to high Dk/t provide an EOP of more than
10%, but hyper-Dk/t lenses are preferable for extended wear. Many
hydrogel lenses today still fall into the low-Dk/t category, particularly
plus-powered and toric lenses, and thus rigid lenses continue to have
a significant advantage in terms of corneal physiology with such cor-
rections.
A further lens type that can cause problems with hypoxia is the
“piggyback” lens fitting. A piggyback lens has a rigid lens fitted on top
of a soft lens to improve vision or tolerance.20 The Softperm lens
(CIBA Vision, Duluth, GA) is an all-in-one lens with a similar philos-
ophy, using a rigid lens center and hydrogel periphery. Unfortunately
it too is made from low-Dk materials.21 One possible alternative is a
“reverse-piggyback” fitting, for which a silicone-hydrogel disposable
lens is worn over the top of a rigid lens, giving the combined benefit
of good vision and potentially high Dk/t (Figure 1-4). Scleral lenses
25
Low Medium High Super Hyper
Dk/t Dk/t Dk/t Dk/t Dk/t
20
Open eye
15
Equivalent
oxygen
percentage
(%)
10
Closed eye
0
0 10 20 30 40 50 60 70 80 90 100
Oxygen transmissibility (ISO/Fatt)
Figure 1-3. Equivalent oxygen percentage (EOP) and Dk/t. Relation between oxygen tension
under a lens and the lens Dk/t, for open and closed eyes. The data are derived from Benjamin
(1993) but using ISO/Fatt Dk values rather than the gas-to-gas values originally used. The
closed-eye curve was created by reducing the open-eye EOP values to ¹⁄₃, a proportion that
approximately reflects the palpebral oxygen availability.(From Fatt I, Weissman BA:
Physiology of the eye: an introduction to the vegetative functions, Boston, 1992,
Butterworth-Heinemann.)
Figure 1-4. Reverse piggyback fitting. A patient with keratoconus wears a silicone-hydrogel
lens over the top of a rigid lens to improve comfort and lens tolerance. (The silicone hydrogel
lens is lightly stained with fluorescein to aid visibility for the photo.)
must be made considerably thicker than the more common intralim-

bal lens designs; therefore higher-Dk materials are desirable. Pullum
and Stapleton22 concluded that for usual scleral lens thicknesses of 0.6
mm in a hyper-Dk material, the mean central corneal swelling induced
was less than 3%.
CORNEAL RESPONSES TO HYPOXIA

If rigid lens wear induces corneal hypoxia, then there is suppression
of corneal aerobic metabolism and stimulation of anaerobic glycolysis.
These changes have many important sequelae, including lowered
epithelial metabolic rate, increased epithelial lactate production, and
an acidic shift in stromal pH.
In addition, there are a number of other corneal responses that are
not solely attributed to hypoxia but in which hypoxia may play an
important role. Such responses include distortion of corneal shape,
hypoesthesia, angiogenesis, and infection.
REDUCED EPITHELIAL METABOLISM

During hypoxia the two aerobic metabolic pathways of the epithelium,
the tricarboxylic acid cycle and the hexose-monophosphate shunt,
operate at a reduced rate, and adenosine triphosphate (ATP) produc-
tion is impaired.23 Although anaerobic metabolism is able to partially
compensate for the decrease in ATP production, the net energy avail-
able to the epithelium may still be drastically reduced.
A reduced epithelial aerobic metabolism resulting from hypoxia
leads to a range of physiologic changes, such as reduction in the
mitotic cell activity, loosening of tight junctions, decrease in numbers
of hemidesmosomes, and separation of corneal epithelial cells. The
surface cells may become more fragile, and there may be a slight
epithelial thinning. In closed-eye wear, rigid lenses with a Dk/t of less
than 20 Barrer/cm can cause severe corneal epithelial damage,
whereas Dk/t of 64 × 10−9 causes relatively little effect.24,25
Conversely, it has been observed that lens wear can increase the aver-
age size of superficial epithelial cells. Mathers et al26 observed that the
epithelial cells of daily-wear GP contact lens patients were larger (613 +/–
103 μm2) than those in their control group of healthy young patients (513
+/– 53 μm2). This may be because the contact lens reduces the effect of
blink-induced epithelial shedding from the corneal surface. Alternatively,
there may be a downregulation of epithelial shedding caused by a sup-
pression of central corneal basal epithelial cell proliferation.27
The most obvious clinical manifestation of hypoxic changes to
epithelial physiology is surface disruption, as observed via fluorescein
staining. The staining can be categorized according to severity.
Superficial Punctate Staining

Superficial punctate staining is the result of premature shedding of
small groups of surface cells and disruption of the ocular surface
mucous layer. A patient with epithelial fluorescein staining is gener-
ally asymptomatic because the injury threshold of the cornea is less
than the touch threshold.
Hypoxia associated with rigid lenses is most likely to produce punc-
tate staining in the central area because this is the area of the cornea
most frequently covered by the lens. It may result from, for example,
moderate short-term hypoxia, low-Dk/t lens overwear, or chronic long-
term hypoxia, such as that caused by extended wear of moderate-Dk
lenses. Ichijima et al28 concluded that rabbits show no change in
epithelial barrier function with fluorophotometry or hypoxic corneal
staining with closed-eye wear of GP lenses with a Dk/t greater than
80 × 10−9.
However, superficial punctate staining of only a mild degree in con-

tact lens wearers may not be diagnostic of an underlying problem.
Furthermore, even rigid lenses of very high Dk/t can induce epithelial
staining as a result of nonhypoxic causes, such as mechanical effects
(e.g., lens adherence) or desiccation (e.g., 3 and 9 o’clock staining).29,30
Epithelial Abrasion
An epithelial abrasion is seen as confluent central fluorescein staining
resulting from overwear of PMMA or closed-eye wear of low O2 trans-
missibility lenses. Scanning electron microscopy shows desquamation
of epithelial superficial and wing cells for low-Dk/t rigid lens groups.28
If the abrasion is traumatic or the result of the lens being adherent
to an epithelium already weakened by hypoxia, then the abrasion will
have sharply demarcated edges. The epithelium in patients with kera-
toconus may also be weakened relative to the healthy cornea because
abrasions are more common in those with keratoconus. Weissman et
al31 found the frequency of abrasion was 5 of 68 (7.4%) during 2 months
for patients with keratoconus and 6 of 426 (1.4%) during 2 months for
patients without keratoconus, a statistically significant difference.
These are acute conditions, and the patient may experience signifi-
cant discomfort or pain. However, the lesion is not usually infected,
stromal infiltration is not present, and after discontinuing lens wear,
rapid healing within a few days may be expected (Figure 1-5). A pro-
phylactic topical antibiotic may be prescribed if there is a risk of sec-
ondary infection.
Microcysts and Vacuoles

Microcysts and vacuoles appear as translucent cysts in the epithelium
and range from 0.1 to 0.01 mm in diameter. The cysts are termed
microcysts if they have a higher refractive index than the surrounding
epithelial cells and show reversed illumination using marginal retroil-
lumination imaging. Conversely, vacuoles have a lower refractive
index and show unreversed illumination. Although rare in daily-wear
contact lens users, these cysts are relatively common in those who use
extended-wear lenses of moderate O2 transmissibility.30,32 As Dk/L
increases, there is a decrease in the incidence of epithelial microcysts.
It takes 6 to 8 weeks of extended wear before microcysts appear. If
microcysts break through to the epithelial surface, then scattered
punctate fluorescein staining may be visible.
Microbial Keratitis
Microbial infections and their sequelae are not primarily hypoxic
responses. Nevertheless, it is worth mentioning these conditions in this
Figure 1-5. A and B, Sterile ulcer.

chapter because they are complications that can potentially occur subse-
quent to corneal hypoxia and the subsequent epithelial disruption.
Signs of microbial keratitis include:
●
Pain that does not resolve or is exacerbated by lens removal and
accompanied by redness, discharge, or decreased vision.
●
An epithelial defect with an underlying stromal excavation and
infiltrate, typically unilateral and likely to be central or mid
peripheral in location.
●
Other possible associated signs are surrounding epithelial,
stromal, and endothelial edema, stromal thinning, necrosis of
the infiltrate, mucopurulent discharge, keratic precipitates, and
an anterior chamber reaction.
Risk factors for microbial keratitis are the presence of pathogenic bac-
teria in the eye and epithelial disruption (fluorescein staining).
Statistically, of patients who have both of these conditions, fewer than
1 in 100 will develop a corneal infection.4 This statistic is a testament
to the natural antimicrobial defenses of the eye.
The front-line ocular defense mechanisms include blinking and
tear flow, which sweep away bacteria before they can adhere to the
cornea.33 Mucous strands are rolled across the cornea by blinking and
tend to trap bacteria. Desquamation of epithelial cells is a regular
occurrence, which assists in removal of bacteria that may have
adhered. There are also tear film antibacterial factors that act toward
lysing bacteria. These include lysozyme, lactoferrin, transferrin, ceru-
loplasmin, beta-lysin, and cellular immune factors. The acquired
immune system of the eye consists of immunoglobulin A (IgA), secre-
tory IgA, and the complement system; the natural immune system
consists of macrophages, neutrophils, and natural killer cells.
Rigid lenses have greater tear flow around the lens than hydrogel
lenses and support a more complete post-lens tear film.34 This charac-
teristic of the fitting of rigid lenses may be one reason why the various
reports of microbial infections consistently show a lower incidence of
infections for patients who wear rigid lenses.
●
Cheng et al35 estimated the annual incidence of microbial
keratitis to be 1.1 per 10,000 (95% confidence interval [CI], 0.6 to
1.7) for users of daily-wear GP lenses. This is similar to the
incidence of microbial keratitis for persons who do not wear
contact lenses.
●
Nilsson and Montan36 found an annual incidence of 1.48 per
10,000 wearers of daily-wear GP lenses.
●
Stapleton et al37 concluded that for daily-wear soft contact lens
users, the relative risk of microbial keratitis was 4.2 times (1.1 to
16.0) that of GP lens wearers; for sterile keratitis, the relative risk
was 2.3 times (1.3 to 4.3) greater than that for GP contact lens
users.
●
Bailey38 found that extended-wear soft lenses were nearly 5 times
more likely to be linked with microbial keratitis than daily-wear soft
lenses and approximately 7.5 times more likely than GP lenses.
●
Chalupa et al39 found the lowest incidence of acute complications
in hard contact lens wearers compared with daily-wear and
extended-wear soft contact lens wearers.
Despite these encouraging statistics, rigid lenses should still be fitted to
minimize the effects of hypoxia and other factors that may compromise
epithelial integrity. Emphasizing the patient’s compliance with lens care
instructions and avoiding contamination of the care solutions should
minimize the possibility of microbial contamination of the lenses.
Bacterial Immunologic Reactions

As with corneal infection, a bacterial immunologic reaction is not
directly a hypoxic response to lens wear. However, both are usually sub-
sequent to a breach in the epithelium that may be hypoxic in origin.
A bacterial immunologic reaction refers to a corneal immunologic
response to toxins produced by bacteria. Sources of bacterial contami-
nation include the lid margins or biofilm on the lens’ surfaces. The lid
margin can harbor organisms, such as Staphylococcus, that secrete exo-
toxins, and the toxins penetrate the cornea via an epithelial defect to
cause localized inflammation. These conditions interrelate with gen-
eral ophthalmologic conditions, such as marginal keratitis, catarrhal
ulcers, and blepharitis.
Acute inflammatory reactions and low-grade sterile peripheral ulcers
have been observed as responses to rigid lens wear.40 Signs of the con-
dition include bulbar or sectorial hyperemia and peripheral corneal
infiltrates approximately 0.5 to 2.0 mm in diameter located in the
epithelium or anterior stroma. The associated epithelium usually shows
minimal fluorescein staining and no ulceration. Keratic precipitates
and anterior chamber inflammation may be present in severe cases.
Sterile infiltrates differ from infectious infiltrates because the latter
tend to be associated with significant pain, epithelial defect, discharge,
anterior chamber reaction, and a central location (the PEDAL
mnemonic).
STROMAL EDEMA
Stromal edema occurs within hours of the onset of hypoxia, with the
degree related to the severity of the hypoxia. An inflow of water into
the stroma (edema) can result from an accumulation of lactate in the
stroma, secondary to a hypoxia-related increase in anaerobic metabo-

lism via the Embden-Meyerhof pathway of the epithelial cells.
In the rabbit model, changes in epithelial, stromal, and aqueous
humor levels of lactate caused by rigid lens wear can be demon-
strated.41 Ichijima and Cavanagh42 found that a level of Dk/L of 84 was
sufficient to avoid changing levels of enzymes related to lactate in the
tear film during extended wear.
Stromal edema may be measured clinically from an increase in the
corneal thickness, using ultrasonic and optical techniques. The edema
response begins within 30 minutes of lens insertion and generally
peaks within 3 hours. The effect of low-Dk lenses (Dk/t <10 Barrer/cm)
may be up to 5% edema with open-eye wear, whereas with medium-Dk
lenses (Dk/t <20 Barrer/cm), edema may be only 1.5% for patients dur-
ing open-eye wear.15
Figure 1-6 provides a guide to the expected corneal edema levels
after overnight wear of rigid lenses in the different Dk categories based
on published data.43 Low-, medium-, and high-Dk category lens mate-
rials usually induce excessive overnight edema (range in average val-
ues from 16% to 10.5%). Only super-Dk and hyper-Dk materials could
be recommended for extended wear:
●
Super-Dk lenses: approximately 7.5% edema (patients unadapted
to lenses)
●
Hyper-Dk lenses: approximately 5% edema
●
No lens: approximately 3% edema
In the rabbit model, a hyper-Dk rigid lens (Menicon SF-P, Nagoya,
Japan) has been shown to cause corneal edema 2.9% higher in
patients with closed-eye wear than in those wearing no lens.44
It is worth noting that corneal thickness measurements can also be
influenced by reflex hypotonic tearing or a physical thinning of the
stroma in long-term wear. Also, there is marked individual variability
in the degree of corneal swelling response.
Stromal Striae and Folds

Striae are visible as fine white vertical lines in the posterior stroma of
the cornea if stromal edema of 6% or higher is present. Thus striae are
not present with current generation daily-wear rigid lenses (medium
Dk or greater). Posterior stromal folds appear as dark lines in the
endothelial specular reflection using biomicroscopy and appear to rep-
resent a buckling of the posterior stroma and endothelial layer. Folds
appear when stromal edema exceeds 10% and thus rarely occur with
daily wear of rigid contact lenses. However, with extended wear of low-
and moderate-Dk lenses (Dk <30 × 10−9 Barrer/cm), posterior folds
can be apparent on eye opening.
25
20
15
Overnight
edema (%)
10
0
Low Dk Medium Dk High Dk Super Dk Hyper Dk No lens
lenses lenses lenses lenses lenses
Figure 1-6. Guide to overnight edema with rigid lenses, showing 95% confidence intervals
(see Table 1-2). (Data modified from La Hood et al [1988] and using the Dk categories cited
by Benjamin [1996].)
Striae and folds remain a beneficial diagnostic indicator of corneal

edema for users of extended-wear lenses. Most rigid materials would
be expected to cause striae immediately at eye opening, but they may
have resolved if the aftercare visit is more than 1 hour after eye open-
ing. Such signs of stromal edema are not expected to be seen at follow-
up examination if lens Dk/t is more than 15 × 10−9 Barrer/cm for daily
wear and at least 34 × 10−9 Barrer/cm for extended wear.15
Distortion
Distortion is an uncommon complication of rigid lens wear and may
result from the effects of hypoxia or the mechanical effect of a poorly
fitting lens. Distortion refers to an irregular corneal shape that causes
a decrease in visual acuity not correctable by spectacles. It is also
known as spectacle blur or corneal warpage. The condition is distinct
from the more common regular shape changes that have been
observed in rigid lens wearers, such as a slight steepening in the ver-
tical meridian.45
Corneal distortion can also be distinguished from keratoconus
because in the former condition the corneal apical curvature is usually
less than 47 D.46 The amount of corneal toricity and the eccentricity
and shape factor are also usually lower in patients with rigid
lens–related corneal distortion compared with those with keratoconus
(Figure 1-7). The correct identification of keratoconus is important
because rigid lenses remain the most effective for masking irregular
corneal topography.47 Similarly, distortion resulting from refractive
surgery can be corrected with rigid lenses.48
If hypoxic in origin, corneal distortion is an effect of localized
corneal edema. The wearing of low-Dk GP lenses or PMMA lenses will
cause more edema in the center of the cornea than in the periphery
and consequently will cause corneal distortion. If the lens does not
center well, then the edema will also be decentered, causing even
greater distortion. When long-term PMMA contact lens wearers are
refit with moderate- to high-Dk GP lenses of similar fit, then a more
regular and symmetric central corneal shape can result, with improved
spectacle visual acuity.49
ENDOTHELIAL RESPONSES
Normal human corneal stromal pH during closed-eye conditions is
7.39 ± 0.01, a level similar to that of the blood. During open-eye con-
ditions, human stromal pH increases approximately 2%, and it may
Figure 1-7. Corneal distortion (warpage) versus keratoconus. A and B, Distortion

from 25 years of polymethylmethacrylate wear. C, Keratoconus.
Continued
Figure 1-7.—cont’d
decrease as much as 5% during wear of an O2-impermeable contact

lens.50 The aqueous humor may also acidify during PMMA or low-Dk
lens wear.51 However, it was observed that changes in aqueous pH
were smaller and slower than changes in the anterior cornea.
The effect of decreasing pH in the corneal stroma is known as aci-
dosis, and it has been attributed to hypercapnia and hypoxia.
Respiratory acidosis can occur when a gas-impermeable lens prevents
CO2 efflux from the corneal stroma (hypercapnia). Metabolic acidosis
can occur if there is a decrease in the pH of the stroma because of

accumulation of stromal lactate. There are short- and long-term
corneal endothelial changes attributed to acidosis.
Endothelial Edema
Endothelial edema is a reversible, short-term change in the corneal
endothelium induced by contact lens wear. It has also been termed
blebs, events, and pseudoguttata. Using the biomicroscope, endothe-
lial edema appears as nonreflective areas in the endothelial specular
reflection. It occurs within 10 minutes of lens insertion, peaks after
approximately 30 minutes, and may last for several hours.52 For wear-
ers of PMMA and GP contact lenses, the edema tends to affect the cen-
tral cornea, and there appears to be an inverse correlation between the
number of blebs and the lens Dk/t.53 The initial bleb response to con-
tact lens wear does not result in cell loss; however, it may foreshadow
long-term changes in the endothelium.
Endothelial Polymegethism
Endothelial polymegethism is a greater than normal variation of cell
size in the corneal endothelial mosaic, observed with the biomicro-
scope or the clinical specular microscope (Figure 1-8). Polymegethism
is graded by the coefficient of variation of cell area, which is the stan-
dard deviation divided by the mean. Although long-term contact lens
Normal Polymegethism
Figure 1-8. Polymegethism. Schematic diagram of the endothelial mosaic, showing the effect
of polymegethism, with an increased number of small and large cells.
wear does not significantly alter endothelial cell density,54 it appears

that polymegethism may compromise the corneal response to stress or
edema.55
A normal endothelium has a coefficient of variation of approxi-
mately 25%, but it may be increased to as much as 46% in a patient
with 20 years of zero Dk/t (PMMA) daily lens wear. Daily wear of
medium-Dk rigid lenses, which do not induce significant corneal
edema, can induce significant polymegethism (to an average of 31%)
after 3 years.56 Patients who have worn PMMA lenses for a prolonged
period do not show significant recovery from polymegethism after
being refitted with high-Dk materials, although further progression is
avoided.57 Therefore it would seem preferable to avoid inducing poly-
megethism by initially fitting patients with lens materials of high Dk
or better.
Corneal Exhaustion Syndrome

Corneal exhaustion syndrome is a rare condition associated with the
presence of marked endothelial polymegethism.55 The signs are intol-
erance to lens wear and blurred, fluctuating vision caused by fluctua-
tions in refractive error. Patients wearing PMMA lenses and patients
fitted for extended wear who have worn these lenses for 10 years or
more are probably most susceptible to developing the condition.
HYPOESTHESIA
The exquisite sensitivity of the human cornea is well known; therefore
it is perhaps surprising that patients with corneal hypoesthesia are
asymptomatic. Many factors have been found to cause reduced corneal
sensitivity, including diabetes, some topical medications, anterior seg-
ment surgery, viral infections, and many others.58
Millodot59 first reported the adverse effect of PMMA lenses on
corneal sensitivity more than 25 years ago. He found that wear of
PMMA contact lenses for 12 hours increased peripheral corneal touch
threshold by approximately 110% in 12 adapted subjects.60 The major-
ity of this decrease in corneal sensitivity occurred after the first 4 hours
of wear. Corneal sensitivity returned to near-normal levels within 30
minutes of removal of PMMA lenses worn for 8 hours.59
Improving the O2 availability to the cornea reduces any effect on
corneal sensitivity.61 Refitting PMMA contact lens wearers with gas
permeable contact lenses leads to an increase in corneal sensitivity.62
Current generation daily-wear rigid contact lenses of medium Dk may
increase corneal touch thresholds by approximately 15%, a statistically
significant but perhaps not clinically significant change (Figure 1-9).
0.55
0.5
0.45
Pressure
g/mm2
0.4
0.35
0.3
Controls Soft CL Wearers RGP Wearers
Figure 1-9. Corneal sensitivity. Corneal touch thresholds are shown for some presenting
patients wearing low-Dk soft materials and medium-Dk rigid materials compared with patients
who did not wear lenses. An 8% to 15% increase in touch threshold was observed with lens
wear. (Data courtesy Dr. SM Ho.)
Overnight wear of rigid lenses of even hyper-Dk material could be

expected to have a significant effect on corneal sensitivity because even
overnight eye closure without lens wear can increase corneal touch
thresholds by 30%.63
HYPEREMIA AND VASCULARIZATION

Vascular changes caused by hypoxia are uncommon in rigid lens wear-
ers. This lack of effect is the result of a key aspect of rigid lenses—the
intralimbal design. Because rigid lenses rarely encroach on the lim-
bus, the potential for untoward effects is minimized. Even if a rigid
lens fitting is less than optimal and the lens is decentered inferiorly,
for example, the Dk/t of the peripheral part of a rigid lens of a
medium- to high-Dk material is usually adequate for daily wear. For
this reason, rigid lenses are usually the lens modality of choice for the
management of vascularization secondary to hydrogel lens wear.64
However, vascular changes can occur in GP lens wearers for other rea-
sons, such as secondary to “3 and 9 o’clock” staining.4
Limbal Hyperemia
It is important to recognize the features of the normal limbus, so that
physiologic or pathologic changes are only ascribed if they are really
present. The normal limbus is a transition zone between the vascular
sclera and the avascular cornea. It is approximately 1 mm in width,
although it is often wider superiorly or inferiorly. The limit of the lim-
bus can be located as the limit of the translucent conjunctival overlay
using marginal retroillumination imaging.65
Limbal hyperemia is a reversible dilation of existing limbal capillar-
ies. It is a common hypoxic complication of hydrogel lenses, and
patients are usually asymptomatic. In rigid lens wearers, limbal and
bulbar conjunctival hyperemia is most commonly a sign of ocular sur-
face desiccation (“3 and 9 o’clock staining”). Hypoxic limbal hyperemia
might only be expected in a rigid lens wearer if the patient had a poorly
centering low-Dk rigid lens or perhaps a medium-Dk rigid lens was
worn for extended wear.
Superficial Vascularization
Superficial vascularization is penetration of blood vessels into the
superficial cornea, and such vessels can be observed as continuous
with the limbal vessels. The superior limbus is most susceptible. Stark
and Martin66 defined vascularization as vessel penetration greater
than 1.5 mm. Corneal vascularization is of concern because the cornea
becomes more susceptible to inflammation or hemorrhage. Because
vascularization can develop in the absence of symptoms, routine fol-
low-up examinations are the only means of detecting this condition.
Intralimbal contact lens designs promote less corneal vasculariza-
tion than hydrogel lenses. Neither long-term daily wear of PMMA con-
tact lenses nor extended wear of hard gas permeable lenses has a
marked effect on the limbal vasculature.67,68 However, there is a risk of
vascularization with piggyback lenses and similar hybrid designs
because of the low Dk/t of the hydrogel periphery (Figure 1-10).20
Vascularization associated with rigid lens wear can occur secondary to
3 and 9 o’clock staining.
Deep Stromal Vascularization

Deep stromal vascularization is characterized by blood vessel growth
deep in the cornea near Descemet’s membrane. With the biomicro-
scope, the vessels appear discontinuous with the limbal blood vessels,
unlike superficial vessels. Deep stromal vascularization carries the sig-
nificant risk of associated opacification or hemorrhage. Deep stromal
vascularization is exceptionally rare in healthy rigid lens wearers, and
Figure 1-10. Corneal vascularization with a Softperm lens. The lens has a rigid center and a
hydrogel lens periphery, both of low-Dk materials.
rigid lenses are advocated for the management of vascularization sec-

ondary to hydrogel lens wear.64
There is a vasogenic stimulus in corneal injury—the combination
of marked corneal edema with infection, disease, or trauma all predis-
pose to the onset of stromal vascularization. Many of the early reports
of deep vascularization associated with contact lens wear involve apha-
kic patients wearing PMMA lenses daily or hydrogel lenses on an
extended basis.4 Similarly, the management of corneal disease or
trauma with scleral, PMMA, or continuous-wear low-water-content
hydrogel lenses increases the likelihood of stromal vascularization.
Fortunately, in the past 10 years there has been a great reduction in the
clinical need for aphakic contact lens wear because the vast majority of
cataract extractions are now associated with intraocular lens implanta-
tion. Nevertheless, there remains a more specialized need for pediatric
aphakic contact lens wear because intraocular lenses are less fre-
quently used for young patients.69
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24. Ichijima H, Petroll WM, Jester JV, et al: Effects of increasing Dk with rigid con-
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26. Mathers WD, Sachdev MS, Petroll M, et al: Morphologic effects of contact lens
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27. Ren DH, Petroll WM, Jester JV, et al: The effect of rigid gas permeable contact
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28. Ichijima H, Yokoi N, Nishizawa A, et al: Fluorophotometric assessment of rabbit
corneal epithelial barrier function after rigid contact lens wear, Cornea 18:87-
91, 1999.
29. Lin ST, Mandell RB: Corneal trauma from overnight wear of rigid or soft contact
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wear, CLAO J 17:96-101, 1991.
31. Weissman B, Chun MW, Barnhart LA: Corneal abrasion associated with contact
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32. Young G, Port M: Rigid gas-permeable extended wear: a comparative clinical
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33. Fleiszig SMJ, Fletcher EL, Lowe R: Microbiology of contact lens care. In Bennett
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34. Bruce AS, Brennan NA: Clinical observations of the post-lens tear film during the
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35. Cheng KH, Leung SL, Hoekman HW, et al: Incidence of contact-lens-associated
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36. Nilsson SE, Montan PG: The annualized incidence of contact lens induced ker-
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37. Stapleton F, Dart JK, Minassian D: Risk factors with contact lens related suppu-
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38. Bailey CS: A review of relative risks associated with four types of contact lenses,
Cornea 9(suppl 1):S59-61, discussion S62-63, 1990.
39. Chalupa E, Swarbrick HA, Holden BA, et al: Severe corneal infections associated
with contact lens wear, Ophthalmology 94:17-22, 1987.
40. Golding TR, Bruce AS, Fletcher EL: Non-ulcerative infiltrative keratitis in RGP
daily wear, Clin Exp Optom 73:178-183, 1990.
41. Ichijima H, Imayasu M, Tanaka H, et al: Effects of RGP lens extended wear on
glucose-lactate metabolism and stromal swelling in the rabbit cornea, CLAO
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42. Ichijima H, Cavanagh HD: Effects of rigid lens extended wear on lactate dehy-
drogenase activity and isozymes in rabbit tears, Cornea 13:429-434, 1994.
43. La Hood D, Sweeney DF, Holden BA: Overnight corneal edema with hydrogel,
rigid gas permeable and silicone elastomer contact lenses, Int Contact Lens
Clin 15:149-154, 1988.
44. Hideji I, MacKeen DL, Hamano H, et al: Swelling and deswelling of rabbit
corneas in response to rigid gas permeable, hydrogel and elastomer contact
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45. Sanaty M, Temel A: Corneal curvature changes in soft and rigid gas permeable
contact lens wearers after two years of lens wear, CLAO J 22:186-188, 1996.
46. Lebow KA, Grohe RM: Differentiating contact lens induced warpage from true
keratoconus using corneal topography, CLAO J 25:114-122, 1999.
47. Griffiths M, Zahner K, Collins M, et al: Masking of irregular corneal topography
with contact lenses, CLAO J 24:76-81, 1998.
48. Lim L, Siow KL, Chong JS, et al: Contact lens wear after photorefractive keratec-
tomy: comparison between rigid gas permeable and soft contact lenses,
CLAO J 25:222-227, 1999.
49. Novo AG, Pavlopoulos G, Feldman ST: Corneal topographic changes after refit-
ting polymethylmethacrylate contact lens wearers into rigid gas permeable
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50. Bonanno JA, Polse KA: Effect of rigid contact lens oxygen transmissibility on
stromal pH in the living human eye, Ophthalmology 94:1305-1309, 1987.
51. Giasson C, Bonanno JA: Corneal epithelial and aqueous humor acidification dur-
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52. Holden BA, Williams L, Zantos SG: The etiology of transient endothelial changes
in the human cornea, Invest Ophthalmol Vis Sci 26:1354-1359, 1985.
53. Ohya S, Nishimaki K, Nakayasu K, et al: Non-contact specular microscopic obser-
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54. MacRae S, Matsuda M, Shelland S, et al: The effects of hard and soft contact
lenses on the endothelium, Am J Ophthalmol 102:50-57, 1986.
55. Sweeney DF: Corneal exhaustion syndrome with long-term wear of contact
lenses, Optom Vis Sci 69:601-608, 1992.
56. Bourne WM, Holtan SB, Hodge DO: Morphologic changes in corneal endothe-
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57. McLaughlin R, Schoessler J: Corneal endothelial response to refitting polymethyl
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58. Martin XY, Safran AB: Corneal hypoesthesia, Surv Ophthalmol 33:28-40, 1988.
59. Millodot M: Effect of hard contact lenses on corneal sensitivity and thickness,
Acta Ophthalmol 53:576-584, 1975.
60. Millodot M: Effect of length of wear of contact lenses on corneal sensitivity, Acta
Ophthalmol 54:721-730, 1976.
61. Millodot M, O’Leary D: Effect of oxygen deprivation on corneal sensitivity, Acta
Ophthalmol 58:434-439, 1980.
62. Bergenske P, Polse K: The effect of rigid gas permeable lenses on corneal sensi-
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63. Millodot M: Diurnal variation of corneal sensitivity, Br J Ophthalmol 56:844-847,
1972.
64. Chan WK, Weissman BA: Corneal pannus associated with contact lens wear, Am
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65. Lawrenson JG, Doshi S, Ruskell GL: Slit-lamp and histological observations of
the normal limbal vasculature and their significance for contact lens wear, J
Br Contact Lens Assoc 14:169-172, 1991.
66. Stark W, Martin N: Extended wear contact lenses for myopic correction, Arch
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2
Material Properties
MILTON M. HOM
ADRIAN S. BRUCE
T he original rigid lens material was polymethylmethacrylate

(PMMA). Much of our thinking with respect to an ideally per-
forming rigid lens today is based on comparisons with our pre-
vious PMMA experience.
From a material properties’ standpoint, PMMA was a wonderful
material. It is considered a hard, glassy, thermoplastic material.
PMMA offered excellent optical clarity, good machinability, and out-
standing wettability, stability, and durability.1 It is the same material
from which old toothbrush handles were made. However, the major
drawback of PMMA was lack of oxygen permeability. As discussed in
Chapter 1, there are many adverse effects of hypoxia related to inade-
quate oxygen transmissibility. For some practitioners, the perfect rigid
material would be PMMA with extremely high Dk.1
DK MEASUREMENT
As a result of the undesirable findings of hypoxia, manufacturers have
taken it on themselves to formulate new products that have higher oxy-
gen permeability. As discussed later, sometimes the properties of these
more permeable materials lend themselves to new problems.
However, the overall benefit of highly oxygen-permeable materials is
superior health for the eye. To many, this outweighs the disadvantages.
There are many different measures of the oxygen permeability of
contact lens materials. The industry standard for measurement is Dk,
which was first described by Fatt in 1971. D represents diffusion, and
k represents solubility. Diffusion is related to the speed of movement
of oxygen molecules in the material. Solubility represents the number
of oxygen molecules dissolved in the material.2 Penetration of oxygen
molecules, or transmissibility, is from diffusion of oxygen through
spaces in the copolymer. As the values for Dk increase, the more per-
meable the lens becomes. In 1993, Benjamin divided contact lens
30
Chapter 2 Material Properties 31
materials into the following five categories based on oxygen transmis-

sion: low (Dk/L <12 Barrer/cm), medium (Dk/L = 12 to 25 Barrer/cm),
high (Dk/L = 26 to 50 Barrer/cm), super (Dk/L = 51 to 80 Barrer/cm),
and hyper (Dk/L >80 Barrer/cm)3 (see Chapter 1).
Dk denotes oxygen transmissibility; Dk/t, or Dk/L, denotes perme-
ability.4 (Dk/t is the term currently used in ISO contact lens terminol-
ogy.) Thickness, or t, denotes the thickness of the contact lens. When
thickness is higher, the total oxygen transmissibility is reduced. When
thickness is lower (lower t), the total transmissibility is increased.5
Polarographic electrode on a bench-top apparatus has been the com-
mon measurement technique used in the past.2,6 The lens is clamped
onto the detector electrode, and the measurement is taken.7 The polaro-
graphic electrode has a central gold or platinum cathode 4 to 8 mm in
diameter. An annular silver ring that acts like an anode surrounds the
cathode. Above the lens sample, the single chamber is filled with water-
saturated air as the measurement is taken. Polymeric films in the food
packaging industry are examined with similar methods.2
Another method for measuring high-Dk materials is the coulomet-
ric or “gas-to-gas” technique.8 The coulometric technique differs from
the polarographic technique and reports higher Dk values,9 unless an
appropriate edge correction is made. A coulometric oxygen sensor is
used to measure Dk values. The coulometric sensor uses a humidified
nitrogen carrier gas to convey the transmitted oxygen to the detector.
Normally a technique for determining gas permeable (GP) Dk values,
the coulometric technique has also been adopted for use with high-Dk
soft lenses.8 Hill10 introduced the “physiologically effective” correlates:
peDk/L and peDk. The peDk/L takes into account hypoxic stress units
and lens transmissibility.
Boundary layer effect also needs to be considered when measuring
oxygen permeability. The boundary layer effect essentially reduces the
“in situ” Dk/t. A boundary layer is formed when the oxygen molecules
arrive at the front surface of the lens faster than they can penetrate. A
boundary layer can form at the back surface of the lens if the oxygen
molecules arrive faster than they can be carried away. Boundary layers
formed at the front and back of the lens entrap oxygen and reduce the
transmissibility. Boundary layers commonly occur and must be con-
sidered for a more accurate Dk value. The procedure for Dk measure-
ment can be corrected to compensate for boundary layer. Boundary
layer effects underestimate the Dk.11
Another effect to consider is edge effect.5 Edge effects overestimate
Dk values.11 Since 1998, ANSI Z80.20 standards have required Dk val-
ues stated by the manufacturers to have this edge correction. As a
result of this change in standards, many of the manufacturers’ stated
32 SECTION II OXYGEN AND THE CORNEA
Dk values have been lowered.9 Some of the companies have resorted

to releasing two Dk values: one that is edge corrected and one that is
not.12 Recently it has been reported that coulometric values also
require edge correction to give values consistent with ANSI Z80.20.13
When evaluating Dk values, there should be an acknowledgment
that the values are measured using the ANSI Z80.20 (ISO/DIS 8321-2)
method at 35˚ C. There are now a number of independent studies of
rigid material Dk values that have used the standard method.9,14-17
Another measurement of oxygen permeability is the equivalent oxy-
gen percentage (EOP). The EOP measures the amount of oxygen deliv-
ered to the cornea while the total barrier effect of the lens in the eye is
considered. The EOP procedure has the apparent advantage of using
the living eye to measure the lenses rather than a bench-top appara-
tus.2 However, the use of the living eye can also be a great disadvan-
tage. The main drawback with EOP is there may be species-to-species
differences. The testing results from the rabbit corneas used in this
measurement may not be applicable to humans.2 Another disadvan-
tage is the great variability in measurement techniques.11
For EOP measurement, a polarographic electrode is covered with a
thin polyethylene or Teflon membrane. The membrane acts as a tiny
chamber to hold a small amount of oxygen. When the electrode is placed
against the cornea, the oxygen passes into the cornea by the process of
diffusion. The contact lens to be tested is worn on the eye. The oxygen
uptake is measured after the contact lens has been worn for 5 minutes.4
An EOP without a lens on the eye is 21%. An EOP of 17.9%
or greater is recommended for extended wear, and an EOP of 9.9% or
greater is recommended for daily wear.7
POLYMERS
Rigid gas permeable monomers are the components that make up
rigid lenses. Each monomer is polymerized into the material to give it
certain desirable properties. The recipes developed by the polymer
chemists designate certain percentages of the monomers.1
Silicone
Silicone is a monomer that can make the polymer gas permeable.
Silicone gives oxygen permeability as a result of silicone-to-oxygen bonds
in the polymer side chains. The angles between the bonds are wider and
more flexible than carbon-to-carbon bonds. The bonds rotate and allow
greater space for oxygen to pass through the polymer. The oxygen mole-
cules rely on diffusion to move through the material.2 The highest Dk
attainable with silicone was 355 Barrer, measured by Fatt 20 years ago.
One property of silicone is hydrophobicity.5 This hydrophobicity

gives the material very poor wetting capability. To make the lens com-
patible with the ocular tear film, the surface needs to be treated to
make it more wettable. Other disadvantages of silicone are softness
and deposit proneness.1
The softness of silicone reduces the dimensional stability. The
lenses become more susceptible to warpage and flexure. Base curve
radius can change when the polymer is not stable.18 Silicone also
makes the lens more prone to filming and deposits. The hydrophobic-
ity of the silicone monomer causes the lens to attract deposits.1
Fluorine
Fluorine adds oxygen permeability by solubility. The high solubility
allows the polymer to have greater transmissibility. Oxygen dissolves
in a material containing fluorine. Fluorine soaks up oxygen like a
sponge, enabling the polymer to increase Dk.1 The affinity fluorine has
for oxygen has been demonstrated by other applications. One use of
fluorochemicals is in artificial blood. The newly created blood supplies
oxygen to the body tissues while carrying away waste products such as
carbon dioxide.19
Another property of fluorine is deposit resistance. One well-known
fluorinated polymer is Teflon, known for preventing matter from stick-
ing to it. A contradiction in monomer properties occurs when fluorine
is added. Fluorine is intensely hydrophobic. This acute hydrophobicity
causes fluorine to attract deposits just as silicone. However, the low
coefficient of friction and low surface tension of fluorine prevent
deposits from sticking and permit removal with blinking.1 The proper
combination of monomers can take advantage of fluorine’s deposit
resistance and at the same time counteract the deposit affinity of sili-
cone when both are in the same polymer.16
Rigidity monomers are usually added to make the lens more rigid.
This is done to compensate for the softness that other monomers,
such as silicone, bring. Without rigidity monomers, the lens would be
flexible like a soft lens.
Methylmethacrylate and Stability Polymers

Methylmethacrylate (MMA) adds stability and strength to the polymer.
Optical clarity and machinability are also enhanced. MMA is related to
PMMA and has some of the same properties. Dimethyl itaconate is
another rigidity and stability monomer.1
Cross-linkers are added to bind the polymer chains. They prevent
the chains from sliding past one another and add stability. The chains
are locked into position with cross-linkers such as ethylene glycol
dimethacrylate. Addition of cross-linkers can make the polymer more

stable. However, too much cross-linker in a polymer can make the
material more brittle and easier to break.1
COPOLYMERS
Silicone/Acrylates
Silicone/acrylates (S/As) are copolymers of MMA and alkylsiloxanyl-
methacryalate. The first well-known material of this genre was Polycon
(Ciba Vision, Duluth, GA). MMA or PMMA provided stability and lens
performance characteristics. Silicone provided the oxygen permeabil-
ity.1 The ratio of PMMA and silicone is generally 65% PMMA and 35%
silicone.19 Another monomer, methacrylic acid, was added for better
wetting capability and to counteract the hydrophobicity of silicone. The
surface of the S/A is actually hydrophobic with highly hydrophilic
zones of methacrylic acid. Some of these zones have a negative charge,
giving the surface a net negative charge.1 The negative charge attracts
water.
The Dk of Polycon was 8 Barrer. This is low by today’s standards.
Manufacturers in the latter part of the 1980s attempted to increase Dk
values of the S/As. Increasing the silicone content was performed to
increase permeability. However, there were drawbacks. Higher sili-
cone content makes the lens softer. Base curve changes, such as minus
lenses flattening and plus lenses steepening, have occurred. Cracking
and crazing have also been reported. The hydrophobicity of silicone
makes the lens attract protein. To counteract this, enzymatic cleaning
was recommended on a regular (weekly) basis.1
Fluoro-Silicone/Acrylates
Fluoro-silicone/acrylates (F-S/As) are the newer generation rigid gas
permeable lens. Bausch and Lomb’s Boston Equalens (Rochester, NY)
was the first lens to incorporate this technology. Fifteen F-S/As have
since replaced S/As. F-S/As differ because of the addition of fluorine
for increased permeability. F-S/As have better deposit resistance,
higher oxygen permeability, and more stability than S/As. When fluo-
rine is added, silicone content can be decreased. Subsequently, better
protein resistance results.1
Because of greater hardness, F-S/As have better optical quality than
SAs. The surface haze seen on S/A lenses is less commonly observed.
The surface of an F-S/A can be polished better. A more polished sur-
face results in better deposit resistance and less surface haze. Comfort
is also better when the surfaces are kept cleaner. Enzymatic cleaning is
also needed less. However, lipid-based deposits are more likely with
F-S/A lenses. Lipid deposits appear as greasy and oily deposits.
F-S/A lenses have an inherent affinity for mucus. The fluorine com-
ponent attracts mucus and enhances the formation of the glycocalyx.
However, compared with S/A lenses, F-S/As have greater tear break-
up times (TBUTs). The adaptation times of F-S/A lenses are shorter
than S/A lenses because of greater comfort.1
Other Copolymers
Menicon Z (Menicon, Clovis, CA) material is derived from fluo-
romethacrylate and siloxanylstyrene and bounded by cross-linkers. Dk
values, measured by Fatt, are 189 Barrer. The ultraviolet (UV)
monomer is benzotriazol. Menicon Z, as well as other Menicon mate-
rials, has limited availability. Menicon is manufactured in the United
States by Con-Cise (San Leandro, CA) and recently received Food and
Drug Administration (FDA) approval for 30-day continuous wear.
Fluorocarbon lenses, such as the Advent lens (Ocular Sciences,
South San Francisco, CA), are composed of fluorine and MMA. The
polymer polyperfluoroether has N-vinyl pyrrolidone added for better
wetting capability. Dk/t values are approximately 100 Barrer. The lens
is flexible like a soft lens.1
Novalens (Nova Vision, Morrisville, NC) is made of strylsilicone.
The lens surface has a neutral surface charge and is more deposit
resistant. The surface is treated to become hydrophilic. However, the
lens cannot be modified because of the special surface treatment.
Silicone elastomer lenses offer tremendous permeability. The
Bausch and Lomb Silsoft lens has excellent permeability and a surface
treatment. The surface treatment counteracts the inherent intense
hydrophobicity of silicone. Elastomeric silicone elastomer lenses han-
dle like soft lenses but feel much like a rigid lens on the eye.1
Silicone elastomer lenses are shipped in purified water. The lenses
partially lose their optimum wettability if allowed to dehydrate. The
loss of wettability may be permanent. The dehydrated lenses are not
able to restore the original contact angle after reimmersion into solu-
tion. Loss of silicone elastomer wettability and reduced comfort have
also been reported after 6 to 12 months of wear.21
Cellulose acetate butyrate (CAB) lenses were the first commercially
available gas permeable lenses. CAB was originally developed in 1938
by Kodak and used in contact lenses in 1974. The major drawbacks of
CAB are poor wettability, dimensional instability, and low Dk. Located
on the cellulose ring are free hydroxyl groups and butyryl groups. The
hydroxyl groups give the polymer wetting capability. The butyryl
groups give the material permeability and flexibility. When the material
is polymerized, the hydroxyl groups are replaced with acetyl and

butyryl groups. The problem with the material is that there is no fixed
composition. Some polymers have larger numbers of hydroxyl groups
and are more wettable. Other polymers have more butyryl groups and
are more permeable and flexible. Different sources of CAB can provide
different properties.
Polystyrene has greater resistance to flexure and lower specific grav-
ity than SAs. Drawbacks of polystyrene are surface stability, brittle-
ness, and low Dk. Styrene is used for Wesley-Jessen’s SoftPerm lens
(Ciba Vision Corporation, Duluth, GA). It composes the rigid center in
the styrene-hydroxyethylmethacrylate (HEMA) combination lens.1
Recently some specialty materials have been introduced, including
two materials (Innovation 50, Harmony) with hydrophilic monomers in
the material matrix to enhance comfort and wetting capability. These
have a purported Dk of 50 and 52, respectively. An additional two mate-
rials have been introduced with photochromic properties (Eclipse,
Varichrome). It is reported that the former material has a Dk of 52, but
the latter has a Dk of only 15. Eclipse changes from green to deep blue,
whereas Varichrome changes from bluish green to deep blue violet.
WETTABILITY
Wetting components make the lens more wettable and help to over-
come the hydrophobic properties of silicone and fluorine. Wetting is
important for proper comfort, excellent visual acuity, and corneal
integrity.21 The tear film wets the lens through three types of surface
interactions: hydrogen bonding, electrostatic interaction, and
hydrophobic interaction. Electrostatic interaction is the strongest of
these binding forces.
The overall net surface charge of a GP surface is negative. Water is
a positively charged molecule. It is attracted to the negative surface by
electrostatic interaction. Wetting components are delicately balanced
in a GP material. Too many wetting monomers make the material
too soft. Too few monomers do not provide adequate wetting.1
Methacrylate acid is a wetting agent that adds a negative charge to the
material surface. It can also be found in soft lens materials. N-vinyl
pyrrolidone adds an electrostatic charge to the polymer. It is also found
in soft lenses. Polyvinyl alcohol and HEMA are other components
used for wetting.
Wetting Angles
Wetting angles are measures of the material’s affinity for water. Lower
wetting angles are more desirable. Higher wetting angles indicate
poorer quality of wetting. The different in vitro methods are sessile

drop, captive bubble, and Wilhelmy plate.
There is a question as to the usefulness of wetting angles. The
cornea is actually a hydrophobic surface. The glycoprotein molecules
form the mucin layer of the tear film. Glycoprotein molecules have
hydrophilic ends (polar sugar ends) and hydrophobic proteinaceous
segments. The hydrophobic ends are attracted to the cornea. The
mucin layer has the hydrophilic surface facing the external corneal
environment and the hydrophobic surface adhering to the cornea.21
The tear film coats the lens when it is placed on the eye.1 The surface
coating is also known as the pellicle. The pellicle acts as camouflage
and can give different rigid gas permeable lenses the same wetting
angles.1
The mucin layer is essential for spreading of the tear film and
wetting. Aqueous tears, without any mucin layer, have an average sur-
face tension of 40 to 42 dyne/cm. The corneal surface has a critical
surface tension of 28 dyne/cm without the mucin layer. The addition
of the mucin layer raises the surface tension of the cornea to allow the
spreading of tears. In vitro methods of measuring wetting angles
described do not consider mucin coverings.21 Producing a surface-
active layer for in vitro measurements is difficult.
Sessile Drop Method

The sessile drop method for wetting angle measurement is one tradi-
tional in vitro method. A drop of water is placed on the test material,
and the angle of contact is measured.1 The angle is formed by a flat
surface and a line tangent to a drop of liquid placed on the surface
(Figure 2-1).22 Angles less than 90 degrees indicate hydrophilicity.
Angles greater than 90 degrees denote hydrophobicity. The sessile
drop method does not offer exacting controls. Numerous factors such
as liquid drop material, drop size, purity, time of measurement after
drop placement, and surface preparation can cause variability.1
Drop of distilled
water
Figure 2-1. The equilibrium sessile drop contact angle is determined by angle A. A is the
absolute sessile-drop contact angle on a flat surface.
Captive Bubble Method

Captive bubble method measures the wetting angle in a bubble chamber
under controlled conditions (Figure 2-2). Poster developed the method
in 1978.1 The test material is immersed in saline or distilled water, and
an air bubble is formed.1,21 When compared with the sessile drop
method, wetting angles are usually one third to one half in value.21 The
difference in values cannot be explained by conventional contact angle
theory because, ideally, the methods should give identical values.21
Captive bubble method takes advantage of soaking the test material
in a solution and may account for these differences.1,21 The hydrophilic
groups on the polymer chain are attracted to the solution and migrate
to the surface (Figure 2-3). When the lens material is soaked, the wet-
ting capability improves. This can also be seen when the lenses are
presoaked before contact lens wear. Soaking the lenses in a condition-
ing solution overnight is beneficial to patient comfort, and soaking the
lenses in solution for 24 to 48 hours can improve wetting capability
and avoid the “first day nonwetting syndrome.”1
Wilhelmy Plate Method

Wilhelmy plate method is another measurement for wetting angles
(Figure 2-4). It dates back to 1863.21 The wetting angle is deduced from
the force measurements as a function of the immersion depth of the
material in water. The advancing angle and receding angle are meas-
ured. The advancing angle relates to the wetting of the tears as it is
spread over the lens surface. It is likened to the lid pushing the tears
over the lens on blink closure. The receding angle relates to the wet-
ting as the tears are withdrawn from the surface. This is similar to the
curtain of tears pulled after the lid when it opens on blinking.1
CLINICAL OBSERVATIONS OF WETTABILITY

Wettability can be observed with the slit lamp. TBUT, tear meniscus,
and tear interference patterns can give the clinician an idea of the lens
␪
␪ ␪
Liquid Gas
Liquid
Nonwettable Very wettable
Figure 2-2. The captive bubble technique. The air bubble is trapped under the inferior surface
of the test material. The angle decreases as wettability increases.
Polymer
surface molecule
Partially Hydrophobic Hydrophilic Fully
dehydrated (Apolar) (Polar) hydrated
Contact
lens
surfaces
Figure 2-3. The wetting can change when the polymer is fully hydrated versus partially dehy-
drated. The side chains can rotate to expose more of the hydrophilic ends and attract water.
wettability. Lenses that wet poorly will exhibit low TBUT. Normal val-
ues for TBUT are 10 seconds or more. When a lens has wettability
problems, the tear film will break up on the lens surface rapidly, some-
times within 1 to 2 seconds. When related to poor wettability, most of
the breakup will occur on particular regions of the lens surface.
Compromised lens surfaces with deposits or scratches will also have
poor wetting.21 Manufacturing defects, such as pitch residue on the
surface, can also cause rapid tear breakup.
Direction Direction
of travel of travel
Advancing contact angle Receding contact angle

Figure 2-4. The Wilhelmy plate method. Advancing and receding angles are calculated as the
test material is immersed and removed from solution.
The tear meniscus surrounding the lens edge and adjacent to the
lids can indicate wetting quality. Smooth, reflective tear surfaces over
the superior and inferior tear prisms and around the circumference of
the rigid lens denote excellent wetting.21 A “black line” appears in the
concave portion of a good quality tear meniscus (Figure 2-5).18
FLEXURE
With GP lenses in thin designs, flexure can be a problem. Rigid lenses
do not normally conform to the cornea. The rigid lens can mask astig-
matism caused by corneal toricity.1 Flexure can occur when there is
one diopter or more of toricity.23 For higher toricities, the lens tends to
conform more to the cornea, and flexure is induced. When the lens
Figure 2-5. The “black line” can be seen encircling the lens just posterior to the edge. The
“black line” represents good-quality wettability and is located in the concave portion of the
tear meniscus.
flexes, a portion of corneal astigmatism is not masked and becomes

apparent during overrefraction and overkeratometry. Visual quality
suffers from larger amounts of flexure.1
Corneal topography, lens thickness, base curve to cornea relation-
ship, inherent rigidity of the material, and lens positioning are factors
that determine flexure. Higher toricities and thinner and steeper
lenses result in greater flexure amounts.1 Past studies about GP flex-
ure focused on first-generation materials.24 Polycon and Polycon II
were cut thin and were notorious for flexure.1,25 The lens-to-cornea fit-
ting relationship and lens parameters were adjusted to solve the prob-
lems with flexure.
Base curve relationship and optical zone diameter influence the
amount of flexure. Fitting flatter than “K” resulted in less flexure than
fitting “on K” or steeper than “K.” One study showed that smaller opti-
cal zone diameters flexed significantly less than larger optical zone
diameters.25 Flexure differences result from differences in sagittal
depths. The larger optical zones and fitting steeper than “K” have more
central clearance and consequently more flexure than lenses with
smaller optical zones and fitted flatter than “K.”
Thicker lenses also flex less. One study has shown increasing cen-
ter thickness reduces lens flexure and controls residual astigmatism.
For older materials like Polycon, increasing the thickness to 0.18 to
0.20 mm was effective.24
One problem fitters in the past faced was the changes in perform-
ance associated with the strategies to reduce flexure. By fitting the lens
flatter, the lens positioning would change. Lenses would fit superiorly
or display excessive movement. If a satisfactory fit was achieved with a
lens fitted slightly steep, changing to a flatter lens could cause decen-
tration. Another challenge was the low Dk values of Polycon materials.
Any increase in lens thickness to reduce flexure would cause a con-
siderable decrease in the already low Dk. The advantage of gas perme-
ability was diminished with thicker Polycon lenses. Today’s materials
possess cross-linkers to enhance rigidity, while providing higher
Dk values. However, one study has shown that the advantage of cross-
linkers may not translate into measurable clinical benefits. A double-
blind study showed Paragon Vision Sciences (Mesa, AZ) Paraperm 30,
without the stability additives, masked the same amounts of resid-
ual astigmatism after fitting as Bausch and Lomb’s Boston ES (with
stabilizers).26
Do the new materials offer better flexure resistance? Although
these newer generation materials may still flex on the eye, the problem
is considered greatly reduced than during the days of Polycon. As a
general rule, it is believed that higher-Dk S/A materials will flex more
than lower-Dk S/A materials, although not as much with the newer
F-S/A materials.27 However, the answer may not be that simple.
Another study has shown that there is no correlation between perme-
ability and flexure measured with autokeratometry. There were no sig-
nificant differences between PMMA, S/A, and F-S/A lenses with
respect to flexure.28
HARDNESS
Hardness is defined as the resistance of material to penetration by
standard needles or similar devices.29 Hardness testers include the
Vickers indenter, Rockwell hardness tester, and Shore durometers.7
Hardness testing can be divided into three categories:
1. Hardness tests that measure the resistance of the material to
indentation. Some durometers are Brinell, Vickers, and Shore.
Some of the tests measure the indentation with the load applied,
and some measure the indentation after the load is taken away.
2. Hardness tests that measure resistance to scratching by another
material. The tests involve pulling the sample beneath a loaded
indenter. Examples of these types of tests are Bierbaum scratch
test and Moh hardness test.
3. Hardness tests that measure recovery efficiency or resilience.
The different Rockwell testers fall under this category.7
Many of the hardness tests used for contact lenses are a combination
of 1 and 3.7 Each of the hardness methods uses an arbitrary scale.
Although each method can be approximately compared with one
another, a precise correlation cannot be made.
For hardness measured on the Shore D scale, PMMA has a value of
approximately 90.7,29 S/A copolymers have a hardness value that is
slightly less because of the softer silicone content.29
IMPACT RESISTANCE
Impact resistance is a measure of the brittleness of the material. The
energy it takes to break a standard test specimen of a specific size
under standard conditions of impact is measured. Wetting agents such
as methacrylic acid can increase brittleness of the material.25
LUMINOUS (LIGHT) TRANSMITTANCE

S/As have light transmittance less than that of PMMA. PMMA has a
luminous transmittance greater than 92%. S/A materials have values
as much as 5% less.29
SPECIFIC GRAVITY
Specific gravity refers to the weight of the lens at a given temperature
divided by the weight of an equal volume of water at the same tem-
perature. Water has a specific gravity of 1.0. Specific gravity values for
rigid lens materials can be low (≤1.10), medium (1.11 to 1.20), or high
(>1.20). Higher specific gravity materials may tend to position inferi-
orly. Sometimes a low specific gravity material can make a lens posi-
tion higher.30,31
COMPARISONS OF PROPERTIES
Table 2-1 shows different contact lens materials and comparisons of
material properties.31 The major problem when comparing the differ-
ent materials is the lack of standardization of some of the measure-
ment techniques. Many of the values are based on the manufacturer’s
literature and claims and do not include edge effect corrections.7
There are problems with comparing wetting angle measurements.
Variables include different solutions used and the effects of soaking.
For instance, a lower surface tension wetting solution combined with
the captive bubble technique produces a low wetting angle no matter
what polymer is used. Coupled with the theory that the pellicle masks
any differences in wetting, some experts question whether wetting
angle measurements offer any clinical significance or rational basis for
comparison.7
There are problems comparing oxygen permeability measure-
ments. Potential sources of error are provided in Table 2-2.11 Despite
these sources of error, the choice of GP lens modality can be made
based on stated Dk values. One suggested material selection protocol
would be:
●
Low Dk/L materials for myopic daily wear only
●
Medium Dk/L for myopic and hyperopic daily wear
●
High Dk/L for myopic flexible wear or hyperopic daily wear
●
Super Dk/L for myopic extended wear or hyperopic flexible wear
●
Hyper Dk/L for myopic and hyperopic extended wear (if the
material is FDA approved for extended wear)3
Another advantage that should be considered when selecting materi-
als is that most high- and hyper-Dk materials have a UV-inhibiting
monomer. UV protection is thought to be helpful in macular degener-
ation and cataract prevention.32
The problems with comparing hardness tests are not reflecting the
actual mechanical failures that normally occur. Patients have problems
with chipping, fracture, splitting, distortion, and warpage. Hardness
44
Table 2-1 Physical Properties Comparison Chart

Material Colors EW† WA‡ Dk§ Dk|| SG¶ UVB # Type
Alberta S-45 C, B N 09 45 1.140 Y PSF
Alberta S-66 C, B N 09 66 1.160 Y PSF
Boston II C, B, GN N 20 14 12 1.130 N S/A
Boston IV C, B, B2 N 17 28 19 1.110 N S/A
SECTION II
Boston ES B,* IB, GN, BR, GY N 52 31 18 1.220 Y F-S/A

Boston Equalens C, B,* B2 Y 30 72 49 1.196 Y F-S/A
Boston RXD B,* IB N 39 45 23 1.270 Y F-S/A
Boston 7 B,* IB N 33 73 49 1.220 Y F-S/A
Fluorocon B Y 15 60 1.150 N F-S/A
FluoroPerm 30 C, B,* B2, GN,* GY* N 13 30 26 1.140 Y F-S/A
FluoroPerm 60 C, B,* GN,* GY* Y 15 60 38 1.150 Y F-S/A
FluoroPerm 60 BN N 15 60 38 1.150 N F-S/A
FluoroPerm 92 C, B,* GN,* GY* Y 16 92 61 1.100 Y F-S/A
FluoroPerm 151 B* Y 42 151 81 1.100 Y F-S/A
Fluorex 300 C, B, GN, GY N 12.6 30 1.113 N F-S/A
OXYGEN AND THE CORNEA

Menicon SF-P B Y 18 102 126 1.120 N F-S/A
Novawet B N 14 55 1.050 N HSS
Ocusil C, B N 14 16 1.110 N S/A
OP-2 C, B, GN, GY, BN N 18 16 1.115 N F-S/A
OP-3 C, B, GN, GY, BN N 15.5 30 1.115 N F-S/A
OP-6 C, B, GN, GY, BN N 23 60 1.113 N F-S/A
Optacryl 60 B N 25 18 1.126 N S/A
Optacryl K B N 25 32 1.110 N S/A
ParaPerm 02 C, B, GN N 25 15 11 1.127 N S/A
ParaPerm EW C, B, GN Y 26 56 36 1.070 N S/A
Chapter 2
Phoenix 18 C, B, IB, GN, GY, N 25 18 1.260 N S/A

GY2, BR, V
Phoenix 32 C, B, IB, GN, GY, N 30 32 1.110 N S/A
GY2, BR, V
Polycon II B N 19 12 9 1.130 N S/A
SPG 1 C, B, GN N 30 19 1.126 N F-S/A
SPG 2 C, B, GN N 27 44 1.126 N F-S/A
SPG 3 C, B, GN N 20 44 1.126 N F-S/A
Trans-Aire C, B, B2, GN, GN2, N 18 45 1.077 N S/A
GY, BN, V, R, Y
PMMA Many N 18 00 0 1.195 N —
Modified from Levitt AP: Specific gravity and RGP lens performance, Contact Lens Spect 11(10):43, 1996.
C, Clear; B, blue; B2, dark blue; IB, ice blue; GN, green; GN2, forest green; GY, gray; GY2, dark gray; BN, brown; V, violet; R, red; Y, yellow; S/A, silicon
acrylate; F-S/A, fluoro-silicon acrylate; HSS, hydrophilic stryl silicon with a 0.005 thick hydrophilic layer; PSF, polysulfone.
*
Available without UV block.
†
Approved for extended or flexible wear.
‡
Wetting angle: the lower the angle, the more wettable the material.
§
The measurement of a material’s ability to pass oxygen: the higher the number, the more oxygen the material can pass.
||
Dk values are measured consistent with ANSI Z80.20 (ISO/DIS 8321-2) method. Average of published values (9, XX2, XX3, XX4, XX5).
¶
Specific gravity: the lower the SG, the lighter the weight of the finished lens. Low SG <1.10, Median SG from 1.10 to 1.20, High SG >1.20
#
UVB, Ultraviolet block is available.
Material Properties
45
Table 2-2 Potential Sources of Error in Oxygen Permeability Measurement

Source of Error Error
Edge correction effect Overestimates DK
Boundary layer effect Underestimates DK
Curved electrode May overstate DK
Temperature change Lower temperature underestimates DK
Interlaboratory variation Variable DK
From Lebow KA, Campbell-Burns D: Understanding the values that describe oxygen flux through
a contact lens, Contact Lens Spectrum 13(1):34-39, 1998.
by indentation of a probe is not necessarily a good measure for choos-

ing materials used by patients. A better test would be tensile stress-
strain analysis on soaked and dry lenses.7
REFERENCES
1. Hom MM: Rigid lens materials. In Hom MM, editor: Manual of contact lens pre-
scribing and fitting with CD-ROM, ed 2, Boston, 2000, Butterworth-
Heinemann, pp 105-111.
2. Fatt I: Oxygen transmission. In Bennett ES, Weissman B, editors: Clinical contact lens
practice, Philadelphia, 1997, Lippincott Williams & Wilkins, pp 13-1 to 13-10.
3. Bennett ES: RGPs: When oxygen is a priority, Contact Lens Spect 13(4):18, 1998.
4. Mandell RB: Oxygen supply and corneal needs. In Mandell RB, editor: Contact
lens practice, ed 4, Springfield, 1988, CC.Thomas, pp 81-106.
5. Hom MM: Soft lens materials. In Hom MM, editor: Manual of contact lens pre-
scribing and fitting with CD-ROM, ed 2, Boston, 2000, Butterworth-
Heinemann, pp 215-218.
6. Gasson A, Morris J: Background. In Gasson A, Morris J, editors: The contact lens
manual, ed 2, Oxford, 1998, Butterworth-Heinemann, pp 1-13.
7. Tighe BJ: Contact lens materials. In Phillips AJ, Speedwell L, editors: Contact
lenses, ed 4, Oxford, 1997, Butterworth-Heinemann pp 50-92.
8. Alvord L, Court J, Davis T, et al: Oxygen permeability of a new type of high Dk
soft contact lens material, Optom Vis Sci 75(1):30-36, 1998.
9. Benjamin WJ: “Wiggle room” and the transitional Dk statistic, Int Contact Lens
Clin 25:118-120, 1998.
10. Hill RM: The “physiologically effective” correlates: peDk/L and peDk, Optom Vis
Sci 76(3):135-140, 1999.
11. Lebow KA, Campbell-Burns D: Understanding the values that describe oxygen
flux through a contact lens, Contact Lens Spectrum 13(1):34-39, 1998.
12. Benjamin WJ: A transitional period for Dk values, Contact Lens Spectrum
13(10):16, 1998.
13. Morgan CF, Brennan NA, Alvord L: Comparison of the coulometric and polaro-
graphic measurement of a high-Dk hydrogel, Optom Vis Sci 78:19-29, 2001.
14. Fatt I, Ruben CM: Oxygen permeability of contact lens materials: a 1993 update,
Contact Lens Anterior Eye 17:11-18, 1994a.
15. Tranoudis I, Efron N: Oxygen permeability of rigid contact lenses, Contact Lens
Anterior Eye 18:49-53, 1995.
16. Holden BA, Newton-Howes J, Winterton L, et al: The Dk project: an interlabora-
tory comparison of Dk/L measurements, Optom Vis Sci 67:476-481, 1990.
17. Polymer Technology Corporation: Boston update—news and information,
Summer:6-7, 1998.
18. Tomlinson A: Choice of material—a material issue, Contact Lens Spectrum
5(9):27-35, 1990.
19. Phillips AJ: Rigid gas permeable corneal lens fitting. In Phillips AJ, Speedwell L,
editors: Contact lenses, ed 4, Boston, 1997, Butterworth-Heinemann, pp 313-
357.
20. Grohe RM, Caroline PJ: Surface deposits on contact lenses. In Bennett ES,
Weissman BA, editors: Clinical contact lens practice, Philadelphia, 1992, JB
Lippincott, pp 24-1 to 24-12.
21. Benjamin WJ: Wettability. In Bennett ES, Grohe RM, editors: Rigid gas-permeable
contact lenses, New York, 1986, Professional Press, pp 118-136.
22. Smith BJ, Fink BA, Hill RM: Dk/L: into the ultra-high zone, Contact Lens Spectrum
14(1):31-34, 1999.
23. Quinn TG: RGP insights: material solutions for gas permeable questions,
Contact Lens Spectrum 15(5):19, 2000.
24. Herman JP: Flexure. In Bennett ES, Grohe RM, editors: Rigid gas-permeable
contact lenses, New York, 1986, Professional Press, pp 137-149.
25. Brown S, et al: Effect of the optic zone diameter on lens flexure and residual
astigmatism, Int Contact Lens Clin 11(12):759-766, 1984.
26. Toscano FR, Bridgewater B: A comparative study of RGP materials in thin lens
designs, Contact Lens Spectrum 12(10):25-28, 1997.
27. Quinn TG: When flexure is a good thing, Contact Lens Spectrum 11(3):12, 1996.
28. Sorbara L, Fonn D, MacNeill K: Effect of rigid gas permeable lens flexure on
vision, Optom Vis Sci 69(12):953-958, 1992.
29. Ratkowski D, Rump J, Bennett ES: The manufacture of rigid gas-permeable lens
materials. In Bennett ES, Grohe RM, editors: Rigid gas-permeable contact
lenses, New York, 1986, Professional Press, pp 92-114.
30. Bennett ES: Material selection. In Bennett ES, Henry VA, editors: Clinical man-
ual of contact lenses, Philadelphia, 1994, JB Lippincott, pp 27-40.
31. Levitt AP: Specific gravity and RGP lens performance, Contact Lens Spectrum
11(10):43, 1996.
32. Giedd B: Understanding the nuances of contact lens materials, Contact Lens
Spectrum 14(7):23, 1999.
3
Gas Permeable Materials
EDWARD S. BENNETT
MATERIAL SELECTION
T he selection of the gas permeable (GP) lens material often is

considered secondary to the lens design and fitting relationship.
However, the material itself has several critical functions,
including the ability to provide sufficient oxygen permeability to meet
the cornea’s oxygen needs, good on-eye surface wettability, stability,
and crisp visual acuity.1,2
A survey provided to the Contact Lens Manufacturers Association
(CLMA) member laboratories found that the question asked most fre-
quently by contact lens fitters to laboratory consultants is “Which gas
permeable lens material should I use?” With more than 30 lens mate-
rials available, this is no easy question to answer. However, instead of
focusing on the specific name brands, GP material selection can be
made relatively simple if materials are divided into categories with the
understanding that materials within a given category do not differ sig-
nificantly. This may not be absolutely true, but some generalizations
can be made in terms of which lens materials would be optimum for
a given patient. It is important to note that the CLMA has recently
adopted GP (oxygen permeability) over rigid gas permeable (RGP)
lenses. This terminology will appear on all literature nationwide and in
all RGP Lens Institute resources and programs.
LENS MATERIALS TODAY

The lens material most commonly used today is fluoro-silicone/acry-
late (F-S/A). Less commonly used today is silicone/acrylate (S/A), with
styrene-based materials used occasionally.
Silicone/Acrylate
The introduction of these copolymers in 1979 was a major break-
through in gas permeable material lens clinical application. These
48
Chapter 3 Gas Permeable Materials 49
lenses were much more stable than the first GP material to obtain
Food and Drug Administration (FDA) approval, which was manufac-
tured from cellulose acetate butyrate (CAB). However, to meet the
corneal oxygen demands for an edema-free state, higher Dk materials
were necessary. This required the need to increase the amount of
cross-linking agents to enhance material stability because of the soft-
ness of silicone and increase the wetting agents, such as methacrylic
acid, to offset the hydrophobicity of silicone. However, in higher Dk
lens materials the stability and surface wettability tended to be com-
promised relative to lower Dk lens materials.3 There is actually an elec-
trostatic attraction between silicone-based lens surfaces and the tear
film (Figure 3-1). They appear to be preferable to F-S/A lens materials
for patients prone to lipid accumulation.4
Fluoro-Silicone/Acrylate
The addition of fluorine to S/A lens materials increases the deposit
resistance of the lens material. Fluorine promotes tear film-mucin
interaction with the lens surface, which increases the over-the-lens tear
film break-up time relative to S/A lens materials.5 F-S/A lens materi-
als have also been found to be more dimensionally stable than S/A
materials.3,6 Through solubility, fluorine also assists in oxygen trans-
mission through the lens material. This allows for the reduction of the
silicone component in the lens material, for increased permeability in
GP materials, and therefore for a number of materials to be FDA
approved for extended wear.
Positively charged
Lens deposits +
+
− −
+ − −
Negatively charged
Silicone acrylate CL
Electrostatic interaction:
1. Like charges repel − −
2. Unlike charges attract − +
3. Lens deposits are positively charged
4. Silicone acrylate lenses are negatively charged due to organic acids
Figure 3-1. Electrostatic attraction of tear film lysozyme to a silicone-based GP lens material.
Improvements in polymer chemistry and manufacturing have

enhanced the performance of currently available F-S/A lens materials.
Polymer Technology Corporation introduced their AEROCOR process
in the mid-1990s. This process results in a lower silicone content
while providing an oxygen-permeable backbone and an oxygen-
permeable cross-linker relative to their previous materials.7 This led to
the introduction of the Boston ES, EO, and XO lens materials. Shortly
thereafter, Paragon Vision Sciences introduced their hyperpurification
process, which, in effect, sorts silicone molecules to select more oxy-
gen-efficient silicone.8 This resulted in the introduction of the Paragon
Thin and Paragon HDS lens materials.
There have been many innovations in lens manufacture that have
resulted in improved performance of F-S/A lens materials. In particu-
lar, the introduction of Computer Numeric Controlled (CNC) lath-
ing equipment has been important. These computer-driven lathes
use software programs to result in greater reproducibility in base curve
radius and edge shape. Lathes in use today also cut smoother and cre-
ate lenses that need less polishing, allowing less room for error in the
final product.9 This has resulted in the introduction of many ultrathin
designs, including such a design in a hyper-Dk lens material (Menicon
Z Thin [Menicon, Nagoya, Japan, and Concise, San Leandro, CA]).
Styrene
Styrene-based lens materials were introduced in the 1980s as a result
of good flexural resistance and low specific gravity.10 This material is
currently used as the rigid center of the SoftPerm lens (Ciba Vision
Corporation, Duluth, GA). This lens has a 14.3-mm overall diameter
with an 8-mm rigid center composed of tertiary butyl styrene and a
wetting agent. The outer surround, composed of a low-water-content
hydrogel, is molecularly bound to the rigid center. The primary bene-
fits of this lens material include initial comfort and centration for
patients who could not achieve good centration of comfort with a GP
lens.10,11 Specifically, patients with keratoconus have especially bene-
fited from this design. However, the limitations of this lens have
included cost, tearing at the junction between the rigid and soft sec-
tions, edema (styrene is low in oxygen permeability), and difficulty in
lens removal.7 This lens may be introduced with a higher Dk GP core
material in the future.
OXYGEN CONSIDERATIONS
Gas permeable lens materials can essentially be divided into three
categories using oxygen permeability as the primary criterion.12
The CLMA has adopted the oxygen permeability method recently pub-
lished by Benjamin and Cappelli.13 The author also uses a modified
version of Benjamin’s14 classification of oxygen permeability with
essentially the omission of the lowest two categories and modifying
the other three categories into low (Dk = 25 to 50), high (Dk = 51 to 99),
and hyper (Dk ≥ 100).2 Although S/A lens materials are still used
today, the industry standard pertains to materials also containing fluo-
rine or F-S/A.
Low Dk (Dk: 25 to 50)

These materials typically have greater stability, more flexural resist-
ance, and better on-eye surface wettability than higher Dk lens mate-
rials.4 These are the materials of choice for daily wear by patients with
myopia. Because myopic designs have a thin lens profile, they should
meet the cornea’s oxygen requirements for safe edema-free daily wear.
This is especially true of the new generation of ultrathin lens designs,
which optimize initial comfort while increasing the likelihood of
achieving a lid attachment fitting relationship. Representative lens
materials include Fluoroperm 30 and Paragon Thin (Paragon Vision
Sciences, Mesa, AZ), Boston ES (Polymer Technology Corporation
(Rochester, NY), Fluorex 300 and 500 (GT Laboratories, Austin, TX),
SGP 3 (Permeable Technologies, Morganville, NJ), and FLOSI
(Lagado, Denver, CO).
High Dk (Dk: 51 to 99)

These materials are more flexible and may not have the on-eye surface
wettability of their lower Dk counterparts. In fact, if they are fit steeper
than K on a patient with moderate-to-high corneal astigmatism, it is
likely that they will flex and not correct all of the corneal astigmatism.
This group of materials is recommended for all patients with hyper-
opia and myopic flexible and extended wearers. One simple way of
looking at these materials is that a +3.00-D lens has approximately
twice the center thickness as a −3.00-D lens. Therefore the +3.00-D
lens will require a lens material with twice the oxygen permeability
(i.e., 60 Dk vs. 30 Dk for the −3.00-D patient). Representative lens
materials include Boston EO (Polymer Technology), Paragon HDS,
Fluoroperm 60 and 92 (Paragon Vision Sciences), and Fluorex 700
(GT Laboratories).
Hyper-Dk (Dk: ≥100)

Hyper-Dk lens materials have Dk values ≥100. These materials are even
more flexible than high Dk materials, and regular replacement is often
recommended (i.e., every 6 to 12 months). This group is recommended
for extended wear for patients with myopia and hyperopia and, ulti-
mately, for continuous wear. This group includes Boston XO (Polymer
Technology Corporation), Paragon HDS 100 and Fluoroperm 151
(Paragon Vision Sciences), and Menicon Z (Nagoya, Japan and Concise,
San Leandro, CA). GP material selection with a focus on oxygen con-
siderations is provided in Box 3-1.
GENERAL CONSIDERATIONS
The type of GP lens can also be described by factors such as refractive
error, corneal topography, refits, occupation and hobbies, and age.2,7,12
Refractive Error
Refractive error was described, in part, in the previous section. With
the thin center thicknesses used today in minus powers—notably the
ultrathin designs—daily-wear patients with myopia benefit from the
dimensional stability provided by low-Dk F-S/A lens designs while still
meeting the cornea’s daily-wear oxygen requirements. Because the
patient with hyperopia, on average, requires a lens with twice the cen-
ter thickness (i.e., +3.00 D power vs. −3.00 D), a lens material with
twice the Dk is required (i.e., Dk of 60 instead of 30). Therefore a high-
Dk lens material is required for these patients. For patients desiring
extended wear, a high-Dk lens material would be preferable if the
patient has myopia; a hyper-Dk lens material would be preferable if
the patient has hyperopia.
Corneal Topography
Patients with myopia and a moderate astigmatism (i.e., ≥1.50 D) would
benefit from the stability and flexural resistance provided by a low-Dk
F-S/A lens material. If a bitoric lens is necessary because of poor
corneal alignment, decentration, or such, a low-Dk material likewise
would be easier to manufacture and would provide a stable correction.
If the patient has keratoconus or a high amount of irregular astigma-
tism, a low-Dk lens material will also provide more flexural resistance
Box 3-1 MATERIAL SELECTION (IN GENERAL)

Low Dk High Dk Hyper-Dk
●
Myopia ●
Hyperopia ●
Hyperopia
●
Daily wear ●
Flexible wear (hyperopia) ●
Extended wear
●
Optimum wettability ●
Extended wear (myopia) (myopia and
●
Optimum stability ●
Prism ballasted lens designs hyperopia)
and, in theory, improved quality of vision versus the softer higher-per-

meable lens materials. Patients with hyperopia would require a high-
Dk lens material.
Refits
Patients with myopia who are accustomed to wearing polymethyl-
methacrylate (PMMA) or low-Dk GP lens materials are more likely to
warp high-Dk GP lenses and would benefit from the stability of low-
Dk F-S/A materials.15,16 These patients are accustomed to using exces-
sive digital pressure on their lenses with minimal damage or warpage.
Soft lens patients, however, are similar to new GP patients because
they are accustomed to cleaning their lenses carefully in the palm of
their hand and can be refit with any GP lens material.
Occupation and Hobbies

Persons with occupations that require long or flexible wear (i.e.,
nurses, police officers, firefighters) would benefit from a high-Dk lens
material. People who spend many hours a day at a computer terminal
would benefit from the most wettable material available—often low-
Dk F-S/A—because they do not tend to blink as often or as fully.
Frequent use of rewetting drops and supplementing the care regimen
with a liquid enzyme is recommended. Athletes who do not benefit
visually from a hydrogel lens will require a large overall diameter (>9.5
mm) and a low edge clearance GP lens design to minimize dislocation
and loss.
Age
For the young patient with progressive myopia, a sturdy stable mate-
rial is important to minimize warpage and wettability problems.
Therefore a low-Dk F-S/A material is recommended. Because young
people are active, often participating in numerous athletic activities, a
larger than average diameter (i.e., 9.6 to 10.5 mm) is recommended to
provide stability of fit and minimize lens dislodgement and loss. The
patient with presbyopia benefits greatly from GP lens wear. The most
common lens design for patients with presbyopia is the aspheric mul-
tifocal design. Because these are thin designs and fit steeper than K,
with the goal of good centration and limited movement with the blink,
a low-Dk material is often used, notably for patients with myopia. The
fabricating laboratory typically recommends a specific material for a
given multifocal design, therefore eliminating this as a variable for the
practitioner. For patients who have the proper lid anatomy and critical
vision needs, a segmented translating bifocal design is recommended.
Because these lenses are prism ballasted and therefore much thicker
54
Refractive Corneal Refits Occupations/ Age

error topography hobbies
Myopia Hyperopia PMMA/Very Children Aphakic

SECTION II
low Dk
Low Dk High Dk Low Dk GP Large OAD High/hyper

GP (DW) GP (DW) GPs Dk GP,
minus lenticular
design
Prolonged Flexible wear

High Dk Hyper Dk near work-
GP (EW) GP (EW) reading, VDT
High Irregular Low Dk FSA High Dk GP

astigmatism astigmatism/ for optimum Presbyopic
OXYGEN AND THE CORNEA
keratoconus wettability
Low Dk GP Low Dk GP
Aspheric Segmented
if myopic
multifocal translating
If ⱖ2.50 D Irregular
bitoric design astigmatism/
keratoconus Low Dk High Dk High Dk
(myopic) (hyperopic)
Figure 3-2. GP material selection.

than aspheric designs, they are always manufactured in a high-Dk lens

material. The patient with aphakia, with the greater center thicknesses
required for a high plus lens power, requires a high- or hyper-Dk lens
material, with the latter recommended for extended wear.
Considerations for GP material selection are provided in Figure 3-2.
In summary, although it can be argued that lens design and fitting
considerations are more important than the specific material to be pre-
scribed, it is nevertheless important to select a GP material that meets
the corneal oxygen demand for the prescribed wearing period and that
optimizes tear film interaction with the front surface of the lens. With
the current generation of F-S/A lens materials, this is certainly possi-
ble, and the material selection process is neither difficult nor time con-
suming.
RFERENCES
1. Jones L: Modern contact lens materials: clinical performance update, Contact
Lens Spectrum 17(9): 24-35, 2002.
2. Bennett ES: Matching the patient with the gas permeable material, Rev Optom
139(5): 45, 46, 2002.
3. Bennett ES, Tomlinson A, Mirowitz MC, et al: Comparison of overnight swelling
and lens performance in RGP extended wear, CLAO J 14:94-100, 1988.
4. Quinn TG: Material solutions for gas permeable questions, Contact Lens Spectrum
15(5):19, 2000.
5. Doane M, Gleason W: Tear film interaction with RGP contact lenses. Presented
at the First International Material Science Symposium, March 1988, St.
Louis.
6. Weinschenk JI: A look at the components in fluorosilicone-acrylates, Contact Lens
Spectrum 4:61-64, 1989.
7. Bennett ES, Levy B: Material selection. In Bennett ES, Henry VA, editors: Clinical
manual of contact lenses, ed 2, Philadelphia, 2000, Lippincott Williams &
Wilkins, pp 59-74.
8. Schachet JL, Rigel LE, Reeder KM, et al: Rethinking the link between RGP lens
performance, Contact Lens Spectrum 13(9):43-47, 1998.
9. Gilfor M: RGPs today: an industry of innovation, Contact Lens Spectrum
13(10):10S-15S, 1998.
10. Morgan P: Practical experience with a new soft/RGP combination lens, Optician
204:16-22, 1992.
11. Tucker IS: Insights on using the SoftPerm lens, Contact Lens Spectrum 8:53-56, 1993.
12. Bennett ES: Choose the right RGP lens material for your patient, Contact Lens
Spectrum 16(5): 9, 19, 2001.
13. Benjamin WJ, Cappelli QA: Oxygen permeability of thirty-seven rigid contact
lens materials, Optom Vis Sci 79(2):103-111, 2002.
14. Benjamin WJ: EOP and Dk/L: the quest for hyper-transmissibility, J Am Optom
Assoc 64:196-200, 1993.
15. Ghormley NR: Rigid EW lenses: complications, Int Contact Lens Clin 14:219,
1987.
16. Henry VA, Bennett ES, Forrest J: Clinical investigation of the Paraperm EW rigid
gas-permeable contact lens, Am J Optom Physiol Opt 64:313-320, 1987.
4
Patient Selection, Evaluation, and
Consultation
EDWARD S. BENNETT
O ne of the common misperceptions about gas permeable (GP)

lenses is that they are complicated: they require too much
time to design and fit. This is not true, particularly with
recent improvements in manufacturing and design technology. GP
lens application should not differ significantly from soft lenses in the
amount of time used by the practitioner for design and fitting and fol-
low-up evaluation. It can be argued, via the relative benefits in eye
health and safety, that follow-up care is less for patients with GP lenses
than for those with soft lenses. In addition, the applications for GP
lenses are increasing as new and improved designs for orthokeratol-
ogy and patients with presbyopia continue to be introduced. Hyper-
oxygen permeability lens materials provide an increasingly better
option for patients desiring or needing oxygen transmission well
beyond that presently available with current soft lens materials. The
future looks even more promising with ongoing advancements in
rigid lens technology.
PATIENT SELECTION
Benefits
The benefits of wearing GP lenses are many, particularly as they are
compared with the performance of soft lenses. These benefits include
quality of vision, ocular health, durability, profitability, and patient
loyalty.1
Quality of Vision
Studies have shown that GP lenses provide refractive error correction
that results in higher quality of vision relative to soft lenses, objectively
and subjectively.2-4 As a rigid lens maintains its shape over the cornea,
the lens provides a more stable, consistent refractive surface. GP
58
Chapter 4 Patient Selection, Evaluation, and Consultation 59
lenses are also less prone to surface deposits, which, in turn, can com-
promise vision. These visual benefits are especially important for
patients with high (regular) astigmatism, irregular corneas, and presby-
opia. Spherical GP lenses and bitoric designs can correct essentially an
unlimited amount of cylinder without the visually distracting lens rota-
tion that can compromise soft toric lens visual performance. As will be
mentioned later, unlike soft lenses, the ability to mold the front surface
of the eye into a more spherical-like nature can improve vision by several
lines on the Snellen acuity chart for a patient with an irregular cornea.
Likewise, the ongoing improvements in manufacturing technology have
resulted in improved optical quality of GP aspheric multifocals, which—
combined with the optimum vision resulting from properly fitted seg-
mented, translating bifocals—provides a tremendous advantage over
soft multifocal and bifocal designs, which are limited to simultaneous
vision and compromised by the water-absorbing lens matrix.
Ocular Health
For several important reasons, GP lenses result in improved eye health
relative to their soft lens counterparts. Clinical studies have concluded
they are less likely to result in corneal staining and ulcerative kerati-
tis.4,5 Likewise, the optical quality and improved surface wettability
characteristics result in less deposit buildup, which, in turn, mini-
mizes the potential for deposit-induced lid inflammation or contact
lens–induced papillary conjunctivitis. Another important health bene-
fit is the increased oxygen transmission of GP lenses over hydrogel
soft lenses. Hydrogel lens wearers, particularly those wearing
extended-wear lenses, exhibit more potential for hypoxia-induced
complications, such as generalized corneal edema, polymegethism,
neovascularization, and microcysts. Oxygen transmission is perhaps
as important a consideration in hyperopic contact lens wear as it is in
extended wear. In 1990 Gordon and Bennett6 concluded that high-
Dk/L GP lenses approximated or exceeded the Holden-Mertz crite-
rion7 for an edema-free state for extended wear and daily wear in the
+3.00 D power, whereas soft extended-wear materials provided an
average of only 40% to 45% of the oxygen necessary for edema-free
extended wear and approximately 60% for edema-free daily wear.8 The
introduction of hyper-Dk GP lens materials makes this disparity even
greater. The introduction of silicone-based soft lens materials has
resulted in an oxygen environment simulating the hyper-Dk/L rigid
lens materials; however, the incidence of peripheral corneal infiltrates
and related complications resulting from limbal compression is not
reduced. The smaller-diameter GP lenses do not compress the limbus
and therefore are unlikely to cause such complications.
60 SECTION III PATIENT SELECTION, FITTING, AND CARE
Stability and Durability

Unlike soft lenses, GP lenses do not tear or easily change shape or col-
oration. Because rigid lenses are durable and relatively deposit resist-
ant, they are easier to clean and disinfect. This benefit, in addition to
the smaller diameter, makes it easier for patients to handle rigid
lenses. Likewise, the optical quality of these lenses results in ease of
verification of lens parameters.
Profitability and Patient Loyalty

The potential profitability can be an important advantage for GP
lenses. This is demonstrated by the results of data from the office of
Gunning and Ames.9-11 In one study,9 the income provided by 100 con-
secutive soft lens patients and 100 GP lens patients was documented
for a 24-month period. The annual revenue generated from GP lens
wearers was nearly two times that of soft lens wearers for the follow-
ing reasons:
●
GP lens patients purchased spectacles twice as often as soft lens
patients
●
On average, the GP lens wearers returned more frequently for
eye examinations
●
The profit per replacement lens was higher for GP lenses
●
GP lens patients purchased contact lens service agreements eight
times more often than soft lens patients
Although the GP lens wearers represented only 38% of the total
contact lens patient base, they contributed 48% of the total contact lens
practice income. These findings were later confirmed from the results
of all active contact lens patients during the previous 4-year period.10,11
Although this is controversial,12 the reason why GP lenses poten-
tially result in greater practice profitability is that the growth of “alter-
native” contact lens replacement lens sites has resulted in many soft
lens patients returning less frequently to the practice of the prescrib-
ing practitioner and possibly leaving the practice altogether. It is evi-
dent that the trend toward mail order and pharmacy contact lens
dispensing has the potential to reduce the entire practice’s profitability
because patients return for follow-up visits and eye health examina-
tions less frequently. Because patients return less frequently, they are
less likely to purchase spectacles, sunglasses, and care products from
the practice. The most significant trend, however, has been the
tremendous increase in replacement lens sales via the Internet; it is
likely that trend will continue. Unless an effective recall system is in
place, this can create additional safety and liability concerns for the
prescribing practitioner. When patients fail to return for follow-up vis-
its, the practitioner is unable to monitor each patient’s ocular health
and compliance with the wear and care regimen, potentially increasing
the complication rate. This problem may be reduced if there is future
regulation of alternative distribution sites. Because of their custom
design and greater cost per lens, GP lenses are rarely price advertised
or promoted by these alternate distribution sites. For these same rea-
sons, GP prescriptions are rarely requested by patients and are not of
great interest to independent suppliers.13 Therefore patients are more
likely to return to their prescribing practitioner for replacement lenses,
which, in turn, serves as an incentive for eye health care examinations,
spectacle purchase, and so on.
Indications
The number of indications for GP lenses is many and increasing.
Among these candidates are patients with astigmatism, presbyopia,
juvenile progressive myopia, myopia and including those desiring a
reduction in their refractive error, keratoconus, irregular corneas, and
borderline dry eye, and those desiring flexible or extended-wear lenses
or soft lens refits. These are important applications for which GP
lenses represent the lens of choice.
Patients with Astigmatism

Although spherical lens patients should never be dismissed as poten-
tial GP lens candidates, patients with astigmatism are excellent candi-
dates because the quality or crispness of vision achieved with rigid
lenses is typically better than that achieved with spherical soft or soft
toric lenses. It is not uncommon for patients with one diopter or more
of refractive astigmatism to be fitted with spherical hydrogel lenses
when GP or toric hydrogel lenses would provide better visual acuity.
However, to fit all patients with moderate astigmatisms into soft toric
lenses would border on malpractice. Whereas the introduction of dis-
posable toric hydrogel lenses (in limited parameters) reduces the risk
of deposit-related problems, patients in need of crisp, stable vision, not
to mention good oxygen transmission, require GP lenses.
Patients with Presbyopia

An underused but important application of GP lenses is the correction
for patients with presbyopia. The introduction of aspheric lens designs
with improved optical quality—in part a result of better polishing meth-
ods—and the ability to incorporate a higher add power have resulted in
many new and improved designs allowing for satisfactory vision at all
distances. In addition, it has been reported that a small but significant
amount of translation occurs with these designs with downward gaze.14
This compliments the increasing number of monocentric optics
segmented, translating bifocal designs that typically have the distance in

the top and the near vision located inferiorly separated by a line or cres-
cent. These designs are prism ballasted, positioned at or near the lower
lid, and shifted or translated on inferior gaze such that the patient is
viewing through the near optics while performing close work. Soft mul-
tifocal and bifocal designs do not have the optical quality of their rigid
lens counterparts, and all use simultaneous vision—in which near and
distance optics are in front of the eye at the same time—because it is
difficult for soft lens bifocals to exhibit translation. Likewise, GP lens
patients benefit visually from GP bifocals versus monovision. In a
recent study, Johnson et al15 found that when subjects wore aspheric
multifocal GP lenses and monovision for 6 weeks each, 75% of these
subjects preferred the aspheric multifocals. If patients interested in
contact lens correction of presbyopia are not given the option of GP
bifocals (vs. soft lens bifocals or monovision), the practitioner’s pre-
scribing habits are bordering on malpractice.
Young Patients with Progressive Myopia

As emphasized in Chapter 15, young patients with progressive myopia
are excellent candidates for GP lenses. Clinical studies have shown that
GP lenses slow the progression of myopia in children aged 8 to 13 years.
In addition, according to the Contact Lens and Myopia Progression
(CLAMP) study, approximately 80% of young people are able to suc-
cessfully adapt to GP lenses.16 For young athletes, the use of larger-
diameter (i.e., 10 mm), lower edge lift designs have been recommended
to minimize lens decentration and loss. In addition, children with
severe myopia also may experience distortion, prismatic effects, effects
of heavy lenses, poor fit, and diminished cosmesis from glasses.17
Orthokeratology
The GP application exhibiting the most recent consumer interest is
orthokeratology. Orthokeratology, or the reduction of myopia through
the application of specially designed rigid lenses, has been in existence
for 40 years. However, there appears to be four reasons why orthoker-
atology has experienced a rebirth in recent years18:
1. The introduction of corneal topography instrumentation to mon-
itor corneal change and predict the amount of myopia reduction
2. The use of reverse geometry lens designs and—more specifi-
cally—four zone designs to accelerate myopia reduction while
often accomplishing this task with one lens only
3. Limiting retainer wear to nighttime only
4. The increasing number of patients desiring an alternative to
refractive surgery
In addition, if corneaplasty, in which rigid lenses mold a softened

cornea into a spherical shape and the cornea is then restored to its
original rigidity, becomes perfected, these orthokeratology designs
should be in high demand.
Irregular Cornea
The application of rigid lenses results in the molding of an irregular
cornea into a more spherical optical surface. As found in the
Collaborative Longitudinal Evaluation of Keratoconus (CLEK) study, rigid
lenses resulted in a significant improvement in corrected visual acuity
compared with manifest refraction.19 This makes the GP lens the lens of
choice for not only patients with keratoconus but also for all patients
exhibiting irregular corneas (e.g., trauma, postsurgical, corneal warpage).
Patients with Borderline Dry Eye

GP lenses have certain benefits for patients with borderline dry eye. The
excellent surface wettability and oxygen transmission are benefits for
patients with dry eye. GP lenses also do not dehydrate and tighten over
time as is possible with soft lenses. However, GP application for the
patient with borderline dry eye is a patient-dependent phenomenon
because some patients are not able to adapt to rigid lenses. In this case,
a daily disposable lens is a viable option, which also has the benefit of
rehydration with rewetting drops when dryness is experienced.
Soft Lens Refits

Whereas it is rarely recommended to refit a successful soft lens wearer
with GP lenses or vice versa, there are many occasions in which a
problematic soft lens wearer can be a satisfied and successful GP lens
wearer. It has been found that patients who have been unable to wear
soft lenses because of such factors as poor vision or complications per-
taining to edema or giant papillary conjunctivitis (GPC) have been suc-
cessfully refitted with GP lenses.20,21 Frequently, patients who continue
to wear soft lenses despite problems in lieu of refitting with GP lenses
often are frustrated with results, and the practitioner incurs consider-
able time and expense. Two important factors in helping to ensure the
success of these patients are (1) using a topical anesthetic at the fitting
visit, and (2) ensuring that the first pair of lenses fit to the patient is at
or near the correct prescription so the patient can immediately experi-
ence one of the primary benefits of GP lenses: good vision.
Flexible and Extended Wear

Patients desiring occasional overnight wear or extended wear of their
contact lenses benefit from the vision and eye health of GP lenses.
This is especially true for patients who have an occupational require-

ment to wear their correction for long periods (e.g., police officers, fire
fighters, nurses). As mentioned previously, GP lenses result in fewer
incidences of inflammatory and sight-threatening conditions.6,22 In
addition, the smaller diameter of GP lenses reduces the incidence of
peripheral corneal complications, which result from soft lens limbal
compression.23,24 The introduction of hyper-Dk lens materials assists
in maintaining an edema-free state with these lenses.
GP lens applications are listed in Box 4-1.
Contraindications
The contraindications of GP lenses are comparable with those for
other types of contact lenses. Obviously, if a patient is sensitive to
something touching the eye, the patient may adapt easier to a soft lens;
however, this is rarely a contraindication. Likewise, patients with
spherical refractive error should not be contraindicated as GP lens
patients. Once again, the benefits of vision, eye health, myopia control,
and presbyopia among others make GPs a viable choice. Certainly
patients who desire only part-time wear or opaque lenses to change
their eye color are best fit into a soft lens. Overall, the viability of a
patient for GP contact lenses depends on anatomic, physiologic, and
psychological considerations. Therefore a comprehensive case history
and a diagnostic evaluation are essential to determine which patients
can successfully wear these lenses.
PRELIMINARY EVALUATION
Case History
The patient selection process is initiated as soon as a patient enters the
office. It is always important to determine if the patient is interested in
contact lenses and, if not, what are the reasons for failing to use this
Box 4-1 GP LENS APPLICATIONS

1. Astigmatism
2. Presbyopia
3. Progressive myopia in young patients
4. Orthokeratology
5. Irregular cornea
6. Borderline dry eye
7. Soft lens refits
8. Flexible and extended wear
form of correction. There are numerous good reasons motivating

patients to wear contact lenses, including a desire to improve cosme-
sis, inconvenience of glasses, potential for vision improvement, sports
and recreation, and occupational benefits.25
In addition, it should be determined whether the patient is a former
contact lens wearer or a dissatisfied present wearer. If so, the reasons
for discontinuation or dissatisfaction should be determined.
Questions pertaining to such factors as lens material, years of wear,
care regimen, and wearing time should be asked. A sample question-
naire for this purpose is given in Box 4-2.
There are several conditions that are important to determine from
the patient because they could impact the patient’s ability to wear con-
tact lenses. These are summarized in Box 4-3.26 Any history of ocular
disease or injury should be noted, especially a disease or injury that
may cause corneal compromise. In addition, a comprehensive medical
history is indicated. Any existing chronic systemic disease, such as
arthritis, diabetes, or atopic skin conditions, should be noted. Diseases
of the thyroid should be delineated in terms of the possible effect on
the patient’s tear chemistry and lid function. Any recurrent episodes of
sinusitis, past or present, should be noted.
Any history of allergies should be elicited, not only the usual aller-
gic reactions of hay fever and asthma but also any hypersensitivities to
drugs or contact lens solutions. The frequent use of systemic drugs
that can suppress normal tear film function, such as antihistamines,
should be noted. These patients are poor candidates for contact lens
wear, although GP lenses may be a safer alternative than soft lenses
because of their deposit-resistant properties.
Box 4-2 QUESTIONNAIRE FOR PRESENT AND FORMER CONTACT LENS WEARERS
1. What type of lens material(s) have you worn?
2. How many years did you wear each type of contact lens?
3. Were these lenses worn successfully or unsuccessfully?
4. What was your primary problem with these lenses?
5. What other (if any) problems were present with these lenses?
6. Do you wear spectacles? If so, do they provide satisfactory vision? How
old is the current prescription?
7. Did problems appear at the onset of lens wear, or was successful lens
wear present before symptomatology?
8. Were previous lens-induced problems present in one eye or both eyes?
9. What is your present wearing time with your contact lenses (if currently
wearing lenses)?
10. What solutions have you used with your present or former lenses?
Box 4-3 CONDITIONS THAT MAY LIMIT OR CONTRAINDICATE CONTACT LENS WEAR
1. Systemic medications: The use of certain medications, such as
antihistamines, anticholinergic agents, some β-adrenergic blockers,
tricyclic antidepressants, and oral contraceptives, can affect contact lens
wear by reducing production of the aqueous phase of the tear film.26
2. Abnormal dry eye as determined via diagnostic testing.
3. Pregnancy: During pregnancy, particularly the third trimester, the tear film
and corneal curvature may change significantly. This usually stabilizes
soon after childbirth.
4. Diabetes: Patients with type I diabetes, in particular, may have varying
degrees of corneal anesthesia, poor corneal epithelial healing, and the
potential to develop neurotrophic keratitis.
5. Collagen vascular disorders: Patients with rheumatoid arthritis and related
collagen vascular disorders may have Sjögren’s syndrome with
keratoconjunctivitis sicca and associated tear film abnormalities.
6. Thyroid imbalance: Hyperthyroidism may result in exophthalmos and lack
of blinking, which can make contact lens wear difficult because of
insufficient tear flow to the cornea.
7. Recurrent ocular infection or inflammation: This can include recurrent
keratitis and contact lens–induced papillary conjunctivitis.
8. Seasonal or chronic allergies: If frequent antihistamine use is necessary,
contact lens wear should be limited or contraindicated when medication
use exists.
From Bennett ES, Watanabe RK: Preliminary evaluation. In Bennett ES, Henry VA, editors:
Clinical manual of contact lenses, ed 2, Philadelphia, 2000, Lippincott Williams & Wilkins, pp 1-33.
Diagnostic Evaluation
In addition to the case history, a thorough preliminary evaluation is
important to determine if the patient is a good candidate for GP lenses
and contact lens wear in general. This includes anatomic measure-
ments, refractive and corneal topography information, biomicroscopic
evaluation, tear film evaluation, and binocular vision status.
Anatomic Measurements
These include pupil diameter, horizontal visible iris diameter (HVID),
palpebral aperture size, blink rate, and lid tension.
Pupil Diameter. Pupil diameter determination is critical for later
determining the optical zone diameter (OZD) and overall diameter of
GP lenses. The OZD of GP lenses should be, at minimum, 1 to 2 mm
larger than the pupil diameter in dim illumination. Pupil sizes can be
categorized as follows (as determined in dim illumination):
Small pupil <5 mm
Medium pupil 5 to 7 mm
Large pupil >7 mm

Measurement of pupil diameter can be performed in dim (but not too
dim to determine the value) illumination using either a interpupillary
distance (PD) ruler or a modified PD ruler with simulated pupil diam-
eters (Figure 4-1).
Horizontal Visible Iris Diameter. The HVID measurement assists
in the determination of the overall diameter of a rigid lens. The HVID
is often between 11 and 13.5 mm. It is determined using a PD ruler
positioned horizontally and tilted inward toward the eye. The visible
iris diameter is then measured (Figure 4-2).
Palpebral Aperture Size. This is an important measurement for
determining the type of GP fitting relationship to use. If the patient
has a small to average aperture size (10 to 12 mm), a lid attachment fit-
ting relationship in which the upper edge of a GP lens is positioned
Figure 4-1. Pupil diameter measurement.

Figure 4-2. Horizontal visible iris diameter measurement.
under the upper lid is often possible. If the aperture size is more than
12 mm, especially if this is accompanied by an upper lid located at or
above the superior limbus, an intrapalpebral fitting relationship with a
smaller-diameter GP lens positioned between the lids is often indi-
cated. This measurement is obtained with a PD ruler positioned verti-
cally with the patient viewing straight ahead (Figure 4-3).
Blink Rate. The blink rate and quality should be evaluated without
the patient’s knowledge. A normal blink rate is 10 to 15 times per
minute. If the patient has an infrequent or incomplete (especially if
<50% closure is obtained) blink, hydrogel lenses for social and occa-
sional wear are recommended.
Lid Tension. During the evaluation of the palpebral conjunctiva
with lid eversion, the patient’s lid tension can be evaluated. Tight or
difficult-to-evert lids will be likely to pull a GP lens superiorly with the
Figure 4-3. Determining palpebral aperture size.
blink. Loose or easily everted lids can result in an inferiorly positioned

GP lens because of the inability of the upper lid to lift the lens.
Refractive and Corneal Topography Information

A thorough evaluation of the patient’s refractive and corneal topogra-
phy status is important in determining the eligibility of a patient for
rigid lenses and the specific lens design to use.
Refraction. A baseline manifest refraction should be recorded. The
retinoscopy reflex can be evaluated for clarity or lack of distortion. An
accurate binocular manifest refraction will help in predicting the
appropriate GP diagnostic lens power. It is important that the first lens
applied to the patient—either through diagnostic or empirical fitting—
provides the patient with good vision.
Corneal Topography. Obviously, as emphasized in Chapter 6, the
use of a videokeratoscope has the advantage of providing topography
information for essentially the entire cornea. In addition, the contact

lens software programs are beneficial for predicting the diagnostic
lens fitting relationship and designing lenses empirically. However,
although it only provides curvature information at four points of the
cornea—all within the central 3 mm—most practitioners use a ker-
atometer for evaluation of corneal curvature. For initial base curve
selection and prediction of residual cylinder, it has proven to be reli-
able. However, fluorescein pattern evaluation remains the most impor-
tant assessment for GP contact lens fitting, whereas centration and
lens lag are most important for assessments of hydrogel lens fit.
Once this information has been recorded, the patient’s residual
astigmatism (i.e., astigmatism not corrected by the contact lens) can be
calculated. For a spherical soft lens wearer, the calculated residual
astigmatism (CRA) is equal to the patient’s refractive cylinder. For a
rigid lens wearer, it is equal to the refractive cylinder minus the corneal
cylinder (i.e., as typically determined via keratometry or simulated ker-
atometry values via videokeratoscopy). Three examples are provided:
Example 1:
Manifest refraction: −2.00 − 1.00 × 180
Keratometry: 42.00 @ 180; 43.00 @ 090
CRA = refractive cylinder − keratometry cylinder
= −1.00 × 180 − (−)1.00 × 180 = 0
Example 2:
Manifest refraction: −2.00 − 2.00 × 180
Keratometry: 42.00 @ 180; 43.00 @ 090
= −2.00 × 180 − (−)1.00 × 180 = −1.00 × 180
Example 3:
Manifest refraction: −2.00 DS
Keratometry: 42.00 @ 180; 43.00 @ 090
= Pl − (−)1.00 × 180 = +1.00 × 180 or
+1.00 − 1.00 × 090
If the actual residual astigmatism (ARA) is 0.75 D or greater, a
spherical GP lens is typically contraindicated because of reduced
vision. However, if the patient otherwise appears to be a good candi-
date for rigid lenses, it is important to select a diagnostic lens and per-
form an overrefraction. In some patients, the ARA will be less than
predicted, often the result of inaccuracy in keratometry, refraction, or
both. In Example 2, a soft toric lens would be the best option if the
ARA equals the CRA. In Example 3, a spherical soft lens would be

indicated if the ARA equals the CRA.
Biomicroscopic Evaluation
An evaluation of the lids, conjunctiva, and cornea with a biomicro-
scope is essential. The inferior and superior palpebral conjunctiva
should be examined for the presence of papillary or follicular hyper-
trophy. Follicles are lymphoid hyperplasias, and papillae are elevations
or projections that are essentially a central vascular response with sec-
ondary lymphocytic and plasma cell infiltration. Allansmith et al27 pro-
vided a classification of lid papillary hypertrophy (Figure 4-4). Grade 0
indicates a smooth or satin lid; grade 1, uniform cobblestone appear-
ance; grade 2, two or three papillae per millimeter; grade 3, papillae
1 mm or larger over the majority of the conjunctiva. Large papillary or
follicular hypertrophy covering the entire conjunctival surface is
termed contact lens–induced papillary conjunctivitis (CLIPC). Patients
with a history of atopy, a faulty contact lens edge, or a mucoprotein
film on the front surface of the lens are most susceptible to CLIPC.
An external evaluation is also important. The presence of such con-
ditions as meibomian gland dysfunction and blepharitis must be man-
aged and under control before fitting contact lenses. If in-turned or
Satin Uniform papillary

appearance
Non uniform papillary Giant papillary

appearance appearance
Figure 4-4. Classification of papillary hypertrophy. (From Allansmith MR, et al: Giant papil-
lary conjunctivitis in contact lens wearers, Am J Ophthalmol 83(5):242-252, 1977.)
disorganized lash patterns (e.g., ectropion or trichiasis) are present,

hydrogel lenses are indicated because they can protect the cornea from
mechanical irritation caused by the lashes. The bulbar conjunctiva
should also be assessed. Moderate injection, especially if persistent, is
often the result of dry eye, blepharitis, or other inflammatory process
and may contraindicate contact lens wear. A rigid lens is often accept-
able when a pinguecula is present because the edge of a soft lens may
aggravate the condition. Conversely, the opposite may be evident when
a pterygium is present because a rigid lens may encroach on the edge
of the growth, whereas a soft lens may blanket it.
The cornea should also be thoroughly evaluated. The presence of
any significant corneal defect, infection, or inflammation contraindi-
cates contact lens wear until the condition is resolved. In particular,
careful evaluation of the limbal vasculature, coalescence of corneal
staining, and endothelial changes is important. A 360-degree evalua-
tion of the limbal vasculature should be performed. It is important to
differentiate normal limbal vasculature from contact lens–induced
vascularization, and this should be carefully documented. Less than
1 mm of vessel engorgement is normal. However, 1 to 2 mm suggests
presence of chronic hypoxia, and this patient would best benefit from
refitting into GP lenses.25 Greater than 2 mm of vascularization is a
contraindication for contact lens wear. In addition, the cornea should
be stained with fluorescein to evaluate epithelial integrity. Areas of coa-
lescence of staining caused by desiccation, foreign body, or another
cause should be noted and recorded as baseline values. The endothe-
lium should be evaluated for the presence of polymegethism. In addi-
tion, the presence of an endothelial dystrophy may contraindicate
contact lens wear.
Tear Film Evaluation

The precorneal tear film plays an important role in determining the
potential for a patient to wear contact lenses successfully and is evalu-
ated at the same time as the cornea. It is likely that more patients are
contraindicated for contact lens wear or limited in their wearing time
because of a deficient tear film.
A good predictor of contact lens success and an often-used test of
tear film quality is tear break-up time (TBUT). Fluorescein is instilled,
and the cornea is evaluated with a wide slit-lamp beam (i.e., 2 to
4 mm) under low magnification with the cobalt blue filter over the illu-
mination system and a Wratten No. 12 or similar yellow filter placed
over the observation system. The patient views straight ahead and is
asked to blink several times and then refrain from blinking. The num-
ber of seconds until multiple dry spots form—appearing as black areas
adjacent to the green-stained tear film—is the TBUT (Figure 4-5). This
value is equal to the time it takes for dry spots to form in the tear film
via the mucin layer being contaminated by the lipid layer of the tear
film. A TBUT less than 10 seconds indicates that the patient may not
be an optimum candidate for contact lens wear.28 A value of between
6 and 9 seconds should limit the patient to a daily-wear schedule
because of borderline dry eyes. These patients should be instructed
that all-day lens wear might not be possible. A TBUT of 5 seconds or
less should be a contraindication to contact lens wear. If such values
are found, it is important to repeat the test several times. In addition,
such conditions as meibomian gland dysfunction or blepharitis can
reduce TBUT and should be managed before fitting the patient into
contact lenses. There are also several noninvasive TBUT tests involv-
ing either the projection of a grid pattern on the tear film or the use of
the keratometer mire image to observe tear breakup.29,30
Several tests are commercially available for evaluation of tear vol-
ume. The most common test is the Schirmer tear test. There are several
methods of performing this test. A Schirmer test strip is placed over the
temporal region of the lower lid such that the 5-mm notched section of
the strip is inserted underneath the lid. The patient should be viewing
superiorly. Depending on the test, the strip can be removed after either
Figure 4-5. Formation of dry spots when determining tear break-up time.
1 minute or 5 minutes of instillation. A value greater than 10 mm for 5

minutes and 6 mm for 1 minute is considered normal. This test is typ-
ically performed without an anesthetic, although anesthetic use results
in more comfort to the patient while minimizing the effects of reflex
tearing. The Schirmer II test has the benefit of anesthetic use with
deliberate irritation of the nasal mucosa and the amount of wetting
measured after a 5-minute period.31 If less than 15 mm of wetting is
present, a reduced reflex lacrimal secretion is present.32
An easier, more valid, and improved initial comfort test of tear vol-
ume is the phenol red thread test, currently marketed as Zone-Quick
by Allergan/Menicon (Irvine, CA).33 This test is performed with a high-
quality, 70-mm cotton thread soaked in phenol red dye. It is performed
identically to the Schirmer test with the edge of the thread tucked over
the temporal section of the lower lid while the patient views superiorly
(Figure 4-6). This test is only performed for 15 seconds, and the
amount of the strip that has changed from yellow to red is measured.
A value of less than 9 mm is diagnostic of dry eye. The average value
in the United States is 24.3 mm.34
Figure 4-6. The phenol red thread test.

If abnormal dry eye is suspected, the application of rose bengal dye

will stain dead and degenerated epithelial cells. A drop of 1% rose ben-
gal solution or use of an impregnated strip moistened with unpre-
served saline solution is instilled into the conjunctival sac. This is then
followed by irrigation of the external eye with an isotonic saline solu-
tion. The severity of the condition will be determined by the amount
and location of the red stain. In patients with keratoconjunctivitis
sicca, the inferior cornea and conjunctiva will exhibit excessive stain-
ing. The following grading sequence has been recommended for eval-
uating this condition:35
0 = absence of staining
1 = staining of less than one third of the cornea
2 = staining of between one third and two thirds of the cornea
3 = staining of between two thirds and the entire cornea
4 = staining over the entire cornea
5 = inferior conjunctival staining
Lissamine green dye has been used in a similar manner as rose ben-
gal dye.36 Other tests for tear film evaluation include tear meniscus
evaluation and lipid layer interference phenomena.
The author recommends using TBUT in combination with the phe-
nol red thread test. In addition, the use of a dry eye questionnaire can
be beneficial in determining if the patient has certain dry eye factors
or works in a dry eye environment (e.g., cigarette smoke, air condi-
tioning, central heating). This questionnaire, modified from
McMonnies, is presented in Box 4-4.33,37
Binocular Vision Status

There are certain patients for whom a GP lens material is not indicated
because of their binocular status; this is particularly true for patients
with high phorias or tropias. Those patients, most often young people,
benefit from base-in or base-out prism to assist in providing binocu-
larity and relieving asthenopia. However, with time, some children’s
binocular anomalies improve such that contact lens wear would be
indicated. For patients who would benefit from vertical prism, base-
down prism can be incorporated into a GP lens; however, this is typi-
cally not prescribed unilaterally and could induce asthenopia.
For prepresbyopic patients with severe myopia, the possibility of
needing a bifocal correction at an earlier age must be addressed. The
effective increase in accommodation necessary will be 0.25 D for
patients with 4-D myopia and 0.50 D for patients with 8-D myopia
who have decided to change from spectacles to contact lenses.38
Likewise, patients with esophoric hyperopia and exophoric myopia
may experience more near-point problems when they switch from
Box 4-4 DRY EYE QUESTIONNAIRE

1. Age _____
2. Sex: Male _____ Female _____
3. Currently wearing (circle one) no contact lenses, rigid contact lenses, soft
contact lenses
4. If you wear contact lenses, do you have a modified wearing schedule
because of dryness?
5. Are your eyes usually sensitive to cigarette, smog, air conditioning, or
central heating? Yes (2) No (0), Sometimes (1)
6. Do you take (please underline): antihistamine tablets (1); antihistamine
eyedrops (1); diuretics (1); sleeping tablets (1); tranquilizers (1); oral
contraceptives (1); medication for duodenal ulcer (1); digestive problems
(1), or high blood pressure (1); hormonic replacement pills (1); other
(write)?
7. Do you have arthritis? Yes (2) No (0) Uncertain (1)
8. Do you have a connective tissue disorder? Yes (2) No (0)
9. Do you have a thyroid abnormality? Yes (2) No (0) Uncertain (1)
10. Do you experience dryness of the nose, mouth, throat, chest, or vagina?
Never (0) Sometimes (1) Often (2) Constantly (3)
11. Are you known to sleep with your eyes open? Yes (2) No (0) Sometimes (1)
12. Do you have eye irritation on waking from sleep? Yes (2) No (0)
Sometimes (1)
13. Have you ever had drops prescribed or other treatment for dry eyes? Yes
(2) No (0)
From Lupelli L: A review of lacrimal function tests in relation to contact lens practice: I, Contact
Lens J 16:4-17, 1998; and Manning FJ, Wehrly SR, Foulks GN: Patient tolerance and ocular surface
straining: characteristics of lissamine green versus rose bengal, Ophthalmology 102:1953-1957, 1995.
spectacles to contact lenses because of the effect on convergence. A

spectacle-corrected patient with hyperopia has a base-out effect when
viewing near objects, whereas a spectacle-corrected patient with
myopia has a base-in effect. When contact lenses are worn, the patient
with hyperopia loses the base-out effect when viewing near objects and
must converge less. Likewise, the patient with contact lens-corrected
myopia loses the base-in prism effect when viewing near objects and
must converge more.25
CONSULTATION
Is the Patient Motivated?
The motivation to wear contact lenses is essentially through a desire to
improve one’s cosmesis, vision, or performance in sports. Typically, by
the conclusion of the preliminary evaluation, it is evident whether the

patient is motivated. This is the result of the patient’s verbal and non-
verbal communication. If the patient is quiet, asks few questions, and
appears to be sensitive about anything touching the eyes, motivation is
low. However, it is apparent that the greater visual or psychological
need that a patient has for contact lenses, the greater the likelihood
that motivation will be high.39 Important factors for motivation are
provided in Box 4-5.
Is the Patient a Good Candidate?

The aforementioned information pertaining to case history, eye health,
tear film function, residual astigmatism, binocular vision status, and
motivation are all important factors that will assist in determining
whether the patient is a good GP lens candidate, soft lens candidate, or
both. In addition, patients who are not good candidates for contact lens
wear, in general, can be ruled out. Figure 4-7 shows the results of a
preliminary evaluation of a patient who is a good candidate for GP
lenses.
Box 4-5 IMPORTANT FACTORS WHEN ASSESSING PATIENT MOTIVATION FOR

CONTACT LENS
●
If the patient is quiet and shows little positive expression during
discussions pertaining to contact lens wear, success is unlikely.
●
If the patient is a younger child and a vanity-conscious parent emphasizes
the need and importance for the child to have contact lenses but this is not
expressed by the patient, success (at that time) is unlikely.
●
Patients who are told they would be best benefited visually by contact
lenses but may not have been prepared psychologically (i.e., keratoconus,
trauma, postsurgical) may be less motivated.
●
If the patient is satisfied with spectacle wear and is only casual about
requesting contact lenses, motivation is typically low. Likewise, timid
patients who are accustomed to wearing spectacles have been found to be
less motivated for contact lenses.
●
Sensitive patients who are resistant to having anything touching their eyes
during relevant examination tests (i.e., tonometry, lid eversion, drop
instillation) are poor candidates.
●
If the patient is concerned about such factors as fees and adaptation, the
patient may not be a good candidate.
●
If the patient is interested only in extended wear and exhibits little interest
in caring for the lenses, compliance would most likely be problematic if
this patient is fit into contact lenses.
Figure 4-7. A prefitting evaluation of a good candidate for RGP contact lenses.
How to Properly Communicate the GP Lens Option to Patients

Despite the benefits of GP lenses, the primary contributing factor as to
why GP lenses are not the preferred mode of refractive correction is
the perception of poor comfort by the practitioner, patient, or both.
This is confirmed by a recent study in which 70% of patients were able
to wear their GP lenses 14 hours per day.40 Sixty percent of those

patients not able to achieve all-day wear were unable because of unac-
ceptable comfort or vision.
It is safe to assume that far too many patients have not fit into GP
lenses when, in fact, because of vision or eye health, this would have
been the preferred method of correction. However, if the practitioner
is unmotivated to fit GP lenses—often the result of inexperience or a
concern as to how the patient will react to the initial application of
these lenses—it is unlikely that these lenses will be presented as a
viable option to potential patients. Likewise, patients’ perception of GP
lenses can be consistent with the axiom that a dissatisfied patient will
tell more people about the bad experience than a satisfied patient
will tell about the positive experience. Therefore a patient who did not
have a good initial experience with GP lenses could greatly influence
other potential GP lens wearers.41
With this in mind, how can GP lenses be presented to the patient so
that the lenses will not be perceived negatively? As discussed in
Chapter 5, the use of a topical anesthetic at the fitting visit, the applica-
tion of lenses at or near the patient’s prescription so the patient can
immediately recognize the benefit of good initial vision, and a com-
fortable design and fitting relationship are all critical factors in achiev-
ing an optimum initial patient experience. However, it all begins with
the initial communication of GP lenses to the patient. The method the
practitioner and staff member use to present rigid lenses can have a
dramatic effect on the patient’s perception of these lenses. If tentative-
ness is exhibited in recommending GP lenses, the patient will under-
standably be hesitant in accepting this option.42 If the patient is told
discomfort or even pain may be experienced when wearing rigid lenses,
it makes it an easy decision for the patient to select soft contact lenses
as the preferred mode of correction.
It is important to remember that any apprehension on the part of the
practitioner or staff member is, often unknowingly, transferred to the
patient nonverbally. An absence of enthusiasm, neutral or negative facial
expression, poor eye contact, and anxiety or tenseness in arm and hand
position all communicate disinterest to the patient. This not only
unfairly limits the contact lens options available to patients but also
reduces their confidence in the practitioner’s ability, especially if they are
ultimately fit into a more appropriate lens material at another practice.42
The verbal presentation of GP lenses is also important. The
patient’s fear of the unknown can often influence acceptance or rejec-
tion of GP lenses. New contact lens wearers are most often hesitant to
place a foreign object on their eyes. This is especially true of male
patients who are not accustomed to applying cosmetics around their
eyes. This fear is intensified by information patients have heard about

real or perceived discomfort during adaptation. Because many GP lens
failures occur because of an inability to adapt to lens wear, it appears
that the verbal presentation of GP lenses is often inadequate and may
even enhance the patient’s preconceived fears. All patients should be
asked about their previous knowledge of contact lenses, so that the
presentation of GP lenses can be tailored to overcome any apprehen-
sions or concerns.
It is best to present GP lenses in a favorable but realistic manner.
The aforementioned benefits of good vision, eye health, ease of han-
dling, durability, and possible myopia control should be presented.43
Eye health, in particular, should be highlighted because of the current
interest in overall health exhibited by patients today.44 It is apparent
that patients can tolerate the initial lens awareness if these benefits are
explained and the patients are told about what to expect during adap-
tation and how improvement in comfort will gradually occur. The ini-
tial lens sensation should be explained in a calm, matter-of-fact
manner. There are several terms that should be avoided during the
presentation, including discomfort, irritation, pain, intolerance, and
failure.42 These terms intensify an already present fear and enhance
the likelihood of failure. Patients perceive words such as “awareness”
and “lid sensation” much more favorably. In addition, using terms
such as “gas permeable,” “oxygen permeable,” or simply “GPs” is more
favorable than using “rigid” to describe these lenses.45 Appropriate and
inappropriate terms to describe GP lenses and an appropriate expla-
nation of adaptation are provided in Box 4-6.
Bennett et al46 obtained confirmation of the importance of present-
ing GP lenses in a positive but realistic manner to new wearers.
Non–contact lens wearers were divided into three groups and fit into
GP lenses. All subjects were regularly monitored and completed and
returned a daily questionnaire pertaining to satisfaction and comfort
during the course of this 1-month study. The three groups were (1) fear-
arousing; (2) neutral content nonenthused, and (3) neutral content
enthusiastic. In group 1, during the initial fitting subjects observed a
video of a doctor discussing GP lenses with a new wearer during the
diagnostic fitting process using terms such as “discomfort,” “possible
pain,” “intolerance,” and “failure.” In group 2, the subjects observed a
video of a doctor who used terms such as “lens awareness” and “initial
lid sensation” to describe GP lenses, but it was apparent that his
attitude was less than enthusiastic about this option. In group 3, the
doctor used the same terminology as in group 2; however, his attitude
was much more positive, and it was apparent that he believed GP
lenses to be a viable option for this patient. Thirty-two of 40 subjects
Box 4-6 HOW TO PRESENT GP LENSES

Avoid These Terms Instead Use
Hurt Initial sensation
Pain Edge awareness
Discomfort Lid sensation
Irritation “Tickling” sensation
Uncomfortable Lid awareness
Painful “Itchy” sensation
Rigid lenses Gas permeable, oxygen permeable, or GP
Representative appropriate presentation: “You will experience an initial lens

awareness that will gradually go away until lens wear is hardly noticeable to
you. In fact, it is common for people to achieve better long-term comfort with
gas permeable lenses than with soft lenses. The sensation you will feel is
simply the lids being in contact with the lens edge. This “tickling” sensation
gradually goes away as your lids get used to the lens. Typically, this occurs
anywhere from a matter of several days to a few weeks. You should even
notice improvement in comfort the first day.”
From Bennett ES: How to present rigid lenses more effectively, Rev Optom Suppl 132(7):8A-10A,
1995.
completed this study. Six of the eight dropouts were from group 1 (fear-
arousing), and the other two were from group 2 (neutral content
nonenthused). Not only did all of the subjects in group 3 (neutral
content enthused) complete the study but also they were significantly
more compliant in returning their daily questionnaires than subjects
in the other two groups.
Therefore the verbal and nonverbal presentation of GP lenses is
critical to patient success with these lenses. This is especially true with
highly sensitive patients, including children, patients with kerato-
conus, and those who experienced some anxiety during prefitting pro-
cedures. Reassurance is obviously important during the adaptation
process. In addition, there are numerous aids available from the RGP
Lens Institute (www.rgpli.org), including the video entitled “Have You
Considered Oxygen Permeables” and the GP Benefits/Applications
laminated pocket card, which will be beneficial in assisting the patient
through this process.
Box 4-7 summarizes the key factors to consider when presenting
GP lenses to a patient interested in contact lens wear.42 If the patient’s
fears and expectations are understood, if the necessary time is devoted
to performing the indicated preliminary testing and explaining the
available options, and if GP lenses are explained properly to the
patient, it is likely that the percentage of patients adapting to GP lenses
Box 4-7 FACTORS TO CONSIDER WHEN PRESENTING GP LENSES

1. Present all contact lens options neutrally, allowing the patient to participate
in the lens choice.
2. Consider using a benefits card, videotape, or other resource to highlight
the benefits and applications of GP lenses.
3. Provide the attributes of each lens type as it pertains to such factors as
vision, health, comfort, and the patient’s lifestyle requirements.
4. Avoid using negative terms such as pain, discomfort, and intolerance.
5. Be aware of nonverbal communication when explaining lens options to a
patient. Any apprehension will be easily communicated.
From Bennett ES: How to present rigid lenses more effectively, Rev Optom Suppl 132(7):8A-10A,
1995.
will be higher than previously expected. In addition, as with anything

else in life, experience is the key. Typically, as practitioners gain more
experience in fitting GP lenses, they will acquire a greater level of con-
fidence and will also be comfortable in presenting this option in a pos-
itive but realistic manner. It is likely that experienced GP lens fitters do
not perceive comfort as an important concern with their patients and
take great pride in fitting this modality to their patients.
SUMMARY
Determining who are the best candidates for GP lenses initially
depends on performing a comprehensive preliminary evaluation to
determine if they are good contact lens candidates in general. If this is
the case, there are few such patients—those with a strong desire to
wear soft lenses, wear the lenses occasionally, or wear tinted lenses—
who are not good candidates for GP lenses. If the patient is a good can-
didate, it is important to communicate this option with confidence in
a manner that will be perceived favorably by the patient.
REFERENCES
1. Bennett ES: Seven reasons why you should recommend RGPs, Rev Optom Suppl
132(7):4A-6A, 1995.
2. Ziel CJ, Gussler JR, Van Meter WS, et al: Contrast sensitivity in extended wear of
the Boston IV lens, CLAO J 16(4):276-278, 1990.
3. Timberlake GT, Doane MG, Bertera JH: Short-term low contrast visual acuity
reduction associated with in vivo contact lens drying, Optom Vis Sci
69(10):755-760, 1992.
4. Johnson T, Schnider C: Clinical performance and patient perforance for hydrogel

versus RGP lenses, Int Contact Lens Clin 18(8):130-135, 1991.
5. Poggio EC, Glynn RJ, Schein OD, et al: The incidence of ulcerative keratitis
among users of daily wear and extended wear contact lenses, N Engl J Med
321(12):779-783, 1989.
6. Gordon JM, Bennett ES: Dk revisited: the hypoxic corneal environment.
Presented at the Annual Meeting of the American Academy of
Ophthalmology, November 1993, Chicago.
7. Holden BA, Mertz GW: Critical oxygen levels to avoid corneal edema for daily
and extended wear contact lenses, Invest Ophthalmol Vis Sci 25:1161-1167,
1984.
8. Bennett ES: RGPs: when oxygen is a priority, Contact Lens Spectrum 13(4): 18, 1998.
9. Gunning JN: Contact lens profitability comparison, Unpublished manuscript.
10. Ames K: Rethink your approach to RGP lenses, Contact Lens Spectrum 8(12):24,
27, 1993.
11. Ames K: Get your share of the RGP pie, Optom Manage 29(9):54-56, 1994.
12. Efron N: Guest editorial, Clin Exp Optom 83(5):243-245, 2000.
13. Bennett ES: Clinical controversies update 1994. In Bennett ES, Weissman BA, edi-
tors: Clinical contact lens practice, Philadelphia, 1994, JB Lippincott, pp 1-9.
14. Byrnes SP, Cannella A: An in-office evaluation of a multifocal RGP lens design,
Contact Lens Spectrum 14(11):29-33, 1999.
15. Johnson J: Multivision vs. monovision: a comparative study. Presented at the
Annual Meeting of the Contact Lens Association of Ophthalmologists,
January 2000, Las Vegas.
16. Walline JJ: Fitting kids with rigid gas permeable lenses, Contact Lens Spectrum 15(7):
33, 2000.
17. Garriott RS: Cover focus: our children’s vision crisis, Rev Optom 136(9):105-110,
1999.
18. Bennett ES: Rebirth of ortho-k, Rev Contact Lens 1(2):36-39, 2001.
19. Szczotka LB, Barr JT, Zadnik K: A summary of the findings from the
Collaborative Longitudinal Evaluation of Keratoconus (CLEK) study,
Optometry 72(9):574-587, 2001.
20. Connelly S: Why do patients want to be refit? Contact Lens Spectrum 7:39-41, 1992.
21. Andrasko G, Smiley T, Nichols L, et al: Clinical recommendations for the man-
agement of symptomatic soft contact lens wearers, Contact Lens Spectrum
8:24-16, 1993.
22. Goldberg EP, Bhatia S, Enns JB: Hydrogel contact lens-corneal interactions: a
new mechanism for deposit formation and corneal injury, CLAO J 23:243-
248, 1997.
23. Suchecki JK, Ehlers WH, Donshik PC: Peripheral corneal infiltrates associated
with contact lens wear, CLAO J 22:41-46, 1996.
24. Dart JK: The epidemiology of contact lens related diseases in the United
Kingdom, CLAO J 19:241-246, 1993.
25. Bennett ES, Watanabe RK: Preliminary evaluation. In Bennett ES, Henry VA, edi-
tors: Clinical manual of contact lenses, ed 2, Philadelphia, 2000, Lippincott
Williams & Wilkins, pp 1-33.
26. Jaanus SD, Bartlett JD, Hiett JA: Ocular effects of systemic drugs In Bartlett JD,
Jaanus SD, editors: Clinical ocular pharmacology, ed 3, Boston, 1995,
Butterworth-Heinemann, pp 970-972.
27. Allansmith MR, et al: Giant papillary conjunctivitis in contact lens wearers, Am J
Ophthalmol 83(5):242-252, 1977.
28. Andres S, Henriques A, Garcia ML, et al: Factors of the precorneal fluid break-up
time (BUT) and tolerance of contact lenses, Int Contact Lens Clin 14:81-120,
1987.
29. Mengher LS, Bron AJ, Tonge SR, et al: Noninvasive assessment of tear film sta-
bility. In Holly FJ, editor: Preocular tear film in health, disease, and contact lens
wear, Lubbock, TX, 1986, Dry Eye Institute, pp 64.
30. Patel S, Murray D, McKenzie A, et al: Effects of fluorescein on tear breakup time
and on tear thinning time, Am J Optom Physiol Opt 62:188-190, 1985.
31. Holly FJ: Diagnosis and treatment of dry eye syndrome, Contact Lens Spectrum
4:37-44, 1989.
32. Lupelli L: A review of lacrimal function tests in relation to contact lens practice:
I. Contact Lens J 16:4-17, 1988.
33. Elliott L, Henderson B, Bennett ES, et al: Comparison of overall performance of
hydrogel and rigid gas permeable lens materials in the contact lens man-
agement of the borderline dry eye patient. Presented at the Annual Meeting
of the American Academy of Optometry, December 1996, Orlando.
34. Sakamoto R, Bennett ES, Henry VA, et al: The phenol red thread test: a cross-cul-
tural study, Invest Ophthalmol Vis Sci 34:3510-3514, 1993.
35. Zuccaro VS: Rose bengal: a vital stain, Contact Lens Forum 39-43, 1981.
36. Manning FJ, Wehrly SR, Foulks GN: Patient tolerance and ocular surface stain-
ing: characteristics of lissamine green versus rose bengal, Ophthalmology
102:1953-1957, 1995.
37. McMonnies CA, Ho A: Patient history in screening for dry eye patients, J Am
Optom Assoc 58:296-301, 1987.
38. Benjamin WJ: Visual optics of contact lens wear. In Bennett ES, Weissman BA,
editors:. Clinical contact lens practice, Philadelphia, 1990, JB Lippincott, pp
14-1-42.
39. White PF, Gilman EL: Preliminary evaluation, In Bennett ES, Weissman BA, edi-
tors: Clinical contact lens practice, Philadelphia, 1990, JB Lippincott, pp 17-1-18.
40. Polse KA, Graham AD, Fusaro RE, et al: Predicting RGP daily wear success,
CLAO J 25(3):152-158, 1999.
41. Bennett ES: RGP fitting: how to increase comfort, Pract Optom 8(4):148-152,
1997.
42. Bennett ES: How to present rigid lenses more effectively, Rev Optom Suppl
132(7):8A-10A, 1995.
43. Davis R, Keech P, Dubow B, et al: Making RGP fitting efficient and successful,
44. Benoit DP: Try RGPs for fun and profit, Contact Lens Spectrum 11(10):47-48,
1996.
45. Quinn TG: Maximizing comfort with RGPs, Contact Lens Spectrum 12(3):21,
1997.
46. Bennett ES, Stulc S, Bassi CJ, et al: Effect of patient personality profile and ver-
bal presentation on successful rigid contact lens adaptation, satisfaction and
compliance, Optom Vis Sci 75:500-505, 1998.
5
Lens Design, Fitting, and Evaluation
EDWARD S. BENNETT
T he ability to properly design, fit, and evaluate a gas permeable

(GP) lens is a skill acquired through experience. The foundation
of a successful contact lens practice begins with this ability,
which in turn promotes practitioner confidence and satisfaction. With
the lens materials and manufacturing methods in use today, the
design and fitting of these lenses is made more efficient, user friendly,
and successful.
EMPIRICAL VERSUS DIAGNOSTIC FITTING

Diagnostic Fitting
Diagnostic fitting of GP lenses has traditionally been the method of
choice for numerous reasons. It allows patients to experience rigid lens
sensation and to leave the office having overcome the initial psycholog-
ical hurdle of having a lens on their eyes. This often results in an
increase in enthusiasm for lens wear by the patient and an increase in
the fitter’s confidence. A study comparing empirical fitting with diag-
nostic fitting found that patients fit diagnostically were much more
motivated to return to the practitioner’s office for dispensing and fol-
low-up care.1 Although a fitting visit and a sufficient number of diag-
nostic lenses are required, diagnostic fitting allows contact lens
practitioners the opportunity to evaluate the lens-to-cornea fitting rela-
tionship and to make the necessary changes to obtain a good fit and
provide acceptable vision to their patients.2 If a poor fitting relationship
or patient dissatisfaction results, different options can be attempted
before the patient leaves the office. In addition, depending on the
design, contact lens practitioners often need to make many observa-
tions beyond lens diameter and base curve radius (BCR). Such factors
as lid tension, pupil size, tear flow, movement, lateral decentration,
peripheral curve relationship, lens movement, lens position, and
wetting characteristics of the lens material need to be evaluated to
86
Chapter 5 Lens Design, Fitting, and Evaluation 87
achieve an optimal fit.3 This is especially true of the peripheral curve

relationship because there is no universal standard between laborato-
ries. If an aspheric design is not being used, it is often recommended
that the practitioner design the peripheral curve radii or, at minimum,
ask the laboratory what parameters are being used.4
The most successful method of diagnostic fitting pertains to simu-
lating the efficiency of soft lens fitting. This process begins with topi-
cal anesthetic use at the fitting visit to optimize initial comfort (to be
discussed). A lens is then provided from a large diagnostic fitting set
or preferably from an inventory that is close to the patient’s indicated
power. Therefore the patient may still experience some awareness,
which will increase as the anesthetic effect reduces; however, if the
patient immediately observes an important benefit of GP lenses (i.e.,
good vision), the patient will be more likely to increase enthusiasm
about this option. In fact, it actually reduces any comfort concerns
the patient may have. Certainly, at minimum, the availability of sev-
eral diagnostic sets would be beneficial. The following sets are recom-
mended:
●
−3.00 D 9.4 mm overall diameter (OAD); 40.50 to 45.25 D BCR
(in 0.25-D steps) standard thickness; peripheral curve radii either
aspheric or tricurve design with secondary curve radius (SCR)
equal to 1 mm flatter than BCR and peripheral curve radius
(PCR) equal to 2 mm flatter than SCR. Both curve widths would
equal 0.4 mm, resulting in an optical zone diameter (OZD)
equal to 7.8 mm. A low-Dk fluoro-silicone/acrylate (F-S/A)
material would be recommended.
●
−3.00 D set identical to above except in an ultrathin design (i.e.,
0.10 to 0.12 mm center thickness).
●
−6.00 D set identical to above.
●
+3.00 D set identical to above with the exception of being
manufactured from a high-Dk F-S/A lens material.
The preferable method of diagnostic fitting for vision and fitting rela-
tionship is the use of a GP lens inventory. Such an inventory is given
in Table 5-1. Fitting and providing replacement lenses from an inven-
tory provides numerous benefits (Box 5-1).5 Immediate vision is expe-
rienced, as mentioned before, in addition to being able to dispense
from the inventory. Likewise, having a GP lens inventory also provides
patients with a service when a lens is lost or needs to be replaced.
Many successful GP lens wearers have decided to change to soft lenses
when a replacement GP lens was unavailable and they had no desire
to wear spectacles, even temporarily.
Another important consideration is whether the diagnostic lenses
should be stored in disinfecting solution. Obviously this would be
88
Table 5-1 GP Lens Inventory

BASE CURVE RADIUS(MM)
Power(D) 7.42 7.50 7.54 7.58 7.63 7.67 7.71 7.76 7.80 7.85 7.89 7.94 7.99 8.04 8.13
−1.25 94 110 123 136 149 162 175 188
−1.50 79 95 111 124 137 150 163 176 189
SECTION III
−1.7 80 96 112 125 138 151 164 177 190

−2.00 1 14 27 40 53 66 81 97 113 126 139 152 165 178 191
−2.25 2 15 28 41 54 67 82 98 114 127 140 153 166 179 192
−2.50 3 16 29 42 55 68 83 99 115 128 141 154 167 180 193
−2.75 4 17 30 43 56 69 84 100 116 129 142 155 168 181 194
−3.00 5 18 31 44 57 70 85 101 117 130 143 156 169 182 195
−3.25 6 19 32 45 58 71 86 102 118 131 144 157 170 183 196
−3.50 7 20 33 46 59 72 87 103 119 132 145 158 171 184 197
−3.75 8 21 34 47 60 73 88 104 120 133 146 159 172 185 198
−4.00 9 22 35 48 61 74 89 105 121 134 147 160 173 186 199
−4.25 10 23 36 49 62 75 90 106 122 135 148 161 174 187 200
−4.50 11 24 37 50 63 76 91 107
−4.75 12 25 38 51 64 77 92 108
−5.00 13 26 39 52 65 78 93 109
Other Parameters:
1. Low-Dk F-S/A lens material
PATIENT SELECTION, FITTING, AND CARE
2. 9.4 mm overall diameter/7.8 mm optical zone diameter (OZD)

3. Secondary curve radius (SCR) = base curve radius + 1 mm
4. Peripheral curve radius (PCR) = secondary curve radius + 2 mm
5. Secondary curve width = peripheral curve width = 0.4 mm
Box 5-1 BENEFITS OF A GP INVENTORY

1. Avoid losing patients between the fitting visit and the dispensing visit
2. Compare two different lens designs with each trial pair
3. Reduce chair time by dispensing parameter changes the same day
4. Impress patients with the added level of service
5. Give new GP lens patients a more realistic experience with appropriate
visual correction
6. Improve your judgment and skills when you see the impact of design
changes immediately
7. Offer same-day replacement
8. Improve your success rate
From Keech P: The top 10 reasons to inventory RGPs, Contact Lens Spectrum 11(10):32-36, 1996.
beneficial for improving on-eye wettability and maintaining the lenses

in a sterile condition. However, especially with frequent use of these
lenses, there are numerous benefits of keeping the lenses in the dry
state. Lenses stored in solution are prone to leakage and evaporation of
the solution, resulting in a lens that adheres to the case and may even
change in BCR because of the change from dry to wet state. It is also
more efficient and convenient to store the lenses in a dry environment
because they can be stored in flat packs and take little shelf space.
However, if a lens is to be reused, it must be cleaned, disinfected, and
blotted dry with a soft tissue before being placed into a case.
Empirical Fitting
Empirical fitting has gained greater acceptance and success in recent
years. Whereas it was initially used, in part, by practitioners who were
not optimally confident in their custom-design skills and therefore
placed their trust in manufacturers’ nomograms and design philoso-
phies, there are good reasons to consider empirical methods today.
Empirical fitting is time efficient and also accurate. The latter is the
result of higher quality manufacturing, which has resulted in greater
success with newer designs with standard parameters (aspheric
peripheries, average diameters, ultrathin construction). One such
design resulted in a 70% first-fit success rate.6 In addition, corneal
topography instrumentation has included sophisticated contact lens
design software with the ability of accurately simulating the fluores-
cein pattern based on topography while recommending a lens design
that results in a high first-fit success rate.7-10 In addition, as mentioned
previously, the powerful effect of providing good vision after initial
application of a GP lens on a new patient should never be underesti-
mated. If the appropriate diagnostic lens power is not available with
the inventory or trial set, ordering a lens empirically makes sense to

lessen the psychological effect of lens awareness.
Topical Anesthetic Use

The use of a topical anesthetic during the diagnostic fitting process to
temporarily increase initial comfort has been controversial. Concerns
about topical anesthetic use have included its potential for softening
the epithelium, resulting in greater incidence of corneal staining.11,12
Likewise, concern has been exhibited that the initial comfort may actu-
ally mislead the patient, who will ultimately experience the typical lens
awareness with GP lenses. Although these are legitimate concerns,
they have not been substantiated by clinical research. In one such
study, one half of the patients received a placebo at dispensing,
whereas the other half received a topical anesthetic immediately before
application of GP lenses.13 After 1 month of lens wear, anesthetized
patients perceived their adaptation time, long-term wear, fit experi-
ence, and overall satisfaction to be significantly higher than patients
who had a placebo. Seventy of 80 patients completed the study; 8 of
the 10 patients who discontinued were in the placebo group. In addi-
tion, no significant difference in corneal staining between these two
groups was found at consecutive visits. These results were consistent
with a previous pilot study.14 It is evident that the first few minutes of
GP lens wear are critical to success. If lens wear is not unpleasant dur-
ing this period, patient satisfaction and the potential for long-term suc-
cessful wear should be good. The topical anesthetic will wear off, and
the patient will gradually experience lens awareness, which is impor-
tant during the initial fitting session. For apprehensive patients, such
as children, patients with keratoconus, and those undergoing soft lens
refits, topical anesthetic use is beneficial. In addition, an important
benefit of anesthetic use for practitioners is the ability to quickly assess
the fluorescein pattern, as opposed to waiting until patients have
reduced their awareness symptoms. This allows rapid lens changes, if
necessary; therefore efficiency is increased.
Another approach has evaluated the effect of nonsteroidal antiin-
flammatory drugs (NSAIDs) on adaptation.15,16 The mechanism of
action of all NSAIDs is to reduce prostaglandin production. Because
prostaglandins are mediators of pain, reducing their production
reduces pain. Voltaren appears to be the most effective drug within
this class at inhibiting prostaglandin synthesis. A recommended
NSAID dosage for GP lens adaptation is16:
●
Instill one drop of Voltaren in each eye 30 minutes and then 15
minutes before lens insertion
●
Instill a third drop just before lens insertion
●
A fourth drop can be instilled 1 hour after insertion
●
This regimen can be maintained for 3 to 5 days or until
adaptation is completed
What is the Bottom Line?

When should a practitioner consider empirical fitting? In a changing
health care environment, where efficiency is the norm and not the excep-
tion, it is understandable that clinicians would consider empirical fitting.
However, it is advisable to use empirical fitting only after sufficient expe-
rience with diagnostic fitting has been obtained to gain competence in
lens parameter and fitting relationships. Empirical fitting also has its
most effective applications in standard, uncomplicated cases. The use of
diagnostic lenses would be recommended for special design cases, such
as for patients who wear bifocals or have an irregular cornea. Topical
anesthetic use during the initial application process should result in an
increase in initial comfort and long-term patient satisfaction and success.
FLUORESCEIN APPLICATION AND EVALUATION

Description and Application
The application of fluorescein to the tear film is essential for proper
evaluation of the lens-to-cornea fitting relationship. Nevertheless, this
is typically one of the first shortcuts taken by practitioners who fit gas
permeable lenses. Omitting this step can result in any of the following
problems:
●
Peripheral seal-off: tear exchange is not possible; therefore debris
removal and additional oxygen supply is eliminated.
●
Areas of bearing or contact of lens against cornea: corneal
distortion can result over time.
●
Regions of excessive edge clearance: more lid awareness, corneal
dryness, or desiccation and lens decentration can result.
●
Corneal compromise: areas of coalesced cornea staining can be
present.
Sodium fluorescein is an organic compound that is inert and harmless
to tissue.17 The application of a drop of sterile ophthalmic irrigating
solution on a small quantity of sodium fluorescein in dry form on thin
strips of filter paper to the bulbar conjunctiva causes the tears to fluo-
resce yellow-green when viewed with a cobalt blue light. This enables
the practitioner to estimate the amount of lens clearance from the
cornea and areas of adherence or bearing.
The procedure for fluorescein application begins with removing the
strip from the package by tearing the center portion and removing the top
half. The strip is then moistened with ophthalmic irrigating solution

and applied to the superior bulbar conjunctiva as the patient views
inferiorly with the upper lid raised. Care must be taken that the tip of
the solution container does not come in contact with the fluorescein
strip. It is advantageous to have the patient’s head tilted back and the
fluorescein only lightly applied to minimize the risk of contact with the
patient’s clothes. Once the procedure has been completed, the patient
should be instructed to blink a few times to spread the fluorescein
while the practitioner aligns the examining instrument.
Instruments for Evaluation

A Burton lamp or a biomicroscope can be used for evaluation of the flu-
orescein pattern. The Burton lamp is a handheld ultraviolet fluorescent
lamp with a +5.00-D magnifier manufactured by Burton Medical
Products (Chatsworth, CA). After fluorescein application, the lamp is
held directly in front of the patient’s eyes, and the pattern is evaluated.
This method is inexpensive, extremely simple, and is especially benefi-
cial when observing both eyes at once or when observing and evaluat-
ing some of the more distinctive patterns, such as those in patients with
high corneal toricity and keratoconus. However, the Burton lamp is lim-
ited in its applications because the amount and size (width) of the illu-
mination and the magnification cannot be varied. In addition, this
instrument is of limited benefit in evaluating corneal compromise.
The primary advantage of using the biomicroscope for fluorescein
evaluation is flexibility. The magnification, illumination, and beam
width can be varied according to practitioner preference. Therefore it
has become the preferred method for evaluation of the lens-to-cornea
fitting relationship and is essential for evaluating corneal compromise.
However, the Burton lamp is a useful adjunct for patients in whom eval-
uating a larger overall field of view is indicated. When evaluating the
fluorescein pattern with a biomicroscope it is important to use a wide
beam, low magnification, and high illumination for optimum results.
It has also become standard practice to use—as an adjunct to the
cobalt blue filter that is placed over the illumination system—a yellow
barrier filter (i.e., Wratten #12 or Tiffen #2) over the observation sys-
tem. The application of this filter will enhance the fluorescence of the
pattern, especially with GP materials that have ultraviolet-blocking
agents.18 This filter is available from many sources, including photo-
graphic supply companies and many contact lens companies, notably
Polymer Technology Corporation (Rochester, NY).
Evaluation
Once fluorescein is applied, the patient should blink several times
before the practitioner assesses the pattern. Allow, at minimum, 20
seconds to elapse before evaluation. The fluorescein pattern assumes

a variety of forms. Areas of tear pooling between the lens and cornea
appear green when observed under a cobalt blue filter, whereas areas
of bearing appear dark or black.
A fluorescein pattern showing the lens evenly contouring the
cornea with only light tear pooling between the lens and cornea is
termed an alignment fit. A steep central fit with excessive fluorescence
or tear pooling centrally is termed apical clearance. Apical bearing rep-
resents the opposite form of pattern or direct contact of the lens
against the central cornea. Astigmatic corneas, in particular those with
more than 1 D of astigmatism, will show a bow-tie or dumbbell-shaped
pattern as a result of excessive pooling in the steeper meridian.
The practitioner should always strive for an alignment fitting rela-
tionship. The only exceptions would pertain to patients in whom an
alignment fit cannot be achieved (i.e., irregular corneas) or is not
desired (i.e., corneal reshaping or orthokeratology). A central light
green fluorescein pattern is present in this fitting relationship. The
periphery of the lens should exhibit a slightly denser green, represent-
ing greater edge clearance from the cornea, allowing tear exchange
and preventing mechanical trauma to the cornea on blinking.
Excessive apical bearing should be avoided because corneal mold-
ing can occur, possibly resulting in warpage or distortion. Conversely,
excessive apical clearance from a steep lens-to-cornea fitting relation-
ship can result in midperipheral corneal bearing and a decrease in tear
flow to the central cornea and in removal of waste products away from
the cornea resulting from minimal peripheral pooling or clearance
(Figure 5-1). A dense green peripheral pattern indicates excessive edge
clearance, which can result in greater lens awareness, frequent dis-
lodgement, and possibly corneal desiccation because of a compromise
in blink quality and a shift of the tear film from the peripheral to the
underneath the periphery of the lens (Figure 5-2). A summary of how
to interpret fluorescein patterns is provided in Table 5-2.19
This aforementioned information only pertains to a well-centered
gas permeable lens. If the lens is decentered, the position of the lens rel-
ative to the cornea must be considered before a practitioner can make
an accurate assessment of the pattern. For example, an inferiorly decen-
tered lens may exhibit excessive superior pooling as a result of a flat
peripheral bevel adjacent to the central cornea. Likewise, false fluores-
cein patterns can result from several causes. If peripheral seal-off is
present, little tear exchange will occur underneath the lens; because this
often results from a steep or apical clearance fit, a practitioner could
mistake this as an alignment or even apical bearing relationship. The
greater edge thickness of a high minus lens may block fluorescence,
giving the appearance of central pooling or a “pseudosteep” pattern.20
Figure 5-1. An apical clearance, low edge clearance fitting relationship.
For the same reason, a “pseudoflat” appearance may result with a plus
lens because of the greater center thickness present.
Fluorescein evaluation of the lens-to-cornea fitting relationship
should be performed at the fitting and all progress evaluation visits. The
ability to accurately assess fluorescein patterns comes only after constant
and frequent evaluations. It is not uncommon to have a lens that centers
optimally but could induce corneal compromise over time because of the
absence of an alignment fluorescein pattern. It is important to under-
stand that any contact lens design philosophy is merely a starting point;
likewise, GP lens laboratories tend to vary considerably in the design
parameters that they recommend.4 These factors, in combination with
individual corneal topographic differences, make evaluating the fitting
relationship of a rigid lens to the cornea with fluorescein critical to long-
term patient success with gas permeable contact lenses.
AUTHOR’S LENS DESIGN AND FITTING PHILOSOPHY

There are a variety of lens design philosophies today, including the one
presented in this chapter. However, it is important to note that—
Figure 5-2. A high edge clearance fitting relationship.
Table 5-2 How to Interpret Fluorescein Patterns

Parameter Appearance Management
Base curve radius Too steep: green Flatten base curve
appearance centrally
Too flat: black Steepen base curve
appearance centrally
Optical zone Too large: green Reduce optical zone/
appearance centrally flatten base curve
Too small: black Increase optical zone/
appearance centrally steepen base curve
Intermediate Too steep/narrow: gray Flatten/widen curves
appearance in midperiphery
Too flat/wide: green Steepen/narrow curves
appearance signifies
excessive edge lift
Peripheral curves Too steep/narrow: gray Flatten/widen curves
appearance in periphery
Too flat/wide: green Steepen/narrow curves
appearance signifies
excessive edge lift
From Bennett ES: Easy ways to improve your RGP lens fitting, Rev Optom Suppl 132(7):15A-17A,
1995.
regardless of the design philosophy—the most important factor is flu-

orescein pattern evaluation of the fitting relationship. The design
parameters used in a GP lens design are defined as follows:
OAD/OZD: The OAD is equal to the overall size of the lens. It is
commonly between 8.8 and 10.0 mm. The inner posterior OZD
encompasses the central 65% to 80% of the lens and provides an
optical correction for the patient’s refractive error.
BCR: The central back surface curvature of the lens, the primary
purpose of the BCR is to optimize the fitting relationship of the
lens to the central and paracentral cornea. The BCR is often
similar to the flatter keratometry value (i.e., “K”). It can be
specified in diopters or millimeters, although the latter is
preferred (Appendix 1).
Peripheral Curve Radii and Width: Surrounding the OZD of the
lens is one to three peripheral curves, which usually encompass
the outer 20% to 35% of the lens. A bicurve lens, consisting of a
base curve and a peripheral curve, is used much less often than a
tricurve lens with a base curve, secondary curve, and a peripheral
curve. The author often uses a tetracurve design that incorporates
an intermediate curve adjacent to the secondary curve and an
outer peripheral curve adjacent to the intermediate curve.
Between each curve is a sharp transition zone, which is often
smoothed or blended during the manufacturing process. These
design parameters are shown in Figure 5-3.
Overall and Optical Zone Diameter

Gas permeable lenses must be large enough to permit an adequate
OZD while still allowing movement of the lens on blinking. The OZD
is often approximately 1.4 mm less than the OAD. The OAD and OZD
of a rigid lens are typically obtained by considering the following vari-
ables: (1) palpebral aperture size, (2) pupil size, (3) refractive power,
and (4) corneal curvature. Palpebral aperture size and pupil size are
particularly important.
Palpebral Aperture Size

The palpebral aperture size is defined as the vertical separation of the
upper and lower lids when the eye is in its normal relaxed state. This
can be determined using a millimeter ruler with the patient’s gaze
directed straight ahead. Normal values range between 9.0 and 10.5
mm. In most lid-to-cornea relationships, there is, at minimum, slight
overlap of the lids over the limbus (Figure 5-4). This relationship often
results in the so-called “lid attachment” type of fit, in which the upper
Figure 5-3. A tetracurve lens design.
edge of the gas permeable lens positions under the upper lid (Figure
5-5). For patients with a larger than average palpebral aperture size in
which the lids are approximately tangent to the limbus, making a lid
attachment fitting relationship difficult to achieve, an interpalpebral fit
is desired (Figure 5-6). This necessitates a smaller than average OAD
lens that will not abut the upper lid but will be positioned away from
it; ideally it will be well centered on the cornea between the lids.
Pupil Size
The OAD should be large enough to allow an OZD that is larger than
the pupil size during dim illumination. Otherwise, the patient is likely
to exhibit symptoms of flare under low illumination conditions, espe-
cially if the lens is decentered.
Refractive Power
It is not uncommon for practitioners to use a larger OAD lens for
patients with hyperopia. Because of the mass of these lenses, they may
decenter inferiorly; therefore although a larger lens has greater mass,
it also allows the incorporation of a special peripheral design (i.e.,
minus lenticular) to increase the likelihood of centration.
Figure 5-4. An example of a normal lid-to-cornea relationship, which is optimum for a lid
attachment fitting relationship.
Figure 5-5. A lid attachment fitting relationship.

Figure 5-6. A large fissure resulting from a highly positioned upper lid.
Corneal Curvature
Steeper than average corneal curvatures (i.e., >45 D) often necessitate
a smaller than average OAD to maintain centration on a cornea that
typically flattens at a higher rate than normal.
Other Considerations
Young people, particularly those involved in sports, can often benefit
from the selection of a larger than average diameter. These lenses typ-
ically move less on the eye with blinking and are also less likely to dis-
place when playing contact sports.
Recommended diameter values are provided in Table 5-3. An aver-
age OAD/OZD of 9.4/8.0 mm should be successful for most patients,
particularly when a lid attachment fitting relationship is desired. A
smaller than average OAD/OZD of 9.0/7.6 mm is recommended for
patients in whom an interpalpebral fitting relationship and/or steeper
than average corneal curvatures are desired. A larger than average
OAD/OZD is indicated for patients with a larger than average pupil
size and for athletes.
In recent years, gas permeable lens designs with OADs as large as
10 to 15 mm have been introduced to increase initial comfort. These
have included ComfortFlow (Acculens, Lakewood, CO), Macrolens (C
& H, Dallas, TX), and Epicon (Specialty Ultravision, Campbell, CA).21-23
It would not be surprising to see the introduction of such “comfort”

designs increase in the near future.
Base Curve Radius

The BCR to be selected for a given patient depends on several factors,
including corneal curvature, lid-to-cornea relationship, and fluorescein
pattern evaluation. Because the cornea is aspheric and tends to flatten
at a greater rate at an increasing distance from the center, the selection
of a BCR that is slightly flatter than K should result in an alignment
fitting relationship. To optimize centration, a steeper BCR is indicated
with increasing corneal toricity and in plus powers because of the
more anterior center of gravity in lenses exhibiting greater mass. A
philosophy for BCR selection is provided in Table 5-3.
It is important to note that to maintain an alignment fitting rela-
tionship, the BCR will need to be steepened for smaller diameters and
flattened for larger diameters. This is the result of the change in sagit-
tal depth created by changing the optical zone of the lens. Increasing
the OZD of the lens will increase sagittal depth, effectively steepening
the fitting relationship. Likewise, reducing the OZD of the lens will
decrease sagittal depth, effectively flattening the fitting relationship. A
simple rule of thumb is to flatten the BCR by 0.25 D for every increase
in OAD of 0.5 mm and to steepen the BCR by 0.25 D for every
decrease in OAD of 0.5 mm.24 The most common scenario would be
an alignment fitting relationship that was achieved for a patient with a
large pupil. A larger OAD/OZD lens would be indicated; however, the
BCR should be flattened by, at minimum, 0.25 D to maintain the
alignment fitting relationship.
GP lenses will always move along the steeper meridian of the
cornea and to the steepest region of the cornea (i.e., apex). Therefore
for a patient with a with-the-rule (WTR) astigmatic cornea, the lens
will typically move vertically; with against-the-rule (ATR) astigmatism,
the lens will typically move horizontally. The latter can be particularly
problematic because the lens tends to decenter laterally. Therefore for
a patient with ATR astigmatism, it is often necessary to select a steeper
BCR than recommended to achieve satisfactory centration. Likewise,
for patients with a corneal apex that is decentered—especially inferi-
orly—the lens tends to decenter and will necessitate a change in BCR,
often steeper than recommended.
Peripheral Curve Radii and Width

The purpose of the PCRs is to allow good tear flow while compensat-
ing for an aspheric corneal shape. The distance from the edge of the
lens and the cornea is termed the edge clearance. This distance should
Chapter 5
Table 5-3 GP Diameter and Base Curve Selection*

OAD/OZD)
9.8/8.4 mm (Large
Corneal Cylinder 9.0/7.6 mm (Interpalpebral & Steep Corneas) 9.4/8.0 mm (Lid Attachment) Pupils & Athletes)
0 − 0.7 5 D 0.25 D flatter than K 0.50 D flatter than K 0.75 D flatter than K
1.00 − 1.25 D “On K” 0.25 D flatter than K 0.50 D flatter than K
1.50 − 1.75 D 0.25 D steeper than K “On K” 0.25 D flatter than K
2.00 − 2.25 D 0.50 D steeper than K 0.25 D steeper than K “On K”
≥ 2.50 D A bitoric lens design is recommended
*
For minus lenses only; for plus lenses select a base curve radius 0.50 D steeper than this philosophy.
Lens Design, Fitting, and Evaluation
101
be slightly greater than central clearance. Closely related to edge clear-

ance and easily quantified is edge lift, or the distance between the lens
edge and an extension of the base curve of the lens. Radial edge lift is
defined as the extension of the lens edge perpendicular to the exten-
sion of the base curve. Axial edge lift, defined as the vertical distance
from the lens edge to an extension of the base curve of lens edge, is the
more commonly used parameter (Figure 5-7). Although this value does
not consider changes in corneal topography, it is easily calculated and
provides similar information as edge clearance (i.e., with an increase
in axial edge lift, it can be assumed that the lens edge is farther from
the cornea). The lens parameter that has the most impact on edge
clearance is the outer PCR and width.25,26 With polymethylmethacry-
late (PMMA) lens designs, a flat, wide peripheral curve was used to
optimize oxygen provided by tear circulation. However, the oxygen per-
meability of current GP lens materials negates the need for a high rate
of tear exchange, whereas the potential drying effects of a high edge
clearance design are eliminated as well. It has been found that a high
edge clearance design funnels in surrounding tears, resulting in dry-
ing of the 3 and 9 o’clock peripheral corneal regions, and potentially
affects blink quality through an increased interaction between the lens
edge and the superior lid.27-31 Likewise, it has been found that a flat
base curve-anterior edge apex lens design fit to achieve lid attachment
may, in some patients, decenter inferiorly because of the increase in
edge clearance resulting from this design.32
A uniform edge clearance, resulting in satisfactory initial comfort,
is obtainable with many of the current aspheric designs (i.e., progres-
sive flattening of back surface because of lathes, which can manufac-
ture lenses with a standard rate of flattening).33,34 In fact, many of the
newer standard designs have used corneal topography in determining
the periphery of a GP lens, which is often aspheric or pseudoaspheric
(i.e., several peripheral curves that are well blended). The author’s rec-
O.A.D.
S (SAG)
Z (axial edge lift)
E (radial edge lift)

Figure 5-7. Axial edge lift versus sagittal edge lift.
ommended peripheral curve system is provided in Box 5-2. Because

GP lenses are not as dependent on the tear pump, this would be con-
sidered a low edge clearance design. However, because of individual
differences in corneal topography, it is important to evaluate the
peripheral lens-to-cornea fitting relationship with fluorescein to rule
out the presence of excessive clearance or seal-off. To maintain a con-
stant edge clearance, the peripheral curve system must be flattened at
a greater rate with BCRs and at a lesser rate for steep BCRs. Therefore
the aforementioned peripheral curve design philosophy can be used
for average BCRs (i.e., 7.5 to 8.2 mm), but slightly flatter values should
be used with flatter BCRs, and slightly steeper values should be used
with steeper BCRs.35
The use of a well-blended peripheral curve system is also important.
A poorly blended or unblended peripheral curve system can produce
dryness, itchiness, and scratchiness.36 It has been found that wearing
a lens with a medium blend is initially more comfortable than an
unblended peripheral curve design.37 To blend the junctions between
peripheral curves, a compensated radius tool with a radius of curva-
ture midway between the two curves to be blended is used. For exam-
ple, in Box 5-2 with a BCR equal to 8.0 mm and peripheral curves of
8.80, 9.80, and 11.20 mm, compensated blending tools equal to 8.40,
9.30, and 10.5 mm would be used.
Box 5-2 AUTHOR’S RECOMMENDED PERIPHERAL CURVE PHILOSOPHY

> 9.0 mm OAD: tetracurve design
Secondary curve radius (SCR)/width = BCR + 0.8 mm/0.2 mm
Intermediate curve radius (ICR)/width = SCR + 1.0 mm/0.2 mm
Peripheral curve radius (PCR)/width = ICR + 1.4 mm/0.3 mm
Example: BCR = 8.00 mm OAD/OZD = 9.4/8.0 mm

SCR/W = 8.00 + 0.8 = 8.80 mm/0.2 mm
ICR/W = 8.80 + 1.0 = 9.80 mm/0.2 mm
PCR/W = 9.80 + 1.4 = 11.20 mm/0.3 mm
≤ 9.0 mm OAD: tricurve design

Secondary curve radius (SCR)/width = BCR + 1.0 mm/0.3 mm
Peripheral curve radius (PCR)/width = SCR + 2.0 mm/0.4 mm
Example: BCR = 8.00 mm OAD/OZD = 9.0/7.6 mm

SCR/W = 8.00 + 1.0 = 9.00 mm/0.3 mm
PCR/W = 9.00 + 2.0 = 11.00 mm/0.4 mm
Center Thickness
Overall lens thickness depends on a number of variables, but prima-
rily lens power and OAD. The center thickness is greater and the cen-
ter of gravity is more anterior for plus lenses, whereas the edge
thickness is greater and the center of gravity is more posterior for
minus lenses (Figure 5-8).
Center thickness is an important parameter for the flexible GP
lens materials. If the lens is too thin, flexure and instability can result.
If the lens is too thick, its mass may result in inferior positioning on
the cornea. The latter situation is especially problematic with GP
lenses. It has been found that increasing the center thickness by 0.04
mm decreases the equivalent oxygen percentage (EOP) by less than 1%
but will increase mass by 24%.38 Fortunately, the introduction of more
Figure 5-8. The difference in the anterior center of gravity of a plus versus a minus power
lens.
advanced manufacturing techniques and instrumentation has resulted

in the introduction of numerous ultrathin lens designs with center
thicknesses as much as 50% less than standard designs (i.e., 0.10 mm
for a −3.00-D lens as compared with 0.15 mm for a standard
design).6,39,40 Except for those with high corneal astigmatism (i.e.,
>1.50 D), an ultrathin lens should be the design of choice for most
spherical GP lens fits. For patients with high corneal astigmatism, a
steeper than K base curve is selected, which often results in flexure-
induced reduction in visual acuity.41,42
Edge Shape and Design

Edge shape has been found to be the most important parameter in ini-
tial lens comfort.43 The edge can be divided into three zones.44 The ante-
rior zone is the section of the edge that encounters the upper lid during
blinking. The posterior zone is a small reverse curve placed onto the pos-
terior lens surface to flare the edge away from the cornea. It allows free
movement of the lens across the cornea with eye excursion and permits
lens removal by the blinking technique. The lens apex is the junction
between the anterior and the posterior zones. It must be smooth and
well rounded to minimize lens awareness during blinking. It has been
found that the anterior edge profile is more important than the poste-
rior profile in terms of comfort.45,46 It is apparent that the interaction of
the eyelid with the lens edge is more critical than the posterior edge
design on the cornea in determining comfort.47 If the edge is defec-
tive—chipped, abraded, blunt, or sharp—and the patient leaves the
office with this lens, it is unlikely that the patient will be able to adapt
to lens wear. Most likely the dissatisfied patient will tell others about the
negative contact lens experience.
A key factor in minimizing comfort-related problems is to carefully
verify the edge. Unfortunately, a survey of contact lens practitioners
found that almost one half do not verify the edge.48 Although the
increasing use of sophisticated automated lathes has resulted in con-
sistently higher-quality GP lenses, the need for careful verification—
profile and frontal views—is still important. It has been found that
although the optimum edge thickness is approximately 90 μm, it can
vary from as little as 42 μm to as much as 170 μm.39,46,49 A nomogram
illustrating factors important in optimizing initial comfort is shown in
Figure 5-9.
Lenticular Applications
A lenticular design is sometimes indicated because of the variance in
edge thickness resulting in changes in lens power and OAD. In a
lenticulated lens, the front surface consists of a central optical portion
106
Important comfort factors
Perception Topical anesthetic Lens design
Avoid use of Assume PT has Consider for all first- Edge Centration Peripheral
"discomfort" negative perception time patients; essential curve system
SECTION III
or "pain" for apprehensive PTs

Use "lens (children, keratoconus)
awareness"
or "lid sensation"
Should be smooth, Optimizes comfort Avoid high edge
tapered and rolled; and reduces dryness clearance (i.e., flat,
polish if necessary wide PC system)
Use + Lent. for Well blended

ⱖ−5.00 D PC junctions
Use − Lent. for
ⱕ − 1.50 D and all +
Use thin lens

designs
Attempt to
achieve
lid attachment
Figure 5-9. Factors important in optimizing initial comfort of a GP lens.

surrounded by a peripheral carrier portion that is thinner and flatter.

The junction of the optic cap and carrier section should have a thick-
ness of 0.12 to 0.14 mm.50,51 If it is thinner at this junction, the lens
can break; if it is thicker, unnecessary lens mass is added to the lens.
For lens powers of −5.00 D or greater, a plus lenticular design is rec-
ommended because the edge thickness is typically 0.20 mm or greater
without this modification.52 A plus lenticular design can minimize
problems associated with thick edges, such as lens awareness, inferior
positioning because of the lid-lens interaction, and corneal desiccation
resulting from compromise in the normal blinking process. In addi-
tion, center thickness and overall lens mass is reduced. A minus
lenticular design is recommended for minus powers of −1.50 D or less
and all plus powers. It is used to increase edge thickness and therefore
enhance lid interaction with the edge and minimize inferior decentra-
tion. An edge thickness 0.06 mm greater than the junction thickness
has been recommended.51
Other Considerations
It is important to make a significant change in lens parameters when
an improvement in the lens-to-cornea fitting relationship is desired.
The magnitude of such design parameter changes is provided in Table
5-4.53 A summary of lens design and fitting pearls is provided in Box
5-3. In addition, typically the right lens is ordered with a dot to distin-
guish it from the left lens. Also, a light blue (visibility) tint is recom-
mended to identify the lens if it is displaced. Other tints are available in
most materials; however, because these lenses are typically ordered with
OADs smaller than the horizontal visible iris diameter and because they
move up to 2 to 3 mm with blinking and may reduce light transmission
significantly, darker, iris-enhancing tints are not recommended.
Table 5-4 Clinically Significant Parameter Changes

Parameter Amount of Change for Clinical Significance
Base curve radius 0.50 D (approx. 0.1 mm)
Overall diameter 0.4 mm
Optical zone diameter 0.3 mm
Secondary curve radius 0.3 mm
Peripheral curve radius 0.5 mm
Center thickness (for high-Dk 0.02 mm
gas permeable lenses)
From Szczotka LB: RGP parameter changes: how much change is significant? Contact Lens
Spectrum 16(4), 2001.
Box 5-3 GP LENS DESIGN AND FITTING PEARLS

1. The use of fluorescein is essential for evaluating the lens-to-cornea fitting
relationship. A lens can exhibit good centration but is not an optimum fit
because of factors such as excessive central clearance or peripheral seal-off
as determined via fluorescein application.
2. An average OAD/OZD is 9.4/8.0 mm. A larger OAD/OZD, such as
9.8/8.4 mm, is recommended for patients with a larger than average
pupil size and for athletes. A smaller than average OAD/OZD is
recommended for patients with an interpalpebral fitting relationship and
a steeper than average corneal curvature.
3. To maintain an alignment fitting relationship, the BCR should be
flattened by 0.25 D for every increase in OAD/OZD of 0.5 mm; the BCR
should be steepened by 0.25 D for every decrease in OAD/OZD of
0.5 mm.
4. It is important to remember that the lens will move along the steeper
meridian and toward the corneal apex. In patients with ATR astigmatic
corneas or an inferior decentered cornea apex, selecting a steeper than
recommended BCR may assist in centration.
5. The use of several peripheral curves (i.e., tetracurve, aspheric, or
pseudoaspheric design) is recommended to optimally align the lens
periphery with the cornea.
6. The use of ultrathin lens designs—when possible—will result in less
lens mass and potentially an improved lens-to-cornea fitting relationship
and better initial comfort.
7. The lens edge should be inspected before dispensing the lens to the
patient to ensure that it is rolled, smooth, and free of defects.
8. A plus lenticular edge design is recommended for all lenses with powers
≥−5.00 D; a minus lenticular edge design is recommended for ≤−1.50 D
and all plus powers.
9. Whenever making a change in lens parameters to improve the fitting
relationship, make the change a significant one.
10. The tear lens power and vertex distance must be considered when
determining contact lens power.
Power Determination
After obtaining an optimum lens-to-cornea fitting relationship, accu-
rate determination of the final lens power is important. Two factors to
be considered in the prediction of lens power are tear lens power and
vertex distance.
Tear Lens Power

If a rigid lens is fitted “on K,” or in alignment with the flatter ker-
atometry reading, the predicted lens power is equal to the spherical
refraction value if this value is less than 4 D. For example, if the
patient’s refraction is equal to −2.50 − 1.00 × 180, with keratometry

readings of 42.00 @ 180, and 43.00 @ 090, and if a BCR of 8.04 mm
(42 D) is fitted, the predicted lens power is −2.50 D. It is incorrect to
assume that the power will be equal to the equivalent sphere or, in this
case, −3.00 (−2.50 + ¹⁄₂ × −1.00).
However, often the BCR is selected slightly flatter or, on occasion,
steeper than K. Therefore a minus or plus tear lens power is induced
and must be compensated for in the power. For example, if a lens is fit-
ted 0.50 D steeper than K, a +0.50 D tear lens power is induced; there-
fore −0.50 D must be added to the lens power. If a lens is fitted 0.75 D
flatter than K, a −0.75 D tear lens power is induced, and +0.75 D is
needed to correct for this change. Either providing the tear lens cor-
rection on an optical cross or using the simple acronym “SAM (steep
add minus) FAP (flat add plus)” can assist in the determination of the
final predicted powers. This can be illustrated by the use of tear lens
power diagrams given in Figure 5-10.
Keratometry readings: 42.50 @ 180, 44.00 @ 90
Flat contact lens Steep contact lens

BCR = 41.75 BCR = 43.00
Eye Eye
Tear lens power = −0.75 D Tear lens power = +0.50

−3.00 +0.75 −3.00 −0.50
−3.00 + +0.75 −3.00 + −0.50
−2.25 D −3.50 D
Contact lens Contact lens
Figure 5-10. Tear layer power cross diagrams can be used for determination of lens power of
steep versus flat base curve radii.
Vertex Distance
Another important consideration in predicting the final lens power is
the effective power at the corneal plane for patients with severe myopia
or hyperopia. Appendix 2 to this text provides the difference in effective
power from the spectacle to the corneal plane, assuming a 12-mm vertex
distance. This can be determined by using the following formula:
Fc = Fs/1 − dFs
where Fc = contact lens power, Fs = spectacle lens power, and D = dis-
tance between the spectacle lens and the contact lens (in meters). If a
12 mm distance is used and the patient’s refraction is equal to −5.00 −
1.50 × 180, at the corneal plane this will equal:
Rx (corneal plane: horizontal meridian) = −5.50/1 − 0.012 × −5.50 =
−5.16 D
Rx (corneal plane: vertical meridian) = −7.00/1 − 0.012 × −7.00 =
−6.46 D
The contact lens power becomes more plus at the corneal plane,
although a +0.25-D change in effective power is not present in specta-
cle refractions less than 4 D. These examples assume a 12-mm vertex
distance, but this should be measured carefully for all patients with
severe myopia and aphakia because an error of only 2 mm can result
in a predicted lens power incorrect by as much as 0.75 D.
As a result of tear lens power and vertex distance, it is extremely
important for practitioners to predict what the final lens power should
be. The following example, using the author’s base curve fitting phi-
losophy, demonstrates how both of these factors can result in a lens
with more than 1 D of plus power less than predicted from only using
the spectacle refraction.
Keratometry readings: 43.00 @ 180; 43.25 @ 090
Spectacle refraction: −6.50 − 0.25 × 180
Spectacle Rx (corneal plane: 12 mm vertex distance):−6.00 − 0.25 × 180
Base curve radius: 42.25 D (0.75 D flatter than K)
Final predicted Rx: Spherical refractive value (corneal plane) −
Tear lens power
= −6.00 − (–0.75 D)
= −5.25 D
One of the many benefits of using diagnostic lenses is that the actual
power determined by refraction over the lenses is often different from
the predicted power. Factors such as an inaccurate refraction, an uncali-
brated keratometer, and so on can result in an inaccurate predicted
power. However, the use of a diagnostic lens with a known power and
base curve in combination with the spherical overrefractive power
should be a more valid predictor of the actual contact lens power neces-
sary for optimum visual performance. If the vision is reduced with a
spherical overrefraction, a spherocylindrical overrefraction should be

performed. A cylindrical overrefraction is often the result of either astig-
matism unrelated to the anterior cornea, flexure, or lens decentration.
Examples of final lens parameters ordered, including power, based on
diagnostic fitting are provided in Figures 5-11 and 5-12.
Figure 5-11. Example of fitting and order data for a patient with myopia.
Figure 5-12. Example of fitting and order data for a patient with hyperopia.
ROLE OF THE LABORATORY

The GP lens laboratory can provide a number of services to assist prac-
titioners. Some of these resources are provided in Box 5-4.2 Most
important is the presence of trained consultants who can assist the
practitioner in material selection, lens design parameters, and prob-
Box 5-4 RESOURCES THE LABORATORY CAN PROVIDE

1. Experienced consultants who can assist with contact lens design, fitting,
troubleshooting, and corneal topography analysis
2. Fitting sets and inventories; loaner fitting sets can often be provided
3. Specialty lens designs such as bifocal, bitoric, and keratoconic lenses
4. Resource materials such as fitting guides and videotapes
5. Modification equipment and training
6. Sponsorship of seminars and workshops
lem solving for spherical and specialty designs. This is especially

important because approximately one half of practitioners order GP
lenses empirically, often providing keratometry values and the refrac-
tion to the laboratory, whereas 75% of practitioners simply indicate
“standard” for their PCRs and widths.2,4 It is evident that the laborato-
ries that are successful today are those who provide the greatest num-
ber of services to practitioners and embrace new technology in
fabricating the lenses. The Contact Lens Manufacturers Association
(CLMA) has a “Seal of Excellence” program that rewards those labora-
tories that produce consistently high-quality lenses. With today’s high
technology lathes, the machine that manufactures the lens can quickly
and precisely make calculations that would take a human much longer
with less predictable results.
SUMMARY
The success of a GP lens patient depends highly on the practitioner’s
ability to design, fit, evaluate, and troubleshoot these lenses. With the
introduction of higher-quality ultrathin lens designs, the probability of
success is increasing.
REFERENCES
1. Bennett ES, Henry VA, Davis LJ, et al: Comparing empirical and diagnostic fitting
of daily wear fluoro-silicone/acrylate contact lenses, Contact Lens Forum 14:38-
44, 1989.
2. Bennett ES: Detailing your RGP Rx, Contact Lens Spectrum 13(10):5s-9s, 1998.
3. Davis R, Keech P, Dubow B, et al: Making RGP fitting efficient and successful,
4. Schwartz CA, Bennett ES, Moore C: Setting standards: what is a peripheral curve?
5. Keech P: The top 10 reasons to inventory RGPs, Contact Lens Spectrum 11(10):
32-36, 1996.
6. Choatt C, Wing E: An RGP lens with a soft lens fit, Contact Lens Spectrum
15(6):49-52, 2000.
7. Soper B, Shovlin J, Bennett ES: Evaluating a topography software based program
for fitting RGPs, Contact Lens Spectrum 11:37-40, 1996.
8. Szczotka LB: Clinical evaluation of a topographically based contact lens fitting
software, Optom Vis Sci 74:14-19, 1997.
9. Evardson WT, Douthwaite WA: Contact lens back surface specification from the
EyeSys videokeratoscope, Contact Lens Ant Eye 22(3):76-82, 1999.
10. Lebow KA: Fitting accuracy of an arc step-based contact lens module, Contact
Lens Spectrum 12(11):25-30, 1997.
11. Jervey JW: Topical anesthetic for the eye: a comparative study, South J Med
48:770-774, 1989.
12. Lyle WM, Page C: Possible adverse effects from local anesthetics and the treat-
ment of these reactions, Am J Optom Physiol Opt 52:736-744, 1975.
13. Bennett ES, Smythe J, Henry VA, et al: The effect of topical anesthetic use on ini-
tial patient satisfaction and overall success with rigid gas permeable contact
14. Schnider CM: Anesthetics and RGPs: crossing the controversial line, Rev Optom
133:41-43, 1996.
15. Gordon A, Bartlett JD, Lin M: The effect of diclofenac sodium on the initial com-
fort of RGP contact lenses: a pilot study, J Am Optom Assoc 70(8):509-513,
1999.
16. Caroline PJ, Andre MP: NSAIDs in RGP adaptation, Contact Lens Spectrum 16(5),
2001.
17. Mandell RB: Trial lens method. In Mandell RB, editor: Contact lens practice, ed 4,
Springfield, IL, 1988, Charles C. Thomas, pp 243-264.
18. Bennett ES, Barr JT, Johnson J: Unmasking the RGP fit with fluorescein, Contact
Lens Spectrum 13(10):31-42, 1998.
19. Bennett ES: Easy ways to improve your RGP lens fitting, Rev Optom Suppl
132(7):15A-17A, 1995.
20. Davis LJ, Bennett ES: Fluorescein patterns in UV-absorbing rigid contact lenses,
Contact Lens Spectrum 4:49-54, 1989.
21. Winkler TD: Case report of a corneo-scleral RGP lens, Contact Lens Spectrum
14(9), 1999.
22. Cutler SI, Szczotka LB, Maynard R, et al: Managing irregular corneas with gas
permeable lenses, Contact Lens Spectrum 17(10):25-31, 2002.
23. Eisenberg JS: Safer, healthier, longer, Rev Optom 138(4):71-76, 2001.
24. Caroline PJ, Norman CW: A blueprint for RGP design. Part 1, Contact Lens
Spectrum 3:39-49, 1988.
25. Bibby MM: Factors affecting peripheral curve design, Am J Optom Physiol Opt
56(1):2-9, 1979.
26. Young G: The effect of rigid lens design on fluorescein fit, Contact Lens Ant Eye
21(2):41-46, 1998.
27. Jurkus JM, Howe VM: Contact lenses: the 7 secrets of RGP success, Rev Optom
136(11):51-58, 1999.
28. Bennett ES: The effect of varying axial edge lift on silicone/acrylate lens per-
formance, Contact Lens J 14:3-7, 1986.
29. Schnider CM, Terry RL, Holden BA: Effect of patient and lens performance char-
acteristics on peripheral corneal desiccation, J Am Optom Assoc 67(3):144-
150, 1996.
30. Stone J: Designing hard lenses in the 1980s, J Br Contact Lens Assoc 4(4):144-150,
1982.
31. Holden T, Bahr K, Koers D, et al: The effect of secondary curve liftoff on periph-
eral corneal desiccation. Poster presented at the Annual Meeting of the
American Academy of Optometry, Denver, December 1987.
32. Sorbara L, Fonn D, Holden BA, et al: Centrally fitted versus lid-attached rigid gas
permeable lenses. Part II. A comparison of the clinical performance, Int
Contact Lens Clin 23(7,8):121-126, 1996.
33. Bennett ES, Henry VA, Seibel DB, et al: Clinical evaluation of the Boston
Equacurve, Contact Lens Forum 15(3):49-52, 1990.
34. Andrasko GJ: A comfort comparison, Contact Lens Spectrum 4(4):49-52, 1989.
35. Bennett ES: Silicone-acrylate lens design, Int Contact Lens Clin 12(1):45-53,
1985.
36. Schnider CM: Getting the edge, Contact Lens Spectrum 7(7):18, 1992.
37. Picciano S, Andrasko GJ: Which factors influence RGP lens comfort, Contact
Lens Spectrum 4(5):31-33, 1989.
38. Hill RM, Brezinski SD: The center thickness factor, Contact Lens Spectrum
2(10):52-54, 1987.
39. Norman C: Today’s RGPs: better performance through innovative technology,
Contact Lens Spectrum 11(11), 1996.
40. Achiron LR: Custom-designed ultra-thin RGP lenses, Contact Lens Spectrum
16(5):40, 2001.
41. Pole JJ, Kochanny L: The comparative flexure of Polycon II, Silcon and Boston II
contact lenses on toric corneas, Optom Monthly 75(4):151-155, 1984.
42. Corzine JC, Klein SA: Factors determining contact lens flexure, Optom Vis Sci
74(8):639-645, 1997.
43. Edwards K: Rigid gas-permeable contact lens problem solving, Optician
219(5740):18-24, 2000.
44. Campbell R, Caroline P: Don’t take RGP edge design for granted, Contact Lens
Spectrum 12(7):56, 1997.
45. La Hood D: The edge shape and comfort of RGP lenses, Am J Optom Physiol Opt
65(8):613, 1988.
46. Andrasko GJ: Getting the edge on RGP comfort, Contact Lens Spectrum 6(8):
37-40, 1991.
47. Bennett ES: RGP fitting: how to increase comfort, Pract Optom 8(4):148-152,
1997.
48. Bennett ES, Grohe RM: RGP quality control: the results of a national survey, J Am
Optom Assoc 66(3):147-153, 1995.
49. Quinn TG: Maximizing comfort with RGPs, Contact Lens Spectrum 12(3):21, 1997.
50. Bier N, Lowther GE: Lens design. In Bier N, Lowther GE, editors: Contact lens cor-
rection, Stoneham, MA, 1977, Butterworths.
51. Snyder C: Designing minus carrier RGP lenses, Contact Lens Spectrum 13(12):20,
1998.
52. Lowther GE: Review of rigid contact lens design and effects of design on lens fit,
Int Contact Lens Clin 15(12):378-389, 1988.
53. Szczotka LB: RGP parameter changes: how much change is significant? Contact
Lens Spectrum 16(4):18, 2001.
6
Computerized Corneal Topography in
Gas Permeable Lens Fitting
LORETTA B. SZCZOTKA-FLYNN
T he classic definition of topography from the American Heritage

Dictionary, 4th Edition is “a graphic representation of the surface
features of a place or region on a map, indicating their relative
positions and elevations.” Therefore many patients and practitioners
expect to find elevation style maps when first looking at a corneal
topography map. However, in ophthalmic applications, corneal topog-
raphy or, more formally, computerized videokeratoscopy (CVK) has
classically been displayed in corneal curvature rather than height data
since the inception of this instrumentation almost 20 years ago. This
concept is gradually changing as true elevation data are beginning to
be acquired directly and routinely displayed as the default CVK map of
choice. Since the 1980s, corneal curvature has been indirectly
acquired by placido-based systems from which elevation data are sec-
ondarily derived. Today placido-based data acquisition systems are still
the most popular systems in clinical practice. However, the Orbscan II
system (Bausch & Lomb, Rochester, NY), a state-of-the-art slit scan-
ning system, acquires elevation data, and from that curvature maps are
produced. As more users are becoming familiar with these elevation
maps, we can officially report data in the “expected” definition of
topography. In addition to the well-known curvature maps, the astute
gas permeable (GP) lens fitter now uses all these data as important
tools in his or her armamentarium.
Most specialty GP lens fitters have already replaced manual ker-
atometry with CVK technology in their practices, and this trend will
likely continue for the average contact lens practitioner. The increased
use of CVK technology during the past 15 years is the result of decreas-
ing costs of the instrumentation while adding enhancements in the
hardware and software. GP lens fitting has already been incorporated
into the most recent versions of all modern CVK instruments.1-4
Additionally, highly sophisticated programs developed for refractive
117
surgery screening are available on most systems that assist in the

detection of disease states such as keratoconus.5-7 This chapter will
describe the most common methods of CVK data acquisition and
options for data displays. Then qualitative and quantitative data selec-
tion as it applies to GP lens fitting will be presented. Once a user
becomes familiar and comfortable with CVK, one may wonder how we
ever practiced sophisticated GP lens fitting without this technology!
DATA ACQUISITION
The two most prominent measuring systems in CVK technology
include reflective devices and slit scanning devices. Purely reflective
devices are the placido-based systems, which use the corneal tear film
as a convex mirror to reflect a series of illuminated annular rings. The
rings may be thin or wide and usually correspond to the type of illu-
mination cone device set at a certain working distance from the
patient’s orbit. Thin ring systems are typical of small cone devices that
are brought close to the bony orbit and use a short working distance.
A computerized algorithm finds the peak luminance within the center
of the ring and identifies this position relative to the videokerato-
graphic axis. The small cone system allows good corneal coverage
without shadow artifacts from noses, brows, or lashes, but it can be
more sensitive to defocus. Wide ring systems are typical of larger cone
illumination devices with much longer working distances from
the patient than the small cone counterpart. These projection systems
use a border detection algorithm to detect each edge of the reflected
thick ring (Figure 6-1) and to identify the positions of the rings relative
to the videokeratographic axis.8
Placido devices measure rate of change of the corneal slope by cal-
culating the positions and distances of the reflected rings from the
center of the image to the periphery in a radial fashion. They can only
acquire information from the anterior corneal surface. Placido sys-
tems have to use many assumptions to calculate the rate of change of
the corneal surface, such as where the surface lies in space.
Additionally, any values from the posterior cornea used in calculations
(such as total optical power or simulated keratometry) must be
assumed based on population means.9 Reflective devices also suffer
from other ambiguities. Because of the inherent symmetry of the illu-
minated rings, placido-based corneal topography cannot disambiguate
a central hill from a central depression on the cornea. Both appear as
a local increase in curvature on the CVK map. For example, consider
reflective optics of two test surfaces, one convex and one concave. The
reflection of an illuminated placido ring from the convex surface
Chapter 6 Computerized Corneal Topography in Gas Permeable Lens Fitting 119
Figure 6-1. Example of thick ring placido system and border detection algorithm defining the
two edges of each ring.
would be erect, and off the concave surface it would be inverted. The
only difference is the direction (erect or inverted) of the specular
image. Therefore curvature ambiguity occurs because erect and
inverted (round and symmetrical) placido ring images look identical.
Nevertheless, placido image systems remain the most commonly used
instruments and provide relatively accurate and repeatable data.
Slit scanning systems enable the acquisition of elevation topogra-
phy from the anterior and posterior corneal surfaces and from the
anterior surface of the crystalline lens. The Orbscan II system is cur-
rently the only commercially available example of this technology and
uses a slit scanning technique in combination with reflective CVK
because of the addition of a placido disk attachment, which acquires
the front surface curvature data. The instrument scans the eye using
light slits that are projected at 45-degree angles to the cornea. Forty
slits (20 from each side) are projected sequentially onto the eye.
A computer algorithm computes the anterior and posterior corneal
surface elevations by comparison to a precalibrated known spatial
position. The corneal thickness is then determined by the difference in
elevation from the anterior and posterior surfaces.
DATA DISPLAYS
CVK maps can be viewed with one of several curvature displays, scal-
ing options, and various refractive and three-dimensional displays.
There is no consistency among topography system manufacturers in
the methods or terminology used to describe the data that are ulti-
mately displayed. However, several common maps and terms exist that
are worth describing. The various terminology used in the industry for
these data displays are listed in Box 6-1. The underlined names will be
used throughout this chapter because they are the most common
terms used in the literature today.
Box 6-1 COMMONLY USED TERMS FOR CVK MAP DISPLAYS

Color Scales
Absolute Scale
Standard Scale
Normalized Scale
Color Map
Autosize Scale
Adjustable Scale
Customized Scale
Curvature Maps
Axial Distance
Sagittal Map
Color Map
Default Map
Tangential Curvature Map

Instantaneous Map
Local Map
True Map
Other Displays
Elevation Map
Height Map
3D Map
Refractive Map
Power Map
Snell’s Law
A critical first step in understanding how a GP lens will fit to a

cornea is to understand the elevation and curvature of a given eye. A
solid comprehension of the surface is of benefit when selecting the
qualitative lens design. There are two curvature map options (axial or
tangential display), which vary by the algorithm applied to the same
raw data. The axial “curvature” is actually a reference distance rather
than a true curvature. It refers to the distance along the normal from
the corneal surface to the optic axis.10-12 As in standard keratometry,
axial curvatures are based on algorithms that assume the cornea is
spherical. The axial algorithm effectively averages all curvatures from
the center to some peripheral location.13 The averaging nature of the
algorithm causes insensitivity to local curvature changes and often
underestimates the power of abrupt curvature variations in the corneal
periphery. It is essentially a smoothing function that flattens out the
steepest areas and steepens the flattest areas.12
Tangential curvature is based on a standard mathematical formula
for a local radius at a given point along a curve. Although tangential
radius of curvature is a derivative of axial data, it is proportional to the
local curvature and is axis independent.12,14 Compared with its axial
counterpart, a tangential map more accurately depicts abrupt and
localized shape changes in patients with diseased or surgically altered
corneas. It provides “true,” not averaged, data. Differences between
axial and tangential data increase as the distance increases from the
vertex normal in any eye. The differences become especially important
for patients with diseased or surgically altered eyes in whom corneal
shape changes are increased in the corneal periphery. Here differences
between axial and tangential data points for the same geographic
corneal location can become significant, producing maps that are
quantitatively and qualitatively different (Figure 6-2). Tangential maps
are predominantly used when required to detect or evaluate sensitive
changes of topography, such as in studies assessing refractive surgery
outcomes15,16 and screening eye bank eyes for photorefractive proce-
dures before transplantation.17 They are also important in keratoconus
screening, classification, and follow-up evaluation because axial maps
are insensitive to subtle changes in the periphery.13,14,18
In contact lens practice, axial and tangential maps should be used in
the decision-making process when fitting and following GP lens
patients. As it applies to the initial lens fitting, axial maps have been
shown to be more applicable for GP base curve selection when fitting
healthy patients,2,19 patients with keratoconus,20,21 and patients after
radial keratotomy.22 Alternatively, tangential maps have been shown to
be the best predictors of base curve for patients after laser in situ ker-
atomileusis (LASIK).23,24 The utility of axial curvature data is logical in
spherical lens curve selection because both measures are spherically
Figure 6-2. Comparison of axial and tangential maps on a patient with keratoconus. Note the
tangential map highlights the central cone position much better than the axial map.
biased. Additionally, GP lenses are fit in a global sense when vaulting a

large area of the cornea, making the averaged axial output appropriate.
Alternatively, the utility of the tangential output is also rational because
it provides more accurate curvature data that are not dependent on an
arbitrary reference axis of the optical system being measured.
Although most veteran GP fitters can easily correlate a corneal cur-
vature map to a fluorescein pattern of a GP lens, it is intuitively diffi-
cult to do so. The best map to “visualize” a potential fluorescein
pattern is the elevation map, which is a true height map. The elevation
of the cornea is measured relative to some reference surface. Typically
the reference surface is a best-fit reference sphere selected by the com-
puter, although for some patients a more sophisticated surface, such
as a spherocylindrical reference surface, may be selected. In areas
where the cornea rises above the reference surface, a hot color is dis-
played. Where the cornea dips below the reference surface, a cool color
is displayed, and green signifies alignment with the reference surface.
Even a normal cornea shows a hot central red peak on an elevation
map (Figure 6-3). All normal corneas are prolate, meaning that merid-
ional curvature decreases from the center to the periphery. Prolateness
of the normal cornea causes it to rise above a central reference sphere,
creating a central hill. Immediately surrounding the “central hill,” the
cornea dips below the reference sphere, resulting in an “annular sea.”
In the far periphery, the cornea once again rises above the reference
surface, resulting in “peripheral highlands”(Figure 6-4). When con-
Figure 6-3. Anterior and posterior elevation map of a healthy cornea.
sidering the fluorescein pattern observed with GP lenses on normal

corneas, most lenses fit on K actually have mild central corneal touch
with alignment in the midperiphery, as would be expected when view-
ing an elevation map.
Elevation maps are much more valuable when viewing postsurgical
and diseased eyes for pre-GP lens fitting evaluations. Consider a post-
LASIK eye where the central cornea has been flattened by surgery. In
Figure 6-4. Schematic representation of normal prolate corneal elevation relative to reference
sphere. The elevation is highlighted red when the cornea rises above the reference sphere, and
blue where the cornea dips below the reference sphere.
comparison to a best-fit reference sphere, the central cornea dips

below the surface, creating a central “depression.” At the edge of the
ablation transition zone, the cornea rises above the reference surface
and creates a relative peak before the cornea dips down again below
the reference surface (Figure 6-5). However, the cornea is not concave
at any point, and, in fact, the highest point of the cornea remains to be
the center of the eye. The classic oblate elevation map produced is
shown in Figure 6-6. The resulting fluorescein pattern reveals a simi-
Figure 6-5. Schematic representation of post–laser in situ keratomileusis (LASIK) corneal ele-
vation relative to reference sphere. The elevation is highlighted red when the cornea rises
above the reference sphere, and blue where the cornea dips below the reference sphere.
Figure 6-6. Elevation map of a post–laser in situ keratomileusis (LASIK) eye.

lar pattern of tear pooling in the central depression where the cornea
dips below the reference sphere, and corneal bearing over the relative
peak outside the ablation zone (Figure 6-7).
Any of these map displays can be viewed on multiple color scales,
which can add more confusion when the practitioner is considering
which map to ultimately select for viewing. Two common options are
the absolute and normalized color scales. The absolute scale is consis-
tent at all times. It always assigns the same dioptric interval to a given
color. Often the absolute color scale has larger dioptric intervals and
encompasses a wide range of curvatures compared with the normal-
ized map. I recommend always engaging the absolute map first to get
a global view of the eye; however, using it as the only map option can
mask subtle differences and irregularity. Some systems use an
absolute scale that mimics the keratometer range (35 to 52 D); in some
cases, this type of absolute scale may saturate on either end, giving a
global sense of curvature but no detail. Figure 6-8 demonstrates a
post–penetrating keratoplasty (PK) patient who saturated the absolute
scale because most curvatures were above the peak 52-D curvature of
the scale.
Figure 6-7. Simulated fluorescein pattern of a gas permeable (GP) lens fit over a post–laser in
situ keratomileusis (LASIK) eye.
Figure 6-8. Absolute color scale from a post–penetrating keratoplasty (PK) patient, which sat-
urated because most curvatures were above the peak 52-D curvature of the scale.
Normalized color scales adjust to a given eye and subdivide the

cornea into multiple dioptric intervals, which vary based on the diop-
tric range of the curvatures present. Smaller intervals provide more
definition and allow subtle irregularities to be viewed compared with
the absolute map. See Figure 6-9, where high astigmatism can now be
observed in the post-PK patient who previously saturated the absolute
scale. Because normalized maps vary from occasion to occasion and
from patient to patient, they should not be used for visual comparisons
for patient follow-up evaluation without referring to the associated
color scales.
The best map to use for patient follow-up evaluation during the GP
lens fitting process is the difference map. These maps feature mathe-
matical subtractions of any two selected maps (e.g., axial, tangential,
elevation). The difference map display commonly features two serial
topography maps and the mathematical difference between them. In
the specialty GP lens practice, this map is most beneficial for moni-
toring (1) patients with keratoconus for progression, (2) unintentional
corneal molding from GP lenses, (3) corneal stability after GP lens dis-
continuation before refractive surgery, (4) intentional corneal molding
Figure 6-9. Normalized scale of the patient in Figure 6-8; high astigmatism can now be
observed in the post–penetrating keratoplasty (PK) patient who previously saturated the
absolute scale.
during orthokeratology (Figure 6-10), and (5) patients after corneal

surgery (Figure 6-11).
There are a few situations where GP-induced unintentional corneal
molding is serious enough to warrant lens refitting or discontinuation.
For example, long-term high-riding lenses can cause inferior corneal
steepening characteristic of keratoconus. Corneal topography is the
best tool to detect these changes because the patient’s vision and cen-
tral keratometry readings may not be significantly affected. In fact, sev-
eral keratoconus detection modules have been specifically developed
to provide assistance in differentiating corneal steepening resulting
from pathologic causes from contact lens–induced corneal molding.5,6
This differentiation becomes especially important when screening for
refractive surgery because surgery is contraindicated for patients with
any corneal thinning disorder, although surgery may be performed on
patients with stable GP-induced corneal warpage with the surgeon’s
discretion. Differentiating the two etiologies is often difficult. Using
topography, Lebow5 has shown that patients with true keratoconus
Figure 6-10. Difference map of a patient during orthokeratology treatment. Central corneal
flattening is observed as early as after one night of wear.
have steeper flat K readings compared with patients with contact

lens–induced corneal warpage (46.9 D vs. 43.04 D). Additionally, the
amount of corneal toricity is greater for patients with keratoconus than
for those with corneal warpage (3.43 D vs. 1.33 D), and patients with
keratoconus have steeper reference spheres (47.58 D vs. 43.6 D) with
greater elevation over their respective reference spheres.
USING TOPOGRAPHY DATA FOR GP LENS FITTING

In the prefitting analysis of a GP lens patient, the fitter should begin
with a qualitative topographic analysis using the correct combination of
maps and color scales. This provides the fitter with useful information
about the corneal surface that may prove to be an obstacle to successful
lens fitting. Even patients with healthy eyes may have asymmetric
topographies creating unusual GP fitting patterns. Bogan et al25 classi-
fied normal corneal topography into five basic patterns. Although more
than 60% of the patients had symmetric CVK maps, almost 40% of
patients with healthy eyes had some degree of asymmetry and irregu-
larity. Identifying the area of asymmetry and localizing the steepest
Figure 6-11. Difference map of a post–penetrating keratoplasty (PK) patient (with kerato-
conus) who is assumed to have early recurrence of keratoconus in the graft based on inferior
steepening of the cornea over time.
zone on the cornea is an important concept when fitting GP lenses.

Corneal lenses follow the “path of least resistance” and migrate to the
steepest semimeridian. Viewing the topography early in the fitting
process can help anticipate possible lens-positioning issues. In diseased
and postsurgical eyes, localized corneal steepening and asymmetry can
be highly exaggerated compared with healthy eyes. GP lens decentra-
tion is common in this subgroup of patients and can be explained by
viewing the topography. Once an isolated steep area is identified, proac-
tive lens design options can be incorporated into the initial lens param-
eters to limit decentration. These are no different than traditional edge
modifications, center thickness changes, and base curve changes one
would incorporate when problem solving unacceptable GP lens fits. For
example, if a lens is expected to decenter inferiorly as in the post-PK eye
in Figure 6-12, a minus carrier lenticular edge design, a lens material
with a low specific gravity, and a flatter base curve-to-cornea fitting rela-
tionship would be good starting points to attempt a high-riding fit.
Assessing the native corneal shape is also of great value before ini-
tiating a GP bifocal lens fit. If the patient has a central corneal apex
Figure 6-12. Asymmetric astigmatism and inferior steepening noted on a post–penetrating

keratoplasty (PK) topography map.
(steepest portion of the cornea is central), then a back surface simulta-

neous GP lens design is a good option. The lens is expected to center
over the geometric corneal apex, which in this case is perfectly posi-
tioned centrally for ideal lens positioning. Conversely, if the apex is
decentered inferiorly, expect the bifocal GP lens to also settle in an
inferior position. This type of topography would be ideally suited for a
prism-ballasted translating GP bifocal lens, which functions best when
decentered.
CONTACT LENS FITTING SOFTWARE MODULES

Manufacturers of CVK instruments quickly realized that GP lens fit-
ting was easily simulated with computerized software modules. Now
every modern instrument has the ability to design and recommend a
GP lens on a given eye, complete with simulated fluorescein patterns
and specialty design options (see example in Figure 6-7). Many topog-
raphers can design toric, reverse geometry, and bifocal lens designs,
and some can even design nonrotationally symmetric aspheric surface
GP lenses that exactly mimic the contour of a given cornea (Keratron
WAVE software, Alliance Medical Marketing, Ponte Vedra Beach, FL).

Most of these sophisticated programs have not been reported in the
peer-reviewed literature, and the quoted success rates are anecdotal.
However, many of the basic spherical software modules have been
reviewed in the literature to have high success rates.4,26 For example,
one study found a success rate of 93% using CVK-based fitting, which
is as good or better than diagnostic lens fitting.3
Corneal topography–based fitting programs can theoretically pro-
vide a better base curve prediction over traditional keratometry-based
nomograms because they incorporate the concepts of individual
corneal eccentricity.27 The average cornea flattens in the periphery with
an average eccentricity, or e-value, of 0.55. In mathematics, an e-value
of 0 signifies a circle or no flattening in the periphery. An e-value of
1.0 signifies maximum flattening for an ellipse. Given two eyes with
the same central radius of curvature, an eye with an e-value closer to 0
has a steeper periphery compared with an eye with an e-value closer to
1, which exhibits significant flattening in the periphery. CVK software
programs measure the individual corneal eccentricity and then apply
the correct base curve to produce a lens with the suggested tear clear-
ance as preprogrammed into the system. The eye with a higher corneal
eccentricity has a flatter base curve suggested compared with one with
a lower eccentricity, even if the central corneal curvature is the same.27
Chan et al28 have shown that using the knowledge of corneal eccen-
tricity allows a better prediction of the base curve-to-cornea relation-
ship than can be provided by central corneal measurements alone.
There are many other advantages of using CVK-based GP lens fit-
ting software for healthy patients in the busy contact lens practice. All
systems provide simulated fluorescein patterns that allow parameter
adjustments to the computer-selected lens or the user’s own design.
Any parameter of the lens may be changed, and the resulting fluores-
cein pattern can be redrawn to view multiple lens fits in a short period.
This allows custom fitting without the need to reuse and resterilize
diagnostic lens sets. In my opinion, the simulated fluorescein patterns
should be engaged for each patient rather than relying on the default
lens suggested by the computer. Even after taking the time to view
multiple fits, the efficiency of this method of fitting is still increased
over traditional diagnostic lens fits. One study documented a 50%
reduction in time required to successfully fit a lens with the same level
of accuracy as trial lens application.4 Although these programs are suc-
cessful for patients with healthy corneas, the software programs are
not expected to perform as well for those with diseased or surgically
altered corneas. In these patients, corneal irregularity creates unex-
pected fitting relationships and lacrimal lens calculations. CVK should
be used for qualitative analysis and suggested starting points for lens
base curve selection, after which a diagnostic lens should be applied to
begin the fitting process.
FITTING IRREGULAR CORNEAS USING CVK

CVK is invaluable for patients with diseased or surgically altered
corneas. Contact lens fitting can be greatly enhanced by using topog-
raphy to select the best design for a given eye. Most postsurgical eyes
have peripheral corneal contours that are vastly different from the
healthy cornea and have no relationship to their central corneal curva-
tures. If using only keratometry to select a lens design, the user is
guessing as to what the peripheral corneal shape is and therefore what
design would be most successful.
Post-PK eyes routinely require specialty designs such as bitoric or
reverse geometry lenses. Spherical lenses may also be used for
patients with a highly irregular astigmatism. Only topography can
reveal the shape that will dictate the lens design. For example, approx-
imately one third of post-PK patients have oblate corneal shapes (flat-
ter in the center and steeper in the periphery) as shown in Figure
6-13.29 If using keratometry only, the fitter may be swayed to fit either
a prolate profile lens or a bitoric lens without knowing what the
peripheral corneal shape is. However, for most patients, an oblate
shape requires a reverse geometry lens design to prevent excessive
edge lift, and the lens should be fit to contour better with the midpe-
ripheral cornea. Corneal topography also reveals if the astigmatism is
localized to the center of the graft, in which case it may be vaulted with
a spherical lens design, or if the astigmatism extends throughout the
graft. In the case of high mixed astigmatism extending to the graft
edge, which occurs in approximately 18% of patients after PK,29 a
bitoric lens is indicated (Figure 6-14). Lastly, approximately 22% of
post-PK patients have some form of graft tilt or asymmetric astigma-
tism (see Figure 6-12), and lens design options should be incorporated
to limit lens decentration over the steep “tilted” area of the graft.
For patients with keratoconus, viewing the CVK map also enhances
lens design selection. Here it is crucial to view the map in the tangen-
tial display to localize the area of the cone. Because axial maps signifi-
cantly average and effectively spread out the pictorial data, almost all
cones look as if they extend to the corneal periphery on axial maps.
However, many patients have central keratoconus, which is evident
when viewing the tangential map (see Figure 6-2). The keratoconus fit-
ting philosophy may change based on cone type. For small centered
cones, it is easy to vault the entire area of ectasia with a small and well-
Figure 6-13. Oblate corneal shape after penetrating keratoplasty (PK).
centered lens. Therefore GP lenses often are small in diameter and

steeper than the average K reading. If the tangential map reveals an
inferior sagging cone, the fitting philosophy may change. Here the
lens may have to be fit flatter than K with a large diameter to maintain
centration and provide full coverage over the ectatic area. Rabinowitz
et al20 have similarly used CVK maps to help classify keratoconus topo-
graphic patterns and then to select initial diagnostic lenses based on
the involvement of the cone. For patients with early keratoconus, when
the cone is typically below the 180-degree midline, the lens of choice
is a large diameter lens to align with the (axial) values of the superior
cornea. For patients with advanced keratoconus, based on topography
analysis and extent of cone size, the diameter of the lens is adjusted to
just vault the ectatic area, and the base curve is selected to touch (align)
on the steeper apex of the cone.
USING CVK DATA POINTS FOR BASE CURVE SELECTION IN PATIENTS WITH
IRREGULAR CORNEAS
CVK can assist in selecting the best starting base curve for trial lens selec-
tion for patients after cornea surgery and for those with keratoconus.
Figure 6-14. High mixed astigmatism after penetrating keratoplasty (PK).
For fitting spherical, prolate profile GP lenses after keratorefractive sur-

gery, a few studies have used CVK maps successfully. Eggink30 used tan-
gential maps to fit post-LASIK eyes. He recommends selecting a point
0.2 mm outside of the refractive ablation zone as measured by a tangen-
tial display. McDonnell22 used axial maps to fit eyes after radial kerato-
tomy. He recommends selecting a point 3.5 mm superior to the visual
axis for the best-fit GP lens base curve. Jani and Szczotka23 have shown
that either the average curvature at the 4.0 mm distance from the vertex
normal on the axial map or the 2.0 mm distance on the tangential map
predicts the best base curve for a large GP lens after LASIK.
Fitting reverse geometry lenses on oblate post-PK or post-refractive
surgery corneas can also be enhanced with quantitative CVK data.
Here the goal is to fit the lens on alignment centrally and in the mid-
periphery. To determine the amount of peripheral lens steepening of
the secondary curve compared with the base curve, a measurement of
the axial curvature outside of the transition zone is required. This
measurement is facilitated by moving the interactive cursor over the
axial display from the center of the map to outside the “knee” of the
surgical optical zone and by calculating the dioptric change across this
transition.31 Then order the secondary curves steeper than the base
curve in the same amount that was measured by topography. For

example, if the cornea is 5 D steeper in the periphery compared with
the average central simulated K reading, then order the GP lens’ sec-
ondary curves 4 to 5 D steeper than the base curve, which was chosen
to align along the central cornea.
Using quantitative CVK data for fitting patients with keratoconus
begins after the qualitative assessment of cone morphology has been
completed. If the fitter is attempting an apical clearance or “feather
touch” lens-to-cornea fitting relationship, then simple CVK-based
guidelines may be followed. In our study of CVK and contact lens fit-
ting for patients with keratoconus, we attempted to find simple “land-
marks” of corneal curvature that could be repeatedly accessed, which
would be predictive of the base curve to provide this fitting approach.21
The reference points analyzed were curvatures from the steep simu-
lated keratometry readings or the apex of the cones. We found that
axial maps provided the best predictive curvatures for GP lens base
curve selection. The tangential values either significantly overesti-
mated or underestimated the lens base curve depending on the refer-
ence point sampled. Therefore for a quick assessment of CVK data for
trial lens application, select the axial steep simulated K value for
patients with centered keratoconus or the axial value at the apex of the
cone for patients with decentered (oval) cones.21
SUMMARY
Understanding CVK is essential for the GP lens fitter. When proceed-
ing with normal or specialty GP lens fits, qualitative CVK analysis and
quantitative data selection can assist in initial lens selection. Corneal
topography analysis should also be used for routine follow-up evalua-
tion and long-term treatment of the GP lens patient.
REFERENCES
1. Bufidis T, Konstas AG, Mamtziou E: The role of computerized corneal topography
in rigid gas permeable contact lens fitting, CLAO J 24(4):206-209, 1998.
2. Donshik PC, Reisner DS, Luistro AE: The use of computerized videokeratography
as an aid in fitting rigid gas permeable contact lenses, Trans Am Ophthalmol
Soc 94:135-143, 1996.
3. Jani BR, Szczotka LB: Efficiency and accuracy of two computerized topography
software systems for fitting rigid gas permeable contact lenses, CLAO J
26(2):91-96, 2000.
4. Szczotka LB: Clinical evaluation of a topographically based contact lens fitting soft-
ware, Optom Vis Sci 74(1):14-19, 1997.
5. Lebow KA, Grohe RM: Differentiating contact lens induced warpage from true
keratoconus using corneal topography, CLAO J 25(2):114-122, 1999.
6. Maeda N, Klyce SD, Smolek MK: Comparison of methods for detecting kerato-
conus using videokeratography, Arch Ophthalmol 113(7):870-874, 1995.
7. Wilson SE, Klyce SD: Screening for corneal topographic abnormalities before
refractive surgery, Ophthalmology 101(1):147-152, 1994.
8. Szczotka LB: Instrumentation for detecting corneal changes from contact lens
wear, Contact Lens Spect 15(4):XX, 2000.
9. Cairns G, McGhee CN, Collins MJ, et al: Accuracy of Orbscan II slit-scanning
elevation topography, J Cataract Refract Surg 28(12):2181-2187, 2002.
10. Roberts C: The accuracy of “power” maps to display curvature data in corneal
topography systems, Invest Ophthalmol Vis Sci 35(9):3525-3532, 1994.
11. Roberts C: Characterization of the inherent error in a spherically-biased corneal
topography system in mapping a radially aspheric surface, J Refract Corneal
Surg 10(2):103-111; discussion 112-116, 1994.
12. Roberts C: Corneal topography: a review of terms and concepts, J Cataract Refract
Surg 22(5):624-629, 1996.
13. Chan JS, Mandell RB, Burger DS, et al: Accuracy of videokeratography for instan-
taneous radius in keratoconus, Optom Vis Sci 72(11):793-799, 1995.
14. Chan JS, Mandell RB: Alignment effects in videokeratography of keratoconus,
CLAO J 23(1):23-28, 1997.
15. Azar DT, Yeh PC: Corneal topographic evaluation of decentration in photorefrac-
tive keratectomy: treatment displacement vs intraoperative drift, Am J
Ophthalmol 124(3):312-320, 1997.
16. Sano Y, Carr JD, Takei K, et al: Videokeratography after excimer laser in situ ker-
atomileusis for myopia, Ophthalmology 107(4):674-684, 2000.
17. Lim-Bon-Siong R, Williams JM, Samapunphong S, et al: Screening of myopic
photorefractive keratectomy in eye bank eyes by computerized videoker-
atography, Arch Ophthalmol 116(5):617-623, 1998.
18. Rabinowitz YS: Tangential vs sagittal videokeratographs in the “early” detection
of keratoconus, Am J Ophthalmol 122(6):887-889, 1996.
19. Wasserman D, Itzkowitz J, Kamenar T, et al: Corneal topographic data: its use in
fitting aspheric contact lenses, CLAO J 18(2):83-85, 1992.
20. Rabinowitz YS, Garbus JJ, Garbus C, et al: Contact lens selection for keratoconus
using a computer-assisted videophotokeratoscope, CLAO J 17(2):88-93,
1991.
21. Szczotka LB, Thomas J: Comparison of axial and instantaneous videokerato-
graphic data in keratoconus and utility in contact lens curvature prediction,
CLAO J 24(1):22-28, 1998.
22. McDonnell PJ, Garbus JJ, Caroline P, et al: Computerized analysis of corneal
topography as an aid in fitting contact lenses after radial keratotomy,
Ophthalmic Surg 23(1):55-59, 1992.
23. Jani B, et al: Topographic reference points for spherical RGP contact lens fitting
after LASIK, Invest Ophthalmol Vis Sci 41(4):S73, 2000.
24. Eggink FA, Beekhuis WH, Nuijts RM: Rigid gas-permeable contact lens fitting in
LASIK patients for the correction of multifocal corneas, Graefes Arch Clin
Exp Ophthalmol 239(5):361-366, 2001.
25. Bogan SJ, Maloney RK, Drews CD, et al: Computer-assisted videokeratography of
corneal topography after radial keratotomy, Arch Ophthalmol 109(6):
834-841, 1991.
26. Szczotka LB, Capretta DM, Lass JH: Clinical evaluation of a computerized topog-
raphy software method for fitting rigid gas permeable contact lenses, CLAO
J 20(4):231-236, 1994.
27. Szczotka L, et al: Corneal topography for contact lens fitting, Optometry Today
6(6):38-46, 1998.
28. Chan JS, Mandell RB, Johnson L, et al: Contact lens base curve prediction from
videokeratography, Optom Vis Sci 75(6):445-449, 1998.
29. Waring GO 3rd, Hannush S, Bogan S, et al: Classification of corneal topography.
In Schanzlin DJ, Robin J, editors: Corneal topography: measuring and modify-
ing the cornea, New York, 1992, Springer Verlag, pp 70-71.
30. Eggink FA, Beekhuis WH, Nuijts RM: Rigid gas-permeable contact lens fitting in
LASIK patients for the correction of multifocal corneas, Graefes Arch Clin
Exp Ophthalmol 239(5):361-366, 2001.
31. Szczotka LB, Aronsky M: Contact lenses after LASIK, J Am Optom Assoc
69(12):775-784, 1998.
7
Lens Care and Patient Education
EDWARD S. BENNETT
T he success or failure of gas permeable (GP) lens–wearing

patients often depends on how well they were educated initially
and during follow-up visits. Whether it is a result of not feeling
confident in handling the lenses, being more sensitive than normal
about the adaptation period, or the inappropriate use or omission of
recommended solutions, patients can become frustrated early during
their adaptation process and discontinue lens wear. Not only does this
discontinuation of lens wear discourage patients from future contact
lens wear but also it can often result in their criticism of GP lens wear
to potential wearers. The purpose of this chapter is to emphasize
proper care and handling for successful long-term wear of GP lenses.
THE CARE SYSTEM

There are several solutions included in a GP lens wearer’s care regi-
men. These include a combination wetting-soaking or wetting-soak-
ing-cleaning solution, a surfactant cleaner, a supplemental enzyme
cleaner, and rewetting drops.
Wetting-Soaking Solution
Combination wetting-soaking solutions have the dual function of wet-
ting or cushioning the lens before insertion and disinfecting the lens
on removal. Among the many ingredients in these solutions are wet-
ting agents and preservatives, which are intended to provide optimum
wettability and disinfection without causing sensitivity reactions.
Wetting Agents
Commonly used wetting agents in combination wetting-soaking solu-
tions are polyvinyl alcohol (PVA) and methylcellulose derivatives. PVA
is water soluble, relatively nonviscous, and nontoxic to ocular tissues,
all desirable properties for successful contact lens wear. It exhibits
good surface wettability while also having optimum viscosity-building
138
Chapter 7 Lens Care and Patient Education 139
properties.1 Methylcellulose derivatives are often used in the more vis-

cous GP lens solutions.
Preservatives
With overnight soaking, preservative agents should be capable of
killing microorganisms without causing epithelial insult and subjec-
tive symptoms of stinging and redness. Preservatives can either inhibit
the growth of microorganisms (bacteriostatic agents) or kill microor-
ganisms (bacteriocidal agents).2 Preservatives in common use today
include polyaminopropyl biguanide (PAPB), chlorhexidine, Polyquad
(Alcon, Fort Worth, TX), benzyl alcohol, and ethylenediamine tetraac-
etate (EDTA). Less commonly used preservatives include benzalko-
nium chloride (BAK) and thimerosal.
Polyaminopropyl Biguanide. PAPB has been used in a common
wetting-soaking solution as an adjunct to chlorhexidine. It has been
proven as a successful soft lens preservative (e.g., Dymed) and has
been added to a GP lens system as a result of its antimicrobial effec-
tiveness, particularly against Serratia marcescans.3
Chlorhexidine. Chlorhexidine, like PAPB, has been a commonly
used preservative in soft lens solutions. However, although it is bacte-
ricidal in action, it has essentially been eliminated because of its bind-
ing properties to hydrogel lens materials. However, as a result of its
large molecular structure and weak cationic action combined with the
excellent surface wettability properties of GP lenses, chlorhexidine, in
a concentration ranging from 0.003% to 0.006%, has been successful
in many GP lens wetting, rewetting, and combination solutions.4
Polyquad. Another preservative that was initially successful in soft
lens chemical disinfection systems, Polyquad, has recently been suc-
cessful as a preservative in a combination wetting-soaking-cleaning
solution.
Benzyl Alcohol. Originally considered as a solvent, it was deter-
mined that benzyl alcohol has good disinfection capabilities. It has
been shown to exhibit negligible binding to fluoro-silicone/acrylate
(F-S/A) lenses while exhibiting many positive qualities, including
water solubility, bipolarity, and low molecular weight.5 It has been
included in several combination cleaning-soaking systems.
Ethylenediamine Tetraacetate. Although not a true preservative,
EDTA is often used in combination with other preservatives because of
its synergistic ability to enhance the bacterial action of pure preserva-
tives against Pseudomonas.6
Benzalkonium Chloride. BAK is quaternary ammonium compound
that is effective against a wide spectrum of bacteria and fungi and
has been a popular preservative in many ophthalmic preparations,
including polymethylmethacrylate (PMMA) and silicone/acrylate

(S/A) lens solutions. However, it is not a common preservative in solu-
tions used with F-S/A lens materials, in part because the lens surface
may become more hydrophobic, with corneal dry spot formation and
superficial punctate keratitis possibly resulting.7-9
Thimerosal. Thimerosal is an organic mercurial compound that is
another preservative that was, at one time, popular with chemical soft
lens systems. However, it has become apparent that some patients are
sensitive to mercurial compounds and may experience stinging, red-
ness, and superficial punctate keratitis.10,11 Although this has not nec-
essarily been a problem with GP lens materials, because it is not an
effective preservative by itself, for optimal effectiveness it should be
used combined with another preservative, often chlorhexidine.12
Representative Examples
There are several commonly used wetting-soaking solutions, including
the Boston Advance Comfort Formula Conditioning Solution (Polymer
Technology Corporation, Rochester, NY), Boston Conditioning Solution
(Polymer Technology Corporation), Opti-Soak Conditioning Solution
(Alcon), COMFORTCARE GP Wetting & Soaking Solution (American
Medical Optics [AMO], Irvine, CA), WET-N-SOAK PLUS Wetting &
Soaking Solution (AMO), Sereine Wetting and Soaking Solution
(Optikem, Denver, CO), and Perma-Cote (Danker, Sarasota, FL).
Rewetting Solutions
Although solutions limited to rewetting the surface of a GP lens do not
have the advantage of rehydrating the lens, as with hydrogels, and
therefore may not increase lens-wearing time unless used frequently,
they do have the benefits of rewetting the lens surface, rinsing away
trapped debris, and breaking up loosely attached deposits. Wetting
agents such as PVA are added to increase contact time; likewise, some
rewetting solutions contain hydroxyethylcellulose, methylcellulose, or
other cellulose derivatives to increase viscosity and prolong surface
wettability. Representative examples include Boston Rewetting Drops
(Polymer Technology Corporation), CLARIS Rewetting Drops,
Optimum by LOBOB Gas Permeable Wetting/Rewetting (Lobob
Laboratories, San Jose, CA), REFRESH CONTACTS Contact Lens
Comfort Drops (Allergan), and Sereine Wetting Solution (Optikem).
Cleaning
There are several types of cleaners and cleaning agents, including
nonabrasive surfactant, abrasive surfactant, and enzymatic and labora-
tory cleaners.
Nonabrasive Surfactant
Most GP lens cleaners are nonabrasive surfactants because they con-
tain detergents that, in combination with digital pressure during the
cleaning process, remove lipids, mucoproteins, and other contami-
nants on the lens surface. These solutions cannot be used directly in
the eye, or a keratitis is likely. Representative examples include COM-
FORTCARE GP Dual Action Daily Cleaner (AMO), RESOLVE/GP
Daily Cleaner (AMO), Optimum by Lobob Extra Strength Cleaner
(Lobob Laboratories), and Sereine Cleaner (Optikem).
Abrasive Surfactant
The attraction of tear proteins, in particular, positively charged
lysozyme to the negative-charged silicone-based GP lens material, can
make removal of these deposits difficult. Therefore several cleaners
have added particulate matter to help cleave off these deposits from the
surface. In fact, these cleaners have been found to be more effective
than nonabrasive cleaners.12 The primary problem with these cleaners
has been the addition of minus power and reduction in center thick-
ness over time because of the digital pressure applied during long-
term cleaning.13-16 With the introduction of smaller particle abrasive
cleaners, this problem has been much less reported. Representative
examples include Boston Advance Cleaner (Polymer Technology
Corporation), Boston Cleaner (Polymer Technology Corporation),
Opti-Free Daily Cleaner (Alcon), and Opti-Soak Daily Cleaner (Alcon).
Combination Solutions
There are several solutions that have combination cleaning-soaking
capabilities such that the ingredients within the solution help to dis-
solve the deposits during the overnight soaking cycle. Several are ben-
zyl alcohol–based solutions (e.g., CLARIS Cleaning and Soaking
Solution, Menicon/Allergan, and Optimum by LOBOB Gas Permeable
Cleaning/Disinfecting/Storage, Lobob Laboratories). Other combina-
tion solutions include COMFORTCARE GP One Step (AMO) and
Sereine Soaking and Cleaning Solution (Optikem).
There are also two all-in-one solutions that are used for wetting, dis-
infecting, and cleaning GP lenses. Unique pH Multi-Purpose Solution
(Alcon) contains hydroxypropyl guar, a proprietary wetting/conditioning
polymer system, along with polyethylene glycol. BOSTON Simplicity
Multi-Action Solution contains PEO sorbitan monolaurate and a betaine
surfactant as cleaning agents and a silicone glycol copolymer, a cellulosic
viscosifier, and a derivatized polyethylene glycol as wetting and cushion-
ing agents. Often these systems are used in combination with a liquid
enzyme to enhance cleaning. If the patient is an allergy sufferer or is
particularly sensitive to preservatives, the use of a saline rinse or soak

before insertion of the lens may reduce irritation.17 In addition, it has
been found that when a surfactant cleaner is used in addition to an all-
in-one solution, less bacteria adherence will occur.18
Enzymatic Cleaner
Because mucoproteinaceous deposits can be difficult to remove, the
use of an enzymatic cleaner can be a useful adjunct to surfactant
agents. Originally used as a tablet that would be dissolved in saline and
for which GP lenses would soak for anywhere from 15 minutes to a few
hours, more recently these products have been replaced by liquid
enzyme cleaners in which a drop of the cleaner can be placed into the
case well for each lens either every night (e.g., Opti-Free Supraclens
Daily Protein Remover from Alcon, which uses porcine pancreatin
enzymes) or weekly (e.g., Boston One Step Liquid Enzymatic Cleaner
from Polymer Technology Corporation, which uses subtilisin). These
products are especially beneficial for extended wear and patients with
dry eye and in conjunction with all-in-one systems. They are not to be
used directly in the eye. Dissolvable tablets are still available from
AMO (PROFREE/GP Weekly Enzymatic Cleaner with papain) and
Alcon (Opti-Zyme Enzymatic Cleaner with pancreatin).
Laboratory Cleaners and Solvents

The use of laboratory-approved extra-strength cleaners, such as the
Boston Laboratory Cleaner (Polymer Technology Corporation) and
Fluoro-Solve (Paragon Vision Sciences, Mesa, AZ), is beneficial for
cases in which an in-office cleaner is indicated. This includes use with
heavily deposited lenses and when lenses exhibit poor initial wettabil-
ity. This may be the result of manufacturing pitch polish. These prod-
ucts are not intended for everyday use but are excellent adjuncts when
these problems occur.
THE EDUCATION VISIT

Procedures
Before dispensing a patient’s new GP lenses, the lenses should be pre-
soaked a minimum of 4 hours before dispensing. It has been recom-
mended to use a laboratory cleaner as well before soaking to remove
any manufacturing residue from the lens to provide a more
hydrophilic surface.21
When the patient is dispensed new GP lenses, several procedures
need to be performed to evaluate their performance before educating
the patient about lens care and handling. This includes visual acuity,
overrefraction, and slit-lamp evaluation.
Visual Acuity
The visual acuity should be assessed once the lenses have settled. If a
topical anesthetic has been used, the lenses can be assessed within 15
minutes after insertion. Not only should the visual acuity be recorded
but also the subjective response. Sometimes the visual acuity is inter-
mittently good but varies with blinking. This is most likely the result
of decentration, and more time should be allowed for the lens to set-
tle; a refit may be necessary.
Overrefraction
A spherocylindrical overrefraction should be performed to determine
if a change in power is necessary. If the addition of the cylinder sig-
nificantly improves the patient’s visual acuity, the cause of the cylinder
should be determined. If it is the result of cylinder unrelated to the
anterior cornea, a decision should be made as to whether GP lenses
are the best option. However, it is recommended that keratometry be
performed over the lenses to determine if flexure is present. If the
overrefraction is cylindrical, the lens is most likely flexing. Selection of
a flatter base curve and standard thickness lens design should mini-
mize this problem.19 In addition, a smaller optical zone diameter will
also decrease flexure.20
Slit-Lamp Evaluation
Evaluation of the surface and fitting relationship of the lenses should
be performed next. If the surface wettability is poor, a laboratory
cleaner or solvent should be used to remove any pitch polish or residue
on the lens, and wetting solution can be rubbed onto the lens surface
to condition it. The lens-to-cornea fitting relationship should be evalu-
ated with fluorescein.
Patient Education
Handling
The success of a patient with GP lenses often is a result of the ability
to handle the lenses with ease. The patient should be able to demon-
strate proficiency with insertion, removal, and recentration.
Insertion. Any new lens wearer is going to exhibit anxiety about ini-
tially placing a contact lens on the eye. This is especially true for the GP
lens wearer who may have heard that GP lenses are uncomfortable.
The key to successful lens insertion is proper lid retraction. For the right
eye, the right middle finger should pin the lower lid back, and the left
middle finger and forefinger should pin the upper lid back. The most
important factor is positioning the fingers over the lashes and pinning
the lid margin against the sclera to create a wide fissure (Figure 7-1). The
next step will be—with the lens on the right forefinger—placing the lens
directly on the eye without hesitation. If there is hesitation, the eye will
move up and out, and the lens will be inserted onto the sclera. In addi-
tion, if the lashes are not pinned back, the lids may slip, and the fissure
becomes too narrow. For the left eye, the right middle finger and fore-
finger retract the upper lid, and the left middle finger retracts the lower
lid with the lens on the left forefinger. The patient has to be reassured
that he or she will not harm the eye during insertion. If the patient is
anxious during this process and becomes frustrated, it is recommended
to reschedule a second visit after the patient has had the opportunity to
simulate the insertion process by placing a drop of warm water on the
finger and gently touching the eye. The water has a slightly numbing
effect, and the patient should gain confidence in the application process.
The patient should be able to successfully insert the lens several times
before leaving with the lenses.
Removal. Whereas GP lens insertion is easier than soft lenses
because of the smaller diameter, removal is slightly more challenging.
Once again, proper lid retraction is important. The middle finger and
forefinger of the left hand can be used to retract the upper lid against
the sclera. The middle finger and forefinger of the right hand are
Figure 7-1. Proper position of fingers over lashes for lens application.
placed over the lower lashes to pin them against the inferior sclera
(Figure 7-2). It is essential for the fingers to be placed over the lashes
such that the lid margins will be used to eject the lens. Once the fin-
gers are in the proper position, the lids should be moved temporally;
when the patient blinks, the lens should be ejected (Figure 7-3). For the
left lens, the right middle finger and forefinger should be placed over
the upper lashes, and the left middle finger and forefinger should be
placed over the lower lashes. Removal should occur over a flat surface
with a towel even though the lens will often eject onto the lashes. It is
relatively easy for the patient to not keep the lashes pinned back, there-
fore allowing the lids to evert. When this occurs, the lens will not eject.
It is imperative for the lid margins to be pinned against the sclera for
successful removal. With the low edge clearance designs in common
use today, the conventional method of using one finger at the lateral
canthus to eject the lens is not as effective in removal. Another effec-
tive method of lens removal is to place the fingers in the same position
as for the other method. However, instead of pushing the lids tempo-
rally, they are instead moved vertically to eject the lens.
Recentration. It is possible for the lens to be displaced over onto the
sclera, especially during the adaptation process when patients are still
perfecting their handling skills. It is important for them to know how
to quickly recenter the lens to lessen their anxiety. The first step is for
the patient to determine where the lens is displaced. The patient can
typically feel through the lid to find the lens. The next step is to look
away from the lens and—with the forefinger against the lateral edge—
the patient then views toward the lens, and it should relocate onto the
cornea.
Figure 7-2. Initiation of lens removal process.

Figure 7-3. Movement of the lid laterally, resulting in lens ejection.
The handling procedures are similar for the assistant training the
patient. The lid retraction is just as important such that lens insertion
and removal can be performed smoothly and confidently. Reassurance
is extremely important when training the first-time GP lens wearer,
and patience is a vital quality for staff members in charge of patient
education. If the patient detects frustration and disappointment from
a staff member, the likelihood of success will decrease as the patient
loses confidence in his or her own ability to handle the lenses.
It is also important to emphasize that the patient needs to handle
the lens over a soft surface, such as a towel, to avoid the possibility of
surface damage, which can result if the lens is dropped on a hard sur-
face, such as the counter or the floor. If this occurs, a drop of wetting
solution should be applied to the forefinger to act as a contact agent
allowing the lens to adhere to the finger and lift off the surface with-
out inducing scratches, which would most likely result if the lens is
dragged across the surface. Patients should also be advised about the
possibility of losing a lens down a sink drain if the lens is handled over
a sink with an open drain. A list of handling guidelines is provided in
Box 7-1.
Care
It is extremely important to not only explain each component of the
GP lens care regimen in the order that the patient will perform it but
also to have the patient repeat the instructions and demonstrate how
to perform the procedures. This would consist of the following:
Box 7-1 PATIENT HANDLING GUIDELINES

1. The patient needs to handle the lenses over a soft surface such as a
towel.
2. Reassurance and patience are critical during the education process.
3. Staff members need to be proficient at teaching handling to ensure the
patient will feel confident when leaving the office with the lenses.
4. If the patient is excessively apprehensive, it may be preferable to
reschedule the appointment to avoid frustration and optimize future
success. The patient can practice by touching the eye with a warm drop of
water on the finger.
5. Lid retraction is critical for success. The fingers need to get underneath
the lashes and pin them back such that the lids will not interfere with
insertion and also so the lid margins will be allowed to eject the lenses
for removal.
6. For recentering the lens, it is important for the patient to initially view away
from the lens and then, with the finger placed at the edge of the lens, the
patient views toward the lens, and it should shift onto the cornea.
1. On removal, clean the lenses in the palm of the hand.

2. Rinse the cleaner with either saline (preferred) or tap water, and
place carefully into an empty clean case.
3. Fill the case wells with the appropriate conditioning/disinfecting
solution.
4. Before insertion, rinse the lenses with saline, and apply wetting
solution to the lenses and insert.
5. Rinse out the case with saline and allow to air dry.
6. Insert with use of the appropriate wetting solution.
Cleaning. It is important to emphasize that the lenses are cleaned
immediately on removal and not on awakening. This allows for the
removal of loosely bound deposits (e.g., lipid, mucoprotein, and tear
debris), which have existed in the liquid state adjacent to the tear film
when the lens is in the on-eye state. If allowed to dehydrate in a dry
case, these deposits can become more bound to the lens material and
therefore more difficult to remove. In addition, the lenses should be
cleaned in the palm of the hand (Figure 7-4) in an up-and-down/back-
and-forth manner similar to cleaning soft lenses; they should not be
cleaned between the fingers.
Cleaning between the fingers or so-called “digital cleaning” can result
in lens warpage and increased minus power because of the greater dig-
ital pressure applied and the circular motion applied during the
process.16,22-24 This is especially true with the softer high-Dk lens mate-
rials.16,22 On a follow-up visit, if a patient with prepresbyopia indicates
Figure 7-4. Cleaning the lens in the palm of the hand.
blur at near viewing or the letters becoming smaller, verifying the lens
power is indicated. Patients who have been long-term PMMA/low Dk
GP lens wearers are typically the patients who have to be educated about
changing their cleaning technique to be gentler with the current gener-
ation of GP lens materials.
It is also important for patients to clean both lenses equally. It is not
uncommon for the patient to clean the first lens (often the right lens)
thoroughly but only briefly clean the other lens, if at all.
Rinsing the Lens. It is controversial as to whether the cleaner can be
rinsed off the lens with tap water. Obviously, patients prefer tap water
use because of convenience and cost savings. It takes a large amount
of conditioning solution or saline to effectively rinse the cleaner off the
lens. The author recommends that tap water can be used for rinsing
off the cleaner at night before disinfection but never after disinfection.
It has been found that case contamination is not greater if tap water is
used for rinsing off the cleaner when compared with saline.25
However, patients must be told that saline is preferred for rinsing
because of the potential contamination of the lenses from tap water,
including Acanthamoeba. Geffen26 has recommended the best com-
promise. He recommends cleaning the lenses with the recommended
GP cleaner followed by a tap water rinse. However, immediately after
the tap water rinse, a brief rinse with the conditioning solution is per-
formed before insertion into the case. This minimizes the risk of any
contaminants coming in contact with the lens—especially if the
patient is noncompliant—and also reinforces the importance of mini-
mizing tap water use to the patient.
Conditioning and Disinfecting. The next step will be for the patient
to place the lenses into their case, which has been completely filled
with conditioning/disinfecting solution. The patient needs to be
instructed as to the importance of this step and the potential of an eye
infection if the lens is placed into a dry, dirty case. If the patient places
the lenses into a dry case not only do any deposits on the lens become
more bound but also the lens can be damaged via direct contact with a
dry case (Figure 7-5). It also maintains the lens in a hydrated state,
which optimizes on-eye wettability when the patient inserts the lens
the next morning.
The lens case needs to have large wells to provide for a sufficient
amount of disinfecting solution while also easily differentiating the
right well from the left to avoid inserting the incorrect lens on the eye.
These cases should also have ridges or holes in the well to minimize
adherence—and possible warpage—if the lens is placed convex side
out (not concave) into the case well.
The use of a liquid enzyme solution at bedtime is also often rec-
ommended as an adjunct to surfactant cleaning. This is performed
either daily (with SupraClens) or weekly (with Boston Enzymatic
Cleaner) via insertion of a drop into the lens well after application of
the conditioning solution.
Figure 7-5. Lens scratches from frequent removal from a dry case.
Before Insertion. The lenses can be inserted directly from the disin-
fecting solution, although this will depend on the solution being used.
However, a rinse with either saline or the wetting solution is often
preferred.
Rinsing and Disinfecting the Case. After insertion with the appro-
priate wetting solution, the case should be rinsed with saline and air
dried. It is important to note that cases can become easily contami-
nated. Bacteria can use a survival strategy to make them more resist-
ant to preservatives when they are present in a nutrient-deprived
environment such as a contact lens case. They can then develop a
biofilm, which consists of a collection of bacterial cells in an
exopolysaccharide glycocalyx slime secreted by the bacterial cells to
provide protection against disinfectants.27 It is evident that the risk for
eye infection is increased when dry, dirty cases are used. To minimize
this problem, it is imperative for patients to rinse their case every
morning with saline and allow it to air dry. Once a week, the case
should be cleaned with soap and water before a saline rinse and air
dry. To further ensure sterility, the opened case can then be placed in
freshly boiled water for 20 minutes. In addition, regular replacement
of lens cases is almost as important as regular lens replacement.
Patients should be told to replace their cases, at minimum, every 3
months, similar to when they replace their toothbrush.28 Likewise,
they should be provided with several cases to ensure that compliance
occurs.
Insertion with Proper Wetting Solution. It must be emphasized to
the patient that only the recommended wetting solution should be
used for application of the GP lenses. Saliva is not to be used because
of the contaminants that can come into contact with the lens. Likewise,
tap water is absolutely contraindicated for insertion of GP lenses not
only because of the impurities in tap water but also because of the pos-
sibility of Acanthamoeba keratitis. Although Acanthamoeba is much
more likely to attach to soft lenses—notably high water ionic
lenses29—interaction of Acanthamoeba directly to the eye via tap water
or a hot tub can result in the possibility of this devastating condition.
Finally, the use of a saline solution that is only recommended for soft
lenses may compromise the wetting ability of GP lenses and affect
long-term comfort.
Adaptation
As mentioned previously, practitioners have to be honest and realistic
when communicating adaptation and, specifically, adaptation symp-
toms. Patients much better perceive the use of terms such as “lens
awareness” and “lid sensation” than “discomfort.” They need to be told
that it is likely total comfort will be achieved once their eyes and eye-
lids become adapted to the lenses. The amount of time for adaptation
is patient dependent. Patients who react negatively to such procedures
as lid eversion, tonometry, and drop instillation should be provided
with a longer adaptation schedule (i.e., 2 to 3 weeks), whereas patients
who exhibit minimal apprehension to these tests and who react favor-
ably to the initial GP lens application can typically adapt within 1 week.
Regardless as to whether the dispensing date is the same or different
from the initial fitting date, if a topical anesthetic has been applied, it
should be allowed to wear off, and thus the patient can experience full
awareness of the lenses and the practitioner can assess how the patient
is reacting and what kind of wearing schedule should be provided.
Normal and abnormal symptoms are provided in Box 7-2. Mild lens
awareness (particularly when viewing superiorly), mild redness, pho-
tophobia, and short-term tearing are normal symptoms. Prolonged
Box 7-2 GP LENS ADAPTATION SYMPTOMS

Normal Adaptation Symptoms
1. Awareness: Patient notices a foreign body sensation that decreases when
the patient views inferiorly (i.e., away from upper lid) and increases with
superior gaze (i.e., into upper lid). This sensation decreases with time;
some improvement in comfort should occur while the patient is still in the
office.
2. Mild redness: This is a normal foreign body response as well.
3. Tearing: If tearing occurs, it should be temporary.
4. Photophobia and sensitivity to wind, dust, and smoke.
5. Intermittent blurry vision in part because of the overall foreign body
reaction and possibly because of increased initial lens lag with the blink.
Abnormal Adaptation Symptoms

1. Pain and persistent awareness: If the patient experiences pain and the lens
awareness does not improve during the first several minutes of lens wear,
an eyelash or foreign body may be trapped under the lens or there may be
a defective edge. The lens should be removed as soon as possible to
minimize patient apprehension. It should be quickly inspected, cleaned,
and reinserted.
2. Prolonged tearing or redness: This would be caused by any of the
aforementioned reasons (i.e., foreign body, rough edge).
3. Severe or persistent halo around lights: This could be caused by an
adherent lens and would be diagnosed via on-eye evaluation with the
biomicroscope.
4. Blurry vision through spectacles for more than 1 hour: Lens adherence or a
lens material providing insufficient oxygen to the cornea could cause this.
tearing, pain, moderate redness, awareness that does not decrease over
time, haloes around lights after lens removal, and prolonged (greater
than 1 hour) spectacle blur are abnormal symptoms. A typical wearing
schedule is provided in Box 7-3. This can be adjusted by how the
patient initially reacts to lens wear. Patients should also be told that if
they discontinue lens wear for any reason, they will need to gradually
rebuild their wearing time over a period of a few days to 1 week
depending on how long they have been out of lens wear.
Daily-wear lens patients should be evaluated 1 week, 1 month, and 3
months after dispensing. If successful at the 3-month visit, they can be
evaluated on a 6-month schedule. They should also be advised to wear
their lenses for several hours before their scheduled follow-up visit to
better evaluate lens performance. The most important visit is the 1-week
visit. If new GP lens–wearing patients are going to experience discom-
fort with lens wear and eventually discontinue wear, it often can be diag-
nosed and remediated at this visit. This is the time when care and
handling procedures should be reinforced (Box 7-4). The patient should
be asked if lens handling has been problem free. If the patient is experi-
encing problems with insertion and removal, this can be solved at this
particular visit with further practice. Likewise, if the patient is experi-
encing any problems that are associated with adaptation (e.g., excessive
awareness), changes in the lens design and fitting relationship can be
made at that time to reduce the symptoms. Patients should be asked if
they are cleaning the lenses every night in the palm of the hand. They
can be asked about their wearing time and solution use as well (Figure
7-6). It has been found that for patients who have had their lens care
instructions reinforced at progress visits, there was only a 6% contami-
nation of their lenses and care products (i.e., solutions, case), whereas
patients who did not have their care instructions reinforced had more
than 50% contamination.30
Other Important Educational Factors

Cosmetics. The importance of educating patients about proper use
of cosmetics, hand creams, and so on cannot be overemphasized. Any
Box 7-3 TYPICAL GP LENS WEARING SCHEDULE

Days 1 and 2: 4 hours
Box 7-4 ESSENTIAL VERBAL INSTRUCTIONS

Dispensing Visit
1. Instruct on insertion and removal, with the patient demonstrating mastery
of these procedures.
2. Discuss each step of the care process, and, more importantly, have the
patient repeat these instructions to ensure understanding and future
compliance.
3. Provide normal adaptation and abnormal adaptation symptoms; use
terminology such as “awareness” and “lid sensation” to describe
adaptation; the patient must also understand that complete comfort should
occur with time.
4. Review the wearing schedule and importance of a gradual build up in
wearing time.
1-Week Visit
1. Review the care instructions to ensure understanding and compliance.
2. Confirm the patient is still using the same solution system.
3. Confirm wearing schedule is as instructed.
4. Inquire if the patient is experiencing any problems with handling; if so,
reinstruction can be provided at that time.
hand cream or soft soap product that contains lanolin can be easily
transferred to the contact lens, resulting in loss of surface wettability
and burning and blurred vision. These products also often contain
additives, such as perfumes, oils, abrasives, and deodorants, that can
further complicate the problem.31 Patients should be instructed to
wash their hands with hard soap, or, if a lanolin-containing soft soap
is used, they should dry their hands thoroughly before handling their
contact lenses.
Mascara and other cosmetics should be applied after contact lenses
have been inserted to avoid trapped particles between the lens and
cornea. Mascara that contains “lash builders” can be especially prob-
lematic because these fibers can possibly result in a mild foreign body
abrasion. There are numerous cosmetic products on the market that
are recommended for contact lens wearers.
If cosmetics are not replaced regularly, bacteria and other organ-
isms can colonize in the mascara tube, possibly resulting in a bacter-
ial infection. Likewise, eyeliner should not be applied to the margin of
the inner lid because it may clog the meibomian glands, possibly
resulting in blepharitis, chalazion, or hordeolum
Swimming. Patients need to be educated about not swimming with
their contact lenses or, if so, to wear the appropriate swimming goggles
Figure 7-6. Information provided on solutions and wearing time recorded at the 1-week fol-
low-up visit.
over their lenses. GP lenses can dislocate easily if the patient swims
underwater.
Educational Materials. There are several educational materials that
can serve as beneficial adjuncts to verbal education of a new GP lens
patient. A comprehensive written booklet can serve as a useful resource,
especially for those patients who want to review their care information.
It also allows the practitioner or staff member to highlight important
guidelines for the patient to review. It can include a review of handling,

care instructions, adaptation, and wearing time. It can also include an
agreement for a patient to sign in duplicate that includes such informa-
tion as the refund policy, replacement lens costs, care regimen, and a
statement indicating that successful contact lens wear is not guaranteed.
However, it is important to understand that patients will typically not
read everything they are provided with; therefore it should not be
expected that they learn everything from a written booklet. In addition,
the booklet should be print quality with illustrations if possible. One that
is commercially available on disk and can be customized for the office is
available from Anadem Publications, Inc. (P.O. Box 14385, Columbus,
OH 43214). GP lens–care pamphlets for the patient are also available
from the RGP Lens Institute (www.rgpli.org). Information that should
be provided in such a booklet is provided in Box 7-5.
Another education source is through videotapes. Patients experi-
encing difficulty in handling lenses can view a video on care handling.
One such video is available from RGP Lens Institute.
Compliance
An estimated 80% of contact lens complications are associated, at
minimum in part, with poor compliance of recommended lens care
guidelines.32 Studies have found that fewer than 50% of patients are
compliant with lens care instructions.33-37 Often expired solutions have
Box 7-5 GP LENS INSTRUCTION MANUAL GUIDELINES

1. Benefits and applications of GP lenses
2. Insertion, removal, and recentration
3. Proper care of the lenses to include:
●
Cleaning
●
Disinfection
●
Storage
4. Normal and abnormal adaptation symptoms
5. Wearing schedule
6. How to minimize loss and surface damage
7. Cosmetics
8. Swimming
9. Visit schedule
10. A patient agreement to include the following:
●
Fee and refund policy
●
Statement that successful wear is not guaranteed
●
Solution regimen
●
Office and doctor’s home telephone numbers
been found to be contaminated, whereas preserved solutions opened

for 21 or fewer days were not contaminated.37 In one survey, almost
one quarter of the respondents indicated they did not clean their
lenses at all.36 It is evident that many, if not the majority of, contact
lens wearers are not compliant with their contact lens care. Among the
more common areas of noncompliance are:
●
The patient does not wash his or her hands before handling the
lenses.
●
The patient does not clean the lenses as often or as
comprehensively as desired (if at all); in fact, the patient may
properly clean the first lens (typically the right lens) but fail to
adequately clean the other lens (i.e., “left lens syndrome”). The
latter problem can result in a deposited lens that can in turn
result in papillary hypertrophy and lens awareness.
●
An inappropriate wetting solution, such as saliva or tap water, is
used.
●
The patient does not use disinfecting solution, or, if used, it is
not regularly replaced; in fact, the patient may top off the
solution instead of replacing it. This has been implicated in a
Pseudomonas bacterial keratitis.4
●
Expired solutions are used.
●
The case is not cleaned or replaced on a regular basis.
●
The patient substitutes another brand for the recommended
solution. Private label contact lens solutions are becoming more
popular and are readily available to consumers. However, this
increases the possibility of an incompatible solution being used
by the patient.28
●
The patient uses lanolin-containing soaps or hand creams before
handling lenses.
Therefore it becomes imperative for the practitioner and staff to
emphasize care and handling at the initial dispensing of the lenses
and at all follow-up visits. In addition, it is important to verify that the
patient understands the care guidelines by having the patient repeat
the instructions to the person educating the patient.
REFERENCES
1. Hill RM, Terry JE: Ophthalmic solutions: viscosity builders, Am J Optom Physiol
Opt 51:847-851, 1974.
2. Mandell RB: Lens care and storage. In Mandell RB, editor: Contact lens practice, ed
4, Springfield, IL, 1988, Charles C. Thomas Publisher, pp 326-351.
3. McLaughlin R, Barr JT, Rosenthal P, et al: The new generation of RGP solutions
meet increasing demands, Contact Lens Spect 5:45-50, 1990.
4. Bennett ES: Lens care and patient education. In Bennett ES, Henry VA, editors:
Clinical manual of contact lenses, ed 2, Philadelphia, 2000, Lippincott
5. Feldman GL: Benzyl alcohol; new life as an ophthalmic preservative, Contact Lens
Spect 4:41-44, 1989.
6. MacGregor DR, Elliker PR: A comparison of some properties of strains of
Pseudomonas aeruginosa sensitive and resistant to quaternary ammonium
compounds, Can J Microbiol 4:449-503, 1968.
7. Wilson WS, Duncan AJ, Jay JL: Effect of benzalkonium chloride on the stability
of the precorneal tear film in rabbit and man, Br J Ophthalmol 59:657-669,
1975.
8. Herskowitz R: Solution interaction and gas-permeable lens performance, Contact
Lens J 15:3-8, 1987.
9. Imayasu M, Moriyama T, Ichijima H, et al: The effects of daily wear of rigid gas
permeable contact lenses treated with contact lens care solutions containing
preservatives on the rabbit cornea, CLAO J 20:186-188, 1994.
10. Binder PS, Rasmussen DM, Gorden M: Keratoconjunctivitis and soft contact lens
solutions, Arch Ophthalmol 99:87-90, 1981.
11. Witten EM, Molinari JF: Allergic keratoconjunctivitis from thimerosal in soft
contact lens solutions, South J Optom 23:12-20, 1981.
12. Chou MH, Rosenthal P, Salamone JC: Which cleaning solution works best,
Contact Lens Forum 10:41-47, 1985.
13. O’Donnell JJ: Patient-induced power changes in rigid gas permeable contact
lenses: a case report and literature review, J Am Optom Assoc 65(11):772-773,
1994.
14. Caroline PJ, Andre MP: Inadvertent patient modification of RGP lenses, Contact
Lens Spect 14:56, 1999.
15. Bennett ES, Henry VA: RGP lens power change with abrasive cleaner use, Int
16. Carrell B, Bennett ES, Henry VA, et al: The effect of abrasive cleaning on RGP
lens performance, J Am Optom Assoc 63:193-198, 1992.
17. Krohn JC: A menu of lens-wear options for allergy-prone patients, Rev Optom
(4):77-80, 2000.
18. Landa AS, van der Mei HC, van Rij G, et al: Efficacy of ophthalmic solutions to
detach adhering Pseudomonas aeruginosa from contact lenses, Cornea
17:293-300, 1998.
19. Herman JP: Flexure of rigid contact lenses on toric corneas as a function of base
curve fitting relationship, J Am Optom Assoc 54(3):209-213, 1983.
21. Quinn TG: Maximizing comfort with RGPs, Contact Lens Spect 12(3):21, 1997.
1987.
Lens Spect 14:56, 1999.
25. Davis LJ: Tap water vs. saline rinsing of rigid gas permeable contact lenses—com-
parative case contamination: a pilot study, Int Contact Lens Clin 23(5):
177-182, 1996.
26. Geffen DI: What your patients need to know about tap water, Contact Lens Spect
13(7):14, 1998.
27. Caroline PJ, Campbell RC: Strategies of microbial cell survival in contact lens
cases, Contact Lens Forum 15:27-36, 1990.
28. Norman C: Solutions for keeping RGPs in top form, Contact Lens Spect 13(11)
16-18s, 1998.
29. Seal DV, Bennett ES, McFadyen AK, et al: Differential adherence of
Acanthamoeba to contact lenses: effects of material characteristics, Optom
Vis Sci 72:23-28, 1995.
30. Wilson LA, Sawant AO, Simmons RB, et al: Microbial contamination of contact
lens care systems, Am J Ophthalmol 109:193, 1990.
31. Baldwin JS: Cosmetics: too long concealed as culprit in eye problems, Contact
Lens Forum 11:38, 1986.
32. Keech PM, Ichikawa L, Barolow W: A prospective study of contact lens complica-
tions in a managed care setting, Optom Vis Sci 73(10):653-658, 1995.
33. Claydon BE, Efron N: Non-compliance in contact lens wear, Ophthalmol Physiol
Opt 14(4):356-364, 1994.
34. Collins MF, Carney LG: Compliance with care and maintenance procedures
amongst contact lens wearers, Clin Exp Optom 69:174, 1986.
35. Chun MW, Weissman BA: Compliance in contact lens care, Am J Optom Physiol
Opt 64:274, 1980.
36. Ky W, Scherick K, Stenson S: Clinical survey of lens care in contact lens patients,
CLAO J 24(4):216-219, 1998.
37. Donzis PB, Mondino BJ, Weissman BA, et al: Microbial contamination of contact
lens systems, Am J Ophthalmol 104(4):325-333, 1987.
8
Modification and Verification
BRUCE W. MORGAN
VINITA ALLEE HENRY
EDWARD S. BENNETT
A successful gas permeable (GP) lens patient often depends on

careful verification of the lenses when they arrive from the lab-
oratory in addition to in-office polishing and repowering when
indicated. Likewise, in cases in which the patient is symptomatic (i.e.,
blurred vision, lens awareness, dryness), the ability and capability to
verify the lenses and, if necessary, modify them is convenient to the
patient and effective troubleshooting by the practitioner.
MODIFICATION
One of the many benefits of GP lenses has been their receptivity to in-
office modifications that immediately improve vision or enhance the
lens-to-cornea fitting relationship for comfort. Surface polishing can
often relieve symptoms of dryness or fluctuating vision. Others who
report dryness may have inadequate lens movement with blinking;
blending or flattening the peripheral curves can rectify that problem.
In some patients, adding a little more power can provide better vision
without having to order a new lens. Patients typically find that polish-
ing the edge or front surface of a GP lens makes the lens much more
comfortable. In addition, almost all modification procedures can be
performed without compromising optical quality.1 Modification proce-
dures usually take no more than 5 to 10 minutes to perform, and pro-
cedures such as an annual polishing can be incorporated into the
service agreement.2
Patients want convenience. If a problem can be solved without hav-
ing to order a new lens, the patient’s time and money will be saved.
Patients place a high value on such personalized service, and any prac-
tice that fits GP lenses should also be verifying and, when necessary,
modifying lenses.
159
Equipment
It is not expensive to modify the current generation of GP lens materi-
als. A practice’s investment can be as little as a few hundred dollars. Even
if the only in-office modification procedure offered is edge polishing, the
number of patients who will benefit, either from an initial polishing to
smooth an otherwise defective edge or solve an acquired problem in
which the patient may have induced an edge defect through careless
handling, should more than compensate for the expenditure, especially
considering the effect dissatisfied patients can have on a practice. A
patient who is experiencing initial discomfort caused by a defective edge
that either goes undetected or results in the lens being sent back to the
laboratory, may become discouraged and not only simply discontinue
GP lens wear but also even abandon contact lenses altogether. As with
soft lens patients, as many in-office services as possible should be per-
formed to keep GP lens patients from discontinuing lens wear.
Modification Unit
The main piece of equipment needed to perform in-office modifica-
tion is the modification unit. The modification unit is basically a
motor-driven spindle mounted in a box, and a splash bowl surrounds
the spindle (Figure 8-1). If this is an initial acquisition, radius tools and
polishing tools must also be purchased. The modification unit and
accessory tools are often offered as a package because spindle size can
vary from one unit to another. Likewise, if a replacement unit is pur-
chased, it should not be assumed that the spindle size of the new unit
matches that of the previous one.
The modification unit should operate at a spindle speed no higher
than 1200 rpm; higher speeds generate excessive heat, which may
damage high- and hyper-Dk materials.1 Some manufacturers sell vari-
able-speed units. These units offer the advantage of using higher spin-
dle speed for lower-Dk materials and for procedures where there is
little risk of compromising optical quality, such as edge polishing.
Suction Cup
A two-piece suction cup to hold the lens during modification proce-
dures is the least expensive yet perhaps the most important modifica-
tion tool. It is used for almost all the different types of procedures and
allows the lens to be attached by either the convex or concave side
of the lens, depending on the procedure. When used, it is imperative
that the lens is well centered on the tool.
Sponge Tools
There are three types of sponge tools commonly used for in-office
modification: a flat sponge for polishing the front surface, a smaller
Chapter 8 Modification and Verification 161
Figure 8-1. A standard modification unit.
flat sponge tool with a central aperture for polishing the edge, and a
cone-shaped sponge tool for polishing the back surface. These sponges
are to be soaked with water before each procedure and, along with fre-
quently applied polish, provide a safe and effective means of modify-
ing GP lenses without compromising the optics of the lens.
Spinner
This tool, particularly the suction-cup type, is beneficial for procedures
such as repowering, surface polishing, and edge polishing. The end of
the spinner is cushioned with ball bearings, so it spins with the spin-
dle. With the spinner rotating the lens, changes can be made to the
lens evenly and symmetrically with little risk of optical compromise.
When purchasing a new spinner, it is important to verify it rotates
freely with little resistance.
Radius Tools
Brass or plastic radius tools are used to blend or flatten peripheral curves
and to reduce the optical zone diameter. These tools are typically covered
with a pad of velveteen or other material. An all-cotton pad should be

used because some polyester blends heat the lens too quickly and may
warp it.3 At minimum, the radius tool set should include these sizes: 7.6
mm, 7.8 mm, 8.0 mm, 8.2 mm, 8.4 mm, 8.8 mm, 9.0 mm, 9.4 mm,
9.8 mm, 10.4 mm, 11.0 mm, and 12.0 mm.
Polish
There are many polishes available, typically having a grit aluminum
base, that help reduce the modification time and keep the lens cool.
With some exceptions, they appear to be successful with all GP mate-
rials. A study by Reeder et al4 evaluated the effectiveness of seven com-
monly used polishes, five premixed and two powder, in repowering a
92-Dk GP lens material. All seven polishes added 0.50 D of power to
the lens. The powder forms were faster at adding the desired amount
of power, taking 35 to 40 seconds. The premixed solutions took up to
2.5 minutes. In each case, the lenses had good or excellent optical qual-
ity after the procedure. It is important to remember that ammonia-
alcohol–based compounds such as Silvo are incompatible with GP
lenses.
Other Tools
Less frequently, a velveteen-covered drum tool and a 90-degree ante-
rior bevel tool may be needed. The drum tool may be used in a similar
fashion as the flat sponge tool for edge polishing and repowering. The
anterior bevel tool is used for thinning a blunt or thick edge.
Packages
Most laboratories sell modification equipment à la carte and in eco-
nomical packages (Box 8-1). Basic packages range from approximately
$225 to $350.5 These typically include a single-speed modification unit
and a minimum number of tools for basic modification procedures,
such as sponge tools, suction cup(s), polish, and possibly a velveteen-
covered drum tool.
Deluxe packages range from approximately $300 to $500. These
include the same equipment as a basic package, possibly with a vari-
able-speed unit. Also included are radius tools and pads, a spinner, an
anterior bevel tool, and a 7× or 10× measuring magnifier. Some labo-
ratories include the spinner and radius tools in their basic package.
Modification Procedures
There is some debate over what procedures are safe for presently avail-
able GP lens materials, particularly the softer, higher-DK varieties. One
procedure that should not be performed on these materials is diameter
Box 8-1 MODIFICATION EQUIPMENT VENDORS

Abba Optical 800-789-5121
Stone Mountain, GA [email protected]
770-498-8545
[email protected] Polychem
Gaithersburg, MD
Conforma Contact Lenses 800-778-7206
Norfolk, VA [email protected]
800-426-1799
[email protected] Precision Optics
Omaha, NE
Contour Fine Tooling 800-584-9110
Marlborough, NH
603-876-4908 Valley Contax
[email protected] Springfield, OR
541-744-9393
Essilor Contact Lens [email protected]
1. Denver, CO
303-623-5367 X-Cel Contacts
2. Tulsa, OK 1. Duluth, GA
918-834-5146 770-622-9235
3. Dallas, TX [email protected]
214-241-4141 2. Baltimore, MD
[email protected] 410-321-4760
4. Lenexa, KS 3. Minneapolis, MN
913-577-5720 612-520-6070
4. Orlando, FL
G.P. Specialists 407-851-2599
Phoenix, AZ 5. Vista, CA
800-366-2522 619-598-0112
[email protected] 6. Pittsburgh, PA
412-531-8393
Larsen Equipment Design 7. Redmond, WA
Seattle, WA 425-881-5665
reduction. These softer materials are more likely to break or chip, and
it is not worth the time and effort to reduce the diameter and then
reshape the edge and reapply peripheral curves. Likewise, prolonged
surface polishing—polishing lasting several minutes—is not recom-
mended, especially with high-Dk and hyper-Dk lens materials. Some of
the defects that can result are not evident with biomicroscopy. Grohe et
al6 evaluated the effect of front surface polishing on 20 GP lenses. After
polishing, the modified lenses were evaluated with high magnification
(100 to 500+) scanning electron microscopy. Several microscopic
surface abnormalities were observed, including microcracks, splitting,

scorching, and bleaching. It was concluded that prolonged polishing,
diameter reduction, and repowering are unacceptable in-office modifi-
cation procedures for high-Dk GP lens materials.
However, recent studies involving high- and hyper-Dk lens materi-
als have been encouraging. One study evaluated the effect of common
modification procedures on the quality of vision, surface wettability,
optical quality, and subjective response.1 Low-Dk silicone/acrylate
(S/A) lenses and high-Dk fluoro-silicone/acrylate (F-S/A) materials
were evaluated before and after surface polishing, edge polishing, and
repowering. With few exceptions, optical quality and quality of vision
were unchanged after modification. The changes that did occur
resulted from adding −0.50 D to the lens power. Short-term wettabil-
ity was rarely compromised. The study concluded that these in-office
modification procedures could be performed without damaging the
lens if a low-to-medium spindle speed is used, polish is frequently
applied, and excessive pressure is not put on the lens.
Edge Polishing
Verification of the lens before any modification procedure is a must. If
the optical quality of the lens is compromised, it will affect the
approach taken. In the worst-case scenario, if the lens is damaged dur-
ing modification, the original specifications can be used to order a
replacement lens.
Edge polishing is one of the most common and vital modification
procedures done in the office. Some practitioners will polish the edges
of every new lens to ensure optimal comfort. It can never be assumed
that a replacement lens will have the same edge as the original or that
the left lens will have the same edge as the right.
If a patient complains of lens awareness or discomfort after insert-
ing a new lens, poor edge quality should be suspected. It is imperative
to evaluate the shape and quality of the lens edge. A simple test for
edge quality is to place the lens in the palm of the hand and push it
across the hand.7 If the lens does not glide easily or feels rough, the
edge is most likely defective. A projection edge inspection device or
reticule can be used to determine the type of edge defect.
Ideally, the anterior and posterior edges should be rolled and
tapered because the posterior edge is in near alignment with the
cornea, and the anterior edge is often in contact with the upper lid. A
defective edge may be too sharp or too blunt; it may have small
microchips; or it may have a rough appearance. An inspection device
that gives a frontal and profile view is especially useful in confirming
the latter two problems.
Once the nature of the edge defect has been determined, one of the
following approaches may be used to polish the edge.
Edge Sponge Tool. A flat sponge tool with a central aperture is com-
monly used for rolling and polishing the anterior and posterior edges.
First, the lens should be mounted onto a water-moistened suction cup.
Cleaning the lens before this step will enhance suction.8 The convex
side of the lens should be placed against the suction cup. Proper cen-
tration is crucial to avoid uneven polishing (Figure 8-2). Once proper
alignment has been achieved, the pressure on the top of the suction
cup should be released. The lens will then adhere to the suction cup.
The sponge should be thoroughly moistened with water to remove
residual dried polish or other debris. As the tool rotates, polish should
be applied to the tool every few seconds. The suction cup should be
held vertical to the tool, and the lens should be pushed into the central
hole of the sponge and moved up and down (Figure 8-3). The lens
should be inspected every 30 seconds until the desired result is
achieved. Prolonged polishing of the edge (more than 2 minutes) may
result in decreasing the diameter of the lens.
Flat Sponge Tool. An alternate way to polish a lens edge is to use a
large, flat sponge tool and a spinner. The lens is attached to the spin-
ner concave side out. The sponge should be moistened with water and
a little polish. Initial position of the lens is at the far right of the sponge
tool with the lens parallel to the tool surface and the edge pressed
lightly into the sponge. This position is held for 5 seconds, and as the
lens spins, it moves gradually toward the left side of the sponge.
Figure 8-2. Proper centration of a GP lens on a suction cup.

Figure 8-3. Edge polishing with a sponge tool.
This procedure should be repeated until the desired result has been
achieved. A similar method is simply to guide the lens across the
sponge tool for 30 to 60 seconds.9
Regardless of the procedure, it is important that the lens edge ends
up at the right side of the sponge tool. Otherwise, the plastic may get
pushed or rolled toward the inner lens surface. The lens should be
kept spinning at all times, and polish should be applied often.
Finger Polishing. The fingers can also serve as polishing pads. A
brass tool that holds the lens concave side out with a suction cup is
useful for this purpose. (SYG Enterprises sells this tool under the
name of “finger-lishing” tool.10) The procedure is to simply wet the
thumb and forefinger with polish, and then the lens edge is polished
as it rotates (Figure 8-4).
Anterior Bevel. When the edge is too thick or blunt, an anterior
bevel should be created before polishing. This method also helps for
patients in whom the lens rides too high from too much lid interaction
with the edge. A cone tool is used to add an anterior bevel to the lens
edge. Most practitioners use a 90-degree cone tool. A 120-degree tool
Figure 8-4. Finger polishing a GP lens edge.
may be used for a wider bevel, or conversely, a 60-degree tool will pro-
duce a narrower bevel.11,12
This procedure is done with the lens attached to the suction cup
convex side out. A velveteen (or similar) pad with a one-quarter section
cut out is placed inside the cone surface. The lens should be placed
within the cone as it rotates, and it should be gently rocked back and
forth, and left and right, with polish added frequently (Figure 8-5).
This rocking motion allows for a bevel with a smooth transition zone.
However, excessive rocking may compromise the quality of the periph-
eral anterior surface. The lens should be examined every 10 to 15 sec-
onds until the desired edge thickness is obtained. The edge should
always be polished after an anterior bevel is applied.
Surface Polishing
Surface polishing may be indicated when a lens exhibits poor initial
wettability, has an adherent mucoprotein film, or has surface
Figure 8-5. Performing a CN bevel to reduce edge thickness.
scratches. In these cases, patients typically report transient blurry

vision, redness, and reduced wearing time.13 The specific problem is
diagnosed with slit-lamp evaluation.
If the problem is poor wettability, the lens should be cleaned with a
laboratory cleaner or solvent and then rubbed with wetting solution
before reinserting it. In these cases, polishing the front surface should
be the last resort because the poor wettability may simply be the result
of residual pitch polish from the manufacturing process. If so, polish-
ing the lens may spread the pitch further around the lens and only
make the problem worse.
If the problem is an acquired mucoprotein film, again the first step
should be a laboratory cleaner or solvent specifically recommended for
GP lenses. If this does not remove the deposits completely, a mild
front surface polish should be considered. (Only occasionally does the
posterior surface attract sufficient deposits to warrant polishing.)
Patients should be educated to clean their lenses every night when
removing them, with weekly enzymatic cleaning. The use of a liquid
enzyme, if approved for that material, is another option.
If surface scratches are the problem, a surface polish is clearly indi-
cated. In almost every case the scratches occur only on the front sur-
face. To avoid scratches, it is important that patients are educated
about proper lens handling, especially with high- and hyper-Dk mate-
rials. Patients should always handle their lenses over a soft cloth rather
than a hard surface that may scratch the lenses. If a lens falls onto a
hard surface, the patient should place a drop of wetting solution on the
finger and gently lift the lens off the surface.
A dirty lens case is another common source of scratches. Any par-

ticulate matter left in the lens well can scratch the lens, especially if the
patient drags the lens out of the well. It is important that patients keep
the case in good condition and replace it frequently. Patients should
always be advised to be gentle when lifting their lens out of its case.
The several approaches to surface polishing include the following.
Flat Sponge Tool. The most common way to polish the front surface
is to use a large (3-inch) flat sponge tool with a suction cup. The
sponge is wetted with water, and the lens is polished as it is attached
to the suction cup convex side out. As the tool rotates, the lens is
placed halfway between the center and edge of the sponge (Figure
8-6).12 The lens is held at a 45-degree angle and rotated in the direction
opposite the rotation of the tool. The lens is pressed approximately ¹⁄₈
inch into the sponge during the procedure, and the process continues
for approximately 20 to 30 seconds before rechecking the surface. The
lens power should be verified to ensure that the optical quality is
unchanged and that no minus power has been inadvertently added. In
all, this procedure takes approximately 2 to 4 minutes.
An alternative method is to use a spinner, either with a flat sponge
or a suction cup in the manner just described, or in combination with
a rounded sponge tool. In the latter method, a spinner is used to roll
the lens from the edge to the center and back until the desired surface
quality is obtained. As long as the spinner continues to rotate, the opti-
cal quality should not change.
Figure 8-6. Polishing the front surface of a GP lens.

In all of the procedures, it is important that polish is applied fre-

quently and minimal pressure is exerted on the lens. Also, the practi-
tioner should not try to totally polish out deep scratches, or the optical
quality may be compromised.
Polishing Pad. To remove thick, adherent mucoprotein deposits or
tiny scratches, a hand polishing pad should be used, such as The
Cleaner Accessory Pad (Eaton Medicals Corp., Memphis, TN).14 The
pad is wetted with preservative-free saline, followed by six to eight
drops of a GP lens daily cleaning solution. The lens is placed on the tip
of the thumb or index finger and rubbed into the pad for approxi-
mately 20 seconds.
Cone-Shaped Sponge. In rare cases, adherent deposits or scratches
may develop on the back surface of the lens. In these cases, a cone-
shaped sponge can be used with a suction cup to polish the lens. The
sponge is then moistened, first with water and then with polish. The
lens is mounted onto the suction cup concave side out. Once the spin-
dle is rotating, polishing compound can be applied and the suction
cup is tilted slightly, with the lens just off the center of the sponge.12
The lens is pressed approximately ¹⁄₈ inch into the sponge and rotated
in the direction opposite the spindle rotation for approximately 15 sec-
onds (Figure 8-7). Then the lens is inspected. This procedure can be
repeated if necessary.
Repowering
The ability to change the power with in-office modification is a signif-
icant advantage when fitting GP lenses. Occasionally, patients will
Figure 8-7. Polishing the back surface of a GP lens.

report blurred vision with GP lenses resulting from overcorrection or

undercorrection. If an overrefraction reveals the need for additional
minus or plus power, there are two options. One is to simply order a
new lens; in the meantime, however, the patient is either without
lenses or endures poor vision. The better solution is to repower the
lens at the visit. There are various methods to perform this procedure.
Spinner and Rounded Sponge Tool. These tools offer an effective
way to add minus power. A cone sponge or any rounded sponge may
be used. The sponge should be mounted vertically on the spindle and
soaked with water and polished. The lens should be positioned convex
side out and centered on the spinner tool. It is important that the spin-
ner tool rotates freely.
As the sponge tool rotates, the lens should be held with the edge
adjacent to the side of the pad to initiate the spinning action (Figure
8-8, A).12 Once the lens is spinning freely, the spinner should be
rotated so that the lens is perpendicular to the sponge tool, approxi-
mately 1 to 1.5 cm from the apex (Figure 8-8, B). It is important that
this position be maintained because this position allows the center of
Figure 8-8. A, Proper position of the lens before adding minus power. B, Addition of minus
power by direct contact of the lens center against the sponge.
the lens to be in contact with the pad while the periphery receives less
friction. This creates a flatter front curvature and therefore produces
up to a 1.00-D increase in minus power.12 The procedure takes 1 to 2
minutes.
As long as the lens is spinning during the procedure, there is little
probability of degrading the optical quality. It is important to be dili-
gent about monitoring the power change every 15 seconds so that over-
correction is avoided. The amount of minus power added depends on
the pressure and duration of polishing and the compound used.
Plus power may also be added in much the same manner. The key
difference is that once the lens is spinning, the lens periphery, and not
the center, is aligned with the sponge tool (Figure 8-9). The polishing
removes material from the periphery rather than the center, which
steepens the front surface and adds plus power to the lens.
Approximately 0.50 D of plus power may be added with this method
because the rate of power change is slower than with minus power.
Flat Sponge Tool and Suction Cup. Another method to add minus
power is to use a flat sponge tool with a suction cup.3 The lens is
mounted on a suction cup convex side out. The flat sponge is wetted
with water and polish, and it is placed spinning on the spindle. The
lens is positioned approximately 1/2 inch from the edge of the tool.
Figure 8-9. Addition of plus power by tilting the spinner at an angle to the sponge.
The lens is held perpendicular to the sponge, and mild pressure is

exerted as the lens is revolved around the tool counterclockwise.
The number of revolutions necessary to add the desired minus
power will be determined with practice. Normally, as much as 0.75 D
of minus power may be added with this method. Again, it is important
that the power and optical quality be checked with the lensometer
every 15 seconds or so.
Drum Tool and Suction Cup. Plus power may also be added with a
flat drum tool covered with velveteen or suede cloth, along with a suc-
tion cup.3 With the motor running, a little polish should be applied to
the center of the tool. The lens should be positioned convex side out
on the suction cup, and the lens should be brought in contact with the
center of the drum tool in a perpendicular fashion. Using mild pres-
sure, the lens should be rotated clockwise and counterclockwise.
Polish should then be applied liberally throughout the procedure.
Approximately 0.50 D of plus power may be added this way.
Blending and Flattening Peripheral Curves

The blending or flattening of the peripheral curve radii is beneficial in
adjusting the fit of a GP lens. If lens movement with blinking is lim-
ited and if the patient has subsequent tear stagnation, the blending of
the junctions between the peripheral curves will facilitate movement
and create a better tear exchange. Blending the peripheral curve junc-
tions can also increase patient comfort.15 If there is peripheral or mid-
peripheral bearing, lens seal-off and adherence may result. This too
can impede the tear exchange. In this case, flattening the peripheral
curve radius can create greater peripheral clearance.
Ignoring these problems will likely lead to edema and irritation.7
These procedures can be performed in a matter of seconds; therefore
the patient need not be inconvenienced by returning the lens to the
laboratory or ordering a new one.
A suction cup and a series of radius tools are used to blend and flat-
ten peripheral curves. It is important to determine the proper radius
tool to use. For blending, the two radii that are to be blended should be
added and then divided by two. It is then necessary to subtract 0.40
mm to compensate for the velveteen pad used atop the tool. Consider
an example with these parameters: base curve radius (BCR), 7.6 mm;
secondary curve radius, 9.0 mm/0.4 mm width; peripheral curve
radius, 11.4 mm/0.3 mm width. To determine the first junction to
blend, add 7.6 and 9.0 to get 16.6. Then divide by two to obtain 8.3
mm. Because the velveteen adds 0.4 mm to the radius, a 7.9 radius
tool (or closest to it) would be selected to blend the curves. To blend the
junction between the secondary and peripheral curves, the desired
radius would be (9.0 + 11.4)/2 = 10.2. Compensating for the velveteen,

a 9.8 radius tool would be used.
It is not recommended to blend using a velveteen-compensated tool
that is less than 0.5 mm flatter than the BCR. A steeper tool can rap-
idly flatten or warp the BCR and reduce the optical zone diameter,
which may compromise vision.
The degree of blend depends on how readily the optical zone and
peripheral curve junctions can be observed. Generally there are three
degrees of blending3:
●
Light blend: with 5 seconds on the tool, the junction remains
easily observable.
●
Medium blend: with 10 seconds on the tool, the junction is still
observable, but shadows are beginning to form.
●
Heavy blend: with 15 to 20 seconds on the tool, the junction is
difficult to read and can appear as one continuous shadow.
To flatten or widen a peripheral curve, a radius tool flatter than the
original radius should be selected. Consider the lens described earlier,
and assume that peripheral bearing is observed during fluorescein
evaluation of the fit. Because the peripheral curve radius is 11.4 mm
and the width is 0.3 mm, a tool with a radius of 12.0 mm can be used
to create a slightly flatter and wider peripheral curve. This should only
take 10 to 30 seconds.
To blend or flatten a peripheral curve, the appropriate radius tool
should be covered with velveteen or a similar material. It is important
to ensure that there are no wrinkles or contaminants. The lens is
attached to the suction cup concave side out. It is important to obtain
adequate suction and to center the lens on the suction cup. If the lens
is not centered well, a decentered optical zone can result.
The radius tool is placed on the spindle of the unit; the motor is
turned on; and polish is applied to the tool. Once the spindle is spin-
ning, the lens is placed gently against the center of the tool in a per-
pendicular fashion (Figure 8-10). For maximum control, the suction
cup should be held as close to the lens as possible. The lens is rotated
in a figure-eight motion in small sweeps across the top of the radius
tool (Figure 8-11).
To keep the lens cool, it should be lifted from the tool and polish
should be added every few seconds. This is a critical step. Insufficient
polish and excessive pressure can lead to heat build up, which can
damage the posterior surface of the lens, especially with softer, high-
Dk materials. Likewise, when using a variable-speed modification
unit, a low spindle speed should be selected to generate less heat.
Posterior surface scratches can result if the surface of the modifica-
tion unit is not kept clean. It is important to ensure that the velveteen
Figure 8-10. The use of a brass radius tool to blend or flatten the peripheral curve radius.
is free of dried polish or other debris during the procedure. The lens
should be inspected using a 7× or 10× hand magnifier to view changes
in junction quality, optical zone diameter, and peripheral curve width.
Another method used to blend or flatten the peripheral curve radii
is to place the suction cup at a 30-degree angle from vertical, with the
entire outer edge of the lens in contact with the covered tool at all
times (Figure 8-12).12 The practitioner rotates the suction cup smoothly
with his or her fingers in the opposite direction of the spindle rotation
(typically counterclockwise). Both of these procedures require skill, but
when performed properly, they can produce the desired result within
seconds. A list of symptoms and the related modification procedures
are provided in Table 8-1.
VERIFICATION
There are several parameters of gas permeable lenses that are impor-
tant for the practitioner to verify before dispensing and periodically
throughout follow-up evaluation. The small amount of time required
Figure 8-11. Modifying the peripheral curve radius using a figure-eight motion.
to verify the GP lens may provide large benefits to the patient and
make the difference between a successful patient and an unsuccessful
one. For example, a new wearer is given lenses with poor edges. The
patient may discontinue GP lenses and have a lifetime bias about the
discomfort of the lens, when a good, well-rounded edge would have
been comfortable and liked by the patient. At minimum, verifying the
BCR, the power, the center thickness, the overall diameter, and the
edges will aid in providing a good-fitting and comfortable lens.
Verification is also a valuable diagnostic tool when patients develop
symptoms. An edge or surface defect or warpage may have resulted
from lens wear and care, affecting the patient’s success with contact
lens wear. The minimum amount of equipment necessary for verifica-
tion of a GP lens is a radiuscope or radius gauge, lensometer, center
thickness gauge, and a 7× or 10× measuring magnifier. A projection
magnifier is also beneficial in evaluating the edges and the surface.
There are additional types of equipment, but the authors recommend
those mentioned previously.
Figure 8-12. Modifying the peripheral curve radius using a 30-degree vertical motion.
Base Curve Radius

It is extremely important to verify the BCR of all GP lenses, preferably
after soaking in solution for a minimum of 12 hours. GP lenses
hydrate some on soaking, and the BCR may fall outside of tolerance
for the radius on hydration. A hydrated GP lens will simulate the lens
in the tear film; therefore this is the proper way to verify the lens. A
radiuscope or radius gauge may be used to measure the BCR and the
front curve radius (Figure 8-13). Measuring peripheral curve radii is
not feasible when the curves are less than 1 mm in width. When meas-
uring the BCR on a radiuscope, the following steps should be followed:
1. Make sure the lens is clean and dry. A dirty lens or a wet lens
will result in a distorted image.
2. Place a small amount of saline or water in the depression of the
lens mount.
3. Place the lens concave side up in the depression. Use caution
not to get solution on top of the lens material, or the image will
be distorted.
178
SECTION III
Table 8-1 GP Lens Modification Procedures

Patient Symptom Lens Evaluation Procedure Needed Precautions
Unilateral discomfort Fails palm test Edge polish with 1-in Use polish liberally
Sharp, blunt, or chipped edge center-hole sponge
Transient blurred vision Decreased wettability Front surface <1200 rpm
“Fog” after blink Deposits Polish with 3-in flat sponge Use polish liberally
Reduced wearing time Scratches/front surface Check optical quality q 20
to 30 sec.
Back surface Same as above
Polish with cone or convex
sponge
Constant blurred vision Normal Repower with cone or convex <1200 rpm
corrected by over- sponge with spinner Use polish liberally
refraction Repower with 3-in sponge Check optical quality q 15 sec.
tool and suction cup Same as above
Figure 8-13. A radiuscope for verifying base curve radius.
4. Center the stage of the radiuscope so that a reflection of a green

beam of light can be observed on the lens surface. The aperture
selector on the back of the instrument should be in the large
aperture position. There will be three images viewed in the
ocular. Two will be a spoke or star pattern, and the other will be
the light filament. The top star pattern (aerial image) floats, so
move the radiuscope scale such that the numbers on the scale
around 7 to 9 mm are observed. When the star pattern is
located, it should be centered in the ocular (Figure 8-14).
Figure 8-14. A spoke or star pattern in the radiuscope.
5. Proceed back down the scale toward zero until the light filament
is passed and the bottom star pattern is observed. When the
bottom star pattern is focused, zero the instrument by using the
silver knob on the left side of the instrument. The silver knob on
the front of the radiuscope is used to focus the internal scale for
the observer.
6. Proceed back up the scale using the coarse adjustment knob, past
the light filament to the top star pattern. When the top star
pattern is clearly in focus, take the reading. The BCR is read from
the millimeter scale to the nearest hundredth. On the radius
gauge, this scale is located on the outside of the instrument. On
the radiuscope, this scale is viewed inside the ocular. A typical
reading is 7.85 mm.
If the needle of the instrument will not position on zero when the star
pattern is in focus, then the needle must be placed at the nearest whole
number. If it is placed on the +1, then 1 should be added to the final
reading. If it is placed on 1, then 1 is subtracted from the final reading.
If on viewing the aerial image, the practitioner observes that one to
two lines focus clearly with the rest of the pattern blurry or not appar-
ent, and by changing the fine adjustment, the spokes 90 degrees away
can be focused, the lens is either warped or toric. In this case, both
readings should be recorded, for example, 7.65/7.72 mm. The power
should be verified on the lensometer, which is discussed in a later
paragraph. If the power is spherical, the lens is warped. If the power is

spherocylindrical, the lens is toric. Contact lens wearers with a warped
lens or a lens that is flexing will demonstrate symptoms of reduced
vision, blur, and a spherocylindrical overrefraction. Unlike the warped
lens, the lens that is flexing will verify spherical on base curve verifi-
cation. A warped lens requires that the patient be educated about lens
care and handling because poor care habits, such as storing concave
side down in a case or cleaning between the thumb and forefinger
instead of the palm of the hand, are likely to cause lens warpage.
Front Curve Radius

The front curve radius is rarely verified unless the lens is a front toric or
bitoric GP lens. The only method to differentiate between back, front,
and bitoric lenses is to determine how many curves are on each surface.
The back toric lens will have two curves on the back and one on the front;
the front toric lens will have one curve on the back and two curves on the
front; and the bitoric lens will have two curves on both surfaces. To
measure the front curve radius, these steps should be followed:
1. Fill the lens mount with saline, and place the lens convex side
up on the lens mount. Note the lens mount is different for
measuring front curve radius.
2. The aerial and real images will be reversed, so the aerial image
will be found around the zero point on the scale, and the real
image will be found around 7 to 9 mm on the scale. Center the
aerial image and proceed up the scale to the top pattern.
3. When the top pattern is in focus, position the needle of the
instrument on the nearest whole number, and proceed back
down the scale toward zero. When the lower image is focused,
take a reading from the scale. For example, if the reading is 1
mm and the scale was zeroed at 9 mm, then 9 − 1 = 8 mm. The
front curve radius is 8 mm. If it is a toric surface and two
readings are obtained, an example of how to record those
readings would be (9 − 1 = 8 and 9 − 1.5 = 7.5), or 7.5/8.0 mm.
Lens Power
When verifying the lens power, the back vertex power is most com-
monly used. It is recommended to check with the laboratory to ensure
that they use back vertex power and not front vertex power. It makes
little difference in low powers, but when the power of the lens is high,
the difference between front and back vertex power can be as much as
1 D.16 Verifying back vertex power is similar to verifying spectacle
power. The lensometer is tilted up, and the clean, dry lens is held on
the lens mount with the back or concave side of the contact lens
against the lens stop. The contact lens should be centered on the lens
stop. It may be beneficial to rest the lens on the thumb, but caution
should be taken not to flex the lens. The reading is taken and recorded
like spectacles (e.g., −4.50 D). If a spherocylindrical reading is
observed with no prism, the powers are recorded exactly according to
the lensometer drum (e.g., −2.00/−5.00 D), that is, the power in each
meridian. If the prism is observed, the lens should be rotated so that
the prism is in the base-down position or the image is displaced below
center. The power should be recorded like spectacles (e.g., −2.00 −
3.00 × 180). The prism will be observed in the lensometer when the
image in the ocular is displaced off the center even though the lens is
centered on the lens stop. The reticule inside the ocular has concentric
black rings that mark off the prism from 1 to 5 prism diopters. For
example, if the center of the target is displaced to the first ring of the
reticule, it corresponds to 1 prism diopter. Primarily, prism is used in
front surface toric or bifocal GP contact lenses to stabilize the lens.
Examples:
Proper notation of a bitoric GP lens would be BCR: 7.50/8.04 mm and
Power: Pl/−3.00 D.
Proper notation of a front toric GP lens would be BCR: 7.76 mm and Power:
−3.00 – 1.00 × 160, 1 prism diopter.
Inspection of the Lens Surface and Edge

The lens parameter that primarily affects comfort is the lens edge. The
lens edge can come from the laboratory in poor shape or become
defective because of lens handling. An easy technique to evaluate the
GP lens edge is the “palm test.” The lens is placed concave side down
on the palm and gently pushed across the surface (Figure 8-15). If the
Figure 8-15. The “palm” test for verifying edge quality.

lens resists movement, does not glide easily, or feels sharp or rough,
the lens edge needs to be polished. Another excellent method of eval-
uating the edge is the use of a projection magnifier. A side profile of the
lens will allow the practitioner to judge the thickness and whether the
lens is rounded, sharp, or blunt (Figure 8-16). A front profile will allow
the practitioner to view microchips in the lens edge (Figure 8-17).
Figure 8-16. A, A profile of a rounded edge. B, Blunt edge via a projection comparator.
Figure 8-17. A frontal view of microchips via a projection comparator.
A measuring magnifier may also be used, but the decreased magnifi-

cation makes the inspection more difficult.
The projection magnifier is also useful for inspecting the surface of
the lens. Other methods for evaluating the lens surface are the biomi-
croscope with the lens on and off the eye; the Contact Lens Edge
Profile Analyzer (Valley Contax, Springfield, OR), which is a modified
spinner that uses the optics of a radiuscope (Figure 8-18); and the
measuring magnifier. Inspection of the lens surface may reveal
deposits, scratches, lens coating, cracking and crazing, manufacturing
defects, residual pitch, or poor wettability.
Center or Edge Thickness

The most frequently used method of determining thickness on any
point of the contact lens is to use a dial gauge (Figure 8-19). Radius
gauges have a center thickness gauge incorporated onto the instru-
ment. Position the portion of the lens that is to be measured under the
plunger. The plunger is gently lowered onto the lens by the thumb.
The thickness is read directly from the gauge. If the center thickness
is being verified and the gauge reads 15, then the center thickness is
0.15 mm. This parameter is important to verify because center thick-
ness affects oxygen transmission, flexure of the lens, position of the
lens, comfort, and warpage of the lens.
Figure 8-18. The Contact Lens Edge Profile Analyzer for verifying edge profile.
Verification of Overall Diameter, Optical Zone Diameter, and Peripheral

Curve Widths
There are several methods of verifying the overall diameter (Figure
8-20). The best method to use is the measuring magnifier. Not only is it
the most accurate method but also it can be used to verify the optical
zone diameter and peripheral curve widths and to determine the blend.
The lens is positioned on the measuring magnifier and gently held with
the index finger. The measuring magnifier is held with a light source
behind it, and the lens is aligned on the scale of the measuring magni-
fier. The scale typically reads from 0 to 20 mm or from 0 to 10 mm. The
Figure 8-19. Center thickness verification with a Vigor gauge.
Figure 8-20. Methods of diameter verification.

overall diameter, the optical zone diameter, and the peripheral curve
widths can be read from the scale. The optical zone diameter is the lens
area between the peripheral curves. There can be from one to three or
more peripheral curves on the lens. Typically lenses are a bicurve (one
peripheral curve in addition to the back curve), a tricurve (two peripheral
curves), or a tetracurve (three peripheral curves). The measuring magni-
fier may need to be moved slightly back and forth to determine the
peripheral curve widths. The heavier the blend between the peripheral
curve junctions, the harder it is to distinguish where one peripheral
curve ends and another starts. Blends are described as light, medium, or
heavy. In a light blend, it is relatively easy to distinguish between the
peripheral curves.
In some lens designs, toric peripheral curves are used, which result
in an oval optical zone. In this case, it is important to rotate the lens
90 degrees to measure the optical zone in another position. Other
methods of verifying overall diameter are a projection magnifier, PD
stick, V-channel gauge, or a dial gauge. Accuracy of these methods is
not as precise as with the measuring magnifier.
SUMMARY
Anyone can learn to verify and modify GP lenses, and staff members
who learn to do so can be of great assistance to a practice. Numerous
organizations (e.g., the RGP Lens Institute, the Contact Lens
Association of Ophthalmologists, the Contact Lens Society of America,
and the Heart of America Contact Lens Society) provide workshops, as
do many members of the Contact Lens Manufacturers Association. The
RGP Lens Institute (800-344-9060; www.rgpli.org) offers instructional
videotapes pertaining to modification, verification, the radiuscope, and
the lensometer. Practice lenses should not be difficult to obtain, and
rigid contact lens laboratories readily assist in these activities.
In summary, the verification and modification of GP lens materials
will enhance a practice’s ability to fit GP lenses and care for the patients.
A little time is required, but it enables the practitioner to solve many
problems efficiently without inconveniencing the patient. If the guide-
lines presented in this chapter are followed, GP lenses can represent a
growing segment of every optometrist’s contact lens practice.
REFERENCES
1. Morgan BW, Henry VA, Bennett ES, et al: The effect of modification procedures
on rigid gas permeable contact lenses: the UM-St. Louis study, J Am Optom
Assoc 63(3):201-214, 1992.
2. Clompus R: How to polish and modify rigid lenses, Rev Optom 124(4):106-113,
1987.
3. Tracy D, Sanford M: Modification procedures, guidelines and tips, Norfolk, VA,
1997, Conforma Laboratories.
4. Reeder RE, Pate JR, Snyder C: Effectiveness and efficiency of rigid gas permeable
lens power modification with various polishes, Int Contact Lens Clin
23(3/4):67-70, 1996.
5. Bennett ES: Offer added value with in-office RGP modification, Contact Lens
Spect 11(10):18-19, 1996.
6. Grohe RM, Caroline PJ, Norman C: The role of in-office modification for RGP
surface defects, Contact Lens Spectrum 3(10):52-60, 1988.
7. Morgan BW, Bennett ES: Modification of RGP lenses, Contact Lens Forum
15(7):33-50, 1990.
8. Meszaros GK: Simplifying lens modification, Contact Lens Forum 11(11):42-49,
1986.
9. Jurkus JM: Modifying RGPs: a straightforward approach, Optom Manage
31(9):54-58, 1996.
10. Bennett ES: Successfully modifying contemporary RGP materials, Optom Today
5(10):27-34, 1997.
11. Bennett ES, Egan DJ: Modification. In: Bennett ES, Grohe RM, editors: Rigid gas
permeable contact lenses, New York, 1986, Professional Press, pp 247-273.
12. Morgan BW, Bennett ES: Modification. In: Bennett ES, Henry VA, editors: Clinical
manual of contact lenses, Philadelphia, 1994, JB Lippincott, pp 172-193.
13. Bennett ES, Clompus RJ, Hansen DW: A hands-on approach to RGP modifica-
tion, Rev Optom 135(1):88-96, 1998.
14. Clompus RJ: How to polish and modify rigid lenses, Rev Optom 124(4):106-113,
1987.
15. Picciano S, Andrasko GJ: Which factors influence RGP lens comfort? Contact
Lens Spect 4(5):31-33, 1989.
16. Sarver MD: Verification of contact lens power, J Am Optom Assoc 34:1304-1306,
1963.
9
Problem Solving
EDWARD S. BENNETT
O ne of the many benefits of gas permeable (GP) lenses is the

fact that when problems are induced they are rarely sight
threatening. Typically GP lens problems can result in blurred
vision, dryness, or reduced comfort. Fortunately, ongoing improve-
ments in GP lens manufacturing technology and material develop-
ment have reduced the incidence of these problems in recent years.
This should continue in the future.
PROGRESS EVALUATIONS
It is recommended that practitioners evaluate GP lens patients after 1
week, 1 month, and 3 months of lens wear, with a regular 6-month
evaluation to follow. At each visit, it is recommended that practitioners
perform the procedures given in Box 9-1.
Case History
A comprehensive case history is important, especially at the 1-week
progress evaluation. As mentioned in Chapter 4, this visit represents a
good opportunity to determine if the patient is having any problems
with handling or care of the lenses and to proceed to reeducate the
patient if necessary. In addition, patients can be asked about their
overall level of satisfaction, and the practitioner can determine if the
patients are experiencing any problems with vision or comfort.
Patients should also be asked about their wearing time to ensure they
have been compliant with the schedule provided to them.
With Lenses On
Before lens removal, several procedures should be performed. First,
the patient’s visual acuity should be performed and compared with the
baseline vision. Spherocylindrical overrefraction should be performed
190
Chapter 9 Problem Solving 191
Box 9-1 GP LENS PROGRESS EVALUATION PROCEDURES

History (symptoms, review care/compliance, determine wearing time, level
of satisfaction, inquire about handling competency)
Visual acuity
Retinoscopy for spherocylindrical overrefraction
Best sphere overrefraction
Biomicroscopic evaluation (before removal)
1. Surface quality (deposits, scratches)
2. Centration and movement with the blink
3. Fluorescein pattern
Biomicroscopic evaluation (after lens removal)
1. Staining
2. Edema
3. Vascularization
4. Papillary hypertrophy
Manifest refraction*
Keratometry*
Verification*
*
Unnecessary at every visit.
using retinoscopy. Best sphere overrefraction can be performed—

preferably with loose trial lenses—and if this improves the patient’s
vision, it can be added to the lens power either with modification or by
reordering the lens.
A biomicroscopic evaluation can assess such factors as lens position
and movement with blinking. In addition, the surface quality can be
evaluated to assess the presence of deposits or scratches. The fluores-
cein pattern can be evaluated to ensure an absence of peripheral seal-
off and excessive bearing.
With Lenses Off

On lens removal, the cornea should be evaluated for signs of staining
and vascularization (360-degree evaluation of limbus). In addition,
with split limbal illumination, central corneal clouding (rare with the
current generation of GP lens materials) can be assessed via looking
outside the oculars at the central cornea. If a haze can be observed
against the dark background of the pupil, corneal edema is present. In
addition, the lids should be evaluated for any increase in papillary
hypertrophy, particularly if the lenses have deposits.
On occasion it is recommended to recheck keratometry and corneal
topography and the manifest refraction to ensure that significant
change has not occurred. Likewise, if the symptoms warrant, lens
192 SECTION IV TREATMENT OPTIONS AND SPECIAL DESIGNS
verification can be important. For example, if the lens is uncomfort-

able, the edge should be evaluated. If the patient complains of reduced
vision, warpage can be confirmed with toric readings on the radius-
cope, and addition of minus power through rigorous cleaning can be
confirmed with the lensometer.
SYMPTOMS AND MANAGEMENT

Blurred Vision
Blurred vision can result initially or be acquired over time. If it occurs
soon after insertion, it typically results from wither flexure, incorrect
power, or poor surface wettability.
Immediate
Flexure. Flexure-induced reduction in visual acuity results from the
bending forces of the upper lid on the lens during blinking. Because it
is the intent of the rigid gas permeable lens to mold the anterior
corneal surface and correct all toricity, if the lens bends during the
blink process, particularly with a patient who has with-the-rule astig-
matism, all of the toricity will not be corrected. Typically this is prob-
lematic for patients with corneal toricity ≥ 1.50 D.
The most common cause of GP lens–induced flexure is excessive
sagittal depth with a minus power GP lens (e.g., via a steep base curve
radius).1-3 Likewise, a large optical zone diameter will result in the same
effect.4 Material flexibility (i.e., high/hyper-Dk lens materials in minus
powers) and a thin center thickness also contribute to lens flexure.5,6
Flexure can be diagnosed at the fitting visit. If the patient’s best cor-
rected vision is reduced with a spherical overrefraction and optimally
corrected with a spherocylindrical correction and if significant residual
astigmatism is not predicted, flexure should be suspected. Diagnosis
of lens-induced flexure can be made via performing keratometry over
the lens; if these values are not spherical but instead are toric (i.e., 41
D × 42 D), flexure is present. However, with the radiuscope, the base
curve radius is spherical.
Management of flexure pertains to changing the lens design and/or
material. Selecting a base curve, at minimum, 0.50 D flatter would be rec-
ommended if this does not compromise the lens-to-cornea fitting rela-
tionship. If an ultrathin design is being fitted, it is recommended to
change to a more standard center thickness. A secondary design change
would be to reduce the optical zone diameter, again by a significant
amount (i.e., ≥ 0.3 mm). If flexure persists after lens design changes, the
selection of a more rigid lower-Dk lens material should solve the problem.
Incorrect Power. If the power of the lens is incorrect, a reduction in

vision will occur. This can be the result of several factors, including
errors in refraction, keratometry, and the base curve radius or power of
the diagnostic lens. Simply adding the spherical overrefraction to the
lens power should solve this problem.
Reduced Surface Wettability. As mentioned in Chapter 7, reduced
surface wettability at the initial dispensing of the lens can result from
a dry or compromised lens surface. Often this can result from residual
pitch polish left on the lens surface from manufacturing. The surface,
as viewed with biomicroscopy, will appear as if the tears are beading
up on the surface (i.e., the tear film mucin is not spreading over the
lens surface) (Figure 9-1).
Management of this problem will first pertain to using a laboratory
cleaner or solvent to clean the surface. Wetting solution can then be
rubbed into the lens surface to recondition the surface, and the lens
can be reapplied. It is also beneficial to soak the lenses in wetting/
disinfection solution overnight before dispensing, whenever possible,
to accelerate tear film mucin spreading on the lens surface. If this
problem persists, the laboratory should be contacted about possible
manufacturing-related problems.
Figure 9-1. Poor initial surface wettability.

Acquired
Warpage. During the past 20 years, a common cause of reduced
vision with GP lenses over time is warpage of the base curve radius.
Excessive digital cleaning in the palm of the hand can cause this per-
manently induced toricity.5,7 It also tends to increase as the Dk of the
material increases and with the use of an abrasive cleaner.7,8 It is dif-
ferentiated from flexure because it is acquired over time and the lens
is toric when verified with the radiuscope. As with flexure, sphero-
cylindrical overrefraction will result in best corrected visual acuity.
Warpage is best managed by a combination of a new lens and patient
reeducation. Patients need to be reminded to clean the lens carefully in
an up-and-down/back-and-forth motion in the palm of the hand, not in
a circular motion. In addition, the lenses should not be cleaned between
the fingers. This has been a traditional method of cleaning that was suc-
cessful with the more rigid polymethylmethacrylate (PMMA) and first-
generation GP lenses, but it can result in frequent lens replacement
with the current generation of GP lenses, particularly high- and hyper-
Dk lens materials.9 Warpage appears to be a problem today because of
improvements in lens materials and manufacturing technology. In
addition, the introduction of milder abrasive cleaners, such as Opti-Free
Daily Cleaner (Alcon, Fort Worth, TX) and the Boston Advance Cleaner
(Polymer Technology Corporation, Rochester, NY), has also reduced the
incidence of this problem. If warpage persists, the use of a “hands-off”
system, such as Claris (Allergan/Menicon, Irvine, CA) or Unique pH
(Alcon), is recommended.
Power Change. It has been found that a patient can increase minus
power in the lenses over time as a result of digital pressure, especially
if the lenses are cleaned in a circular motion in the palm of the hand
(Figure 9-2).7,10-12 It can also be exacerbated by the use of an abrasive
cleaner and with higher-Dk lens materials.7 The center thickness of the
lenses also decreases.7,12
This problem can be decreased, as discussed in Chapter 7, using
the same methods of reducing warpage and changes in patient educa-
tion, cleaner, and possibly lens material. Patients need to be educated
to clean the lenses carefully in a noncircular manner in the palm of the
hand. The use of a mild abrasive or nonabrasive cleaner is recom-
mended. As a last resort, the patient can be refit into a lens of lower-
Dk material.
Poor Acquired Surface Wettability. Another common cause of
acquired reduction in vision is the presence of poor surface wettability.
Although this can be, in part, lipid based, often it is present in the
form of a mucoprotein film or haze (see Figure 9-2). This mucuslike
film is easily diagnosed with the biomicroscope. Among the possible
Figure 9-2. Mucoprotein film.
causes for this problem include marginal dry eye (i.e., tear quality or
volume), lid margin disease, poor compliance with care and cleaning,
poor surface wettability of the lens material, and less than optimum
blink quality, which is often lens induced.
Management of this problem depends on the cause. When a patient
has lenses with heavy deposits, the lenses should be cleaned in the
office with a laboratory cleaner or solvent. In addition, the patient’s
method of lens care should be evaluated. The questions provided in
Box 9-2 should be asked. It is important to determine if the patient is
cleaning the lenses appropriately in the palm of the hand every night
on removal. In addition, the lenses should be cleaned equally (i.e., not
cleaning the right lens more than the left). Likewise, the patient should
be asked if the lenses are placed into fresh soaking solution on
removal at night and reminded not to use a cream or soft soap prod-
uct that contains lanolin before handling the lenses. If the lenses are
placed into a dry case, the mucoprotein deposits can dry out on the
lens surface and be more difficult to remove. If a liquid enzyme was
prescribed, it should be used as recommended; if not, it should be
added to the patient’s care regimen. There should be confirmation that
the patient is using the care system that was prescribed.
If the patient has borderline dry eyes, it becomes important that
the patient is compliant with the prescribed care system and also
Box 9-2 LENS CARE QUESTIONS TO REVIEW COMPLIANCE

1. Are you cleaning the lenses on removal every night?
2. Are you cleaning them in an up-and-down/back-and-forth manner in the
palm of the hand?
3. Are you placing the lenses in fresh disinfecting solution every night?
4. Are you using a liquid enzyme (if prescribed) as recommended?
5. Are you cleaning the left lens and the right lens?
6. Are you using the same solutions as originally prescribed?
7. Are you handling the lenses after using a lanolin-based hand cream or
soft soap?
incorporates liquid enzyme into this system. If the patient has ble-
pharitis or meibomian gland dysfunction, these conditions need to be
managed because they are disruptive to the tear film and can induce
dryness-related symptoms and signs, including deposits. Finally, a
change in lens material should be considered, especially if either a
high– or hyper–fluoro-silicone/acrylate (F-S/A) or silicone/acrylate
(S/A) lens material is being worn.
Dryness
Dryness is often associated with corneal desiccation (3 and 9 o’clock
staining) or inferior decentration.
Corneal Desiccation
Corneal desiccation, or “3 and 9 o’clock staining,” is a common GP
lens–induced problem that is present in more than 50% of wearers.9
It pertains to a drying or dehydration of the peripheral exposed cornea.
In the majority of patients it would be considered grade 1 isolated
superficial punctate keratitis (SPK). In certain patients, the staining
can coalesce, typically resulting in symptoms of dryness and redness
(Figure 9-3). Although rare, scarring, neovascularization, and opacifi-
cation can occur.7 Corneal desiccation is easily diagnosed using bio-
microscopy. Management includes changes in lens design, material,
and lid hygiene.
Corneal desiccation has been associated with inferior decentration.9
The incidence of corneal desiccation was found to be twice as much
for inferior decentering lenses than for those exhibiting lid attach-
ment. Several factors influence lens centration. An important factor is
to minimize lens mass with the use of an ultrathin design, if possi-
ble.13 The use of a lenticular, when indicated, is also important. In par-
ticular, a plus lenticular for lens powers ≥−5.00 D will reduce edge
thickness and minimize the risk of the upper lid literally bumping the
Figure 9-3. Corneal desiccation.
lens inferiorly. A lid attachment fitting relationship is important and

should be strived for. If the patient exhibits a large fissure, a small
diameter is necessary to keep the lens from “bumping” into the upper
lid. Likewise, a minus lenticular for all low minus (i.e., ≤–1.50 D) and
plus lenses will increase edge thickness, allowing for more lid interac-
tion and lifting of the lens. For plus power lenses, a steeper than “K”
base curve radius will assist in centration of a heavy lens with an ante-
rior center of gravity.
Edge clearance, and its role in corneal desiccation, is rather contro-
versial. Insufficient edge clearance can result in peripheral seal-off and
poor tear exchange.14 However, more common and important is to
avoid excessive edge clearance or peripheral tear volume.15-21 With a
high edge clearance design, it is possible for more lid–lens edge inter-
action, which can compromise the blink process, drying out the
peripheral cornea. In addition, the peripheral tears can funnel under-
neath the lens periphery, resulting in drying or desiccation (Figure
9-4). Traditional PMMA designs typically had high edge clearance to
optimize oxygen flow with oxygenated tears. A peripheral curve radius of
12 mm or greater with a width of 0.4 mm or greater was not uncommon.
Figure 9-4. High edge clearance lens design.
A GP lens peripheral curve width averaging 10.5 to 11.0 mm is recom-

mended, as is an aspheric periphery to approximate alignment.
However, the best method for determining whether edge clearance is
excessive is to evaluate the fluorescein pattern. The fluorescein pattern
should exhibit slightly greater—but not excessive—peripheral clear-
ance than centrally.
Lens material is also important. As mentioned before, F-S/A lens
materials appear to maintain the tear film mucin in contact with the
lens surface for a longer period than S/A lenses.22 In particular, for
patients with myopia, the low-Dk materials are especially wettable,
although advancements in material chemistry have improved the sur-
face wettability characteristics of newly introduced high- and hyper-Dk
F-S/A materials.
As mentioned in the previous section, proper lid hygiene is impor-
tant to optimize tear film quality. In addition, patients with borderline
tear quality are more prone to desiccation and may require a less than
all-day wearing schedule. Likewise, patients who are taking medica-
tions—notably antihistamines—that reduce tear volume are more
prone to dryness-related symptoms and clinical signs. The use of an
aggressive cleaning regimen supplemented by frequent rewetting
drops will benefit these patients.
Poor Acquired Surface Wettability

This problem is managed as indicated in the section discussing
blurred vision.
Reduced Comfort
Immediate
If the patient indicates that initial comfort is poor, it could be the result
of several factors. The patient may be apprehensive or sensitive to the
GP lens, and therefore the patient is more likely to react with tearing
and excessive lens awareness. The use of a topical anesthetic at the ini-
tial fitting helps minimize this problem. In addition, it is important to
use milder terms such as “lens awareness” and “lid sensation” when
describing GP lenses to a new patient. Sensitive patients may benefit
from a slower adaptation schedule.
Another common cause of initial reduced comfort is a defective
edge. Manufacturing quality has increased in recent years, in part
because of programs such as the CLMA Seal of Excellence, resulting
in more consistent edges. However, it is important to verify the edge
when such symptoms are present. Finally, some of the same lens
design factors that cause desiccation (e.g., thickness, absence of a
lenticular, excessive edge clearance) can increase initial lens awareness
and should be managed accordingly.
Patients should also be educated that they may experience, on occa-
sion, a transient awareness whenever a foreign body becomes trapped
behind the lens. This results in superficial staining, which pertains to
the path the particle traveled before being ejected (Figure 9-5). This
typically lasts for a matter of seconds.
Figure 9-5. Foreign body “tracklike” staining.

Acquired
Vascularized Limbal Keratitis. Associated with corneal desiccation,
vascularized limbal keratitis (VLK) is a more acute peripheral corneal
complication. Most common in patients who wear GP extended-wear
lenses, this condition consists of a raised inflamed translucent area in
the 3 and 9 o’clock region. It is accompanied by corneal staining, vas-
cularization, and conjunctival injection (Figure 9-6).23 Patients report
reduced wearing time, discomfort, redness, and often an awareness of
a “white spot” on their eye. It often affects patients who wear S/A lenses
with a low edge lift. The edge of the lens tends to compress the periph-
eral cornea, leading to a heaping up of epithelium adjacent to the edge.
Management of this condition initially pertains to combination
antibiotic-steroid therapy (i.e., Tobradex qid; Alcon, Fort Worth, TX),
and the patient should be evaluated at 24 hours. Typically after 4 to 5
days, this region has dramatically regressed, and tapering of the med-
ication can occur (Figure 9-7).23,24 Refitting into a more wettable mate-
rial would be the recommended initial step. If the material exhibits
good wettability, flattening the peripheral curve radius should improve
tear flow and minimize the recurrence of this problem. Likewise, if the
patient is wearing the lenses on an extended-wear schedule, reducing
to daily wear should be beneficial.
Figure 9-6. Vascularized limbal keratitis.

Figure 9-7. The patient in Figure 9-6 after 5 days of discontinuation of lens wear.
Corneal Desiccation. This can be managed as discussed in the sec-

tion on dryness.
Poor Acquired Surface Wettability. This is managed as discussed in
the section on blurred vision.
Ideas for successfully solving problems with GP lenses based on
clinical signs and symptoms are provided in Tables 9-1 and 9-2.
REFITTING
GP lenses are a great problem solver as well. They are often used in the
refitting of soft lens patients who are experiencing problems and for
PMMA and first-generation GP lens wearers who are experiencing
hypoxia-related complications.
Soft to GP Lens Refits

It would not be advisable to refit satisfied asymptomatic soft lens wear-
ers into GP lenses just as it would not be advisable to refit satisfied GP
wearers into soft lenses. However, soft lens wearers who have experi-
enced recurring complications, such as giant papillary conjunctivitis
(GPC), ulcerative keratitis, peripheral infiltrates, and vascularization,
are excellent candidates for GP lenses.25 These patients appreciate the
Table 9-1 GP Problem-Solving
202
Condition Symptoms Causes Diagnosis Management

Flexure Vision varies with blink; High astigmatism Toricity with Flatter BCR
poor initial vision overkeratometry Increase CT
Steep BCR Sph-Cyl overrefraction Reduce OZD
Thin design Lower-Dk material
SECTION IV
Large OZD
Warpage Vision gradually reduces Digital cleaning Toricity with radiuscope Clean in palm of hand
High-Hyper-Dk Sph-Cyl overrefraction “Hands-Off” care system
Lower-Dk material
Power change Vision reduces at Near Digital cleaning Increased minus power Clean in palm of hand
(prepresbyopic); may Abrasive cleaning with lensometer Nonabrasive cleaner
be asymptomatic
Decentration
Inferior Vision varies with blink Thick lens design Biomicroscope: shows Ultrathin design
Lens awareness High WTR cylinder inferior decentration & Lenticular: (+) if power ≥
Corneal apex located excessive movement −5.00 D (−) for all (+)
inferior lenses; ≤ −1.50 D
Plus power lenses Bitoric if ≥ 2.50 D cyl
Tight or loose lid
tension
Superior Flare around lights Flat BCR Biomicroscope: shows Steepen BCR
Lens awareness Thin CT superior position; Increase CT
TREATMENT OPTIONS AND SPECIAL DESIGNS
Tight lid tension possible adherence (+) lenticular if high

Superior corneal apex minus power
Lateral Flare around lights ATR cylinder Biomicroscope shows Steepen BCR
Lens awareness Corneal apex lateral decentration & Increase OAD
Vision varies with blink decentered laterally movement along Aspheric design
horizontal meridian Soft Toric
Wettability
Initial Poor initial/fluctuating Manufacturer-induced Beading up of tear Use lab cleaner/solvent
vision problems (pitch, film on surface & recondition
Chapter 9
poor finishing) Haze Presoak lens

Use of lanolin If frequent talk to lab
Acquired Gradual reduction in Patient compliance Mucoprotein haze/film Re-educate on
vision with cleaning regimen on front surface care/cleaning
Use of lanolin-based Papillary hypertrophy Avoid lanolin-based
hand creams/soaps soaps prior to insertion
Poor material Use liquid enzyme
wettability Change to F-S/A
Poor tear quality/ material
volume
Use of medications
with drying effect
Blepharitis, meibomian
gland dysfunction
(MGD)
Corneal Dryness Poor tear 3 & 9 o’clock punctate Ignore if diffuse (50% of
desiccation Redness quality/volume staining GP wearers)
Lens awareness Inferior decentration Injection Decrease center/edge
(gradual/low-grade) Thick lens (center or Possible opacification/ thickness; add lenticular
edge) vascularization Decrease edge lift (steepen
High edge clearance PCR/decrease
S/A material PCW; aspheric)
Problem Solving
Poor lid hygiene F-S/A material

Poor blink quality Blink training
Lid hygiene; if MGD, warm
compresses/lid massage
203
Continued
204
SECTION IV
Table 9-1 GP Pr0blem-Solving—cont’d

Condition Symptoms Causes Diagnosis Management
Frequent use rewetting
drops
Vascularized Acute lens awareness Dryness Opaque, elevated D/C lens wear × 5–7 days
limbal Reduced wearing time S/A material vascularized region at Ab/steroid combination
keratitis Red eye Low edge lift design 3 or 9 o’clock region (qid × 1 week then taper)
Opaque area at corneal Steep BCR of cornea F-S/A material
periphery observed on Extended wear schedule Daily wear
inspection in mirror Flatter, wider PCR/PCW
Flatter BCR
Reduce diameter
Table 9-2 Symptom-Based GP Lens Problem Solving

Symptom Management
Blurred vision
Immediate
Flexure Flatter BCR
Increase center thickness
Decrease OAD/OZD
Lower Dk material
Incorrect power Reorder with correct power
Reduced surface wettability Presoak overnight
Lab cleaner/solvent
Recondition with wetting
If frequent, talk with laboratory
Acquired
Warpage Clean gently in the palm of hand
Nonabrasive cleaner
Overnight soak in cleaning/disinfecting
solution
Power change Clean gently in palm of hand
Nonabrasive cleaner
Reduced surface wettability Lab cleaner/solvent
Reeducate about proper care & cleaning
Add liquid enzyme
F-S/A lens material
R/O lid margin disease
Dryness
Corneal desiccation None unless the staining is coalesced
Improve centration via:
●
Decrease center thickness
●
Add lenticular:
+ lenticular if ≥ −5.00 D power
− lenticular if ≤ −1.50 D or all plus
Decrease edge lift via steeper PCR,
decreased PCW or aspheric periphery
F-S/A lens material
Frequent use of rewetting drops
Treat lid margin disease if present
Reduced surface wettability Manage similar to recommendations for
blurred vision
Reduced comfort
Immediate Verify edge; if defective, polish
Evaluate fitting relationship (if decentered
Continued
Table 9-2 Symptom-Based GP Lens Problem Solving—cont’d

Symptom Management
inferiorly, manage similar to corneal
desiccation)
If patient is sensitive to lens wear, provide
a more lengthy adaptation schedule
Acquired
Vascularized limbal keratitis Ab-steroid combination qid × 5-7 days
Flatter PCR/increased PCW
Decrease OAD
F-S/A lens material
Daily wear schedule
Reduced surface wettability Manage similar to recommendations for
blurred vision
Corneal desiccation Manage similar to recommendations for
dryness
improved ocular health that often results. However, the primary rea-
son to refit soft lens patients into GP lenses pertains to vision. It is not
uncommon for spherical soft lens wearers to be dissatisfied with their
vision because of some level of uncorrected astigmatism. Likewise, a
soft toric lens wearer who experiences variable vision because of lens
rotation would appreciate the vision obtained with GP lenses. It is
important to always recommend GP lenses as a viable alternative for
patients experiencing blurred vision with soft lenses.
When discussing GP lenses as an alternative, it is important to rec-
ognize that soft lens wearers have most likely been given the percep-
tion that GP lenses are uncomfortable. This perception has to be
managed as soon as possible. GP lenses should be presented as rec-
ommended in Chapter 4. “Discomfort” should not be mentioned;
“lens awareness” should be substituted. The RGP Lens Institute has
numerous consumer-related educational videotapes and brochures
available (www.rgpli.org) (Box 9-3).
The most important factor in the refitting process is to make it as
similar to soft lenses as possible, in particular, the initial comfort. The
first step is to use a topical anesthetic during the initial application,
which is the moment that a soft lens wearer is especially apprehensive.
The anesthetic gradually wears off, and the patient then experiences a
more realistic sensation. However, during the interim, the patient
experiences the most important benefit of GP lenses, good quality of
vision, which may, in turn, take the focus entirely off of the comfort
Box 9-3 EDUCATIONAL VIDEOTAPES FOR GP LENS PROBLEM SOLVING FROM THE
RGP LENS INSTITUTE
GP Problem Solving: Part One: How to manage decreased surface wettability,
flexure, warpage, corneal desiccation, and adherence. In addition, video
grand rounds of cases pertaining to myopia, hyperopia, against-the-rule
astigmatism, high with-the-rule astigmatism, irregular cornea, and
presbyopia are included.
GP Problem Solving: Part Two: How to manage GP lens decentration,
including inferior, superior, and lateral decentration. In addition, information
on how to refit PMMA and soft lens patients into GP lenses is provided.
Have You Considered Oxygen Permeable? This is an in-office patient
promotional video emphasizing the benefits and applications of GP lenses.
issue. In other words, the first GP lenses soft lens wearers will wear
will be in their prescription, so they can experience quality of vision
that they may never have experienced before. Therefore fitting from an
inventory or empirically is recommended.
PMMA/First-Generation GP to GP Lens
Why Refit
There is an old adage that says “If it’s not broke, don’t fix it.” This is often
associated with PMMA lens wear in a satisfied patient. However, the
problem is that it is broken. PMMA lenses and, for that matter, all GP
lenses with a Dk value less than 20 do not meet the Holden-Mertz cri-
terion for edema-free daily wear.26 Therefore although there are PMMA
and low-Dk GP lens wearers today, they are a walking time bomb for
corneal compromise. These lenses are still being fitted today, particularly
specialty lens designs such as bifocal designs and those for patients with
keratoconus. In addition, the prescribing of these lenses in the twenty-
first century is contrary to the standard of care for today’s patients just as
fitting a first-generation hydrogel or soft toric would be.
Corneal hypoxic conditions include central corneal clouding (CCC),
edematous corneal formations (ECFs), polymegethism, corneal
exhaustion syndrome, and corneal warpage syndrome. CCC is present
in almost every PMMA lens wearer.27 It is a circumscribed region of
epithelial edema that is located centrally and appears as a grayish haze
against the dark background of the pupil when viewed with sclerotic
scatter. Patients with CCC often see well out of their contact lenses but
experience “spectacle blur” when viewing through spectacles. ECFs are
subepithelial dendritic-appearing formations located in the central

cornea. They represent chronic low-grade edema and develop gradu-
ally in the long-term PMMA lens wearer.28
Polymegethism
Polymegethism pertains to alterations in endothelial cell size or area.
Because the endothelium controls corneal hydration, this is particu-
larly critical to minimize, if not avoid. The use of high magnification,
high illumination, and specular reflection with the biomicroscope is
critical to diagnose these endothelial cell changes. Chronic hypoxia
with endothelial disruption can result in difficulty in reducing edema,
resulting in recurring corneal abrasions and loss of wearing time. This
is termed corneal exhaustion syndrome.29 Corneal warpage syndrome
pertains to corneal distortion resulting from chronic hypoxia. This
condition, present in as many as 30% of long-term PMMA lens wear-
ers, results in irregular astigmatism and unpredictable changes in ker-
atometry readings and refraction. This could represent the mechanical
effect of a GP lens on a softer edematous cornea. In addition, hypoxic
corneal change can induce decentration of the lens, which, in turn, can
result in corneal distortion, which is easily detected via evaluation of
the corneal topography.30,31 Refitting these patients can be particularly
challenging because they can exhibit keratoconus-like changes,
although in patients with corneal warpage syndrome these changes
are either partially or totally reversible.
Patient Education
Patients who are satisfied with PMMA or first-generation GP lenses
will often need to be convinced of the benefits of current GP lenses.
They can be told about the consequences of edema and the benefit of
being able to achieve satisfactory vision with their spectacles. There are
two educational videotapes from the RGP Lens Institute that are ben-
eficial for educating these patients. These include “Oxygen-Permeable
Contact Lenses—Promotional” and “GP Problem Solving Part 2.”
Once fit, patients need to be reeducated about lens care. PMMA
lenses, in particular, are more resistant to scratches and warpage than
current-generation GP lens materials. Patients need to be told to han-
dle the lenses over a soft surface and, if a lens is dropped, to place a
drop of wetting solution on the tip of a finger and gently pick up the
lens. In addition, they need to clean the lens gently in the palm of the
hand, not between the fingers. On occasion, patients will temporarily
exhibit sensitivity to their new lenses. They should be warned that this
can occur, and practitioners should reassure them that this temporary
corneal sensation gradually disappears.
Refitting Process
These patients should be fit immediately into GP lenses without loss
of wearing time.32 It has been found that the refraction and keratome-
try values will stabilize underneath the GP lenses as the hypoxia grad-
ually decreases.33 If the patient has corneal warpage syndrome, it
would be preferable to reduce the patient’s wearing time to the mini-
mum number of hours (often 8 to 10 hours) and have the patient
return to the office after 1 week. At that time, the corneal distortion and
other clinical signs of hypoxia should be less, and the refitting process
should be more straightforward. Unless a corneal abrasion is present,
these patients should never discontinue lens wear cold turkey in an
effort to stabilize refractive readings and corneal health. Large and
unpredictable refractive and topographic changes can result.34,35
If a satisfactory lens-to-cornea fitting relationship is present with
the PMMA/first-generation GP lenses, often this design can be dupli-
cated in the new material, particularly if a low-Dk F-S/A material is
being fitted. This is recommended because of the rigidity and surface
wettability of these materials. If a poor lens-to-cornea fitting relation-
ship is present, refitting the patient into a new design is recom-
mended. Current GP lenses are typically fitted with a larger diameter,
flatter base curve radius, and steeper periphery than PMMA lenses.
Patients should also be told that they will be prescribed new spectacles
once refractive stabilization has occurred, usually in approximately 2
weeks, although it can be longer for patients with corneal warpage syn-
drome.
SUMMARY
GP lens problem solving is actually straightforward, and although this
chapter does not attempt to address every problem nor will the man-
agement options suggested result in success for every patient, the
great majority of problems are a result of blurred vision, dryness, and
reduced comfort. The management of these problems is not compli-
cated and is often successful. In addition, soft lens wearers experienc-
ing eye health compromise or reduced vision are good candidates for
GP lenses.
REFERENCES
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74(8):639-645, 1997.
2. Herman JP: Flexure. In Bennett ES, Grohe RM, editors: Rigid gas-permeable contact
lenses, New York, 1986, Professional Press, pp 137-150.
5. Bennett ES, Egan DJ: Rigid gas-permeable lens problem-solving, J Am Optom
Assoc 57:504-512, 1986.
6. Egan DJ, Bennett ES: Trouble-shooting rigid contact lens flexure—a case report,
Int Contact Lens Clin 12:147, 1985.
7. Carrell BA, Bennett ES, Henry VA, et al: The effect of rigid gas permeable lens
cleaners on lens parameter stability, J Am Optom Assoc 63:193-198, 1992.
1987.
9. Henry VA, Bennett ES, Forrest JF: Clinical investigation of the Paraperm EW
rigid gas-permeable contact lens, Am J Optom Physiol Opt 64:313-320, 1987.
10. O’Donnell JJ: Patient-induced power changes in rigid gas permeable contact
lenses: a case report and literature review, J Am Optom Assoc 65(11):772-773,
1994.
Lens Spectrum 14:56, 1999.
13. Quinn TG: Avoiding the low riding lens, Contact Lens Spectrum 16(7), 2000.
14. Schnider CM, Terry RB, Holden BA: Effects of lens design on peripheral corneal
desiccation, J Am Optom Assoc 68:163-170, 1997.
15. Edrington TB, Barr JT: Peripheral corneal desiccation, Contact Lens Spectrum
17(1):46, 2002.
16. Bell GR: A new theory on 3 and 9 o’clock staining, Contact Lens Spectrum
12(12):44-47, 1997.
17. Edwards K: Rigid gas-permeable contact lens problem solving, Optician
219(5740):18-24, 2000.
18. Bennett ES: Silicone/acrylate lens design, Int Contact Lens Clin 12:45, 1985.
19. Bennett ES: The effect of varying axial edge lift on silicone/acrylate lens per-
formance, Contact Lens J 14:3-7, 1986.
20. Lowther GE: Review of rigid contact lens design and effects of design on lens fit,
Int Contact Lens Clin 15:378-389, 1988.
21. Musset A, Stone J: Contact lens design tables, London, 1981, Butterworth-
Heineman, pp 1-12.
22. Doane M, Gleason W: Tear film interaction with RGP contact lenses. Presented
at the First International Material Science Symposium, March 1988,
St. Louis.
23. Grohe RM, Lebow KA: Vascularized limbal keratitis, Int Contact Lens Clin
16(7&8):197-209, 1989.
24. Bennett ES: Rigid gas-permeable lens problem solving. In Bennett ES, Henry
VA, editors: Clinical manual of contact lenses, ed 2, Philadelphia, 2000,
Lippincott Williams & Wilkins, pp 181-210.
25. Connelly S: Why do patients want to be refit? Contact Lens Spectrum 7:39-41,
1992.
26. Holden BA, Mertz GW: Critical oxygen levels to avoid corneal edema for daily and
extended wear contact lenses, Invest Ophthalmol Vis Sci 25:1161-1167, 1984.
27. Finnemore VM, Korb JE: Corneal edema with polymethylmethacrylate versus gas
polymer rigid polymer contact lenses of identical design, J Am Optom Assoc
51:271-274, 1980.
28. Kame RT: Clinical management of edematous corneal formations, Rev Optom
116:69-71, 1979.
29. Sweeney DF: Corneal exhaustion syndrome with long-term wear of contact
30. Wilson SE, Lin DTC, Klyce SD, et al: Rigid contact lens decentration: a risk fac-
tor for corneal distortion, CLAO J 16:177-182, 1990.
31. Wilson SE, Lin DTC, Klyce SD, et al: Topographic changes in contact
lens–induced corneal warpage, Ophthalmology 97:734-744, 1990.
32. Bennett ES: Immediate refitting of gas permeable lenses, J Am Optom Assoc
54:239-242, 1983.
33. Bennett ES, Tomlinson A: A controlled comparison of two techniques of refitting
long-term PMMA contact lens wearers, Am J Optom Physiol Opt 60:139-145,
1983.
34. Hartstein J: Keratoconus that developed in patients wearing corneal contact
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35. Bennett ES, Gilbreath MK: Handling PMMA-induced corneal distortion: a case
study, Optom Monthly 74:529-533, 1983.
appendix
9-1
Representative Cases
CASE ONE
Initial Summary
An 11-year-old boy is interested in contact lenses. His mother indicated
that he is nearsighted and has been wearing spectacles for almost 2
years. The patient is unhappy with wearing spectacles, particularly
when he plays soccer and baseball.
Clinical Findings
His ocular health was normal. His refractive findings were the following:
Manifest refraction: OD: −2.25 − 1.00 × 180 20/20+2
OS: −2.00 − 0.75 × 176 20/15−1
Keratometry: OD: 42.50 @ 180; 43.50 @ 090
OS: 42.00 @ 180; 42.75 @ 090 (clear mires OU)
Lid-to-cornea relationship: Normal (upper lid overlaps superior lim-
bus by 1.5 mm)
Pupil size: 5 mm with room illumination
Management
As a young patient with progressive myopia, GP lenses were presented
as the preferred alternative. The RGP Lens Institute GP Benefits/
Applications Pocket Card was shown to the patient and his mother,
and the benefits were explained. Although the mother was a soft lens
wearer, she was receptive to the benefits of good quality of vision and
the possibility of slowing down his myopia progression. The following
design was empirically ordered:
1. OAD/OZD: 9.8/8.4 mm OU. A large diameter was selected to
minimize dislodgement and loss during sports.
2. BCR: OD: 42.25 D (7.99 mm); OS: 41.50 D (8.13 mm). A slightly
flatter than “K” base curve radius was selected to achieve
alignment on an aspheric cornea.
3. Peripheral curve radii/widths: OD: SCR/W: 8.8/0.3 mm; ICR/W:
9.8/0.2 mm; PCR/W: 11.2/0.2 mm; OS: SCR/W: 8.9/0.3 mm;
ICR/W: 9.9/0.2 mm; PCR/W: 11.3/0.2 mm; medium blend OU.
213
4. Center thickness: ultrathin (0.12 mm) OU as the amount of

corneal cylinder is relatively low.
5. Lens material: Paragon Thin. A low-Dk fluorosilicone/acrylate
material was used for purposes of stability and wettability.
6. Power: OD: −2.00 D (−2.25 D spherical refractive error +
correction for − tear lens induced by 0.25 D flat base curve radius);
OS: −1.50 D (−2.00 spherical refractive error + correction for −
tear lens induced by 0.50 D flat base curve radius).
Final Comment
Young patients with progressive myopia are excellent candidates for GP
lenses although it is initially important to verify that it is the patient who
desires contact lenses and not only the parents. Spectacles can hinder
one’s athletic performance and self-esteem. Even if the parents wear
soft lenses, they are typically receptive to what lens the doctor recom-
mends. Certainly they are impressed that the GP modality can improve
the quality of life of their son or daughter via the potential effect on
myopia progression. Because young people can be apprehensive about
the initial awareness, the use of a topical anesthetic when the lenses are
dispensed will help any apprehension that is present.
CASE TWO
Initial Summary
An 18-year-old man is interested in contact lenses. He had been fit into
soft lenses 4 years previously, but he had discontinued lens wear
within 1 year because of blurry vision (through the entire 12-month
process) and a corneal ulcer resulting after 1 year of wear. His doctor
did not recommend GP lenses as an option. The patient is unhappy
with wearing spectacles, primarily from the cosmetic appearance.
Clinical Findings
His ocular health was normal. His refractive findings were the follow-
ing:
Manifest refraction: OD: +4.25 − 0.75 × 180 20/20+2
OS: +4.00 − 0.75 × 180 20/15−1
Keratometry: OD: 42.00 @ 180; 42.75 @ 090
OS: 42.00 @ 180; 42.75 @ 090 (clear mires OU)
bus by 1 mm)
Pupil size: 4.5 mm with room illumination
The following design was empirically ordered:
Appendix 9-1 Representative Cases 215
1. OAD/OZD: 9.4/8.0 mm OU. A standard diameter was selected

because of the lid-to-cornea relationship and an average pupil
diameter.
2. BCR: 42.25 D (7.99 mm) OU: A steeper than recommended base
curve radius for patients with myopia is recommended to assist
with lens centration.
3. Peripheral curve radii/widths: SCR/W: 8.8/0.3 mm; ICR/W:
9.8/0.2 mm; PCR/W: 11.2/0.2 mm; medium blend OU.
4. Center thickness: Minimum (at these powers you would predict a
center thickness of twice the thickness of a minus lens of
comparable power).
5. Lens material: Boston EO. A high-Dk fluoro-silicone/acrylate
material was used for the purpose of oxygen permeability. To meet
the Holden-Mertz criterion for an edema-free state of the cornea, a
lens with approximately twice the Dk value for the daily-wear
patient with hyperopia will be required compared with the daily-
wear patient with myopia.
6. Power: OD: +4.25 D (+4.25 D spherical refractive error will be
+4.50 D at the corneal plane + correction for + tear lens induced
by 0.25 D steep base curve radius); OS: +4.00 D (+4.00 D
spherical refractive error will be +4.25 D at the corneal plane +
correction for + tear lens induced by 0.25 D steep base curve
radius).
7. Minus lenticular: This manufacturing process will result in a
thicker edge and increased probability of centration because of lid
interaction with the edge.
Final Comment
Contact lenses can change the life of the patient with hyperopia visu-
ally and functionally. The magnifying spectacles—even with the cur-
rent spectacle lens technology—are heavy, limiting in their field of
vision, and typically not cosmetically appealing. Soft lenses, particu-
larly soft toric lenses, do not come close to meeting the corneal oxygen
demand. Chronic hypoxia can potentially result in ocular infection,
such as a corneal ulcer. GP lenses can provide the vision and eye health
needed by this group of patients.
CASE THREE
Initial Summary
A 27-year-old man is interested in new contact lenses. He has been a
14-year GP lens wearer who feels his vision has gradually been blurry.
He indicates he wears his lenses all waking hours and occasionally

sleeps in them. He cleans them occasionally between the fingers and
often stores them dry in the case. He also indicated he wanted a new
pair of spectacles because his vision is not clear when wearing them.
Clinical Findings
His ocular health shows the following:
Slit-lamp evaluation: Mild central superficial punctate keratitis,
grade 1+ papillary hypertrophy (everted upper lid), grade 1 central
corneal clouding
Contact lens evaluation:
VA: OD: 20/25; OS: 20/25 −2
Overrefraction: OD: +0.25 − 0.75 × 162 20/20;
OS: Pl − 0.50 × 016 20/20
Slit-lamp evaluation: Good centration OU with alignment fluorescein
pattern and 1-mm lag with blinking; upper edge was directly in contact
with the upper lid. Mucoprotein film and surface scratches OU.
His refractive findings were the following:
OS: −5.75 − 0.75 × 018 20/25−1
Keratometry: OD: 43.50 @ 160; 44.50 @ 070
OS: 43.00 @ 015; 43.50 @ 105 (slight mire distortion
OU)
Lid-to-cornea relationship: Normal (upper lid overlaps superior
limbus by 1 mm)
His lenses verified as the following:
1. Material: Polycon II (via previous records)
2. BCR: OD: 7.72 × 7.80 mm; OS: 7.78 × 7.85 mm
3. OAD/OZD: 9.0/7.4 mm
4. Power: OD: −4.75 D; OS: −5.00 D
Management
It is apparent that this patient’s reduced visual acuity with lens wear is the
result of multiple causes. The lenses are somewhat warped and that
should impact acuity and induce spherocylindrical overrefraction. In
addition, his lenses have deposits. These problems appear to be, in part,
a result of poor compliance because he fails to clean them every night,
and when he does, he cleans them between the fingers, not in the palm
of the hand. Therefore he was reeducated about proper and regular clean-
ing. In addition, he was refitted into a low-Dk fluorosilicone/acrylate lens
material (Boston ES) to optimize wettability and oxygen. He exhibits a
low-grade edema and mild corneal distortion resulting from chronic
hypoxia. Refitting into a higher-Dk lens material should eliminate the
edema, improve mire quality, and provide improved vision with the man-
ifest refraction and therefore improved vision through his glasses. In
addition, he was advised to wear these lenses for daily wear only and to
soak them in fresh soaking solution after cleaning them at night.
Final Comment
Fortunately the number of PMMA lens wearers has reduced greatly in
recent years. However, on occasion, a practitioner may have an early-
generation GP lens wearer who exhibits signs of mild hypoxia.
Refitting into a higher-Dk material should eliminate this problem;
however, if it is a daily-wear patient with myopia, a low-Dk F-S/A mate-
rial would be preferable to a high-DK material because these patients
are more prone to warping their lenses, and the stability provided by a
low-Dk material would be the better option.
CASE FOUR
Initial Summary
An 18-year-old man is interested in new contact lenses. He has been a
5-year monthly replacement soft lens wearer who believes his vision
has gradually been blurry. In addition, he has had to discontinue lens
wear in the past several times because of “swelling of the lids” and one
other time because of an eye infection.
Clinical Findings
Slit-lamp evaluation: Mild diffuse superficial punctate keratitis and
grade 1+ papillary hypertrophy (everted upper lid)
VA: OD: 20/25; OS: 20/25 +1
Overrefraction: OD: +0.25 − 0.75 × 180 20/20+2;
OS: +0.25 − 0.75 × 180 20/20+1
Slit-lamp evaluation: Good centration OU and minimal lag with
blinking although a positive pushup was present OU. Mucoprotein
film OU.
OS: −3.75 − 0.75 × 175 20/20+2
Keratometry: OD: 42.50 @ 180; 43.25 @ 090
OS: 43.00 @ 180; 43.75 @ 090 (clear mires OU)
Lid-to-cornea relationship: Normal (upper lid 1 mm over superior
limbus)
Management
GP and soft toric lenses were presented to the patient. Although the
soft toric lenses should have resulted in better visual acuity than spher-
ical lenses, the benefit of potentially improved eye health and less risk
of eye infection and discontinuation of lens wear appealed to the
patient. It was explained that he would experience some lens aware-
ness initially. The following lenses were diagnostically fitted:
BCR: 42.00 D (8.04 mm) OD 42.50 D (7.94 mm) OS
OAD/OZD: 9.4/8.0 mm OU
Power: −3.00 DS OU
Paragon Thin
A topical anesthetic was used to provide better initial comfort and
accelerate the time it would take to evaluate the fluorescein pattern.
The patient was predicted to need a corrective power of −3.25 D OU
because of having a spherical refractive value of −3.75 D, and the base
curve radii were 0.50 D flatter than “K,” creating a minus tear layer
requiring addition of plus (“flat add plus”). Therefore the patient expe-
rienced good initial vision with the diagnostic lenses, which was
important to making his first experience with GP lenses a positive one.
An optimum fitting relationship with lid attachment was achieved.
The initial comfort was aided by the ultrathin design selected for this
patient.
Final Comment
Soft lens wearers who have either experienced complications or com-
promised vision are very good candidates for GP lenses. In particular,
patients who have some uncorrected refractive astigmatism with
spherical soft lenses or rotational problems or corneal hypoxia with
soft toric lenses almost always appreciate the quality of vision they
achieve with GP lenses. The use of a topical anesthetic eases them into
the adaptation process. Providing lenses that approximate their cor-
rection allows them to experience an important benefit of GP lenses,
good quality of vision, which may, in fact, appear to make the lenses
more comfortable. The use of a thin design assists in achieving lid
attachment and also aids initial comfort.
CASE FIVE
Initial Summary
A 14-year-old girl is interested in new contact lenses.
Clinical Findings
Her ocular health was normal. Her refractive findings were the fol-
lowing:
OS: −6.00 − 1.50 × 180 20/15−1
Keratometry: OD: 43.50 @ 180; 45.00 @ 090
OS: 43.00 @ 180; 44.50 @ 090 (clear mires OU)
bus by 1.1 mm
Pupil size: 5 mm with room illumination
Management
As a young patient with progressive myopia, GP lenses were presented
as the preferred alternative. In an effort to provide the most comfort-
able fitting relationship and minimize movement while optimizing
centration, the following lens design was diagnostically fit:
Material: Boston EO
BCR: 7.67 mm (44.00 D) OD; 7.76 mm (43.50 D) OS
OAD/OZD: 9.6/8.2 mm
CT: (ultrathin): 0.11 mm OU
Power: −5.00 D OU
VA: OD: 20/25; OS: 20/25 +1
Overrefraction: OD: +0.25 − 1.00 × 180 20/20+2;
OS: +0.25 − 1.00 × 180 20/20+1
Overkeratometry: OD: 42.00/43.00
OS: 41.50/42.50
Slit-lamp evaluation (with lenses on): Good centration and a lid
attachment fitting relationship were achieved with these lenses. A
mild apical clearance fluorescein pattern was also found in both eyes
with slit-lamp evaluation.
Contact lens verification:
Power: −5.00 D OU
BCR: OD: 7.67 mm; OS: 7.76 mm
Because toricity is present on overkeratometry but not with the
radiuscope (which would have been indicative of warpage), these
lenses are flexing. This is most likely a combination of several factors,
the most important of which is a steeper than “K” base curve radius.
Other factors contributing to this problem include an ultrathin design,
a large optical zone diameter, and a high-Dk material. The following
lenses were successfully fit with an absence of significant flexure:
Lens material: Boston ES OU
BCR: 7.76 mm (43.50 D) OD; 7.85 mm (43.00 D) OS

SCR/W: 8.60/0.3 mm OU
ICR/W: 9.60/0.2 mm OU
PCR/W: 11.00/0.2 mm OU
CT: 0.14 mm OU
Power: −5.75 D OD; −5.50 D OS
Plus lenticular OU
Final Comment
GP lens flexure can be especially problematic for patients with highly
toric corneas, particularly when a steeper than “K” base curve radius is
selected. This can be diagnosed easily during the diagnostic fitting
process because performing keratometry over the lenses will result in
toric readings, not spherical; however, the base curve radii will be
spherical when verified with the radiuscope. Selecting a flatter base
curve (minimum 0.50-D change) is the first and most significant
change. Using a standard thickness, a smaller optical zone diameter
(i.e., decreasing sagittal depth via a flatter profile), and a more rigid
low-Dk lens material should also reduce this problem.
CASE SIX
Initial Summary
A 31-year-old man is experiencing dryness with his GP contact lenses.
He has been an 11-year wearer of GP contact lenses (silicone/acrylate
with a Dk of 26). Recently his wearing time has reduced from 14 hours
to 10 hours. He has noticed his eyes becoming red as the day pro-
gresses. He also observes glare around lights when driving at night.
He replaced his lenses less than 1 year before because of deposits and
scratches, but the dryness symptoms continued to increase.
Clinical Findings
Slit-lamp evaluation: Corneal desiccation with grade 2+ coalesced
staining temporally and grade 1+ staining nasally. Vascularization of
approximately 1.5 mm temporally was present OU. Meibomian gland
dysfunction was present OU.
VA: OD: 20/20 −2 (fluctuates); OS: 20/20 −1 (fluctuates)
Overrefraction: OD: −0.25 − 0.25 × 080 20/20+1;
OS: Pl − 0.25 × 088 20/20+1
Slit-lamp evaluation: Inferior decentration OU and 3 to 4 mm lag

with blinking OU. The fluorescein pattern is in alignment immedi-
ately after blinking but changes at its inferior position of rest.
OS: −7.50 − 0.75 × 174 20/20+2
Keratometry: OD: 43.50 @ 180; 44.25 @ 090
OS: 44.00 @ 180; 44.75 @ 090 (clear mires OU)
Lid-to-cornea relationship: Normal (upper lid at superior limbus)
Contact lens verification:
BCR: 43.00 D (7.85 mm) OD 43.50 D (7.76 mm) OS
CT: 0.15 mm OU
Edge thickness 0.26 mm OU
Management
The following lenses were diagnostically fitted:
BCR: 43.50 D (7.76 mm) OD 44.00 D (7.67 mm) OS
Boston ES thin (0.11 mm)
A slight apical clearance fluorescein pattern was present with good
centration and an interpalpebral lid-to-cornea fitting relationship.
Overrefraction: OD: −1.00 DS 20/15−2
OS: −0.75 DS 20/15−2
The following lenses were ordered:
BCR: 43.50 D (7.76 mm) OD 44.00 D (7.67 mm) OS
Power: −7.00 D OD; −6.75 D OS
SCR/W: 8.50/0.3 mm; ICR/W: 9.50/0.2 mm; PCR/W: 10.90/0.2
mm OU
Medium blend OU
CT: 0.11 mm OU
+ lenticular OU
Boston ES thin
A smaller overall diameter was selected because of the large palpe-
bral fissure, which could make a lid attachment fitting relationship dif-
ficult to achieve. In addition, reducing overall diameter in combination
with a large reduction in center thickness should significantly reduce
lens mass and therefore improve centration. The addition of a plus
lenticular should assist in better lid attachment and also reduce edge
thickness. The power to be ordered equals the predicted value because
the spherical manifest refraction value equals −7.00 D OD and −6.75
D OS. Because both lenses were fit “on K” because of the smaller over-
all diameter, there was no tear lens correction. A low-Dk fluoro-
silicone/acrylate lens material was used to optimize tear film
interaction with the lens surface. The patient was also provided with
lid hygiene instructions (e.g., warm compresses, lid massage, and
cleaning) and rewetting drops to be used as needed.
Final Comment
Coalesced corneal desiccation, or “3 and 9 o’clock staining,” is often
the result of an inferior decentered lens because the superior edge typ-
ically exhibits greater edge lift when the lens positions inferiorly.
When combined with a thick edge, as often is the case with a high
minus lens—particularly when a plus lenticular is absent—the lens
can literally be pushed inferiorly. In addition, the patient’s blink qual-
ity is compromised, and the peripheral exposed region of the cornea
dries out. A large fissure combined with a larger overall diameter can
also aggravate this because a lid attachment cannot be achieved (or
rarely), and the lens edge literally sits adjacent to the lid, creating an
increase in lid–lens interaction and possible compromises in blink
quality and comfort. Likewise, such factors as low tear quality have to
be ruled out, and lid-related conditions need to be controlled to mini-
mize dryness-related clinical signs and symptoms.
10
Keratoconus
EDWARD S. BENNETT
SHELLEY CUTLER
K eratoconus is a noninflammatory, self-limiting ectasia of the axial

portion of the cornea.1 It is characterized by thinning and steep-
ening of this region in a variable progression. Mild to moderate
reduction in vision results from this progression.
The incidence of keratoconus in the general population has been
estimated to be between 0.5 and 2 per 1,0002-7 and between 130,000
and 140,000 persons in the United States.2 It is a variable condition,
and it typically is initiated soon after puberty8 and progresses during
a 5- to 10-year period. The end result can range from mild loss of best-
corrected visual acuity (i.e., subclinical or forme fruste) to the need for
a penetrating keratoplasty.
The incidence appears to be similar between females and males,
with a slightly higher incidence in males.9,10 Keratoconus is almost
always bilateral with 2% to 7% of the cases being unilateral.8,11,12 It is
evident that one eye will exhibit changes before the other eye, and this
eye will show more marked progression.13-17 It may take several years
to determine that a patient’s keratoconus is bilateral.
ETIOLOGY
Histopathology
Although the specific cause of the corneal changes observed in
patients with keratoconus has not been definitively established,
Yabinowitz18 has indicated a triad of classic histopathologic corneal
changes that have been observed. These include (1) thinning of the
stroma, (2) breaks in Bowman’s layer, and (3) iron deposition in the
basal layers of the corneal epithelium.
It is evident that all layers of the cornea are most likely affected in
patients with keratoconus. The earliest histopathologic signs appear in
223
the epithelium. These changes are most prominent in the basal layer
and include cell degeneration, breaks accompanied by epithelium
downgrowth into Bowman’s layer, particles within a thickened subep-
ithelial basement membranelike layer, and accumulation of ferritin
particles within and between epithelial cells.18 As the condition pro-
gresses, Bowman’s layer may exhibit breaks filled by eruptions of
underlying stromal collagen and reticular scarring.17 It has been found
that these breaks in the basement membrane and Bowman’s layer are
unique in their composition to keratoconic corneas, and the subse-
quent wound healing responses may explain the differences observed
histologically in the keratoconic cornea.19 The stromal collagen fibrils
are affected significantly with compaction and loss of arrangement of
the anterior stromal fibrils, decrease in the number of collagen lamel-
lae keratocytes, and normal and degenerating fibroblasts with fine
granular and microfibrillar material associated with the keratocytes.7,18
Descemet’s membrane is typically unaltered except for breaks
observed in patients with acute hydrops. Likewise, the endothelium is
often normal, although in some patients, intracellular dark structures,
pleomorphism, and elongation of cells can occur.
Biochemical studies of keratoconic corneas indicate that the loss of
corneal stroma after digestion by proteolytic enzymes could be caused
by increased levels of proteases and other catabolic enzymes20 or
decreased levels of protease inhibitors.21 The role of interleukin-1
(IL-1) also appears to be important.22 It is produced by the epithelium
and endothelium, and keratocytes can be shown to express the IL-1
receptor. IL-1 induces keratocyte death in vitro and negative keratocyte
chemotaxis, and it has been demonstrated that keratocytes from kera-
toconic corneas have a fourfold greater number of IL-1 receptors than
normal corneas.23 The apparent important role of IL-1 in the regulation
of corneal cell proliferation, differentiation, and death suggests that
the increased expression of the IL-1 receptor sensitizes the keratocytes
to IL-1 released from the epithelium or endothelium, causing a loss of
keratocytes through apoptosis and a decrease in stromal mass over
time.22
Possible Etiologic Factors
Atopic History
The etiologic factor most commonly associated with keratoconus has
been some form of atopic condition, including allergies, hay fever,
eczema, and asthma. The incidence of atopic history and keratoconus
has ranged from 42% to 55%, with most reports showing a slightly
Chapter 10 Keratoconus 225
greater than 50% incidence.10,12,24-26 The known immunologic distur-

bance associated with atopic disease—namely, raised serum levels of
immunoglobulin E—has also been found to exist in approximately
50% of patients with keratoconus.27 A Danish study concluded that
urticaria was more than twice as common in patients with keratoconus
than in the general population; hay fever was 40 times as common;
asthma was 10 times as common; and atopic dermatitis was 50 times
as common.28 It has also been found that severe ocular atopic disease
had a more direct influence on patients’ progression of keratoconus
than mild forms of the disease, and patients with atopic keratocon-
junctivitis or vernal keratoconjunctivitis tended to need penetrating
keratoplasty more often than those with mild allergic eye disease, con-
tact lens-associated giant papillary conjunctivitis, or no disease.12
Because itching is a primary symptom in patients with atopic condi-
tions, it has been found that vigorous eye rubbing may cause keratoconus
via mechanical trauma. Ridley29 reported an incidence of 70% from 600
patients with keratoconus, and Rabinowitz et al25 reported an incidence
of 80% from 218 patients with keratoconus. In the Collaborative
Longitudinal Evaluation of Keratoconus (CLEK) study, 50.4% of the
patients reported vigorous eye rubbing, with 96% reporting bilateral eye
rubbing.10 Numerous reports of eye rubbing possibly associated with
causing keratoconus have been documented.30-32 However, to date a
cause-and-effect relationship has not been established.12,33
Heredity
Although not a high correlation, there appears to be an association
between heredity and keratoconus. Various studies have shown that
6% to 15% of patients with keratoconus have a positive family history,
including 13.5% of the CLEK patients.6,10,12,34-36 In addition, with the
use of videokeratoscopy, 30 family members of 5 patients with kerato-
conus were found to have related corneal abnormalities—often sub-
clinical—including central steepening, inferior corneal steepening,
and anisometropia.37 A few reports of isolated cases of identical twins
with keratoconus have been documented.7,38-40 In a study of 150
patients with keratoconus, a statistically significant excess of older
mothers was found compared with the general population.41 The find-
ing of a maternal age factor suggests that keratoconus is chromoso-
mally determined, although it is possible that the genetic mechanism
may act synergistically with another mechanism, such as allergy,
which may itself be independently genetically determined. A molecu-
lar genetic analysis in a family with keratoconus in three generations
suggested that chromosome 21 might be the location of the defective
gene in some patients with keratoconus.42
Systemic Conditions
Keratoconus has also been associated with a large number of systemic
diseases. Some of the more common conditions are discussed below.
Down’s syndrome (trisomy 21) is a common chromosomal anomaly
that often results from an extra chromosome 21.7 It has often been
associated with keratoconus, and an incidence as high as 8% has been
reported.43-47 The presence of excessive corneal changes and hydrops
has been attributed to “chronic traumatizing mannerisms” observed in
each of these patients.7,47 Keratoconus has been reported in association
with many noninflammatory connective tissue disorders. Prominent
among these conditions is Ehlers-Danlos syndrome, in which the
basic defect is abnormal cross-linking of collagen. Seven forms have
been described, but it has been reported that ocular tissues are defec-
tive only in patients with type IV.48-50 Other connective tissue disorders
and dysplastic conditions with which keratoconus has been associated
include osteogenesis imperfecta,51 Rieger’s syndrome,52 craniofacial
dysostosis (Crouzon’s syndrome),53 and Marfan’s syndrome.48,54 It has
also been found to be associated with infantile tapetoretinal degenera-
tion.55,56 Often multiple ocular disorders are diagnosed in patients with
these conditions. Although these associations have been documented,
it is important to note that the largest and most valid study on kerato-
conus to date—the CLEK study—found no incidence of these condi-
tions in their study of 1209 patients with keratoconus.10
Contact Lens Wear

Previous rigid contact lens wear—more specifically polymethyl-
methacrylate (PMMA) lenses—has been documented in many pub-
lished reports as a causative factor in keratoconus because of mechanical
pressure on the cornea.57-66 In one representative study, it was reported
that 26.5% of 162 patients with keratoconus had worn PMMA lenses
before diagnosis of keratoconus compared with 1248 control subjects
who were soft lens wearers, only one of whom had this condition.64 The
problem, of course, is determining if contact lenses caused the condition
or, because early in the condition patients typically have myopia and
astigmatism and benefit visually from rigid lenses as a corrective option,
if they were actually prescribed while the condition was in an early
phase. In none of the reports were topographic studies performed before
contact lens fitting to determine whether the patients had early disease
before wearing contact lenses. Because rigid lenses are often the treat-
ment of choice for patients with keratoconus and because early kerato-
conus can be subtle to detect, a causative relationship between the two
may be impossible to conclude, even if it exists.67
Therefore it can be concluded that a definitive etiology, common to

all patients with keratoconus, has not been established. Certainly it is
possible that certain persons have a genetic predisposition for kerato-
conus, and possibly, via mechanical trauma from eye rubbing or rigid
contact lens wear, the disease process is activated with—among other
early events in the pathogenesis of keratoconus—an increased release
of IL-1 from the epithelium.68
DIAGNOSIS AND PROGRESSION

Symptoms and Clinical Signs
The earlier a patient can be diagnosed as having or possibly having
keratoconus, the sooner the practitioner can institute the appropriate
treatment and adequately educate the patient. For the condition to be
diagnosed, the practitioner must be aware of the signs and symptoms
of keratoconus and encourage frequent follow-up care for monitoring
progression. The introduction of videokeratoscopy has allowed for eas-
ier diagnosis of incipient keratoconus and identification of subclinical
cases while serving as an excellent method for monitoring progression
of the condition.
Symptoms
The diagnosis of keratoconus begins with a comprehensive case his-
tory. The practitioner must ask the correct questions and be a good lis-
tener because the symptoms of incipient keratoconus are varied and
frequently confused with psychogenic complaints. Often the patient
has difficulty putting his or her problems into words. Monocular
diplopia or “ghost” images and blurring of images are common symp-
toms, but practitioners may fail to ask questions eliciting a description
of image blur. Vision may not actually be blurred but distorted; letters
may be confused, and parts of letters or words may be missing or
altered. Therefore the practitioner should ask the patient about any
distortion of vision with one eye (i.e., whether it is at night with street
lights or actual monocular distortion).
It is not uncommon for the patient with incipient keratoconus
to own many pairs of glasses, perhaps an indication that the previ-
ous doctor had difficulty ascertaining the prescription. In addition,
if questioned, the patient may report a history of blurred vision but
may have difficulty naming the condition. Finally, asthenopic com-
plaints, polyopia, photophobia, and halos around lights may be
reported.
Vision
A gradual decrease in visual acuity is often the first clinical sign of ker-
atoconus. The vision of one eye will typically be affected before the
other, and the blur will be present for near and far distances. The
patient may be able to see better by squinting or holding printed mate-
rial close to the eyes.
Refractive Changes
Early refractive changes include a shift toward myopia and increased
refractive astigmatism. In addition, one of the first clinical signs
observed by the practitioner via retinoscopy is a “scissorslike” motion
resulting from corneal apex distortion.
Ophthalmoscopy
On ophthalmoscopy, a circular, oblong, or dumbbell-shaped shadow
may appear that looks like a large indefinite cataract separating the
central from the peripheral reflex. On closer inspection, this phenom-
enon is noted to be corneal in location. Fundus details are indistinct
and unable to be focused.
A technique called photodiagnosis has been beneficial in diagnos-
ing and following the size, shape, and location of advanced or severe
cones (Figure 10-1). In this technique, the image of the cone is viewed
against the red fundus reflex. The procedure is as follows:
Figure 10-1. Photodiagnosis. (Courtesy Patrick Caroline.)

1. The pupil is dilated.

2. The examiner views the cornea through the direct ophthalmo-
scope at a distance of 2 feet.
3. In patients with advanced and severe keratoconus (> 50 D), the
cone can be observed easily against the red reflex, although it can
often be observed early in the condition as well.
4. This image can be recorded with a fundus camera using a high
plus lens.
Corneal Topography
Keratometry. Keratometry is beneficial for the diagnosis and monitor-
ing of keratoconus. However, keratometry has numerous limitations,
most noticeably the measurement of only a few paracentral points on the
cornea. This can make diagnosis of keratoconus difficult, especially if the
patient has a decentered apex of the cone (as do many patients with ker-
atoconus). This can often result in a false-negative finding because the
central keratometry values could be in the normal range (i.e., 41 to 45 D),
but the decentered apex has a value much higher or steeper.69
The earliest sign of keratoconus is lack of parallelism of the kerato-
metric mires (Figure 10-2). The mires are typically mildly distorted
Figure 10-2. Absence of parallelism of keratometry mires in early keratoconus.

Table 10-1 Extended Keratometer Range with A +1.25 D Lens

EXTENDED VALUE
Keratometer Value +1.25 D +2.25 D
44.75 D 52.13 D 58.74 D
45.00 D 52.46 D 59.07 D
45.25 D 52.76 D 59.40 D
45.50 D 53.05 D 59.73 D
45.75 D 53.34 D 60.06 D
46.00 D 53.63 D 60.38 D
46.25 D 53.92 D 60.71 D
46.50 D 54.21 D 61.04 D
46.75 D 54.51 D 61.37 D
47.00 D 54.80 D 61.70 D
47.25 D 55.09 D 62.03 D
47.50 D 55.38 D 62.36 D
47.75 D 55.67 D 62.69 D
48.00 D 55.96 D 63.02 D
48.25 D 56.25 D 63.35 D
48.50 D 56.55 D 63.68 D
48.75 D 56.84 D 64.01 D
49.00 D 57.13 D 64.34 D
49.25 D 57.42 D 64.67 D
49.50 D 57.71 D 65.00 D
49.75 D 58.00 D 65.33 D
50.00 D 58.30 D 65.66 D
50.25 D 58.59 D 65.99 D
50.50 D 58.88 D 66.32 D
50.75 D 59.17 D 66.65 D
51.00 D 59.46 D 66.98 D
51.25 D 59.75 D 67.31 D
51.50 D 60.04 D 67.64 D
51.75 D 60.33 D 67.97 D
52.00 D 60.63 D 68.30 D
because the corneal astigmatism is typically irregular and increased

relative to previous findings, if available. If the condition is incipient,
the keratometry readings may range from 43.00 D to 48.00 D. Once
the condition advances beyond the curvature values of the keratometer
(in the absence of more sophisticated topography evaluation instru-
mentation), a +1.25-D ophthalmic lens can be mounted over the
objective (patient end) to add approximately 8 D to the keratometer

readings. A +2.25-D lens can add approximately 14 D (Table 10-1).67,70
Videokeratography. Videokeratography (VKG) has been extremely
beneficial for the diagnosis and monitoring of patients with kerato-
conus. The location of the apex and the progression of the condition
can be observed via evaluation of the color map. The localized area of
steepening can easily be observed with a color map (Figure 10-3).
Although diagnosis of keratoconus is most often the result of the
appearance of pathognomonic slit-lamp signs, one of the most benefi-
cial applications of VKG instrumentation is the detection of kerato-
conus before the onset of slit-lamp signs. Keratometry mires may still
be regular; however, subtle signs of keratoconus can be displayed via
the color-coded videokeratographs.37,71 These patients can then be
monitored to determine if further progression and diagnosis of the
condition occurs. In addition, a compression of the mires will be pres-
ent in the affected region via the reflection of the photokeratoscopic
rings. Essentially, keratoconus has three characteristics observed via
VKG that are not present in healthy patients: (1) an increased area of
corneal power surrounded by concentric areas of decreasing power, (2)
inferior-superior power asymmetry, and (3) skewing of the steepest
radial axes above and below the horizontal meridian.18
Figure 10-3. Corneal topography map of a patient with keratoconus.

When evaluating the VKG color map, it is important to use the tan-
gential (instantaneous) rather than the sagittal (axial) radius of curva-
ture.17,71 The use of the sagittal radius in VKG distorts the apparent
position and power of an apex that is located in the peripheral cornea.
This distortion is even more exaggerated in patients with keratoconus,
particularly in those with advanced (>55 D) cases.72 With the cone apex
aligned with the optical system of a VKG, Mandell17,73 determined that
a true apex power reading can be obtained and therefore compared
with the normal range in the detection of keratoconus. It was con-
cluded that if the cone apex power is 48 to 49 D, keratoconus might be
suspected for that patient. For powers of 49 to 50 D, keratoconus is
highly likely, and for powers greater than 50 D, the diagnosis is almost
certain. The modified Rabinowitz-McDonnell method18,74,75 uses the
following guidelines. If the central corneal power is greater than 47.2
D or if the difference between the inferior and superior paracentral
corneal regions (i.e., I-S value) is greater than 1.4 D, then keratoconus
may be suspect for the cornea. If the central corneal power is greater
than 48.7 D or the I-S value is greater than 1.4 D, then the cornea is
classified as keratoconic.
Several VKG systems have developed applications for the screening
and diagnosis of keratoconus.74,76-80 This is particularly important
because keratoconus is a contraindication for refractive surgery, and it
has been found that as many as 5% to 7% of refractive surgery candi-
dates have subclinical keratoconus.81,82 In addition, although more data
are forthcoming from the topography assessment group (TAG) of the
CLEK study, it is evident that previous philosophies indicating that the
apex of the cornea is typically inferior-central are erroneous. The affected
region of steepening can occur anywhere on the cornea. The apex—
although rarely superior in location—is often located as far as several
millimeters from the central cornea with an apex location that tends to
vary between the eyes of a patient with keratoconus. Inferior steepening,
more prominent temporally, is the most common pattern observed.83
Likewise, before the introduction of VKG, cones were described as hav-
ing two basic shapes, oval and nipple, that could be differentiated by slit-
lamp biomicroscopy and some form of early-generation Placido’s
disk–based instrument. VKG instrumentation has demonstrated that
the corneal shape in patients with keratoconus is more complex.75,84,85
The use of a VKG system is also valuable in monitoring the pro-
gression of keratoconus. This factor, in addition to providing informa-
tion on apex size and location, is invaluable in assisting in the design
of the contact lens. Although the presence of a VKG instrument is not
essential for the management of keratoconus, it is beneficial for the
diagnosis and monitoring of the condition.
Biomicroscopy
Biomicroscopy is essential for the diagnosis of keratoconus. As with
VKG, subtle corneal changes can be detected (i.e., changes occurring
within the specific layers of the cornea). The classic clinical signs of
keratoconus that, at minimum, should be present for diagnosis are
Vogt’s striae, Fleischer’s ring, and scarring.
Vogt’s striae are a series of vertical or oblique lines or folds located
in the posterior stroma or Descemet’s membrane (Figure 10-4). They
are most likely the result of the stretching of the corneal lamellae. They
can be observed easily via viewing through the contact lens itself with
the slit beam. They were present in 65% of the patients in the CLEK
study.10 They temporally disappear when transient pressure is applied
to the globe through the upper lid.86
Fleischer’s ring is a yellow-brown to olive-green discoloration
appearing as a broken or interrupted ring encircling the base of the
cone (Figure 10-5). It was present in 86% of the patients in the CLEK
study, with 56% bilateral and 30% unilateral.10 It appears to outline the
base of the cone and represents hemosiderin deposits in the deep
epithelium near Bowman’s membrane. Sometimes this is best viewed
through a cobalt filter.
Thinning of the cornea can be observed at the region of the cone via
an optic section. Increased visibility of the nerve fibers can be observed
Figure 10-4. Vogt’s striae.

at the corneoscleral junction as a result of a change in their density.

Mandell and Polse87 found an average minimum corneal thickness of
0.377 mm in patients with keratoconus and 0.506 mm in healthy
patients. Because of the thinning, it has been found that intraocular
pressure (IOP) was lower than normal in patients with keratoconus
and then increased for those who required penetrating keratoplasty.88
This reduction in IOP in patients with keratoconus is probably the
result of an increase in outflow facility.89 In patients with severe cases,
corneal hydrops can occur secondary to a rupture in Descemet’s mem-
brane, allowing aqueous humor from the anterior chamber to flow
through the damaged endothelium, causing corneal edema and even-
tually scarring.
Corneal scarring at or near the apex of the cone is characteristic of
the condition, particularly in later stages of advanced cases (Figure
10-6). Irregular superficial scars form at the apex of the cone as the
condition progresses. They begin as discrete dots in Bowman’s mem-
brane; fibrillar connective tissue invades the space between the opaci-
Figure 10-5. Fleischer’s ring.

Figure 10-6. Corneal scarring in advanced keratoconus.
ties; and they proceed to increase and become opaque.90 Corneal scars
were graded as “definitely present” in 29.4% and “probably present” in
8.2% of patients in the CLEK study.91 In addition, factors found to be
associated with corneal scarring included corneal staining, contact
lens wear, Fleischer’s ring, a steeper cornea, and advancing age.
Corneal hydrops occurs secondary to a rupture in Descemet’s mem-
brane in patients with advanced keratoconus, resulting in aqueous
access to the corneal stroma, which results in first corneal edema and
ultimately corneal scarring.67
In patients with advanced cases, the profile of the affected region or
cone can be grossly observed via Munson’s sign (Figure 10-7). This can
be confirmed by having the patient view inferiorly until the lower lid
is at the equator of the cone; the shape of the lid will be altered because
of protrusion of the cone, and Munson’s sign will be evident. The cone
can also be grossly viewed via Rizzuti’s phenomenon.92 When illumi-
nating the cornea with a penlight from the temporal side of the cornea,
focused anterior to the iris, light is sharply focused on the temporal
side of the nasal limbus.
Progression
As mentioned before, in early stages of keratoconus, it can be difficult
to diagnose although mild corneal irregularity may be present and a
Figure 10-7. Munson’s sign
scissors reflex via retinoscopy is often present. As the condition pro-

gresses, slit-lamp signs, in particular, are intensified. Corneal scarring
is possible, and Munson’s sign may be present. The stages of kerato-
conus progression are summarized in Box 10-1.
Differential Diagnosis
Corneal Warpage Syndrome

Keratoconus can often be differentiated from corneal warpage syn-
drome via a combination of the case history and a comprehensive clin-
ical examination including videokeratoscopy.69 Patients with corneal
warpage syndrome typically have a long-term history of rigid contact
lens wear. This condition typically results from a combination of
chronic hypoxia and the mechanical effects induced by the contact lens
itself. It has been most associated with PMMA lenses, although it can
occur with soft and gas permeable (GP) lens wear, the latter often
caused by a poor lens-to-cornea fitting relationship. Although a scis-
sors-like retinoscopy reflex and corneal distortion are present in both
conditions, patients with corneal warpage syndrome typically manifest
signs of corneal hypoxia, while rarely exhibiting corneal steepening
beyond 50 D.93 In addition, the degree or mire irregularity or mis-
alignment is typically less in patients with corneal warpage syndrome
than in those with keratoconus. The localized area of corneal steepen-
ing present in a videokeratoscopy color map of a patient with kerato-
conus is often absent for patients with corneal warpage syndrome.
Box 10-1 KERATOCONUS CLASSIFICATION

Stage One
1. Fully correctable with spectacles
2. Slight increase in refractive astigmatism
3. Slight or no keratometric mire distortion
4. Normal keratometry readings
5. Mild area of steepening with videokeratoscopy
6. Mild scissors reflex with retinoscopy
7. Difficult to diagnose
Stage Two
1. Definite corneal distortion and irregular astigmatism observed with
keratometry and videokeratoscopy
2. Further increase in myopia and refractive astigmatism
3. Keratometer values exhibit 1 to 4 D of steepening
Stage Three
1. Best-corrected spectacle visual acuity is greatly decreased
2. Accurate keratometry readings are difficult to obtain because of mire
distortion
3. Keratometry/topography readings have steepened 5 to 10 D
4. Increase in irregular astigmatism; commonly ranging from 2 to 8 D
5. Slit-lamp findings, including corneal thinning, increased nerve fiber
visibility, Vogt’s striae, Fleischer’s ring, and possibly scarring, are often
present
Stage Four
1. Intensification of above signs, with the cornea steepening to greater than
55 D
2. Scarring present at apex
3. Munson’s sign present
The slit-lamp signs often present in patients with keratoconus (e.g.,

Vogt’s striae, Fleischer’s ring, and apical thinning) are not present in
patients with corneal warpage syndrome. Corneal warpage syndrome,
unlike keratoconus, is not a progressive condition and is, at minimum,
partially reversible with discontinuation of lens wear, refitting into a
higher oxygen-permeable material, or a better centering GP lens
design.
Superior Decentering Gas Permeable Lens

A pseudokeratoconic videokeratoscopy color map can result from
wearing a highly positioned GP lens. This lens-to-cornea fitting
relationship can induce superior cornea flattening accompanied by

inferior steepening, thus simulating a keratoconus color map. As with
corneal warpage syndrome, none of the classical slit-lamp signs of ker-
atoconus will be present. When in doubt, the patient’s lenses should
be removed, and the patient’s corneal topography should be monitored
over a period of a few hours. If lens-induced steepening is present, the
inferior region should flatten by as much as several diopters during
this period.
Pellucid Marginal Degeneration

Pellucid marginal degeneration is characterized by a peripheral band
of thinning of the peripheral cornea in the 4 o’clock to 8 o’clock posi-
tion.18 As with keratoconus, it is a progressive disorder affecting both
eyes. Slit-lamp evaluation should be beneficial in differentiating
whether the regions of thinning have been caused by keratoconus or
pellucid marginal degeneration. In addition, in patients with pellucid
marginal degeneration, the VKG has a classical butterfly appearance
demonstrating a large amount of against-the-rule astigmatism
(Figures 10-8 and 10-9).94
Figure 10-8. Topography map in early pellucid marginal degeneration.

Figure 10-9. Corneal topography map in advanced pellucid marginal degeneration.
Keratoglobus
Keratoglobus is a condition in which the entire cornea thins, most
notably near the limbus, as opposed to the localized thinning in
patients with keratoconus.7,18 Although, like keratoconus, ker-
atoglobus is a bilateral condition, it is typically present from birth and
tends not to be progressive. Unlike keratoconus, keratoglobus is rare,
and the thinning is such that rupture can occur, even with little
trauma.
PATIENT CONSULTATION
Patients should be informed about keratoconus as soon as it is sus-
pected. At that time, the condition should be explained, including the
progression and the fact that some patients (about one in eight)
require corneal transplantation because of the scarring and subse-
quent reduced vision that can result in the worst-case situation. A dis-
cussion of corrective options, in particular GP lenses, should be
provided. Because patients with keratoconus are often inquisitive—
not to mention understandably concerned—they can be directed to
web sites that can supplement their knowledge of the condition (Table
10-2).95 In addition, the National Keratoconus Foundation has an
excellent consumer brochure on keratoconus. Because the CLEK study
has found that one in nine patients with keratoconus have missed
Table 10-2 Useful Keratoconus Internet Sites

Organization Web Link
1. All about vision www.allaboutvision.com
2. Center for Keratoconus www.kcenter.org
3. The Collaborative Longitudinal Evaluation www.optometry.ohio-
of Keratoconus (CLEK) Study state.edu/CLEK
4. UK Keratoconus Self Help and Support www.keratoconus-group.uk
Group
5. National Keratoconus Foundation www.nkcf.org
work as a result of their condition, this should be communicated as

well.10
In addition, it is important to recognize that patients with kerato-
conus may have contrasting personalities than those not exhibiting the
condition. It has been found that patients with keratoconus demon-
strated abnormal results on the same psychological scales (i.e., pas-
sive-aggressive, paranoid, hypomanic, disorganized thinking patterns,
and substance abuse) as patients with chronic eye disease.96
MANAGEMENT
Spectacles
Because of the increase in corneal irregularity as the condition pro-
gresses and the benefits of GP lens wear on reducing the irregularity,
spectacle lens wear is often not beneficial as a vision correction. In
addition, there is tremendous variation—including diurnal—in refrac-
tive error, not to mention the impact of the progression of the disease.
In addition, there is often significant anisometropia caused by the
asymmetric nature of the disease, resulting in one eye exhibiting
greater disease progression.67 However, 16% of patients in the CLEK
study wore spectacles as their only mode of visual correction,10 and
spectacles have been shown to result in good visual acuity, particularly
in early stages of the condition or for patients in whom keratoconus
does not progress to advanced stages.97 With this in mind, it is espe-
cially important to perform an accurate refraction, in particular,
obtaining the indicated astigmatic power and axis. This is likewise
important in providing a supplemental correction for the GP lens-
wearing patient with keratoconus who otherwise tends to wear his or
her contact lenses during waking hours.
Gas Permeable Contact Lenses
Benefits
GP contact lenses are often the preferred mode of correction for
patients with keratoconus as they are for those with other forms of
irregular corneal conditions because of their ability to provide a more
uniform surface. GP lenses neutralize the majority of the optical aber-
rations of the anterior corneal surface because the tear fluid lens
formed beneath the lens has a similar refractive index to the cornea
and therefore neutralizes most of the aberrations of the anterior
corneal surface. Therefore in most cases, particularly for patients with
more advanced forms of keratoconus, the patient’s visual performance
will be improved with GP lenses.98 Almost 75% of the subjects in the
CLEK study were corrected with rigid lenses.10 This value is similar to
the 75% of patients with keratoconus wearing rigid lenses in the CLEK
pilot study97 and is similar to other reports.65,99 In studies comparing
the visual performance of GP lenses with spectacles100 and with both
spectacles and soft lenses,98 GP lenses provided the best visual per-
formance. For many patients, vision will be several lines better on the
acuity chart with GP lenses versus other correction options, and in
advanced cases, it is common for patients, even with the most precise
refraction, to be unable to exhibit satisfaction with spectacle correc-
tion, even for part-time wear. However, it must be emphasized that
even if the visual acuity chart vision is “normal” with GP contact lens
correction, most likely there is some decrement in vision performance.
Contrast threshold measurements have shown a vision loss at low spa-
tial frequencies (0.25 c/degrees) that is not improved by contact lens
fitting.101 Therefore, although GP lenses can provide a significant
improvement in visual acuity for patients with keratoconus, there may
still be residual loss of visual function.
It must be emphasized, however, that as keratoconus progresses,
GP lenses can have a detrimental effect on relatively fragile corneal
apex if they either decenter or exhibit too much pressure on the apex.
Corneal staining and scarring can potentially be induced by such a fit-
ting relationship.102
GP Lens-to-Cornea Fitting Relationships

Three common rigid lens-to-cornea fitting relationships have been
used for patients with keratoconus. These include apical bearing, api-
cal clearance, and three-point touch.69
Apical Bearing. The use of a large overall diameter lens design in
combination with a flat base curve has been a traditional philosophy
for fitting patients with keratoconus because of a perception that this
approach will slow down or halt the progression of the condition.

Likewise, it has been theorized to result in improved vision versus
other methods because of the effect of the base curve of the lens on the
irregular corneal apex. The resulting fluorescein pattern shows exces-
sive central bearing accompanied by midperipheral and peripheral
pooling (Figure 10-10).
This method is rarely used today because it is believed that exces-
sive pressure of the lens on a region of the cornea that is thin and frag-
ile could encourage distortion and apical scarring.102-104 Korb102 reports
a small sample of seven patients, all with bilateral keratoconus but
none exhibiting scarring, who were fit with a small diameter, apical
clearance lens on one eye and a larger diameter, apical bearing lens on
the other eye. At the end of 1 year, four of the seven eyes with kerato-
conic corneas fit with apical bearing lenses manifested apical scarring
compared with none of the seven eyes fit with the apical clearance lens
design.
Apical Clearance. An apical clearance design has been recom-
mended to minimize or eliminate the aforementioned potential com-
plications of an apical bearing lens design.102,103,105 This form of fitting
relationship should result in minimum lens-induced apical corneal
compromise. Essentially this is accomplished with a small diameter,
steep base curve lens, which results in an apical clearance fitting rela-
tionship (Figure 10-11).
In the CLEK study, the feasibility of this fitting philosophy was
based on the post-fitting frequency of the slit-lamp findings, such as:
Figure 10-10. Apical bearing relationship in keratoconus. (Courtesy Ursula Lotzkat.)

Figure 10-11. Apical clearance relationship in keratoconus. (Courtesy Ursula Lotzkat.)
(1) moderate epithelial punctate staining, (2) moderate central corneal

erosion, (3) corneal edema, (4) contact lens imprint, and (5) develop-
ment of central corneal scarring.106 They fitted 30 eyes with an apical
clearance lens design using the 8.6/6.5 mm overall/optical zone diam-
eter (OZD) CLEK diagnostic fitting set. Ultimately, they were provided
with the lens that was 0.2 mm steeper than the first definite apical
clearance lens (FDACL, or flattest lens not to exhibit apical bearing).
The results found that the average wearing time increased from a base-
line of 10.5 hours/day with their previous lenses to 13.7 hours/day with
the apical clearance lenses after 12 months. In addition, there was not
a decrement in visual acuity compared with the baseline values.
Nevertheless, if this philosophy is to be used, the fluorescein pattern
should be monitored to ensure that peripheral seal-off or lens-to-
cornea adherence does not occur.
Three-Point Touch. The most popular rigid lens fitting approach for
patients with keratoconus is most likely three-point touch. The goal,
through diagnostic fitting, is to achieve mild or “feather” touch of the
lens over the apex of the cone accompanied by, at minimum, two other
areas of touch approximately 180 degrees from the apex at the corneal
midperiphery (Figure 10-12). This “feather touch” bearing of the apex
and midperiphery creates a bulls-eye appearance on fluorescein evalu-
ation. Four zones are created: slight apical touch, paracentral clear-
ance, midperipheral bearing, and peripheral clearance (Figure 10-13).
Figure 10-12. Three-point touch.
Figure 10-13. Three-point touch fitting relationship.

With this design, the weight of the lens is distributed across a

healthy cornea and not focused on one specific area. It is theorized that
mild apical bearing will provide some amount of regularity to the ante-
rior corneal surface in that region and possibly improve visual acuity
compared with the apical clearance method. For this fitting method to
be successful, it should have as little movement as possible that still
allows some tear flow under the lens. This fitting relationship is diffi-
cult to achieve with a moderately decentered apex because the optical
center of the lens will gravitate to the apex of the cornea, often result-
ing in lens decentration and possibly subjective symptoms of flare.
Although there are special designs available for the decentered cone
(to be discussed), if using a more conventional lens design, trial and
error is the best method of achieving a satisfactory fit. It is important
to monitor patients with a three-point fitting relationship to ensure the
apical bearing does not become excessive, resulting in loss of the bulls-
eye fitting relationship and possibly corneal staining and scarring.
Authors’ Fitting Philosophy

It must be emphasized that fitting patients with keratoconus with GP
lenses is not limited to the so-called experts, some of whom may use
antiquated materials and fitting methods. The emphasis on the fitting
process should pertain to exhibiting patience during the diagnostic fit-
ting procedure while understanding that much of the time is devoted
to basically a trial and error process, possibly with multiple designs.
The first author (Bennett) uses a common sense approach that incor-
porates many of the principles used by other practitioners.69,107,108 The
primary goal is to achieve a three-point touch fluorescein pattern with
a diagnostic GP lens, and then the lens should be designed to be con-
sistent with the stage of the condition.
The Fitting Process. The use of a diagnostic fitting set is imperative
when fitting a patient with keratoconus with GP lenses. There are
numerous lens designs, all typically sharing several common factors,
including steep base curve radii and decreasing OZDs and increasing
minus powers with steeper base curve radii. Lens designs available
from the Contact Lens Manufacturers Association (CLMA) member
laboratories are listed in Appendix 10-1. In many cases, the laboratory
will have loaner fitting sets for practitioners who only occasionally
evaluate patients with keratoconus. It is preferable to have a “bread
and butter” fitting set and a second specialty fitting set when an accept-
able fitting relationship does not occur with the primary design. The
authors’ diagnostic fitting set is provided in Table 10-3.
When fitting a patient with keratoconus, the use of a topical anes-
thetic during the fitting process is important. These patients tend to
exhibit greater initial sensitivity to rigid lenses than other patients,
246
Table 10-3 Keratoconus Diagnostic Lens Fitting Set (Bennett)

SECTION IV
Lens # OAD/OZD BCR SCR/W ICR/W PCR/W POWER

1. 9.0/7.2 mm 7.3 mm 8.4/0.3 mm 10.2/0.3 mm 12.3/0.3 mm −3.00 D
2. 9.0/7.2 mm 7.2 mm 8.3/0.3 mm 9.9/0.3 mm 12.2/0.3 mm −3.00 D
3. 9.0/7.2 mm 7.1 mm 8.1/0.3 mm 9.7/0.3 mm 12.1/0.3 mm −3.00 D
4. 8.8/7.0 mm 7.0 mm 8.0/0.3 mm 9.6/0.3 mm 12.0/0.3 mm −4.00 D
5. 8.8/7.0 mm 6.9 mm 7.9/0.3 mm 9.5/0.3 mm 11.9/0.3 mm −4.00 D
6. 8.8/7.0 mm 6.8 mm 7.8/0.3 mm 9.4/0.3 mm 11.8/0.3 mm −5.00 D
7. 8.6/6.8 mm 6.7 mm 7.7/0.3 mm 9.3/0.3 mm 11.7/0.3 mm −5.00 D
8. 8.6/6.8 mm 6.6 mm 7.6/0.3 mm 9.2/0.3 mm 11.6/0.3 mm −6.00 D
9. 8.6/6.8 mm 6.5 mm 7.5/0.3 mm 9.1/0.3 mm 11.5/0.3 mm −6.00 D
10. 8.4/6.6 mm 6.4 mm 7.3/0.3 mm 9.0/0.3 mm 11.4/0.3 mm −7.00 D
11. 8.4/6.6 mm 6.3 mm 7.2/0.3 mm 8.8/0.3 mm 11.3/0.3 mm −7.00 D
12. 8.4/6.6 mm 6.2 mm 7.1/0.3 mm 8.7/0.3 mm 11.2/0.3 mm −8.00 D
13. 8.2/6.4 mm 6.1 mm 6.9/0.3 mm 8.5/0.3 mm 11.1/0.3 mm −8.00 D
14. 8.2/6.4 mm 6.0 mm 6.8/0.3 mm 8.4/0.3 mm 11.0/0.3 mm −9.00 D
15. 8.2/6.4 mm 5.9 mm 6.7/0.3 mm 8.3/0.3 mm 10.9/0.3 mm −9.00 D
most likely the result of many factors. First, the corneal irregularity
often makes an alignment fitting relationship impossible and there-
fore increases lens awareness. In addition, numerous patients with
keratoconus are not particularly motivated for GP lens wear but were
encouraged to pursue this option by their eye care practitioner. Topical
anesthetic application will minimize initial lens awareness, increase
patient satisfaction, improve attitude toward adaptation,109 and reduce
chair time. The latter is particularly important because several lenses
may have to be attempted before an acceptable fitting relationship is
found.
The initial lens should have a base curve radius equal to the steep
keratometry value. The fluorescein pattern should not be viewed
immediately after instillation because a false pattern of apical clear-
ance may exist when in fact bearing will be present after several blinks.
Slit-lamp evaluation with cobalt blue illumination and the use of a yel-
low Wratten or Tiffen filter will dictate what change in base curve
radius, if any, is indicated. The use of high illumination and low mag-
nification is important when viewing the pattern. It is beneficial to
view the pattern with a Burton lamp or, if not available, to view the pat-
tern grossly outside of the oculars to provide the benefit of a larger
field of view.
With a base curve radius equal to the steep keratometry (or simu-
lated “K” value), a slight apical clearance pattern is commonly
observed. The base curve radius can then be changed in 0.50- to
1.00-D steps until apical bearing is first observed. At this time, a three-
point touch or bulls-eye fitting relationship should be present. Careful
evaluation of the peripheral fluorescein pattern is also important to
ensure that peripheral seal-off is absent. An alignment fluorescein pat-
tern is not expected with this or other keratoconus designs; however,
good centration is important. If the lens decenters inferiorly as a result
of a corneal apex that is greatly displaced in that direction, either a
larger diameter or one of the specialized lens designs discussed later
in this chapter can be used.
Lens Design. Once three-point touch has been obtained, it is impor-
tant to design the lens to be consistent with the changes in corneal
topography. As discussed earlier, some VKG instruments have soft-
ware for keratoconic GP lens design that can be beneficial as this con-
dition progresses. Generally, the OZD should be decreased as the
cornea steepens to maintain optimum centration. In this philosophy,
which can vary depending on such factors as pupil size, fissure size,
and lens position, the OZD is often equal to the base curve radius in
millimeters. For example, if the base curve radius is 7.00 mm, the
OZD will likewise be approximately 7.00 mm.
As the condition progresses, the overall diameter can be reduced in

small increments, but the OZD must be reduced in greater incre-
ments to maintain an acceptable fitting relationship. OZDs as small as
5 to 6 mm are not uncommon. Nevertheless, there is a risk-to-benefit
ratio; if the patient is experiencing glare, such that it interferes with his
or her quality of life, the OZD must be increased.
The peripheral curve system should be such that, at minimum,
three to four curves are necessary to correspond with the rapidly flat-
tening midperipheral and peripheral cornea. The outer peripheral
curve should generally be flatter and wider than conventional designs
to provide greater edge clearance and prevent peripheral seal-off and
lens-to-cornea adherence. Often, a minimum radius of 12.00 mm with
a 0.3 to 0.4 mm width will provide sufficient edge clearance. However,
the ability to modify the periphery in-office is important for the contact
lens management of patients with keratoconus. This lens design is
summarized in Table 10-4.
Because almost all lenses ordered will be in minus—if not high
minus—power, the center thickness should be 0.02 to 0.03 mm
greater than that of conventional designs to minimize flexure. Lenses
with powers ≥5.00 D should also be ordered with a plus lenticular or
similar peripheral design to minimize edge thickness. An example of
a combination mild-to-moderate keratoconic case is provided below.
Table 10-4 Keratoconus Spherical Gas Permeable Lens Design Philosophy

(Bennett)
Stage Average “K” Value Lens Design
One <45.00 D Conventional Lens Design
Two 45–50 D Overall Diameter (OAD) = 9.0 mm
Optical Zone Diameter (OZD) = Base Curve
Radius (BCR) in mm
Tetracurve Design
Three 50–55 D OAD = 8.6–8.8 mm
OZD = BCR (in mm)
Tetracurve or Pentacurve Design
Peripheral Curve Radius = 12.00 mm
Peripheral Curve Width = 0.3–0.4 mm
Four >55 D OAD = 8.0 mm
OZD = BCR (in mm)
Pentacurve Design
Peripheral Curve Radius = 12.00 mm
Peripheral Curve Width = 0.3–0.4 mm
Example One: Keratometry: OD: 45.25 @ 163; 48.25 @ 076

(mild distortion)
OS: 50.75 @ 026; 54.25 @ 123 (moderate
distortion)
Refraction: OD: −3.25 −3.25 × 165 20/25-2
OS: −6.25 −3.75 × 030 20/50-1
Diagnostic Fitting: BCR: OD: 7.00 mm; OS: 6.2 mm
Fluorescein pattern exhibited mild apical
clearance
OS > OD; changed to 7.10 mm (−4.00 D) OD
& 6.4 mm (−7.00 D) OS, resulting in three-
point touch OU. The spherical overrefraction
was:
OD: −1.75 DS 20/20
OS: −0.75 DS 20/25
Final Lens Design: OD OS
BCR: 7.10 mm 6.40 mm
OAD/OZD: 9.0/7.20 mm 8.6/6.4 mm
SCR/W: 8.10/0.3 mm 7.40/0.2 mm
ICR/W: 9.60/0.3 mm 8.60/0.3 mm
10.20/0.3 mm
PCR/W: 12.00/0.3 mm 12.00/0.3 mm
Power: −5.75 D −7.75 D
Material: FP 30
Other: +Lenticular (OU)
Lens Material. Although lens design is the key factor for patients
with keratoconus, material selection is also important. Although
PMMA and very low-Dk (i.e., <20) materials are still in use today
because of their ability to correct corneal astigmatism while often pro-
viding excellent wettability, it is important to select a material that will
not further compromise the cornea through hypoxia. Because kerato-
conus lens designs are almost always of minus power and therefore
thin in design, a low-Dk (i.e., 30 to 50) fluoro-silicone/acrylate lens
(F-S/A) material should provide sufficient oxygen transmission while
also providing good rigidity to minimize the effects of flexure.
Extended wear is contraindicated for patients with keratoconus
because of the possibility of further compromising an already abnor-
mal cornea.
Problem Solving
As a result of the irregularity and fragility of the cornea, it is important
that patients with keratoconus are evaluated on a regular basis.
Fortunately, these patients are often receptive to follow-up care as a
preventative measure to ensure the condition is successfully managed.

When the condition is progressing, patients should be evaluated, at
minimum, every 6 months. Once it has stabilized, annual examina-
tions should be performed.
The goal in fitting GP lenses for patients with keratoconus is not
necessarily to achieve a certain fluorescein pattern but rather to allow
adequate wearing time with acceptable comfort with best vision while
minimizing tissue insult. Problems are not uncommon for patients
with keratoconus, but they are also typically manageable. A simple
guide to managing these problems is presented in Table 10-5.
Reduced Comfort. As mentioned before, patients with keratoconus
tend to be more sensitive to contact lens wear, and therefore the impor-
tance of using terms such as lens awareness to describe adaptation
supplemented by a topical anesthetic during the diagnostic fitting
process is important. In addition, a well-centered fitting is important
to initial comfort in addition to a thin edge. Because many of these
designs—particularly in patients with advanced stages of kerato-
conus—are in high minus powers, the edge thickness can be greater
than desired, resulting in greater lid awareness and possible decentra-
tion. The use of a plus lenticular is often indicated; nevertheless, the
thickness can still be thicker than desired. The ability to thin the edge
in-office, typically via the application of an anterior bevel, is invaluable
Table 10-5 Keratoconus Gas Permeable Lens Problem-Solving

Problem Management
1. Reduced Comfort Optimize centration, minimize edge thickness
(+ lenticular); topical anesthetic at fit
2. Reduced Vision Overcorrection with spectacles; consider PK if
patient is dissatisfied with vision
3. Decentration Steepen base curve radius, decrease OZD,
decrease edge thickness; if persistent consider
piggyback
4. Frequent Dislodgement Steepen base curve radius; consider piggyback
design
5. Adherence Flatten/wide peripheral curve; reduce OZD
6. Staining If coalesced, discontinue lens wear until healed;
if good fitting relationship, return to previous
design; clean and polish back surface; steepen
base curve radius; if paracentral erosion, blend
peripheral curve junctions
in these cases. If the patient still experiences lens awareness, the use
of a piggyback-type design would be recommended.
Reduced Vision. Although the use of GP lenses often improves
vision by several lines on the acuity chart compared with the best spec-
tacle correction, the quality of vision can still be reduced significantly,
particularly for patients with advanced stages of keratoconus. Every
effort should be made to perform an accurate spherocylindrical over-
refraction to put into overspectacles for use during critical vision tasks.
When the patient is no longer satisfied with his or her vision, consul-
tation with a corneal specialist for a possible penetrating keratoplasty
is recommended, particularly if dense corneal scarring is present.
Decentration. If the lens decenters inferiorly, several options are
available. Reducing the OZD, keeping the edge thickness to a mini-
mum, steepening the base curve radius, or ultimately using a piggy-
back-type design should be beneficial.
Frequent Decentration/Dislodgement. If the lens is frequently
decentering off the cornea or dislodging from the eye, this could be the
result of excessive inferior edge clearance. An excessively flat base
curve radius almost always causes this, and simply refitting into a
steeper base curve will solve this problem. Selecting a large diameter
lens design or a piggyback-type modality are options as well.
Adherence. Because of the absence of an alignment fitting relation-
ship, absence of or minimal lens movement can occur. Often, periph-
eral seal-off is present, and this problem can be managed by flattening
and widening the peripheral curve in-office. Additionally, the optical
zone may be too large, increasing the disparity from alignment in the
fitting relationship.
Staining. Corneal staining can often be thought of as synonymous
with keratoconus resulting from the fragility of the cornea and, partic-
ularly, if a foreign body such as a rigid contact lens is being worn
(Figure 10-14). An easy mistake to make when a patient has experi-
enced a mild corneal abrasion necessitating temporary discontinua-
tion of lens wear is to then refit the patient into a different design.
Because it is not uncommon for patients with keratoconus to wear
their GP lenses all waking hours, for any of a number of possible eti-
ologies, punctate staining can coalesce, resulting in a corneal abrasion.
However, if the patient has a good lens-to-cornea fitting relationship,
he or she should resume wearing these lenses once the staining has
resolved.
A swirl staining pattern located over the apex of the cone is com-
mon in patients with keratoconus.17,67 This is typically mild and should
simply be monitored. If it coalesces, resulting in lens awareness, the
back surface of the lenses should be cleaned and polished to remove
Figure 10-14. Corneal staining in keratoconus. (Courtesy Ursula Lotzkat.)
adherent mucoprotein deposits on tight-fitting keratoconic lenses. If

persistent, changing to an apical clearance GP design or a piggyback-
type design would be recommended.
A paracentral erosion is often the result of a steep fitting relation-
ship with a sharp junction between peripheral curve radii. Blending
the peripheral curve junctions and flattening the peripheral curve
radius should solve this problem.
Other Designs and Fitting Methods

There are several commercially available lens designs in common use
specifically for patients with keratoconus. This section is by no means
comprehensive, but it will address some of these designs.
Rose K Lens. The Rose K lens (Lens Dynamics, Inc., Golden, CO)
has a complex, computer-generated peripheral curve system that was
the result of several hundred fittings by Dr. Paul Rose of New
Zealand.110 It is a popular lens design in the United States and consists
of an optical zone that decreases as the base curve steepens with as
small as a 4-mm optical zone in the steepest curvatures to a 6.5-mm
optical zone in the flatter curvatures.69,111 The smaller than average
OZD is intended to minimize midperipheral lens impingement and
pooling or bubbles at the base of the cone.112 The peripheral curve radii
are blended so as to constitute an aspheric-like periphery. Toric curves
are available on the front and back surfaces and peripherally.110 Mild
apical touch accompanied by a light midperipheral bearing fitting rela-

tionship is recommended.
The diagnostic fitting set is invaluable—as it is with any keratoconic
lens design—in the GP treatment of these patients. It consists of 26
lenses with base curve radii ranging from 5.10 to 7.60 mm with a stan-
dard 8.7 mm overall diameter and a medium or standard edge lift.
Diagnostic fitting sets with high and low edge lifts are available,
although in the authors’ experience, the latter is rarely needed. Although
8.7 mm is the standard diameter, larger and smaller diameters are avail-
able. Smaller diameters tend to be more successful for patients with the
most advanced cases if not visually limited by the smaller OZD.
Cox113 found an overall success rate of 66%, whereas Caroline and
Andre111 were able to successfully fit 32 of 33 keratoconic eyes with 24
of these eyes fit with the initial lens. However, because of the expense
and the possibility of flare in patients with advanced cases, practition-
ers who often treat patients with keratoconus would benefit from the
addition of a second diagnostic set of another keratoconic lens design.
CLEK Lens Design. As part of the CLEK study, a rigid lens diagnostic
fitting set was designed and standardized.106 The diagnostic fitting set
and the proposed fitting method provide the practitioner with an easy-
to-follow protocol with an inexpensive fitting set (Table 10-6). The
standardized fitting protocol is based on sagittal height and is as
follows:67
1. Base curve radii are available in 0.05 mm in the trial set to

increase fitting sensitivity.
2. Contact lens powers range from −3.00 D to −9.00 D to, in most
cases, result in a low overrefractive power.
3. The overall diameter was established at 8.6 mm to provide an
interpalpebral fit in which the lens positions over the apex of the
conical area of the cornea.
4. The OZD was set at 6.5 mm to minimize areas of tear pooling
and debris accumulation under the optical zone.
5. The secondary curve radius ranged from 8.00 to 8.25 mm or sim-
ilar to nonkeratoconic GP lens designs because the midperiph-
eral-to-peripheral cornea is often normal.
6. The peripheral curve radius was set at 11.00 mm at 0.2 mm wide.
7. The center thickness was calculated to result in an edge thickness
of 0.10 mm for each trial lens.
8. PMMA was selected as the lens material because of its machin-
ability, dimensional stability, durability, and low cost with the
assumption that the lenses will be ordered in one of the recom-
mended GP lens materials.
Table 10-6 The CLEK Diagnostic Fitting Set*

Lens # BCR (mm/D) Power OAD/OZD (mm) SCR (mm) PCR (mm)
1 7.85 (42.99) −3.00 8.6/6.5 8.25 11.00
2 7.80 (43.27) −4.00 8.6/6.5 8.25 11.00
3 7.75 (43.55) −3.00 8.6/6.5 8.25 11.00
4 7.70 (43.83) −4.00 8.6/6.5 8.25 11.00
5 7.65 (44.12) −3.00 8.6/6.5 8.25 11.00
6 7.60 (44.41) −4.00 8.6/6.5 8.25 11.00
7 7.55 (44.70) −5.00 8.6/6.5 8.25 11.00
8 7.50 (45.00) −4.00 8.6/6.5 8.25 11.00
9 7.45 (45.30) −5.00 8.6/6.5 8.25 11.00
10 7.40 (45.61) −6.00 8.6/6.5 8.25 11.00
11 7.35 (45.92) −4.00 8.6/6.5 8.25 11.00
12 7.30 (46.23) −5.00 8.6/6.5 8.25 11.00
13 7.25 (46.55) −6.00 8.6/6.5 8.25 11.00
14 7.20 (46.87) −5.00 8.6/6.5 8.25 11.00
15 7.15 (47.20) −6.00 8.6/6.5 8.25 11.00
16 7.10 (47.54) −7.00 8.6/6.5 8.25 11.00
17 7.05 (47.87) −5.00 8.6/6.5 8.25 11.00
18 7.00 (48.21) −6.00 8.6/6.5 8.25 11.00
19 6.95 (48.56) −7.00 8.6/6.5 8.25 11.00
20 6.90 (48.91) −6.00 8.6/6.5 8.25 11.00
21 6.85 (49.27) −7.00 8.6/6.5 8.25 11.00
22 6.80 (49.63) −8.00 8.6/6.5 8.25 11.00
23 6.75 (50.00) −6.00 8.6/6.5 8.25 11.00
24 6.70 (50.37) −7.00 8.6/6.5 8.25 11.00
25 6.65 (50.75) −8.00 8.6/6.5 8.25 11.00
26 6.60 (51.14) −6.00 8.6/6.5 8.00 11.00
27 6.55 (51.53) −7.00 8.6/6.5 8.00 11.00
28 6.50 (51.92) −8.00 8.6/6.5 8.00 11.00
29 6.45 (52.33) −7.00 8.6/6.5 8.00 11.00
30 6.40 (52.73) −8.00 8.6/6.5 8.00 11.00
31 6.35 (53.15) −9.00 8.6/6.5 8.00 11.00
32 6.30 (53.57) −7.00 8.6/6.5 8.00 11.00
Edrington TB, Barr JT, Zadnik K, et al: Standardized rigid contact lens fitting protocol for
keratoconus, Optom Vis Sci 73:369-375, 1996.
*Center thickness is 0.13 mm; peripheral curve radius is 11.00 mm.
The diagnostic lens would be selected equal to the average K (or sim-
ulated K) value. If the keratometry values were 46 D (7.34 mm) × 50 D
(6.75 mm), a 48-D (7.03 mm) diagnostic lens would be selected. If this
lens exhibited apical bearing, the next steeper base curve radius trial
lens would be selected. This process would be continued until the first
definite apical clearance fluorescein pattern has resulted, which is the
recommended fitting relationship with this design. Any laboratory can

manufacture the CLEK design lens, although Conforma Laboratories
(Norfolk, VA) manufactured the trial sets for the CLEK study.
Soper Cone Lens. Designed by contact lens specialist Joe Soper in
the 1970s, the Soper Cone is a bicurve lens in which two posterior
curves are separately cut and polished. The fitting philosophy is based
on sagittal depth. This lens is intended to fit in an apical clearance
manner, in which support and bearing are directed off the apex of the
cornea and onto the paracentral cornea.114 This design is effective for
small cones, but it is also successful for cones with a slightly inferior
displaced apex.115
The peripheral curve is a standard 7.50 mm (45 D) curvature unless
the base curve radius is flatter than 6.49 mm, in which case the
peripheral curve is 7.85 mm. A representative Soper Cone fitting set is
available from many CLMA-member laboratories. The overall and
optical zone diameters are selected depending on the degree of kera-
toconus.69 For patients with mild keratoconus, a 7.4/6.0-mm lens is
used; for patients with moderate keratoconus, an 8.5/7.0-mm lens
is used; and for patients with advanced keratoconus, a 9.5/8.0-mm
lens is selected.
McGuire Lens. This design system was introduced in 1978 and rep-
resents a modification of the Soper design. It is fit to achieve an align-
ment to slight apical clearance fluorescein pattern. This lens design
has a steep central curvature with four progressively flatter peripheral
curve radii, which should be blended well to create an almost aspheric-
like peripheral design. The peripheral curve radii are flatter than the
base curve radius by 3 D, 9 D, 17 D, and 27 D. The three inner curves
are 0.3 mm wide, and the peripheral curve is 0.4 mm wide. It is avail-
able in three overall/optical zone diameters depending on whether the
patient has a nipple cone (8.1/5.5 mm), oval cone (8.6/6.0 mm), or
globus cone (9.1/6.5 mm). Like the Soper design, the McGuire lens is
available from many laboratories. However, it has the advantage of a
progressively flatter periphery, which should result in a more uniform
edge clearance.
Duozone Lens. The Duozone lens (Con-Cise Contact Lens Co., San
Leandro, CA) has been designed for patients with keratoconus in
whom the cone is advanced and located, at minimum, 1 mm away
from the line of sight.17 This lens was designed with a central posterior
curve to contour the cornea and provide optimum visual correction.
The posterior central zone is divided into two zones.116 The 3-mm cen-
tral zone has a steep curvature and is designed to vault the cone. This
central zone is not functional, and the zone is given a radius to achieve
an optimum fitting relationship with the apex of the cone. The central
zone is surrounded by an annular zone equal to a width of 2.5 to 3.0

mm, which, with the front surface, provides the refractive correction
of the patient’s eye.69
For the Duozone lens to achieve minimum clearance over the
decentered corneal apex and to avoid the touch of a regular spherical
design, the central optical zone can be made as steep as necessary. The
annular zone contains the optical correction for the patient’s refractive
error. This lens will tend to center over the eccentric cone, thus mov-
ing the central zone of the lens away from the pupil. The central zone
is limited to approximately 3 mm so that it does not extend more than
halfway into the papillary axis.
The first parameter selected when fitting the Duozone lens is the cen-
tral zone diameter. The central zone diameter is based on the diameter
of the conical area of the cornea, as measured using VKG.17 The sagittal
depth of the cone can then be determined from the radius reading. This
value is converted to the spherical curve with the same sagittal depth for
the central zone of the contact lens. Next, the radius of curvature of the
annular zone is selected. This is also performed using topography by
averaging the radii at eight points in the middle of the annular zone 2.5
mm from the center of the cone apex. Once the central and annular zone
radii are determined, a spherical GP lens is used to determine the refrac-
tive power needed. The spherical GP lens used corresponds to the base
curve radius of the corneal map radius 2.5 mm from the cone (the same
as the radius of curvature for the annular zone), and the annular zone
power is then determined by performing an overrefraction.
For those with advanced keratoconus, the Duozone lens has been
found to provide a successful fit in 65% of patients.117 Although this
lens certainly represents a viable option for patients with decentered
cones, the central zone has limited flexibility. It has been found that it
is difficult to manufacture a central zone much smaller than 3 mm and
that a larger zone may cause visual interruptions.116
KBA Lens. The KBA lens (Precision Technology Services,
Vancouver, Canada) was designed by John Mountford and Don Noack
and is available in Boston XO lens material. KBA stands for kerato-
conus biaspheric. This lens has a standard posterior central aspheric
zone that extends to 0.5 mm from the edge.117 The standard peripheral
curve is 9.75 mm in radius at 0.5 mm wide. The front surface has a
compensating aspheric curve that in effect renders the lens optically
spherical instead of aspheric. This assists in neutralizing induced
radial astigmatism, which should improve vision and reduce flare in
low illumination.
For patients with an early stage of keratoconus, a standard 0.98
eccentricity is most commonly used. As the cone steepens, the back
surface eccentricity can be altered in 0.1 steps up to a value of 1.50.

There is a computer program associated with this design that will per-
form the necessary calculations if eccentricity or any design parameter
is altered and arrive at the recommended power and base curve radius.
The standard lens diameter is 10.2 mm, although this can be varied to
improve the fitting relationship.
There is a 25-lens diagnostic fitting set available from the manufac-
turer. This consists of base curve radii ranging from 5.2 to 7.4 mm
with the steeper curvatures (i.e., 5.2 to 6.0 mm) having a −15.00-D
power and the flatter curvatures (i.e., 6.1 to 7.4 mm) having a −9.00-D
power. All lenses have a 10.2-mm overall diameter. The KBA lens can
be fit using either keratometry or topography data. The initial diag-
nostic lens is fit 0.60 mm steeper than K. Apical clearance is desired
with the smaller nipple cones; an inferior crescent of light touch is
desired with larger oval cones. If inadequate edge lift is present, a
higher edge lift design (i.e., peripheral curve radius equal to 10.50 mm
or 12.25 mm) can be ordered.
Ni-Cone Lens. Patented in 1986, the Ni-Cone lens (Lancaster
Contact Lens, Inc., Lancaster, PA) is a multiple back surface vaulting
system designed with specific formulas.110 This design essentially has
three separate base curve radii and one peripheral curve. The purpose
of the multiple back surface vaulting system is to assist in creating bet-
ter alignment with the keratoconic cornea. These base curve radii are
simultaneously cut on a computer lathe. The primary base curve corre-
sponds to the apex of the cone; the second base curve acts as a buffer
between the diseased and the nondiseased areas of the cornea; the third
base curve corresponds to and bears on the normal peripheral corneal
tissue.110,118 The overall diameter and optical zones are not standard and
may vary as a result of base curve radii and other parameters.
There are three diagnostic fitting sets for the Ni-Cone lens. The No.
1 cone lenses are for patients with keratometry readings between 40
and 52 D; the No. 2 cone lenses are for patients with keratometry read-
ings between 52 and 65 D; and the No. 3 cone lenses are for patients
with keratometry readings steeper than 65 D. All diagnostic lenses
have a peripheral curve radius equal to 12.25 mm and a width of 0.1
mm.69 When fitting these lenses, a primary curve radius equal to the
median keratometry value should be selected. For 550 patients fit into
the Ni-Cone lens, a significant increase in wearing time (from 11.5 to
13.5 hours/day) and visual acuity (from 20/40 to 20/25) was achieved
when compared with their previous correction.118
Aspheric Designs. There are a few laboratories that make true
aspheric contact lenses designed specifically for the keratoconic
cornea. The posterior radii can be steep in some designs; therefore this
can be a limiting factor with this design.110 The goal is to vault the apex
of the cone or lightly touch it and align the more normal peripheral
cornea. Because aspheric lens designs tend to increase in plus power
toward the periphery, patients with presbyopia and keratoconus can
benefit visually. Traditional designs such as the VFLII and the Ellip-
See-Con (Conforma Contact Lens Co.) are progressive aspheres, which
gradually flatten from the center of the lens to the periphery to provide
better alignment with an ecstatic cornea. The degree of asphericity of
eccentricity increases as the rate of flattening increases.115 “E-values” of
0.4 to 0.6 are ellipsoidal in shape and fit a nipple cone most effectively,
whereas e-values of greater than 1.0 are paraboloidal and hyperboloidal
shaped and fit oval-shaped corneas.
The ComfortKone lens (MetroOptics, Austin, TX) is a triaspheric
lens with a 4.0-mm optical zone, which is designed to fit the peak of
the cone to enhance visual acuity. The triaspheric periphery is
intended to maximize overall cornea-to-contact lens alignment. The
fitting set consists of 24 lenses. The diameter is either 8.5 or 9.0 mm,
and there is a choice of base curves with differing aspheric fitting
curves.110 When ordering the ComfortKone lens, the OZD and periph-
eral curve system are controlled; therefore ease of fitting is a benefit of
this design. The practitioner needs to determine the base curve radius,
power, overall diameter, and aspheric fitting curve of the lens to be
ordered.69 It has been found that, even with first-time patients, an
average of only 1.5 lenses per eye is required for a successful out-
come.120 The success of this lens may be because of the generation of
computer-controlled lathes for better optical quality.
The CentraCone lens from Blanchard Laboratory (Manchester, NH)
has a posterior design divided into three principal areas. The optical
zone is spherical (5.75 mm diameter) and is fit to provide apical clear-
ance or a slight apical touch. The paracentral area of the lens is designed
to applanate the cornea tangentially, thereby assisting it to position the
lens as centrally as the corneal shape permits. The peripheral profile area
has a reverse aspheric zone applied, which produces a wider peripheral
zone. Unique to this design is the Bi-Sym enhancement, which allows
the midperiphery of the lower quadrant of the lens to be steepened inde-
pendently of the upper zone. This enhancement allows for a much-
improved fit of the decentered or severe cone, for which excessive lower
edge lift is common. The Valley K lens (Valley Contax, Springfield, OR)
is a unique design modified after the McGuire lens. This design has
computer-lathe curves midway between the basic four–peripheral curve
McGuire design, creating an almost aspheric periphery. It is repro-
ducible, and the peripheral curve system can be modified as needed by
making the curves flatter or steeper for a given base curve.110
The Infinity Cone lens (Infinity Optical, Inc.) fits on the sagittal
value principle by using larger diameters (9.0 mm and 9.5 mm). The
periphery of the lens should be fit to the peripheral area of the cornea
as far away from the apex of the cone as practical.
The KAS lens (Aero Contact Lens, Inc., Kalamazoo, MI) has a
paraboloidal ocular surface geometry with a spherical front surface.
The edge lift is considered hyperboloidal, and diameters range from
7.5 to 10.0 mm. By nature of the lens design, as much as a +2.25-D
addition can be achieved.110
Contex, Inc. (Sherman Oaks, CA) has numerous aspheric lens
designs for patients with keratoconus. The Aspheric-20 lens is the
most common, having a hyperbolic design. Larger than average diam-
eters are recommended, and varying edge lift designs are available.110
A recipe for fitting GP lenses for patients with keratoconus based
on the type of cone has been published by the coauthor and is provided
in Box 10-2.110
Piggyback-Type Designs
Because of the difficulty of achieving an alignment fitting relationship,
it is not uncommon for GP lens design adaptation to take longer
because the initial comfort is often less. This problem, in addition to
the difficulty in achieving good centration—especially in those with
advanced or displaced cones—makes the option of a piggyback-type
Box 10-2 RECIPE FOR KERATOCONUS INITIAL LENS SELECTION BASED ON TYPE
OF CONE
A. Nipple Cone
1. Rose K
2. ComfortKone
3. Valley K
4. Aspheric
B. Sagging Cone
1. Duozone
C. Keratoglobus
1. Ni-Cone
D. Advanced Cones (topographies reveal much distortion secondary to
scarring and resemble a reverse geometry pattern)
1. ComfortKone
2. Valley K
3. Rose K
4. Ni-Cone
Modified from Cutler SI: Managing keratoconus with proprietary designs, Contact Lens
Spectrum 14(10):21-28, 1999.
design viable. Some patients have persistent epithelial staining

because of bearing over the apex, which precludes GP lens wear alone.
In addition, some patients with keratoconus experience difficulty in
adapting because of poor motivation to wear contact lenses. The deci-
sion to wear contact lenses was mandated by their eye care practi-
tioner, not by their own desire to wear lenses. These designs either
consist of a high- or hyper-Dk GP lens fit over a soft lens (i.e., tradi-
tional and FlexLens designs) or integration of a GP lens into a soft lens
periphery (i.e., SoftPerm). The underlying (or adjacent) hydrogel
lens improves tolerance, and the GP lens optimizes vision. The soft lens
also provides some amount of protection to the cornea.
Traditional Piggyback. With this combination design, a highly oxy-
gen-transmissible soft lens is fitted initially so that good movement
and centration are achieved. Because of oxygen transmission, the use
of silicone-hydrogel lenses has been recommended.121 Although it is
highly likely that the soft lens is approved for extended wear, the addi-
tion of a GP lens will reduce oxygen transmission such that daily wear
is required. Even patients with keratoconus who are wearing GP
lenses only should maintain a daily-wear schedule to reduce the risk of
further compromise to the cornea.
Once the soft lens has been fit, keratometry is performed over the
anterior surface of the soft lens. A high-Dk or preferably a hyper-Dk
GP material should be fit with minimal edge and center thickness to
promote good centration and decreased lid sensation (Figure
10-15).69,122 Most of the power can be placed into the soft lens with the
Figure 10-15. A traditional piggyback fitting relationship.

GP lens having the important role of reducing the irregularity of the

front surface of the soft lens. The GP lens is fit from 1 mm steeper
than K to the midpoint of the two overkeratometry values.107,123,124
A steep GP fit is acceptable because normal lacrimal exchange is
occurring underneath the soft lens. In addition, limited GP lens move-
ment with blinking will minimize the risk of dislodgement.
A soft lens wetting and disinfecting system should be used with
these lenses, although a GP-compatible cleaner can be used with the
rigid lens.69 Patients should be instructed to insert the soft lenses first.
The GP lenses are removed first, one at a time, preferably with the use
of a suction device for ease of removal.
Piggyback lenses have had limited use, ranging from 1% to 2%10 to
7.8%122 of keratoconic contact lens fits. In the latter report, more than
half of the piggyback lenses were fit because of persistent apical
epithelial defects. Other reasons for using piggyback lenses included
recurrent abrasions and GP lens intolerance. Piggyback lenses have
not enjoyed greater use because of such factors as patient handling dif-
ficulties, expense, and a poor fitting relationship. In the latter category,
the soft lens may result in edge standoff and resulting patient aware-
ness; the GP lens could decenter; or trapped bubbles may be present
between the two lenses. Nevertheless, increased wearing times,
greater comfort, equivalent or better visual acuity, and the elimination
of preexisting corneal complications as compared with GP lenses
alone have been reported.125 In addition, the corneal physiology
appears to be unchanged.124-126
Flexlens. The Flexlens piggyback system (Salvatori Ophthalmics,
Inc., Sarasota, FL) was first introduced in the 1970s. It consists of a
hydrogel lens with a cut-out or depressed section in the center for a
hyper-GP lens to fit. It is available in 45% water content hefilcon A or
55% water content methafilcon A. The overall diameter of the soft lens
is 14.5 mm with a typical cut-out diameter of 10.2 mm. A standard
hyper-Dk (preferably thin) GP lens design that is 1 mm smaller (i.e.,
9.2 mm) to allow for movement is placed within the recessed area
(Figure 10-16).127 The Flexlens has the same advantages and compro-
mises as conventional piggyback lenses. However, from a comfort and
centration standpoint, it is a viable option, especially in practices with
many patients with keratoconus.
SoftPerm Lens. The SoftPerm lens (Ciba Vision Corp., Duluth, GA)
is actually one lens that incorporates a rigid lens center and a soft
periphery. The center 8 mm is a styrene-based material with a Dk of
25. The periphery of this 14.3-mm overall diameter lens is a 20% water
content soft lens. It is available with base curve radii as steep as 6.5
mm. In addition, the introduction of a peripheral curve into the rigid
Figure 10-16. The Flexlens.
lens section has assisted in providing lens movement with blinking.

Although a greater than 50% success rate has been reported128 and it
has the benefit of a one-lens system, problems with this lens have
included cornea hypoxia because of the relatively low oxygen perme-
ability of both materials, adherence, and tearing of the lens at the junc-
tion between the two lens materials.129,130 It is hoped that the
manufacturer will introduce a newer version of this lens made with a
high- or hyper-permeable GP lens material.
Scleral and Semiscleral Lenses

Large scleral and limbus-limbus corneal designs have some of the ben-
efits of piggyback lenses without the need for a second lens. In particu-
lar, they provide better initial comfort and improved centration.67,131-133 If
refitting into a smaller, traditional corneal design is not successful, refit-
ting into a scleral design may result in improved centration with essen-
tially no contact of the contact lens with the corneal apex. This type of
design can also potentially result in improved visual acuity because of
the ability to use a larger OZD. One study pertaining to a 17.2-mm diam-
eter fenestrated semiscleral lens resulted in a greater than 90% success
rate and an increase of wearing time from 4 to 6 hours to 10 to 15 hours
with pre- and post-surgical keratoconus patients.134 However, some
patients may find the excess bulk of the lens to be irritating, and
the physical size of the lens can discourage patients.69 Removal of these
lenses may also present a problem because of the suction created by the
lens-sclera interface. For patients with lens intolerance or discomfort
with corneal lenses, however, scleral GP lenses are a viable option to
postpone or prevent surgical intervention.67,69
Many laboratories manufacture large corneal and semiscleral lens
designs. The Macrolens (C & H Contact Lens, Inc., Dallas, TX) is a
popular semiscleral lens that is available in diameters of 13.9 and 15.0

mm. As with other scleral and piggyback designs, the Macrolens
should provide good initial comfort, limited movement, and minimal
lid interaction. The ideal fit recommended by the manufacturer is
alignment centrally and peripherally with midperipheral pooling.
Bitoric Lenses
Toric back surface lenses have little application for patients with ker-
atoconus because of the irregular toricity of the cornea. Although
keratoconic corneas typically have a high level of toricity that, in the-
ory, would benefit from a toric lens, the toric curvatures and corre-
sponding power corrections are 90 degrees apart. This is often not
the case for the irregular astigmatism in patients with keratoconus,
especially in those with moderate and advanced cases. The astigma-
tism in patients with keratoconus is usually confined to a small area
within the apical area, close to the visual axis. Posterior toric lens
designs are most effective in limbal-to-limbal or global cylinder cases,
not local cylinder cases.135 If the apex of the cone is decentered, a suc-
cessful fit is difficult to achieve.17 The corneal toricity error from the
central cornea to the apex varies from 0 to 3 D when the apex is decen-
tered by 1 mm and from 0 to approximately 6 D when the cone is
decentered by 2 mm.
If, however, the cone apex is well centered and the topography map
shows a symmetrical bow-tie pattern, which is rare and almost always
found in mild or subclinical forms, a bitoric lens can be successful.17,136
It has also been successful in combination with a soft lens (i.e., piggy-
back).137 However, if the condition continues to progress, one of the
aforementioned designs will most likely be indicated.
Soft Lenses
As with bitoric GP lens designs, spherical and toric soft lenses have lit-
tle application for patients with keratoconus. In the CLEK study, soft
lenses were worn bilaterally by 2% of the patients and unilaterally by
2% of the patients.10 The inability of a soft lens to neutralize corneal
irregularity and improve vision limits its application typically to mild
cases before the onset of significant irregular astigmatism.17,67
In a comparison study in which six types of contact lenses were
compared in their ability to mask irregular astigmatism in patients
with keratoconus, correction with GP lenses provided the highest lev-
els of visual acuity and best masked the majority of the corneal irregu-
larity.98 It was concluded that there is probably no advantage to
patients with keratoconus wearing soft lenses as opposed to spectacles.
Therefore to optimize vision in patients with keratoconus who are
unable to adapt to GP lenses, a scleral GP or piggyback combination

system is recommended.
Penetrating Keratoplasty
It is always important to be able to communicate to a patient with ker-
atoconus at the time of possible diagnosis that an outcome of kerato-
conus—for advanced cases—is corneal transplantation. Between 10%
and 22% of patients with keratoconus will have a penetrating kerato-
plasty as a result of their condition.6,9,10,12,97,138,139 Ten percent of the
CLEK study patients underwent penetrating keratoplasty; however,
patients who underwent bilateral transplantations were excluded from
participating in this study. Tuft et al12 reported that 21.6% of 2363
patients with keratoconus had undergone grafting. The mean duration
of the condition before grafting was 8.8 years. The primary reasons for
grafting included unstable contact lens fit (52.6%) and axial corneal
scarring (36.3%). High-risk factors for the eventual need for penetrat-
ing keratoplasty appear to be (1) onset at a young age (<20 years of
age), (2) keratometry readings >55 D, (3) best corrected visual acuity
<20/40, and (4) apical scarring.12,140
Corneal transplantation is highly successful with as many as 96%
of cases resulting in clear grafts.141-143 It has been reported that 84% of
grafts resulted in ≥20/40 vision, and 40% achieved ≥20/20.144
Coster145 reported that 93% of patients undergoing grafting believed it
was “worth the trouble.” It is also important to emphasize that surgery
can be avoided in many cases by the fitting of contact lenses. In one
study of 190 eyes referred for a penetrating keratoplasty, 69% could be
successfully refitted into contact lenses.138 Kastl146 found that 95% of
64 patients could be successfully fit into contact lenses. Belin et al147
and Fowler et al148 found that 87% of patients referred for surgery
could be successfully fit with contact lenses with 85% achieving 20/30
or better corrected visual acuity. Therefore it is evident that contact
lenses should be considered initially with surgery an option primarily
when contact lens wear is intolerable or when the condition has pro-
gressed such that significant apical scarring is present.
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appendix
10-1
CLMA Laboratories Keratoconus GP
Designs
273
Lens Design Lens Material Diameter B Base Curve Power (D)
274
ABB Optical: 800-225-1812
http://www.abboptical.com
SECTION IV
Cone Adaptive Any Made to Order Made to Order
Dyna Intra- Boston XO 11.2 mm (Standard/
Limbal Custom Available)
McGuire Any Made to Order
Rose K Boston EO, XO 8.7 mm (Standard
Custom Available)
S Cone Boston XO 7.0-9.2 mm 4.50-8.00 mm +20.00 to −35.00

Soper Any Made to Order
ABBA Optical, Inc.: 800-331-2015
http://www.abbaoptical.com
ABBA-KONE Paragon HDS Made to Order
Soper Cone Any Made to Order
Acculens, Inc.: 800-525-2470
Mail to: [email protected]
AccuCone Any Made to Order
McGuire Cone Any Made to Order
Aero Contact Lens of Ohio, Inc.: 888-866-9400
Lexington PK (Post Graft) Any 9.7/10.2 mm/Custom Made to Order
Lexington PRK (Post R-K) Any 10.0 mm/Custom Made to Order
R-2000 Any Made to Order
Appendix 10-1
American Contact Lens Service, Inc.: 800-428-4479
Custom Any Made to Order
Blanchard Contact Lens Inc.: 800-367-4009
http://www.blanchardlab.com
CentraCone Boston ES, EO 9.0 mm Standard 5.30-7.60 mm Plano to −30.00
(8.6, 8.2 available) (0.10-mm steps) (0.25 D steps)
Rose K Boston EO, XO 8.7 mm (Standard/ Made to Order Made to Order
CLMA Laboratories Keratoconus GP Designs

Custom Available) (0.05-mm steps)
CL Works Co., Ltd.: (822) 3474-5642
http://www.clworks.com
Custom Boston XO Made to Order
Cardinal Contact Lens, Inc. (Available in CANADA Only) -International CLMA Member*: 800-263-3973

Apex Cone Boston ES, EO, XO Made to Order
Aspherix – K All Boston Materials Made to Order
and Aquasil
McGuire Cone All Boston Materials Made to Order
and Aquasil
Soper Cone All Boston Materials Made to Order
275
and Aquasil
Continued
276
Chessman’s Contact Lens Lab: 800-486-5367
SECTION IV
Clear Optics, Contact Lens Laboratory: 800-221-0213 (NM only), 505-983-5075
Con-Cise Contact Lens Co.: 800-772-3911
http://www.Con-Cise.com

Burger Any Made to Order
Con-Cise Any Made to Order
Rose K Boston ES Made to Order
Conforma Contact Lenses: 800-426-1700
http://www.conforma.com
Conforma-K Boston ES, XO Made to Order
CooperVision Canada Corp. International CLMA Member*: 888-475-8555
http://coopervision.ca
Custom Any Boston Material Made to Order
Corneal Design Corporation: 800-634-0785

Appendix 10-1
Corneal Lens Corp NZ ltd NEW ZEALAND -International CLMA Member*: 64-3-3666247
Centra PGA -Cone Any 8.2-10.5 mm 4.00-8.00 mm +/−30.00
Conoid Any 8.2-10.4 mm 4.00-8.00 mm +/−30.00
Custom Multicurve Any Made to Order
Correctech, Inc.: 888-879-7176
ORION Therapy Hydro2, Flosi, Made to Order
SGP 1, 2, 3
Custom Craft Lens Service Of Nevada, Inc.: 800-232-3937

Cak Any Made to Order
Danker Laboratories, Inc.: 800-237-9641
http://www.dankerlabs.com
K-2 Design Any Made to Order
Dist-O-Con, Inc.: 800-543-8007
Dist-O-Cone Fluorex 300 or 9.0 mm 6.03-7.03 mm Made to Order
Paragon HDS
277
Continued
278
Dist-O-Con, Inc.: 800-543-8007—cont’d
Paragon HDS
SECTION IV
Paragon HDS
Diversified Ophthalmics, Inc.: 800-626-2281
Ultima “K” Paragon HDS Made to Order Made to Order +/−20.00
Firestone Optics, Inc.-Corneal Lens Laboratory: 800-373-2020

http://firestoneoptics.com
Flexilens Pvt. Ltd. INDIA -International CLMA Member*: 9122 2836-6539
http://www.flexilens.com
Custom XL-20, XL-30, XL-40, Made to Order
SGPII, FP-70, FS
Frontier Contact Lens Lab: 800-433-3261
Dyna Intra-Limbal Boston XO 11.2 mm (Standard/ Made to Order
Custom Available)
Custom Available) (0.05 steps)
G.P. Specialists: 800-366-2522
Appendix 10-1
http://www.gp2c.com
Custom Cone Any Made to Order
Global Contact Lens, Inc.: 800-988-5130
Aspheric Cone Any Made to Order
GL-cone Any Made to Order

Hawkins Contact Lens Ltd.: 888-234-3380
Herslof Contact Lens Service: 800-558-7073
IVM Corporation: 800-444-6302
http://members.aol.com/ivmcontact
Aspheric K Any Made to Order
EXCAT Cone Any Made to Order
279
Continued
280
Insight Contact Lens Labs: 800-486-8228
SECTION IV
Int’l Contact Lens Labs, Inc.: 800-422-8489
McGuire Cone Any Made to Order 5.00-7.00 mm Made to Order

Lancaster Contact Lens, Inc.: 800-733-6540
Ni-cone (Patented) Any Made to Order
Lens Dynamics, Inc.: 800-228-2691
http://www.lensdynamics.com
Custom Available)
Lens Mode: 800-852-5880
System 10 Porus 5.65-10.25 mm 4.82-7.34 mm +10.00 to −35.00
System 10 Porus F 5.65-10.25 mm 4.82-7.34 mm +10.00 to −35.00
Luzerne Optical Labs, Ltd.: 800-233-9637
Appendix 10-1
http://www.luzerneoptical.com
Metro Optics -Arkansas, Inc.: 800-482-6905
A-Series Any 7.8-9.5 mm Made to Order
Metro Optics Of Austin, Inc.: 800-223-1858 (Austin, TX)
http://www.Metro-optics.com
Comfort Kone 7.8-9.5 mm Made to Order

FluoroPerm 30
Mid South Premier Ophthalmics, LLC: 800-735-6662
http://www.mspremier.com
Ultima K FluoroPerm 30, Made to Order Made to Order +/−20.00
60, Paragon
HDS
New Era Custom Contacts: 800-548-8125
281
Continued
282
OPTIK K & R, Inc. CANADA -International CLMA Member*: 800-465-0048
http://www.KandR.com
SECTION IV
Oculus Limited SINGAPORE -International CLMA Member*: (65) 62845922
http://www.oculuslens.com

Opti Con, Inc.: 800-232-6784
Any Any Made to Order
PC Optical Products, Inc.: 800-433-4885
http://www.pcoptical.com
Custom Available)
Paracon, Inc.: 800-547-6330
Custom Available)
McGuire Cone Any 8.3/8.7/9.0 mm 5.10-7.10 mm
PL/−20.00
Rose K Boston ES 8.0/8.3/9.0/9.3 mm Made to Order
Soper Cone Any 8.3/8.7/9.0 mm 5.10-7.10 mm
Appendix 10-1
PL/−20.00
Platt Contact Lens Service: 800-537-5711
CV-6 Any Made to Order
PLATT DB Any Made to Order
Precision Optics, Inc.: 800-584-9110
Custom Any, Hydro 2 Made to Order

McGuire Cone Any, Hydro 2 Made to Order
Soper Cone Any, Hydro 2 Made to Order
Professional Lens Service, Inc.: 888-450-5367
Progressive Vision Technologies: 800-442-3032
http://www.progressiveyes.com
A-Series FluoroPerm 30 7.8-9.5 mm Made to Order
Rooney Optical, Inc.: 800-362-1400
http://www.rooneyoptical.com
Dual Base Any Made to Order
283
Continued
284
Safeway Contact Lens, Inc.: 800-354-4291
SECTION IV
Soderberg Contact Lens: 800-736-9339(MN)–See Directory for other locations
http://www.soseyes.com
McGuire Any 8.1/8.6/9.1 mm Made to Order
SK 2000 Boston XO Made to Order
Soper Any 8.0/8.5/9.0 mm Made to Order

Tru-Form Optics, Inc.: 800-792-1095
http://www.tfoptics.com
Pro ECC Any Made to Order Made to Order +20.00 to −30.00
Tru-Kone Any Made to Order
Ultralentes Ind. Optica Ltda. BRAZIL -International CLMA Member*: (55) 51 227-4410
Ultracone HDS, SGPs, Paraperm, 7.5-12.5 mm 4.96-7.50 mm up to −35.00
FluoroPerm, LDF
Ultraflat HDS, SGPs, Paraperm, 10.1-12.5 mm 7.84-10.22 mm +/−35.00
FluoroPerm, LDF
Universal Contact Lens: 800-255-8895
Appendix 10-1
Universal Contact Lenses of FL., Inc.: 800-874-4884
C5 Any 8.0-9.4 mm 5.00-7.50 mm Made to Order
CLCK Any Made to Order

Valley Contax: 800-547-8815
http://www.valleycontax.com
APK Any Made to Order
Valley Kone Any Made to Order
Westlens: 800-451-3668

APK Any Made to Order
Winchester Optical Company: 800-621-2664
http://www.Wineyesite.com
285
11
Astigmatic Correction
EDWARD S. BENNETT
S uccessfully fitting patients exhibiting a significant amount of

residual astigmatism or high corneal toricity often presents a
challenge to practitioners. However, these patients may be fitted
with special rigid lens designs if the practitioner has a comprehensive
knowledge of the alternative forms of correction available. This chap-
ter reviews the principles of astigmatic rigid contact lens correction,
available lens designs, and problem solving, and indicates the role gas
permeable (GP) lenses have in a soft lens–dominated industry.
RESIDUAL ASTIGMATISM
Residual astigmatism has been defined as the refractive error present
when a contact lens is placed on the cornea to correct an existing
ametropia.1 With a spherical GP lens in place on the eye, the residual
astigmatism is approximately equal to the difference between the
corneal astigmatism and the refractive or composite astigmatic error
of the eye. With a spherical soft lens, it is equal to the refractive astig-
matic error only.
Residual astigmatism can be classified as either physiologic or
induced. Physiologic residual astigmatism results from the compo-
nents of the refractive system of the eye.2 Any of the following may
contribute to residual physiologic astigmatism: (1) the posterior
corneal surface may have power at the aqueous interface, which is usu-
ally not considered; (2) different meridians of the crystalline lens may
have different curvatures at the interfaces; (3) the fluid lens may not
totally correct the anterior corneal surface cylinder; (4) the cornea and
other media may have varying indices; (5) the crystalline lens may be
tilted; and (6) the incident beam of light may be oblique to the cornea.
Induced residual astigmatism pertains to the status of the lens on the
eye and may result from one or more of the following:2 (1) the lens is
warped3; (2) the lens is flexing on the eye4-7 (in 1 and 2, 0.25 D of residual
astigmatism results from each 0.25 D of warpage or flexure)8; (3) a decen-
286
Chapter 11 Astigmatic Correction 287
tered lens, which may induce astigmatism2; (4) the contact lens may be
tilted sufficiently on the cornea to induce radial astigmatism, a common
problem for patients with aphakia with keyhole or otherwise displaced
pupils9; and (5) a toric anterior or posterior curve(s) on a rigid lens.10-12
Calculated and Actual Residual Astigmatism

Studies have been performed to evaluate the correlation between the
calculated residual astigmatism (CRA) and the measured or actual
residual astigmatism (ARA).13-15 The CRA can be directly determined
by subtracting the patient’s central anterior corneal toricity—as meas-
ured via keratometry or corneal topography—from the total astigma-
tism of the eye at the plane of the cornea. The following examples
illustrate the determination of CRA. In these examples, TRA refers to
the total refractive astigmatism, and 䉭K refers to the difference
between the keratometry readings of the two corneal meridians.
Example 1:
Given: Spectacle Rx = −2.00 − 2.00 × 095
Keratometry = 43.00 @ 095; 44.00 @ 005
Then: CRA = TRA − 䉭K
= −2.00 × 095 − (−1.00 × 095)
= −1.00 × 095
Example 2:
Keratometry = 42.00 @ 010; 45.00 @ 100
= −1.50 × 010 − (−3.00 × 010)
= +1.50 × 010
transposed
= +1.50 − 1.50 × 100
= −1.50 × 100
Example 3:
Given: Spectacle Rx = +2.00 −3.50 × 180
Keratometry = 41.50 @ 180; 44.50 @ 090
= −3.50 × 180 − (−3.00 × 180)
= −0.50 × 180
Example 4:
Given: Spectacle Rx = +14.00 − 3.50 × 175
Keratometry = 42.00 @ 180; 45.50 @ 090
F90 (12 mm vertex distance):

+10.50
= ________________
1 – 0.012 (+10.50)
= +12.01 D
+14.00
= ________________
1 – 0.012 (+14.00)
= +16.82 D
Spectacle Rx (at corneal plane) = +16.82 − 4.81 × 175
= −4.81 × 175 − (−3.50 × 175)
= −1.31 × 175
Example 5:
Keratometry = 42.00 @ 180; 45.00 @ 090
–12.00
= ________________
1 – 0.012 (–12.00)
= –10.49 D
–9.00
= ________________
1 – 0.012 (–9.00)
= –8.12 D
Spectacle Rx (at corneal plane) = −8.12 − 2.37 × 180
Then: CRAs = TRA − 䉭K
= −2.37 × 180 − (−3.00 × 180)
= +0.63 × 180
transposed
= +0.63 − 0.63 × 090
= −0.63 × 090
Examples 1 and 2 are representative of residual astigmatism because
the majority of patients manifest against-the-rule residual astigma-
tism.15,16 The importance of carefully determining vertex distance and
including it in calculations to derive the patient’s refractive correction in
the corneal plane is illustrated in Examples 4 and 5. In both examples,
if vertex distance were ignored, the CRA would equal zero. Vertex dis-
tance calculations should be used whenever one or both principal
meridians have a correction equal to or greater than +/− 4.00 D.
If a spherical GP lens of standard thickness is selected for a diag-

nostic fitting, the predicted spherocylindrical overrefraction can be cal-
culated by using the following guidelines:
1. List the spectacle correction (Rx), keratometry readings, diagnostic

lens power, and base curve.
2. The effective power should be determined at the corneal plane, if
indicated.
3. Determine the lacrimal lens power induced by the base curve of
the lens.
4. Add together the powers of the contact lens, lacrimal lens, and the
difference between the keratometry readings of the principal
corneal meridians.
5. Subtract the value obtained in (4) from the Rx to obtain the over-
refraction, using the following formula:
Overrefraction (OR) = Spectacle Rx − [Contact lens power (CLP) +
Lacrimal lens power (LLP)] + 䉭K
The following two examples illustrate this principle:
Example 6:
1. Spectacle Rx = +3.50 − 1.00 × 005
Keratometry = 41.00 @ 005; 43.50 @ 095
Diagnostic lens = +3.00, 41.75 (8.08 mm) base curve radius
(BCR)
2. No vertex distance correction is necessary.
3. LLP = BCR of diagnostic lens (in diopters) – flatter corneal
(axis) meridian:
+41.75 − (+)41.00 = +0.75 D
(Because the base curve is steeper than the flatter corneal merid-
ian, the tear lens fills in the void and gives more plus power.)
4. [CLP + LLP] + 䉭K = [+3.00 + (+)0.75] + (−)2.50 × 005
= +3.75 −2.50 × 005
5. OR = Spectacle Rx − [CLP + LLP] + 䉭K
= +3.50 − 1.00 × 005 − (+3.75 −2.50 × 005)
= −0.25 +1.50 × 005
transposed
= +1.25 −1.50 × 095
Example 7:
1. Spectacle Rx = −2.00 − 2.50 × 180
Keratometry = 42.00 @ 180; 44.00 @ 090
Diagnostic lens = −3.00, 42.25 (7.99 mm) BCR
2. At corneal plane, spectacle Rx = approximately −2.00 −2.25 × 180
3. LLP = +42.25 − (+)42.00 = +0.25 D
(Because the base curve is steeper than the flatter corneal

meridian, the tear lens fills in the void and gives more plus power.)
4. [CLP + LLP] + 䉭K = −3.00 + (+)0.25 + (−)2.00 × 180
= −2.75 −2.00 × 180
5. OR = Spectacle Rx − [CLP + LLP] + 䉭K
= −2.00 − 0.25 × 180 − (−2.75 −2.00 × 180)
= +0.75 − 0.25 × 180
The ARA determined with spherical GP lens wear has been shown
to have a partial positive correlation with the prefit calculated value.14,15
Several studies have found that the CRA will approximate −0.50 D axis
090, but the actual measured value will be less.13,14,16 For polymethyl-
methacrylate (PMMA) lenses, Sarver13 found the mean CRA to be
equal to −0.51 × 090 +/−30 degrees, whereas the mean ARA was equal
to −0.23 D × 090 +/−30 degrees.
There are several causes for the difference between CRA and ARA.
If the corneal cap is aspheric, then the CRA will be a poor predictor.2,17
In addition, if the incidence of light on the anterior corneal surface is
oblique to this surface, an astigmatic error is introduced.1 Also, any of
the causes of contact lens-induced residual astigmatism will invalidate
the CRA value.
Perhaps of most importance, however, is the possible problem of
differing keratometric and refractive cylinder axes. Because both of
these measurements are prone to some degree of error, a different
ARA could result if the cylinder axes were assumed to be equal but
were, in fact, different. If the refractive and corneal axes differ by more
than 15 degrees, it can be assumed that the axes are unequal, and
crossed cylinder equations—obtainable from several programmed cal-
culators or via Dr. Paul Whitten’s program available to American
Optometric Association (AOA) Contact Lens Section members (go to
www.aoanet.org)—can be used. This may be worthwhile, especially if
the resultant axis is oblique.
Methods of Correction For Residual Astigmatism

Residual astigmatism with a GP contact lens may cause a reduction in
visual acuity that is unacceptable to the patient. This depends on the
amount of residual astigmatism, the patient’s refractive error (patients
with severe myopia and hyperopia/aphakia may be able to tolerate a
higher amount of residual cylinder than patients with a lesser refrac-
tive error), and whether critical vision demands are made in the course
of work activities or hobbies. Therefore the amount of residual astig-
matism for which a special lens design or fitting procedure is neces-
sary will vary from patient to patient, although it can be assumed that
if the ARA measured after lens wear is 0.75 D or greater, a patient’s
visual acuity will be noticeably decreased. Methods of correcting resid-
ual astigmatism include spherical GP lenses, spherical soft lenses, soft

toric lenses, and front surface toric GP lenses.
Spherical GP Lenses
Spherical GP lenses can be successfully fitted to patients exhibiting
residual astigmatism if any one of the following conditions exists:
●
ARA is lower than the CRA
●
The patient’s acuity is not decreased to an unacceptable level
●
The demand on critical vision is not low
●
The lens can flex on the eye to reduce residual astigmatism
Typically patients will not tolerate ≥0.75 D of residual astigmatism with
a spherical GP lens. However, this will depend on several factors. First,
the ARA may be less than that predicted via the CRA. This could be the
result of slight inaccuracies in the refractive cylinder or the keratomet-
ric (or simulated keratometric) values. Likewise, as previously noted,
the ARA is often less than that calculated for patients with against-the-
rule astigmatism. Therefore, if −1.00 × 090 is the CRA, the ARA may
only be −0.50 × 090. Consequently, it is important to use diagnostic
lenses to determine if residual astigmatism will be problematic, even if
the CRA would predict a significant reduction in acuity.
There are several other considerations. A patient with severe
myopia will exhibit a lower amount of astigmatism at the corneal
plane. If, for example, the keratometry values in Example 5 were 42.00
@ 180 and 44.25 @ 090 and the refraction stayed unchanged at
−9.00 − 3.00 × 180, the CRA at the corneal plane would be only −0.12
× 180 because the refractive cylinder at the corneal plane is −2.37 ×
180. Likewise, patients exhibiting a high refractive error may be able to
tolerate 0.75 to 1.00 D of residual astigmatism, as would patients who
manifest critical vision demands.
There is one refractive situation in which residual astigmatism can
be reduced by the flexing of a thin GP lens on the eye. It has been
found that when the corneal toricity is with-the-rule and the residual
astigmatism is against-the-rule, a thin spherical lens will flex and
reduce the amount of residual astigmatism.5,18 With the flexibility of
high-Dk GP polymers, designing the lenses such that the BCR is
steeper than “K” in an ultrathin design should optimize flexure. This
is illustrated in the following example:
Example 8:
Keratometry = 42.00@180; 44.00 @ 090
Then: CRA = −1.00 × 180 − (−)2.00 × 180
= +1.00 × 180
transposed
= +1.00 − 1.00 × 090
A Menicon Z (Nagoya, Japan) thin design can be fitted with the fol-
lowing parameters: 9.6/8.2 mm OAD/OZD; 7.89 mm (42.75 D) BCR;
and 0.11 mm CT. It is likely that this lens will flex and correct, at min-
imum, 50% of the residual astigmatism.
Spherical Soft Lenses

There is one situation in which a spherical soft lens is indicated. If the
patient’s spectacle Rx shows little to no refractive astigmatism, then
good visual acuity should be obtained with a soft lens. This is demon-
strated in the following example:
Example 9:
Keratometry = 42.00@ 090; 43.25 @ 180
Then: CRA= −0.25 × 090 − (−)1.25 × 090
= +1.00 × 090
transposed
= +1.00 − 1.00 × 180
In this example, the residual astigmatism for the soft lens wearer is equal
to the refractive astigmatism, or only −0.25 D. The use of a spherical soft
lens avoids the necessity of ordering a more expensive special design lens.
Soft Toric Lens

The improvements in optical quality, expanded lens parameter availabil-
ity, and, in most cases, disposable or frequent replacement modes have
made the soft toric lens the recommended option for most patients with
residual astigmatism. Two such examples are provided below:
Example 10:
(at corneal plane): −3.00 − 1.75 × 180
Keratometry = 43.00 @ 180; 43.75 @ 090
Then: CRA = −1.75 − (−)0.75 × 180 = −1.00 × 180
Example 11:
(at corneal plane): −3.00 − 0.75 × 180
Keratometry = 43.00 @ 180; 44.75 @ 090
Then: CRA = −0.75 − (−)1.75 × 180 = +1.00 × 180
Because soft toric lenses are most effective as the astigmatic power
decreases and are also available in planned replacement and dispos-
able lenses for cylinder powers between −0.75 to −2.00 D, these are
excellent cases for prescribing soft toric lenses as opposed to spherical

or toric GP lenses.
Front Surface Toric GP Lenses

Circular Prism Ballasted. The incorporation of prism into a GP lens
allows the patient’s residual cylinder to be ground onto the front surface
of the lens. The purpose of the prism is to stabilize the lens from pos-
sible rotational movement induced by the action of the lids. Circular
(nontruncated) prism-ballasted front surface toric lenses are recom-
mended for patients who have lower lids at or below the lower limbus,
those having a large palpebral aperture with loose lids, and for patients
experiencing comfort-related problems with truncated lenses.19
When fitting a patient with a significant amount of CRA, it is
preferable to fit a spherical GP lens to determine if the ARA is similar
to the CRA. If this is true, a prism-ballasted diagnostic lens is then rec-
ommended to more accurately evaluate the lens-to-cornea fitting rela-
tionship.19,20 Such a diagnostic set is provided in Table 11-1. Because of
the difference in mass, a prism-ballasted lens is more likely to decen-
ter inferiorly than a spherical lens. In addition, the prism of a ballasted
lens induces some cylindrical power such that if a spherical diagnostic
lens was used, the overrefraction might not be totally accurate.
If a diagnostic fitting set is available, although a steeper than “K” fit-
ting relationship has been recommended,1,20 an “on K” to slightly flat
base curve should allow for the lens to decenter and position on or near
the lower lid as desired. It is also important to assess the rotational effect
exerted by the lids. This effect varies because of factors such as the lid
configuration, location, tightness, and the forcefulness of the blink. As a
result of the natural alignment or symmetry of the superior lid, there is
a tendency for the lens to rotate nasally or excyclorotate. Tight lids and a
forceful blink may rotate the lens even more out of alignment. There are
several methods to assess lens rotation, including the following:
1. Slit-lamp beam rotation. Most slit lamps available today have a

degree marking on the base such that an optic section can be
aligned with the mark on the lens that corresponds to the prism
base and the number of degrees of rotation can be read directly
from the degree marking. This is an accurate and commonly
used method of determining rotation for soft toric and front sur-
face toric GP lenses.
2. Trial frame. The patient can wear a trial frame in combination
with a cylinder lens or any similar type of lens with marks or a
line to judge rotation. The marks on the spectacle trial lens can
be aligned with the prism base and the optical section beam, and
the degree reading can be read directly from the trial frame.
294
SECTION IV
Table 11-1 Circular Prism-Ballasted Diagnostic Lens Set

Base Curve OAD/OZD Power SCR/W PCR/W
40.50 D (8.33 mm) 9.2/8.0 mm −3.00 D 9.3/0.3 mm 11.3/0.3 mm
41.00 D (8.23 mm) 9.2/8.0 mm −3.00 D 9.2/0.3 mm 11.2/0.3 mm
41.50 D (8.13 mm) 9.2/8.0 mm −3.00 D 9.1/0.3 mm 11.1/0.3 mm
42.00 D (8.04 mm) 9.0/7.8 mm −3.00 D 9.0/0.3 mm 11.0/0.3 mm
42.50 D (7.94 mm) 9.0/7.8 mm −3.00 D 8.9/0.3 mm 10.9/0.3 mm
43.00 D (7.85 mm) 9.0/7.8 mm −3.00 D 8.9/0.3 mm 10.9/0.3 mm
43.50 D (7.76 mm) 9.0/7.8 mm −3.00 D 8.8/0.3 mm 10.8/0.3 mm
44.00 D (7.67 mm) 9.0/7.8 mm −3.00 D 8.7/0.3 mm 10.7/0.3 mm
44.50 D (7.58 mm) 8.8/7.6 mm −3.00 D 8.6/0.3 mm 10.6/0.3 mm
45.00 D (7.50 mm) 8.8/7.6 mm −3.00 D 8.5/0.3 mm 10.5/0.3 mm
45.50 D (7.42 mm) 8.8/7.6 mm −3.00 D 8.4/0.3 mm 10.4/0.3 mm
3. “Guesstimate.” A convenient but less accurate method is to simply

estimate the amount of rotation via observation. If this method is
used, the lens can be viewed as a clock with every “hour” of rotation
equal to 30 degrees. For example, if the mark on the right lens is at
5:30, it is rotated approximately 15 degrees.
After the amount of rotation has been determined by one of these

methods, the contact lens powers must be adjusted accordingly. If the
right lens is rotated 15 degrees nasally and the left lens is rotated 15
degrees nasally, then the LARS (left add, right subtract) principle is
used. In other words, the axis of the left lens is increased 15 degrees,
and 15 degrees is subtracted from the axis of the right lens to arrive at
the final lens cylinder and axis (Figure 11-1). On average, circular
prism-ballasted lenses rotate 10 to 15 degrees nasally on the eye.
The desired amount of prism to be incorporated into the lens is the
minimum amount that produces stabilization. For circular prism-
ballasted designs, Borish2 recommends using ³⁄₄ to 1䉭 for moderate
and high minus lenses and 1¹⁄₄ to 1¹⁄₂ 䉭 for low minus and plus lenses.
More prism is necessary for plus lenses because of a thinner edge.
For the same reason, more ballast may be necessary for smaller lenses,
in particular, low minus and plus power lenses.
An overall diameter similar to a spherical lens should be used. To
estimate the center thickness of a prism-ballasted lens, Borish2 uses
the following equation:
Center thickness × 100 = Prismatic power × Overall diameter
Figure 11-1. The “LARS” principle.

Therefore, if 1䉭 were used to stabilize a 9.0-mm diameter lens, 0.09

mm would have to be added to the conventional spherical center thick-
ness to obtain an estimate of the center thickness in prism-ballasted
form. If the conventional spherical center thickness for the indicated
(spherical equivalent) contact lens power were 0.15 mm, the center
thickness would equal 0.15 + 0.09, or 0.24 mm, in ballasted form.
A well-fitting lens will move slightly superiorly with blinking but
with little or no rotation, exhibiting a direct vertical movement (Figure
11-2). If the lens is decentered superiorly, as can occur with high minus
lenses, the amount of prism can be increased or the upper edge can be
thinned by using an anterior bevel cone tool and covering the rest of
the lens edge with tape.
When a desirable lens-to-cornea fitting relationship has been
achieved and an overrefraction through the ballasted sphere has
been performed, the lenses can be ordered. The calculations required
to arrive at the final parameters are illustrated in Example 12.
Figure 11-2. An optimally fitting front surface toric lens.

Example 12:
OD OS
Spectacle Rx = −1.50 − 1.00 × 090 −2.50 − 1.25 × 090
Keratometry = 43.25 DS 43.00 @ 090; 43.50 @ 180
Diagnostic lens = 43.00 DS; −3.00 D 42.75 DS, −3.00 D
(prism ballasted) (prism ballasted)
Slit-lamp evaluation: Inferior positioning with 1 mm lag after blink OU
Overrefraction: +1.25 − 1.50 × 090 +0.75 − 1.25 × 090
CL power: Dx lens power + overrefraction
= −3.00 + (+)1.25 − 1.50 × 090 −3.00 + (+)0.75 − 1.25 × 090
= −1.75 − 1.50 × 090 −2.25 − 1.25 × 090
Because the cylinder will be ground on the front surface of the lens in
plus cylinder form, the contact lens powers are transposed to:
= −3.25 + 1.50 × 180 −3.50 + 1.25 × 180
and, with compensation for lens rotation, becomes:
= −3.25 + 1.50 × 165 −3.50 + 1.25 × 015
The contact lens order can be written as follows:
OD OS
Base curve radius 43.50 D (7.76 mm) 42.75 D (7.89 mm)
CL power −3.25 + 1.50 × 165 −3.50 + 1.25 × 015
OAD/OZD 9.2/8.0 mm 9.2/8.0 mm
SCR/W 8.8/0.3 mm 8.9/0.3 mm
PCR/W 10.8/0.3 mm 10.9/0.3 mm
CT 0.24 mm 0.24 mm
Prism 1䉭 double-dot base 1䉭 dot base
Material Paragon HDS
The base of the prism on the right lens should be double dotted so
the patient can distinguish between the lenses. The center thickness
was derived from Borish’s equation and assumed a standard center
thickness of 0.15 mm for an approximate −2.50 to −3.00 D equivalent
power. Because these lenses are thick, a high-Dk GP material is rec-
ommended.
Truncated Prism-Ballasted. These lenses are indicated for patients
with normal-to-high positioning lower lids and upper lids at or near
the limbus.19 Many laboratories automatically or strongly encourage
truncating the bottom of the lens for the purpose of providing addi-
tional stability. If this is performed, the truncation should be inspected
to ensure it is well polished and therefore will not result in lens aware-
ness. Fortunately, truncation-induced awareness is rare and only
occurs if the truncation is not well polished or the upper lid picks up
the lens too superiorly during blinking.
A well-fitting truncated lens on the eye is shown in Figure 11-3. The
truncated area should align with the lower lid after blinking. The lens
should lift slightly with blinking, similar to a circular prism-ballasted
lens, and then settle in an inferior-central position.
The vertical diameter should equal a minimum of 8.8 mm to incor-

porate the necessary amount of prism and truncation. The horizontal
diameter should be approximately 0.5 mm larger than the vertical diam-
eter, and the optical zone diameter should be a minimum of 7.8 mm. The
optical zone should also be decentered superiorly by 0.5 mm to compen-
sate for the inferior positioning of this prism-ballasted truncated design.
Truncating a prism-ballasted lens reduces the ballast for minus
lenses and increases it for plus lenses. Therefore, when determining
the amount of prism, minus lenses actually need more ballast than
plus, the reverse of what is recommended for circular prism-ballasted
lenses. On diagnostic fitting, it may be observed that the nasal rotation
of the base is less than with circular prism-ballasted lenses. This is a
direct result of the combined action of prism and truncation. After the
diagnostic fitting of the patient in Example 12 with truncated lenses,
the contact lens order may instead be the following:
OD OS
Base curve radius 43.50 D (7.76 mm) 42.75 D (7.89 mm)
CL power −3.25 + 1.50 × 170 −3.50 + 1.25 × 010
OAD 9.4/8.9 mm 9.4/8.9 mm
OZD 7.8 mm 7.8 mm
SCR/W 8.8/0.3 mm 8.9/0.3 mm
PCR/W 10.8/0.3 mm 10.9/0.3 mm
CT 0.27 mm 0.27 mm
Prism 1.25 䉭 double-dot base 1.25 䉭 dot base
Material Boston EO
Figure 11-3. A prism-ballasted front surface toric lens.

Verification of the power of a prism-ballasted front surface toric

lens is accomplished similar to a spherical lens. The back surface of
the lens is placed against the lensometer stop similar to a spherical
lens. The lens is then rotated until the target mires exhibit maximum
base-down prism (i.e., positioned at axis 090 degrees). The sphere and
cylinder powers and the axis can be read directly from the lensometer.
Likewise, the amount of prism can be read with the lens centered on
the lens stop.19 Because the image of the lens may be degraded as a
result of aberrations, manufacturing defects, and increased center
thickness when compared with a spherical lens, Sarver1 has suggested
a method of reducing the lens top aperture: a hole of 3 to 4 mm is
drilled through a thin piece of opaque plastic, and the plastic is
attached to the face of the lensometer lens stop to decrease the periph-
eral aberrations.
The problems associated with prism-ballasted front surface toric
lenses include the following:
1. Blurred vision—particularly near vision—resulting from rotation
2. Lens awareness resulting from lens weight and truncation
3. Inferior decentration, possibly resulting in fluctuating vision,
dryness, and injection
4. Less than optimum optical quality
5. Because the front surface cannot be modified or the cylinder
power will be compromised, polishing and repowering cannot be
performed
6. If a prism-ballasted lens is fitted on one eye only, asthenopia can
result from a vertical imbalance. Low amounts of prism (0.75 to
1.00䉭) may be tolerated, but other options discussed in this
chapter should be considered for these patients
Because of these problems, GP front surface toric lenses should be
considered only when a patient is unable to wear or achieve satisfac-
tory vision from a spherical or soft toric lens. However, for a patient
who is a satisfied spherical GP lens wearer but who manifests a sig-
nificant amount of residual cylinder or either experiences rotational
problems with soft toric lenses or has a history of soft lens-induced
complications (i.e., giant papillary conjunctivitis [GPC], ulcerative ker-
atitis), front surface toric GP lenses are a viable option.
Periballast Lens
A periballast lens design is cut in lenticular form with a high minus
carrier. Two forms of this lens design are available. In one form, the
final lens is cut with no flange at the top, and the entire 1.0 to 1.3 mm
of flange is left at the bottom to achieve the ballast. In the other form,
the lens is manufactured such that a small amount of flange remains

at the top to provide a minus carrier effect.
The periballasted lens design provides an alternative solution to the
problems sometimes associated with the thickness of prism-ballasted
lenses because these lenses can be fabricated much thinner. The opti-
cal quality is improved, and a monocular fit is possible. The greatest
problem with the periballasted lens design is blurred vision resulting
from excessive rotation. In addition, lens awareness from the flange
irritating the lower lid is possible.
HIGH ASTIGMATISM
Whereas a small amount of corneal astigmatism is often favorable for
good centration of spherical lenses, a large amount (2.50 D or greater)
can easily have the reverse effect. As corneal cylinder increases, an
alignment fit becomes more difficult to achieve because the lens is not
parallel to the entire cornea but instead is often aligned with the flat-
ter meridian (i.e., horizontal in a with-the-rule cornea); the steeper
meridian has excessive clearance.
Soft toric lenses are an option for these patients; however, as the
refractive cylinder increases, any lens rotation on the eye will result in
an increase in cylinder induced by this axis misalignment, resulting in
mild-to-moderate compromise in vision.21 These designs have bene-
fited from advancements in manufacturing technology, greater param-
eter availability allowing for almost any cylinder power and axis to be
manufactured, and availability in frequent replacement and disposable
modalities. However, the latter modalities are typically reserved for rel-
atively low amounts of cylinder power (i.e., ≤ 2 D of refractive astig-
matism). In addition, if corneal distortion or irregular astigmatism is
present, a much better visual result can be attained with the selection
of a GP lens. A soft toric lens should be reserved for those astigmatic
patients who are highly motivated for soft lenses, have regular astig-
matism, and whose need for critical distance vision is not great.22
Therefore GP lenses play an important role in the correction of the
high astigmatism and, in fact, are often the lens of choice for visual
purposes. GP lens alternatives for those with high astigmatism
include spherical and aspheric lens designs but more commonly
include back surface toric and bitoric designs.
Spherical and Aspheric Lens Designs

For patients with ≥2.50 D of corneal astigmatism, it is not a bad idea to
initially diagnostically fit with a spherical GP lens, particularly if a bitoric
diagnostic fitting set is not available. The spherical lenses can be impor-
tant in evaluating lens centration and corneal alignment. If the patient
has myopia, a low-Dk (i.e., 25 to 50) lens material should be selected to

minimize flexure. The BCR will need to be slightly steeper than “K”
(often one third to one fourth the difference in corneal cylinder) to
achieve a well-centered interpalpebral lens-to-cornea fitting relationship.
In addition, the center thickness in minus powers should be, at mini-
mum, 0.02 mm thicker than in conventional designs used for low astig-
matic patients to reduce the effects of lens bending or flexure. This can
be confirmed via overkeratometry. If more than 0.50 D of toricity is pres-
ent via overkeratometry, a flatter BCR or bitoric design should be used.
Unfortunately, as corneal cylinder increases, it becomes increas-
ingly difficult for the lens to exhibit good centration. This can result in
patient symptoms of dryness and fluctuating vision accompanied by
corneal desiccation. In addition, even if good centration is present,
flexure-induced reduction in vision, corneal desiccation resulting from
excessive edge clearance, and lens rocking on the eye resulting in
corneal staining can occur.23 Likewise, the loss of alignment resulting
in an obvious meridian of bearing accompanied by a meridian of
excessive clearance (Figure 11-4) can result in excessive flattening and
possible corneal distortion in the meridian of bearing; this problem
can be accelerated if lens decentration is present.24,25
An aspheric lens design, in particular a progressive or biaspheric
design (not an aspheric periphery only), may exhibit slightly better cen-
tration and a less obvious astigmatic fluorescein pattern on highly
Figure 11-4. The fluorescein pattern of a spherical lens on a highly astigmatic cornea.
astigmatic patients. The borderline patients for bitoric lens designs,

notably the 2D to 3D corneal astigmat, can benefit from such a design.26
However, because of the limitations in effective optical zone often pres-
ent with these designs, it is imperative that good centration is present.
Back Surface Toric Lens Designs

Back surface (posterior or inside) toric lenses are designed to provide
an alignment fitting relationship for patients with a highly astigmatic
cornea. In other words, the back surface is “professionally warped” to
provide toric curves to approximate the curvature of the cornea in each
meridian. Manufacturers have used a procedure known as crimping to
bend the lens to effectively arrive at these curvatures; however, more
sophisticated toric-generated tools have resulted in more accurate back
surface and bitoric lens designs and better optical quality. Although
back toric lenses have the benefits of improved centration and an
alignment fitting relationship compared with spherical GP lenses, as
will be discussed, cylinder is induced with this design that often
results in compromised vision.
For fitting back surface toric and bitoric lens designs, there are many
different philosophies to determine the toric base curves.27-30 Typically,
these philosophies recommend a slightly flatter than “K” curvature in the
flatter meridian and an even greater amount of flattening in the steeper
meridian. The reason that the curvatures are selected flatter than the
respective keratometry (or simulated keratometry) values pertains to the
same reason a slightly flatter than “K” base curve is selected on a near
spherical cornea: because the cornea is aspheric, a slightly flatter base
curve (often 0.25 D flatter than “K”) will align with the progressive flat-
tening of the cornea from center to periphery. In addition, because the
ideal GP lens patient, from a corneal cylinder standpoint, is one exhibit-
ing a slight amount of corneal toricity to provide adequate tear exchange
from a slight rocking of the lens; this can be induced by selecting a BCR
in the steeper meridian equal to 0.75 to 1.00 D flatter than the curvature
value in that meridian. This is the basis of the Remba27 and Mandell-
Moore30 base curve philosophies. The latter will be used throughout the
remainder of this chapter. It is as follows:
Corneal cylinder Flat meridian Steep meridian
2.0 D “on K” 0.50 D flatter
2.5 D 0.25 D flatter 0.50 D flatter
To determine the BCRs and back vertex powers, Sarver’s1 formula

can be used:
F1s = F1 f + (Kf − Ks)
where F1s = the back vertex power of the contact lens in the steeper
principal meridian (in air); F1f = the back vertex power of the contact
lens in the flatter principal meridian (in air); Ks = the BCR of the con-
tact lens in the steeper principal lens meridian (expressed in diopters);
and Kf = the BCR of the contact lens in the flatter principal lens merid-
ian (expressed in diopters).
Example 13:
Spectacle Rx: +1.00 − 4.00 × 180
Keratometry: 41.00 @ 180; 45.00 @ 090
Spherical Dx lens: 42.00 D (8.04 mm)/−1.00 D
The diagnostic lens decentered inferiorly with minimal movement
and excessive vertical pooling of fluorescein. A back surface toric lens
design, using the Mandell-Moore method, would be as follows:
Kf = 41.00 + (−)0.25 = 40.75 D
Ks = 45.00 + (−)1.00 = 44.00 D
F1f = +1.00 + (+0.25 or lacrimal lens power correction) = +1.25 D
F1s = +1.25 + (40.75 − 44.00) = −2.00 D
An example of a back surface toric lens order for BCRs and powers in
this example are as follows:
Base curves: 40.75 D/44.00 D Power
(8.28 mm/7.63 mm) +1.25 D
Only the power determined in the flatter meridian (i.e., the most plus
power) should be ordered. Therein lies the major limitation to the use
of back surface toric lenses. The great majority of patients with high
astigmatism would not be able to achieve optimum visual acuity from
a back surface toric design because of the problem of induced cylinder.
A back surface toric GP contact lens in situ induces a cylinder in the
optical system (contact lens, fluid lens) designed to correct the
ametropia. This minus cylinder is a result of the difference between
the index of the contact lens (approximately 1.49 but depends on the
lens material) and the index of the tear lens (n = 1.336). The minus
cylinder axis will lie along the flatter principal meridian of the toric
back surface of the contact lens. This induced cylinder rarely corrects
and typically compounds the residual astigmatism.
When determining the changes in power induced by a back sur-
face toric GP lens, the following contact lens conversion factors are
important1,20:
1. From back surface lens toricity (measured with the radiuscope) to

contact lens cylinder power in air (measured with the lensome-
ter): multiply by 1.452 (or approximately 1.5)
2. From back surface lens toricity (measured with the radiuscope) to
the contact lens cylinder power measured in fluid (on the eye or
induced): multiply by 0.456 (or approximately 0.5)
3. From contact lens cylinder power in air (measured with the
lensometer) to the contact lens cylinder power in fluid (on the eye
or induced): multiply by 0.314 (or approximately one third)
4. From the contact lens cylinder power in fluid (on the eye or
induced) to the contact lens cylinder power in air (measured with
the lensometer): multiply by 3.19 (or approximately 3)
Because of the aforementioned values, this has been termed the

1:2:3 principle.31 Because the back surface cylinder of the back surface
toric lens will be known, the induced cylinder will be one half of this
value, and the amount of cylinder will three halves this value. These
values are, of course, assuming a refractive index of the material equal
to approximately that of PMMA (1.49). The actual induced cylinder is
less, especially with high-Dk polymers (n = 1.44 to 1.47) compared with
low-Dk polymers (1.47 to 1.48).32
Referring back to Example 13, the amount of back surface toricity in
the lens is 3.25 (i.e., 44.00 to 40.75); therefore “2” is known. The
amount of induced cylinder would be one half of this value or approxi-
mately −1.50 × 180. This should represent the amount of uncorrected
astigmatism in the back toric lens and would represent the amount of
the overrefraction that would be required to optimize visual acuity. The
amount of cylinder measured with the lensometer would be 1.5 × 3.25
or approximately −4.75 D. Because the flatter (most plus power) merid-
ian remains unchanged, the actual power measured with the lensome-
ter would be +1.25 D (power in flatter meridian) + (−)4.75 = −3.50 D.
Because −2.00 D is the desired power in the steeper meridian (see
Sarver’s equations in Example 13), essentially the patient would be
“overpowered” by −1.50 D in this meridian with a back surface toric lens
(Figure 11-5). If +1.50 × 180 is added to the front surface, the induced
cylinder is corrected, and the meridians will read +1.25 D/−2.00 D. The
patient should exhibit good vision. This is termed a bitoric lens because
of toric front surface powers and back surface curvatures.
A toric back surface lens therefore will generally increase the total
residual astigmatism present because it induces a minus cylinder at axis
180 on a with-the-rule cornea, whereas the residual astigmatism is gen-
erally against-the-rule. However, a back surface toric lens is the lens of
choice when the cornea toricity is against-the-rule, and the residual astig-
matism is approximately 0.452 times the 䉭K value of the back surface
toricity (i.e., if the patient has against-the-rule corneal and refractive astig-
If: keratometry 41.00 @ 180; 45.00 @ 090

refraction 1.00 4.00 180
Then (per Mandell-Moore), back surface toric design
40.75 @ 180; 44.00 @ 090
1. Induced cylinder (residual cylinder on eye)

2. Equals 1/2 of back surface (radiuscope) cylinder
1 or 1/2 3.50 approximately 1.75 180
1. Back surface (radiuscopic) cylinder

2 2. Equals 3.50 180
1. Cylinder power in air (lensometer)

2. Equals 3/2 times radiuscopic cylinder and
3 3/1 times induced cylinder or
3/2 3.50 approximately 5.25 180
3/1 1.75 approximately 5.25 180
Figure 11-5. The 1:2:3 principle.
matism and the refractive astigmatism equals approximately 1.5 times the
back surface cylinder). Example 14 illustrates how this can occur.
Example 14:
Spectacle Rx: Pl − 3.75 × 090
Keratometry: 42.00 @ 090; 44.75 @ 180
Design toric base curvatures: 41.75 @ 090; 44.00 @ 090
䉭K of back surface = 44.00 − 41.75 = 2.25 D
Induced cylinder = 0.5 × −2.25 = −1.12 or approximately −1.00 D
Residual astigmatism = refractive cylinder − corneal cylinder
= −3.75 − (−)2.75 = −1.00 × 090
Another use for back surface toric lenses would be if the lens selected has
an inside toricity of one third or less that of the corneal toricity.33 However,
this design defeats the purpose of toric fitting because such a lens may not
have enough toricity to properly align on the astigmatic cornea.
Bitoric Lens Designs

The primary purposes of a bitoric lens design are to correct for the cylin-
der induced by a back surface toric lens and to provide good visual acuity
and a satisfactory lens-to-cornea fitting relationship for patients with high

astigmatism by providing cylinder on the front surface to correct the
induced cylinder and, if present, any physiologic residual astigmatism.
Ease of Fitting
A misperception of bitoric lenses is that they are complicated and dif-
ficult to fit. A goal of this section is to emphasize that this does not
need to be the case, that, in fact, bitoric lenses are little different than
spherical GP lenses other than having two tear lens calculations (ver-
tical and horizontal meridians) as compared with one. In a survey of
Diplomates in the Cornea and Contact Lens Section of the American
Academy of Optometry, the respondents were asked to rate on a scale
of 1 (very easy to design and fit) to 5 (very difficult to design and fit)
how they would rate the design and fitting of back surface/bitoric
lenses.34 The results were:
1. 10.5%
2. 43.3%
3. 35.8%
4. 10.4%
5. 0.0%
In summary, 89.6% rated these lenses from very easy (1) to accept-
able (3). No respondent indicated that these designs were very difficult
to design and fit. In a separate survey of the Cornea and Contact Lens
Section Diplomates, on a 1 (not a benefit) to 5 (a very strong benefit)
scale, GP lenses were rated 4.34 and soft lenses were rated 3.07 as they
apply to patients with severe astigmatism.35
Optical Principles
In Example 13, it was demonstrated that if the induced cylinder is cor-
rected on the front surface of the lens, a bitoric lens design has been
created. This is further illustrated in Example 15.
Example 15:
Spectacle refraction: −1.75 − 3.00 × 180
(corneal plane): −1.75 − 2.75 × 180
Keratometry: 42.75 @ 180; 45.50 @ 090
CRA: −2.75 − (−)2.75 = 0
Base curve radii: 42.50 (7.94 mm) @ 180/45.00 (7.50 mm) @ 090
Lens powers (via Mandell-Moore): −1.50 D/−4.00 D
In this example, there is no CRA. If the induced astigmatism, which is
equal to approximately one half of the back surface toricity of the lens
or 0.5 × (−2.50 × 180) or −1.25 × 180, is corrected with corresponding
plus cylinder on the front surface (i.e., +1.25 × 180), a spherical power
effect is created. This lens can rotate any amount on the eye without
affecting vision because the corresponding vergence correction will be
present.33,36 Figure 11-6 illustrates the extreme case in which the lens
has rotated 90 degrees. However, it can be shown that the tear layer
will compensate, and the front surface cylinder correction will still
equal the new cylinder and axis of the induced cylinder.
Fitting Methods
Empirical Fitting. One of the roadblocks to bitoric success is the mis-
perception that bitoric lens design is too challenging for the practitioner,
especially determining the BCRs and powers. This is simply not true,
other than the aforementioned additional tear lens calculation. Methods
of calculating these values without the use of diagnostic lenses include
Mandell-Moore, computational, and optical cross.
Mandell-Moore. The Mandell-Moore Bitoric Lens Guide is an easy-
to-use resource for determining the BCRs and lens powers.30 Once the
spectacle refraction and keratometry readings are provided, this guide
incorporates the tear lens powers using the aforementioned fit factor.
It has been found to compare favorably in overall success to bitoric
Lens power Tear lens Vergence at

in air power corneal surface
5.00 0 5.00
Proper corneal 2.50 0 2.50

alignment
2.50 2.50 5.00
90 Lens 5.00 2.50 2.50

rotation
Figure 11-6. An example of how the principle of the “spherical effect” bitoric lens design works.
diagnostic fitting in a recent study.37 Essentially the vertexed power and

keratometry reading (or simulated value) is input per meridian. The fit
factor, which represents the tear lens correction for the amount of base
curve flattening, is then input. An example of a representative
Mandell-Moore guide and a blank one for future reference use are pro-
vided in Figures 11-7 and 11-8.
Figure 11-7. Mandell-Moore guide (example).

Figure 11-8. Mandell-Moore guide (blank).

A pad containing Mandell-Moore Bitoric Lens Guide forms is avail-

able from the RGP Lens Institute (www.rgpli.org). This is an excellent
empirical method for determining BCRs and powers.
Computational. As illustrated in Example 13, the computational
method, via Sarver,1 is also beneficial in determining bitoric lens pow-
ers and BCRs. This can be illustrated in the following example:
Example 16(a):
Refraction (at corneal plane): −2.00 − 3.00 × 180
Keratometry: 42.00 @ 180; 45.00 @ 090
Calculate residual cylinder: Spectacle cylinder − corneal cylinder
= −3.00 × 180 − (−)3.00 × 180 = 0
Select BCRs (via Mandell-Moore):
Kf = 42.00 − (+)0.25 = 41.75 (8.08 mm) @ 180
Ks = 45.00 − (+)0.75 = 44.25 (7.63 mm) @ 090
Calculate back vertex powers:
Ff = −2.00 + (+)0.25 = −1.75 D
Fs = Ff + (Kf − Ks) = −1.75 + (41.75 − 44.25) = −4.25 D
Final powers/BCR: −1.75 D/8.08 mm; −4.25 D/7.63 mm
Another relatively simple method related to the above is the acronym
SAM-FAP for steep add minus–flat add plus. In other words, if both
meridians are being fitted with BCRs flatter than “K,” the correspon-
ding amount of plus can be added to the refractive power at the corneal
plane in each meridian.
Optical cross method. Another method of empirically determining
bitoric lens powers and BCRs is via the use of optical crosses. This is
illustrated in the following example:
Example 16(b):
Refraction (at corneal plane): −2.00 − 3.00 × 180
Keratometry: 42.00 @ 180; 45.00 @ 090
0.75
5.00
0.25
42.00 2.00
45.00
4.25 D
Final lens powers and BCRs: 41.75 1.75 D
44.25
The BCRs determined by any of these methods should be verified as

ordered with the radiuscope. Likewise, the lens powers should be ver-
ified as ordered. The practitioner should not have to calculate the
induced cylinder. It is the responsibility of the fabricating laboratory to
compensate for the back surface toricity and provide the ordered pow-
ers, which in Example 16 are equal to −1.75 D and −4.25 D.
Diagnostic Fitting. Diagnostic fitting with bitoric lenses makes fit-
ting these lenses as easy as fitting spherical GP lenses. In other words,
it simply requires selecting the indicated lens, performing a spherical
overrefraction, and adding this to the diagnostic lens powers for the
final order. The benefit of diagnostic fitting is the opportunity to achieve
an optimum fitting relationship and powers to help ensure future suc-
cess. Many Contact Lens Manufacturer Association (CLMA) member
laboratories have bitoric lens fitting sets for loan or purchase.
A popular representative bitoric fitting set is the Polycon II SPE (i.e.,
“spherical power effect”) diagnostic set available from Ciba Vision
Corporation (Duluth, GA). These 10-lens diagnostic fitting sets are avail-
able with 2 D (recommended for <3 D of corneal cylinder), 3 D (recom-
mended for 3 to 5 D of corneal cylinder), and 4 D (recommended for >5 D
of corneal astigmatism). Excellent success rates have been achieved with
this design with visual acuity equal to or better than that obtained with
the best spectacle correction.38-40 The 3 D bitoric diagnostic fitting set is
recommended for most fits. These lenses have powers of Pl/−3.00 D
with BCRs available from 40.50/43.50 to 45/48 in 0.50 D steps
(i.e., 40.50/43.50; 41/44; 41.50/44.50; 42/45; 42.50/45.50; 43/46;
43.50/46.50; 44/47; 44.50/47.50; and 45/48). The induced cylinder is
already incorporated into the lens.
To initiate the fitting process, an SPE diagnostic lens should be
selected that is 0.12 to 0.50 D flatter than “K.” Because these lenses are
in 0.50-D steps, there will only be one lens in the fitting set that meets
this criterion. To obtain the final power, it is as simple as performing
a spherical overrefraction and adding this value to both diagnostic lens
powers (i.e., Pl/−3.00 D). This is illustrated in Example 17:
Example 17:
Spectacle Rx: −0.50 − 3.00 × 180
Keratometry: 42.25 @ 180; 45.25 @ 090
Diagnostic lens: BCR: 42/45 Pl/−3.00 D
Slit-lamp evaluation: Alignment fluorescein pattern and good
centration
Overrefraction: −0.25 DS 20/20+2
Final order: BCR = 42 (8.04 mm)/45 (7.50 mm)
Powers = −0.25 D/−3.25 D
Boston ES bitoric
In this example, although a Polycon II lens was used for the diagnostic
fitting, a higher-Dk lens material was used to meet the corneal oxygen
demands for a daily-wear lens patient with myopia (i.e., Dk = 25 to 50).
In addition, because there was an absence of residual astigmatism, a
spherical overrefraction is not unusual. As with spherical GP diagnos-
tic lenses, if there is little residual astigmatism (typically <0.75 D), it
may not reduce the patient’s visual acuity significantly and therefore
would not need to be incorporated into the final lens powers.
When a spherical overrefraction results in less than optimum visual
acuity, however, it is likely the residual astigmatism is significant
and—as with a spherical diagnostic lens—a spherocylindrical over-
refraction needs to be performed. When this occurs, a cylinder power
effect (i.e., incorporates induced and residual astigmatic corrections;
CPE) lens design is indicated. Determining the powers for a CPE
bitoric lens is a little more challenging than an SPE design. It can be
summarized as follows:
1. Select the recommended SPE diagnostic lens.
2. Perform a spherical overrefraction; if visual acuity is significantly
reduced, a spherocylindrical overrefraction is indicated.
3. Finally, add the overrefraction in a given meridian to the diag-
nostic lens power in the same meridian.19
Representative CPE bitoric cases are provided in Examples 18 and 19:
Example 18:
Spectacle Rx: +1.00 − 4.00 @ 180
Keratometry: 42.00 @ 180; 45.00 @ 090
Diagnostic Polycon SPE lens: 41.50/44.50 Pl/−3.00 D
Overrefraction (sphere): +1.25 DS 20/25−1
Overrefraction (spherocylindrical): +1.50 − 1.00 × 180 20/20+1
Add the overrefraction to the corresponding power in the diagnostic
lens.
To obtain the final lens powers:
180-degree meridian: +1.50 + plano = +1.50 D
090-degree meridian: [+1.50 + (−)1.00] + (−)3.00 = −2.50 D
Final order: 41.50 (8.13 mm)/44.50 (7.48 mm) +1.50/−2.50 D
Material: Fluoroperm 60
Example 19:
Spectacle Rx: +1.00 − 3.00 @ 180
Keratometry: 42.00 @ 180; 46.00 @ 090
Diagnostic Polycon SPE lens: 41.50/44.50 Pl/−3.00 D
Overrefraction (sphere): +1.25 DS 20/25−1
Overrefraction (spherocylindrical): +2.50 − 1.00 × 090 20/20+1

Add the overrefraction to the corresponding power in the diagnostic lens.
To obtain the final lens powers:
180-degree meridian: [+2.50 + (−1.00)] + plano = +1.50 D
090-degree meridian: +2.50 + (−)3.00 = −0.50 D
Final order: 41.50 (8.13 mm)/44.50 (7.48 mm) +1.50/−0.50 D
Material: Fluoroperm 60
The important difference between an SPE and a CPE lens design is the
absence of a spherical power effect with the CPE lens. In other words,
if this lens rotates, the residual astigmatic correction will rotate as well,
potentially resulting in compromised vision. Fortunately, because of
the high amount of corneal toricity, the lens tends to lock into the
respective meridians, and rotational effects are rarely encountered. A
CPE bitoric lens is recommended whenever the residual astigmatism
is such that vision is compromised.
Verifying a bitoric lens is straightforward. The BCRs will have the
appearance of a warped lens via verification with a radiuscope. The
lens can be rotated until one part of the spoke image is in focus; after
recording this value, the value obtained when the spoke image 90
degrees away comes into focus should be recorded. When verifying the
powers with the lensometer, the same principle is true. The lens
should be rotated until one line image comes into focus, and this
power should be recorded. To obtain the second power reading, the
power wheel should then be turned until the perpendicular line image
comes into focus.
Bitoric Lens Material and Design Parameters. In addition to BCRs
and powers, other factors to consider include 1) lens material, 2)
peripheral curve radii (PCRs), and 3) center thickness.
Lens Material. The GP lens material for a bitoric lens design should
be equivalent to that of a spherical design. A high-Dk (i.e., 51 to 100)
or hyper-Dk (i.e., >100) material is recommended for plus powers and
extended and flexible wear; a low-Dk (i.e., 25 to 50) material is recom-
mended for daily-wear lens patients with myopia.
Peripheral Curve Radii. Either spherical or toric PCRs can be
ordered. The author’s philosophy is when the corneal toricity is ≥4 D,
toric PCRs should be used. These are necessary to minimize the
potential for peripheral seal-off in one meridian accompanied by
excessive clearance in the other meridian. To obtain these values, 1
mm can be added to BCRs to determine the secondary curve radii
(SCRs), and an additional 2 mm can be added for the PCRs. When the
toricity is <4 D, spherical PCRs can be used. To accomplish this, take
the mean of the BCRs and add 1 mm for the SCR and an additional 2
mm for the PCR. These are illustrated in Examples 20 and 21.
Example 20:
Keratometry: 42.00 @ 180; 45.00 @ 090
BCR: 41.75 (8.08 mm)/44.25 (7.63 mm)
Determine mean BCR: 43.00 D (7.85 mm)
SCR/W: Mean BCR + 1 mm = 8.85 (rounded to 8.9 mm)/0.3 mm
PCR/W: SCR + 2 = 8.9 + 2 = 10.9/0.3 mm
Final order: BCR: 8.08/7.63 mm
SCR/W: 8.9/0.3 mm
PCR/W: 10.9/0.3 mm
Example 21:
Keratometry: 42.00 @ 180; 47.50 @ 090
BCR: 41.75 (8.08 mm)/46.25 (7.30 mm)
SCR/W: BCR + 1 mm = 8.08 + 1 = 9.08 (rounded to 9.1)/0.3 mm;
7.30 + 1 = 8.3/0.3 mm
PCR/W: SCR + 2 = 9.1 + 2 or 11.1/0.3 mm; 8.3 + 2 = 10.3/0.3 mm
Final order: BCR: 8.08/7.30 mm
SCR/W: 9.1/8.3 @ 0.3 mm
PCR/W: 11.1/10.3 @ 0.3 mm
Another option that has been recommended for patients in whom the
corneal cylinder is relatively low (i.e., 1.50 to 2.25 D) but a spherical GP
lens does not exhibit optimum centration is to use a spherical BCR but
toric peripheral curves. Using a similar formula as above, 1 mm could
be added to both keratometry values for the toric SCRs; an additional
2 mm could be added for the toric PCRs. This is described in the fol-
lowing example:
Example 22:
Keratometry: 42.00 (8.04 mm) @ 180; 44.00 (7.67 mm) @ 090
BCR: 42.50 (7.94 mm)
Toric SCR: 8.04 (rounded to 8.00) + 1 = 9.00 mm; 7.67 (rounded to
7.70 mm) + 1 = 8.7 mm
Toric PCR: 9.00 + 2 = 11.00 mm; 8.7 + 2 = 10.7 mm
Whenever toric BCRs are used with a spherical BCR, an oblique opti-
cal zone diameter will result (Figure 11-9).
Center Thickness. Because bitoric lenses are thin lens designs, the
center thickness of a bitoric lens is equal to the center thickness of a
spherical lens in the most plus power meridian. For example, if the
bitoric lens powers were −3.00/−6.00 D, the center thickness of a
spherical lens with a power of −3.00 D in the material being used
should be ordered.
Additional Considerations. Other considerations include the highly
astigmatic cornea and oblique or irregular astigmatism.
Figure 11-9. Elliptical optical zone created by toric peripheral curves.
Highly Astigmatic Corneas. Another situation that may be encoun-

tered is the patient with extremely severe astigmatism for whom the
diagnostic lenses do not provide sufficient toricity. The resulting fluo-
rescein pattern is slightly-to-moderately astigmatic instead of in align-
ment. When this occurs, the diagnostic fitting can proceed as provided
in Examples 17 to 19. Once the overrefraction has been performed and
the powers determined, the steeper meridian can be designed even
steeper to increase the amount of lens toricity to provide a better fitting
relationship. A corresponding amount of minus power can then be
added to the power in that meridian to arrive at the final power in the
steeper meridian. This is demonstrated in Example 23.
Example 23:
Spectacle Rx: −4.00 − 6.00 × 180
(corneal plane): −3.75 − 5.25 × 180
Keratometry: 41.75 @ 180; 47 @ 090
Polycon 3 D SPE Dx lens: 41.50/44.50 Pl/−3.00
Overrefraction: −3.50 DS 20/20 (fluctuates)
Powers: (add OR to Dx lens powers) −3.50/−6.50 D
Slit-lamp evaluation: Lens decenters slightly inferiorly; excessive vertical
clearance and horizontal bearing
Solution: Steepen vertical meridian 1 D to 45.50, and add 1 D minus
to the power in that meridian = −6.50 + (−)1.00 = −7.50 D
Final order: 41.50 (8.13 mm)/45.50 (7.42 mm) −3.50/−7.50 D
Irregular Astigmatism. Bitoric lenses are rarely successful for
patients with irregular astigmatism, notably when the refractive
cylinder axis and corneal cylinder axis differ by ≥ 15 degrees. In par-
ticular, bitoric lenses are not recommended for patients with condi-
tions such as keratoconus, in which the corneal curvature varies
greatly in different regions of the cornea.41 Bitoric lenses exhibit

their greatest success for patients with regular astigmatism, in which
the steep and flat meridians are separated by approximately 90
degrees and the steep and flat meridians of the lens can align
accordingly.
SUMMARY
Bitoric GP lens designs should be the lens of choice for patients with
severe astigmatism. These designs have been found to not only con-
sistently demonstrate improved visual acuity as compared with that
obtained with the best spectacle correction but also as compared with
spherical rigid lenses.42 Table 11-2 shows the results provided by
Diplomates in the Cornea and Contact Lens Section of the American
Academy of Optometry pertaining to various refractive errors and
which lens modality (i.e., soft toric, spherical GP, back surface toric
GP, SPE bitoric, or CPE bitoric) they would customarily fit in this case,
knowing that this can be influenced by numerous other variables.34
The first two cases are patients with 1 and 2 D of corneal cylinder who
would be good candidates for either soft toric or spherical GP lenses,
and the results show parity between these two options. The third
Table 11-2 Cornea and Contact Lens Section of the AAO Lens Preference
Question: Assuming the following patients are first-time contact lens wearers
who you find to be good contact lens candidates and exhibit no preference for
contact lens type, which one of the following contact lens options would you
recommend?
Case 1: −1.00 −1.00 × 180; 43 @ 180; 44 @ 090
Case 2: −1.00 −2.00 × 180; 42 @ 180; 44 @ 090
Case 3: −1.00 −3.50 × 180; 42 @ 180; 45.25 @ 090
Case 4: −1.00 −3.50 × 180; 42 @ 180; 44 @ 090
Case 5: −1.00 −3.50 × 180; 42 @ 180; 46.50 @ 090
PREFERENCES
Back Surf. SPE CPE
Soft Toric Sph. GP Toric GP Bitoric Bitoric
Case 1: 52.9% 47.1% 0.0% 0.0% 0.0%
Case 2: 42.6% 44.1% 3.0% 10.3% 0.0%
Case 3: 14.7% 10.2% 11.7% 58.8% 4.4%
Case 4: 32.4% 2.9% 22.0% 5.9% 36.8%
Case 5: 20.5% 0.0% 11.8% 11.8% 55.9%
From Blackmore K, et al.34
Box 11-1 GP TORIC EDUCATIONAL RESOURCES

●
Ciba Vision Corporation: Polycon II SPE Fitting Set
●
AOA Contact Lens Section web site: www.aoanet.org
●
GP Product Directory (list of CLMA member laboratories and the lens
designs they fabricate): www.rgpli.org
●
GP Lens Management Guide (fitting specialty patients including those
requiring bitoric lenses): www.rgpli.org
●
Advanced GP Fitting (videotape): www.rgpli.org
patient has a 3.25 D corneal astigmatism with no residual astigmatism,

making an SPE bitoric lens a viable option, which was also the con-
clusion of the respondents. Cases 4 and 5 would result in some resid-
ual astigmatism, making a CPE bitoric lens a viable option, and it was
the first selection for both patients.
There are many resources available for GP toric education. These
are summarized in Box 11-1. With the increasing quality of toric lens
fabrication from GP lens laboratories, and the benefits provided—
specifically, improvements in the fit and the quality of vision as com-
pared with other options—bitoric GP lenses are an excellent option for
patients with severe astigmatism.
REFERENCES
1. Mandell RB, editor: Contact lens practice, ed 4, Springfield, IL, 1998, Charles C.
Thomas Pub, pp 265-283.
2. Borish IM: Clinical refraction, vol 2, Chicago, 1975, Professional Press.
3. Bailey NJ: Residual astigmatism with contact lenses: part 3. Possible sites, Rev
Optom 98(3):31-32, 1961.
4. Harris MG: Contact lens flexure and residual astigmatism on toric corneas, J Am
Optom Assoc 41(3):247-248, 1970.
6. Corzine JC, Klein SA: Factors determining rigid contact lens flexure, Optom Vis Sci
74(8):639-645, 1997.
7. Lin M, Snyder AC: Flexure and residual astigmatism with RGP lenses of low,
medium and high oxygen permeability, Int Contact Lens Clin 26(1):5-8, 1999.
8. Pole JJ: The effect of the base curve on the flexure of Polycon lenses, Int Contact
Lens Clin 10(1):49-52, 1983.
9. Sarver MD: The effect of contact lens tilt upon residual astigmatism, Am J Optom
40(12):730-744, 1963.
10. Ellerbrock VJ: The role of toric surfaces in contact lens practice, Am J Optom
40(8):439-446, 1963.
11. Goldberg JB: Clinical application of toric base curve contact lenses, Optom Weekly
53(39):1911-1915, 1962.
12. Korb DR: A preliminary report on toric contact lenses, Optom Weekly 51(48):2501-
2505, 1960.
13. Sarver MD: A study of residual astigmatism, Am J Optom 46(8):578-582, 1969.
14. Dellande WD: A comparison of predicted and measured residual astigmatism in
corneal contact lens wearers, Am J Optom 47(6):459-463, 1970.
15. Kratz JD, Walton WG: A modification of Javal’s rule for the correction of astig-
matism, Am J Optom 26(7):295-306, 1949.
16. Carter JH: Residual astigmatism of the human eye, Optom Weekly 54(27):1271-
1272, 1963.
17. Mandell RB: Corneal contour and contact lenses. Presented at the Annual
Meeting of the American Academy of Optometry, December 1963, Chicago.
18. Salmon T: Beneficial flexure-using thin RGPs to correct residual astigmatism,
Contact Lens Spect 7(8):39-42, 1992.
19. Silbert JA: Rigid lens correction of astigmatism. In Bennett ES, Weissman BA,
editors: Clinical contact lens practice, Philadelphia, 1990, Lippincott Williams
& Wilkins, pp 40-1 to 40-24.
20. Bennett ES, Blaze P, Remba MR: Correction of astigmatism. In Bennett ES,
Henry VA, editors: Clinical manual of contact lenses, ed 2, Philadelphia,
2000, Lippincott Williams & Wilkins, pp 351-409.
21. Myers RI, Jones DH, Meinell P: Using overrefraction for problem solving in soft
toric fitting, Int Contact Lens Clin 17:232-235, 1990.
22. Snyder AC: Evaluation of “high-cylinder” toric soft contact lenses, Int Contact
Lens Clin 160-164, 1997.
23. Henry VA, Bennett ES: Contact lenses for the difficult-to-fit patient, Contact Lens
Forum 14:49-68, 1989.
24. Wilson SE, Lin DTC, Klyce SD, et al: Topographic changes in contact lens-
induced corneal warpage, Ophthalmology 97:734-744, 1990.
25. Wilson SE, Lin DTC, Klyce SD, et al: RGP decentration: a risk factor for corneal
warpage, CLAO J 16:177-183, 1990.
26. Seibel DB, Bennett ES, Henry VA, et al: Clinical evaluation of the Boston
Equacurve, Contact Lens Forum 13:39, 1988.
27. Remba MJ: Contact lenses and the astigmatic cornea, Rev Optom 99(24):25-30,
1962.
28. Barr J: Toric gas-permeable hard contact lens design, Int Contact Lens Clin
11(11):652-653, 1984.
29. Edwards KH: The calculation and fitting of toric lenses, Ophthal Optician 16:106-
114, 1982.
30. Mandell RB, Moore CF: A bitoric guide that is really simple, Contact Lens Spect
3:83-85, 1988.
31. Neefe CW: Prescribing torics: easy as 1:2:3, Contact Lens Forum 6(3):59-65, 1981.
32. Quinn TG: Astigmatism. In Bennett ES, editor: Contact lens problem solving, St.
Louis, 1995, Mosby, pp 83-108.
33. Grosvenor TP: Optical principles of toric contact lenses, Optom Weekly 67(2):37-
39, 1976.
34. Blackmore K, Bachand N, Bennett ES, et al: Survey of the Cornea and Contact
Lens Diplomates of the American Academy of Optometry regarding GP
toric fitting trends, Optometry (submitted).
35. Bennett ES: Will GP lenses be obsolete in 2010? Presented at the Annual
Meeting of the American Academy of Optometry, December 2002, San
Diego.
36. Bergenske PD: A recipe for SPE, Contact Lens Spect 16(2):15, 2001.
37. Pitts K: Putting a bitoric RGP lens fitting guide to the test, Contact Lens Spect
16(10):34-40, 2001.
38. Sarver MD, Kame RT, Williams CT: A bitoric rigid gas permeable contact lens
with spherical power effect, J Am Optom Assoc 56:184-189, 1985.
39. Kame RT, Hayashida JK: A simplified approach to bitoric gas permeable lens fit-
ting, Int Contact Lens Clin 15:53-58, 1988.
40. Weissman BA, Chun MW: The use of spherical power effect bitoric rigid contact
lenses in hospital practice, J Am Optom Assoc 58:626-630, 1987.
41. Shovlin JP: Bitoric RGPs for keratoconus? Rev Optom 138(1), 2001.
42. Kajita M, Ito S, Yamada A, et al: Diagnostic bitoric rigid gas permeable contact
lenses, CLAO J 25(3):163-166, 1999.
appendix
11-1
Bitoric Case Grand Rounds
CASE ONE
Patient Information
A 23-year-old law student desires new spectacles because vision is not
great with current glasses; the patient has been an 8-year GP lens
wearer (approximately 10 h/day).
Lid-to-Cornea Relationship
Upper lid overlaps superior limbus by 1 mm.
Refractive Data
●
Refraction: OD: −2.25 −4.00 × 180 20/20
OS: −2.75 −4.25 × 180 20/20
●
Keratometry: OD: 44.00 @ 180; 47.50 @ 090
OS: 43.50 @ 180; 47.00 @ 090
Empirical Fitting: Mandell-Moore

1) What are the BCRs?
Using the fit factor, the flat meridian is fit 0.25 D flatter
●
than “K” or 43.75 D (OD) and 43.25 D (OS); the steep

meridian is fit 0.75 D flatter than “K” or 46.75 (OD) and
46.25 (OS).
2) What are the predicted powers?
Because a minus tear lens is being created via a flat base
●
curve, plus power needs to be added to the refractive power

at the corneal plane; therefore +0.25 is added to (−)2.25, and
+0.75 is added to −5.75 (the vertical meridian power of −6.25
at the corneal plane) for the right eye, or −2.00/−5.00 D.
With the same tear power calculations applied to the left
eye, the powers are −2.50/−5.50 D.
Diagnostic Fitting (Polycon SPE)

1) What diagnostic lenses should be fit?
●
Selecting the lenses that are 0.12 to 0.50 D flatter than “K”:
321
= OD: 43.50 D (7.76 mm)/46.50 D (7.26 mm) Pl/−3.00 D

= OS: 43.00 D (7.85 mm)/46.00 D (7.34 mm) Pl/−3.00 D
2) If the overrefraction is −1.75 DS OD and −2.25 DS OS, what are
the final powers (assuming an acceptable fitting relationship)?
●
Adding −1.75 to the diagnostic lens powers OD and −2.25 D
to the diagnostic lens powers OS results in the following:
−1.75/−4.75 D OD; −2.25/−5.25 D OS
3) What lens material should be ordered?
●
Low-Dk fluoro-silicone/acrylate (F-S/A)
4) What about center thickness?
●
Equal to spherical lens of more plus power meridian
(approximately 0.16 mm)
5) What about overall diameter?
●
Same as spherical (9.4 mm)
6) What about peripheral curves?
●
With <4 D of lens toricity, use spherical PCRs
●
Add 1 and 3 mm to mean BCR
●
Mean BCR = 45 D (7.50 mm) OD; 44.50 (7.58 mm) OS
●
PCs = 8.50 mm and 10.50 mm OD; 8.60 mm and
10.60 mm OS
CASE TWO
Patient Information
A 16-year-old spectacle wearer has been wearing soft toric lenses for
sports.
Lid-to-Cornea Relationship
Upper lid overlaps superior limbus by 1 mm.
Refractive Data
●
Refraction: OD: +0.75 − 5.75 × 180 20/20
OS: +1.00 − 5.75 × 180 20/20
●
Keratometry: OD: 41.50 @ 180; 47.00 @ 090
OS: 41.50 @ 180; 47.00 @ 090
●
Grade 2 papillary hypertrophy OU
●
Vascularization × 2 mm inferiorly OU

1) What diagnostic lenses should be fit?
●
Selecting the lenses that are 0.12 to 0.50 D flatter than “K”:
Appendix 11-1 Biotoric Case Grand Rounds 323
= OU: 41.00 D (8.23 mm)/44.00 D (7.67 mm) Pl/−3.00 D

2) If OR = +1.25 DS OD and +1.50 DS OS, what are the powers to
order?
●
OD: +1.25/−1.75 OS: +1.50/−1.50
3) What would be the fluorescein pattern?
●
Mild dumbbell pattern OU
4) What changes would you make in BCR to optimize the fitting
relationship?
●
Steepen steeper curve and add minus; for example, change
to 41.00 (8.23 mm)/45.00 (7.50 mm) and add 1 D to steeper
meridian power
5) What would be the final lens powers?
●
OD: +1.25/−2.75; OS: +1.50/−2.50 D
6) What peripheral curves would you order?
●
If ≥ 4 D of corneal toricity, add 1 mm and 3 mm to each base
curve
●
Toric SCR/PCR = 9.2/8.5 mm; 11.2/10.5 mm OU
CASE THREE
Patient Information
A 19-year-old male college student had symptoms of eyestrain, partic-
ularly after prolonged reading; he has been a spherical GP lens wearer
for 4 years.
Visual Acuity Through Current GP Lenses

●
OD: 20/25 −2; OS: 20/25 − 1
Overrefraction Over Current GP Lenses

●
+0.25 − 1.00 × 090 20/20+2 OU
Refractive Data
●
Refraction: −0.50 − 2.00 × 180 OU 20/20
●
Keratometry: 42.00 @ 180; 45.00 @ 090 OU
●
Inferior decentration; dumbbell fluorescein pattern OU

1) What SPE diagnostic lenses to use?
●
41.50/44.50 Pl/−3.00 D OU
2) If OR = +1.00 − 1.00 × 090 20/20, what are the final powers?
●
Pl/−2.00 D
12
Presbyopia: Gas Permeable Bifocal
Fitting And Problem-Solving
EDWARD S. BENNETT
DAVID HANSEN
erhaps the best kept secret with gas permeable (GP) lenses is the
P availability, applications, and benefits of bifocal and multifocal

lens designs. Multifocal lens designs are typically aspheric.
These are thin designs that typically progress in near power from the
center to the periphery of the lens. They primarily use simultaneous
vision in which multiple foci (i.e., near, intermediate, and distance
powers) are in front of the pupil simultaneously. Bifocal lenses are
almost exclusively translating designs in which the upper section (i.e.,
via crescent, executive, or annular shape) of the lens is for distance
vision and the lower section is for near vision. These are prism bal-
lasted and are successful via their ability to shift superiorly or translate
with superior gaze. It is evident that GP multifocal and bifocal lens
designs represent the area for greatest potential growth. With almost
80 million people in the United States who have reached presbyopia
in recent years, this cohort can be a great source of multifocal contact
lens patients. However, only 1 million people with presbyopia wear
some form of presbyopic contact lens correction, which represents
only 3% of contact lens wearers.1,2 Of these contact lens wearers with
presbyopia, 70% wear a monovision correction.
The low usage of GP bifocal and multifocal lens designs and con-
tact lens presbyopic designs in general is most likely the result of sev-
eral factors. These designs are perceived as being complicated or
challenging to fit. This “practitioner apprehension” has often resulted
in opting for an easier solution, such as monovision correction, single-
vision contact lenses in combination with reading glasses, or specta-
cles only.3 This would be acceptable if the bifocal option was presented
to patients, and if interested, they would be referred to practitioners
who fit specialty GP lenses. Unfortunately, it is not uncommon for
patients to be told, “Bifocals lenses do not work”; “Yes, you will be fit
324
Chapter 12 Presbyopia: Gas Permeable Bifocal Fitting And Problem-Solving 325
into bifocal lenses” (and then are fit with monovision correction); or
“There really is no such thing as bifocal contact lenses.” However, it is
important to emphasize that when the 50-member Advisory
Committee of the RGP Lens Institute was surveyed as to how many
fits did it take for them to become comfortable with any specific GP
bifocal or multifocal lens design, the most common response was
three.4
Certainly, GP bifocal and multifocal lenses are not going to be suc-
cessful if this option is not presented to patients. A pertinent example
is a recent study in which 160 non–contact lens-wearing subjects were
divided equally into “reactive” and “proactive” groups.5 The reactive
group was not presented with contact lenses as a corrective option
unless initiated by the patient. With the proactive group, contact lenses
were actively discussed as a vision correction option, and the patient
was invited to try them. Only 9 of 80 patients in the reactive group
were fit into contact lenses, whereas 46 of 80 patients of the proactive
group—including 21 of 33 patients with presbyopia—were fit into con-
tact lenses. Therefore this would represent a 6.3-fold increase in
contact lens wearers. This is especially important with GP bifocal and
multifocal lens designs because the visual freedom (i.e., absence of or
limited need for spectacles) is a powerful benefit if patients are aware
of this option and the practitioner is motivated to provide it. GP bifo-
cal and multifocal wearers can be among the most satisfied patients,
and because they represent an age cohort that is at the high end of
earnings potential, the income generated by a GP bifocal practice can
be increased by fitting these patients and the patients who are referred
to the practice. The success rate of GP bifocal and multifocal lens
designs is high with several studies resulting in a success rate of 75%
or greater.6-10 In addition, if GP multifocal lenses are fit to patients who
are wearing another mode of contact lens, it has been found that 86%
prefer the multifocal correction.11 Likewise, in a study in which
patients with presbyopia were randomized into wearing GP monovi-
sion lenses for 6 weeks and then a GP multifocal lens (or vice versa),
75% preferred the multifocal lens.12 In addition, they rated the overall
satisfaction and visual adaptation significantly higher with the multi-
focal lens. It is apparent that GP multifocal and bifocal lens use is
increasing and represents a large potential area of growth in the con-
tact lens industry. A trend toward bifocal and multifocal GP lens fitting
and away from monovision correction was demonstrated in a recent
survey of the Cornea and Contact Lens Diplomates of the Academy of
Optometry13 as compared with a 1998 survey.14 It is also evident that
leading contact lens practitioners tend to position bifocal and multifo-
cal GP lenses first and monovision correction second.15 The goal of
this chapter is to present the various GP corrective options for patients

with presbyopia with an emphasis on the patient selection, prelimi-
nary evaluation, lens design, fitting, and problem-solving of GP multi-
focal and bifocal lens designs.
OTHER FORMS OF GAS PERMEABLE PRESBYOPIC CORRECTION

Single-Vision Contact Lenses and Reading Glasses
This is an option that should be presented to every patient with pres-
byopia—current single-vision wearers and nonwearers—although it is
preferred by only a few patients. The most important benefit of this
option is optimal vision at distance with single-vision contact lenses
and at near with reading spectacles. In addition, this results in less
chair time for the practitioner and less expense for the patient.
However, many patients are not motivated to wear spectacles for all of
their near tasks. In addition, the frequent application and removal of
spectacles can be frustrating to a patient with presbyopia. It is not
uncommon for a patient opting for reading glasses to later change to
a bifocal or multifocal contact lens, assuming, of course, that this lat-
ter option was present to him or her.
Monovision
Definition and Benefits

Monovision correction is the use of single-vision contact lenses for the
correction of presbyopia; one lens has the appropriate power to opti-
mize distance vision in one eye (often the dominant eye), whereas the
other lens has the appropriate power to optimize near vision. It is
understood that a “cerebral adaptation” process will occur in which the
brain will adapt to provide good distance vision out of the distance eye
and suppress the near vision and vice versa out of the near-corrected
eye.
A relatively high success rate of 80% has been reported with mono-
vision correction.16-18 This can be attributed to many benefits of this
option, including19:
●
Only one lens is changed for present wearers
●
No special lens design is necessary
●
It is less expensive
●
Less chair time is necessary
●
Lenses are thinner (in some cases) and more physiologically
acceptable
●
Some possible bifocal and multifocal contact lens problems are
avoided, including ghost images and glare (notably at night),
reduced illumination, reduced contrast sensitivity, and fluctuating
vision (particularly in pupil-dependent lens designs)20
Factors Important in Prescribing Monovision

While in the practitioner’s office, it is important for the patient to deter-
mine the possible compromises of monovision correction. Binocular
function should be evaluated to determine the impact of monovision
correction on stereopsis. The monovision prescription can be placed in
a trial frame, and the patient can walk around the office to obtain more
of a real-life perception. Likewise, if the patient is a current single-vision
lens wearer, a near power lens can be worn in one eye, and the patient
can likewise gain some insight into its visual performance.
Selecting the proper eye for near correction depends on several fac-
tors. This eye is typically—but not always—the nondominant eye. It is
important that distance vision is impaired as minimally as possible. If
the patient has amblyopia, the eye exhibiting poorer vision should be
prescribed the near power lens. If the patient exhibits anisometropia,
the higher myopic (lower hyperopic) eye should be considered for near
correction.
The full monovision prescription should be prescribed for opti-
mum near and distance vision. In addition, the most wettable GP lens
material should be fit because of decreasing tear volume with age.
Monovision correction patients should be told that although they could
adapt to this process within days, it could take as long as 8 weeks.18 In
addition, they should be encouraged or, preferably, required to pur-
chase either a second distance vision contact lens or “driving” specta-
cles (i.e., with minus power to be worn over the near eye) for use
during driving and other critical distance vision tasks.
Problems
Monovision correction has resulted in a number of induced problems,
including reduced stereopsis,19 increased disability glare,21 reduced
contrast sensitivity, notably at high spatial frequencies,20,22-24 suppres-
sion as the add increases,25 asthenopia, and reduction in distance
vision, which can compromise tasks requiring critical distance vision.
In addition, it is possible that a practitioner could be liable for any
injury in which a monovision contact lens correction may have been a
contributing factor.26 It has been recommended that monovision
correction, including adaptation symptoms, adverse effects, and the

availability of other corrective options, should be presented to the
patient on an informed consent form. These factors, and because a
monovision correction was implicated in a report of a contact lens-
related aircraft accident,27 have substantiated why the Federal Aviation
Administration prohibits the use of monovision contact lens wear for
pilots.
Another induced problem pertains to induced anisometropia in the
refractive correction, which has been found to be significant in 30% of
monovision wearers.28 Likewise, the anisometropic contact lens cor-
rection can present a significant challenge to the presbyopic visual sys-
tem, and some patients simply cannot adapt to the blur induced by this
correction.29
It is apparent that the GP multifocal and bifocal designs present
today enhance the visual process and result in improved visual func-
tioning, patient satisfaction, and a higher success rate than monovi-
sion correction.11,12,21,29 In addition, soft multifocal designs—which are
compromised by reduced optical quality as compared with GP
designs—appear to result in, at minimum, parity in visual perform-
ance compared with monovision correction and, in some cases, pro-
gressive addition spectacles.21,30-32 Nevertheless, monovision
correction is a popular option for presbyopic contact lens correction
and should be an option presented to all qualified patients. However,
in the authors’ opinion, bifocal contact lenses should be emphasized
as the primary corrective option. If monovision correction is pre-
scribed, patients should be aware of the limitations, and a secondary
distance vision correction should be prescribed for critical distance
vision tasks.
PATIENT EVALUATION AND SELECTION

Prefitting Evaluation Tests
Case History
A comprehensive case history is important to determine if the patient
is a good candidate for GP multifocal lenses, not to mention contact
lens wear in general. The case history presents an important opportu-
nity to assess patient motivation and goals (to be discussed) and
whether there are systemic-related contraindications or concerns. The
latter could include medications (e.g., antihistamines) that reduce tear
volume. Likewise, is there a history of unsuccessful contact lens wear
and why? It is important to ask about previous surgeries, notably, cos-
metic lid surgery, which can impact which type of lens design will be
prescribed. How patients spend their time each day is also important.
What are their occupational and recreational needs? What distances
are most important to them and why?
Anatomic Measurements
It is important to measure the lid-to-limbus relationship, lid tonicity,
palpebral fissure size, and pupil size. If the lower lid is positioned
below the lower limbus (notably ≥1 mm below) during straight-ahead
gaze, a translating bifocal design is not recommended because of the
inability of the lens to shift sufficiently with downward gaze such that
the bifocal segment would position in front of the pupil (Figure 12-1).
Lid tonicity is important as well. As people “mature chronically,” the
structure and function of the lids change, which can adversely affect
bifocal contact lens success. A loose lower lid will not allow for an ade-
quate support structure to result in lens translation on downward
gaze.33 Recording the palpebral aperture size and the relationship of the
eyelids to the center of the pupil will be beneficial in determining the
type of design and overall lens diameter.34 It is also important to record
two pupil size measurements.3,35 The first measurement can be per-
formed with the interpupillary distance ruler positioned across the
pupil with normal room illumination. Once this value has been
recorded during mesopic conditions, the lights can be dimmed to
record the pupil size during scotopic conditions. The pupil size meas-
urement is particularly important to determine whether an aspheric
design can be selected. In patients exhibiting a large pupil size—greater
Figure 12-1. A low lower lid that represents a poor candidate for translating bifocal
designs. (Courtesy Ursula Lotzkat.)
than 5 mm during mesopic conditions—an aspheric design will typi-

cally result in symptoms of glare and reduced distance vision, especially
during low illumination conditions such as nighttime driving. It is also
imperative to measure and record the position of the lower lid in rela-
tionship to the lower pupil margin to assist in determining the seg
height of a segmented translating bifocal.
Tear Quality and Volume

Patients’ tear quality and quantity should be evaluated as they would
for any other potential contact lens wearer. Because tear volume
decreases over time, it is especially important to perform these tests
for the potential contact lens wearer with presbyopia. The tear menis-
cus should be evaluated, and the customary tests for tear volume (i.e.,
Zone Quick from Allergan/Menicon [Irvine, CA], or Schirmer test)
and tear quality (i.e., tear break-up time [TBUT]) should be performed.
A TBUT of 5 seconds or less—on repeated measurement—typically
contraindicates contact lens wear; a value between 6 and 9 seconds
should result in advising the patient that all-day wear may not be
achieved.19 If the patient has blepharitis or meibomian gland dysfunc-
tion, this should be managed before initiating GP lens fitting. If a
patient with presbyopia is experiencing dry eye symptoms or clinical
signs but is motivated for contact lens wear, punctual occlusion should
increase the likelihood of success.36,37
Manifest Refraction
A careful refraction will be beneficial for patient selection. Patients
with emmetropia or low ametropia are often not motivated for bifocal
contact lens wear because of possible compromise in their distance
vision. The best candidates for bifocal wear should have >1.25 D of
myopia and >1 D of hyperopia.38 In addition, if amblyopia is present,
caution should be used when considering a bifocal contact lens, par-
ticularly if the amblyopia has resulted in several lines of reduction in
Snellen acuity.
Corneal Topography
Corneal topography instrumentation is certainly not a requirement for
GP management of patients with presbyopia; however, it can provide
information that can be beneficial in the decision-making process. If
the corneal apex is decentered excessively, an aspheric lens design—in
which the optical center should position directly in front of the center
of the pupil for optimum distance vision—should be discouraged
because of reduced vision at this distance. Likewise, an inferior decen-
tered apex lends itself well to a translating design.3,39,40
Patient Consultation
If the patient is deemed a good contact lens candidate, it is important
to review all of the options available to him or her. These options
include single-vision lenses and near spectacles, monovision correc-
tion, and soft or GP bifocal contact lenses. The latter category should
be mentioned and emphasized.
The patient’s goals and expectations should then be discussed. As
mentioned before, it is important to determine what the patient’s occu-
pational and recreational visual needs are and whether bifocal contact
lenses will meet those needs. What is the patient’s goal from wearing
contact lenses? Patients must understand that these lenses differ from
spectacles. The dynamics of lens movement on the eye must be
explained such that they understand the stability of visual correction
present with spectacles is not the same with GP bifocal and multifocal
designs. They may experience transient blur in certain directions of
gaze. It is important to mention that some visual compromise may be
present as compared with spectacles such that the patient who desires
good vision at all distances during all activities should be told he or she
is not a good candidate for this modality. The goal of presbyopic con-
tact lens wear should be to reduce, rather than eliminate, the need for
supplemental near correction14; in other words, the goal should be to
satisfy “most of the visual needs, most of the time.”15 It may be neces-
sary for an intermediate distance correction during prolonged com-
puter use by a GP bifocal (not multifocal) wearer with presbyopia or a
+1.00-D spectacle correction for prolonged reading of small print for
the patient with absolute presbyopia who is an aspheric multifocal GP
wearer. These scenarios are typically the exception to the rule.
However, the practitioner is more likely to be successful and patient
confidence in the practitioner maintained if practitioners “under-
promise and overdeliver.”41
A realistic approach to GP bifocal adaptation should include a dis-
cussion of the time frame for adaptation, including the possible need
for lens exchanges. It is safer to tell a patient that it could take up to 8
weeks to achieve success than to have a patient return after 1 week dis-
satisfied because his or her expectations included relatively instant
gratification. However, the patient can be reassured that if he or she is
patient and motivated, it is likely the lenses will be successful.42
Obviously, the current GP wearer who has developed presbyopic
symptoms is one of the easiest patients to fit into a GP multifocal lens.
However, the spectacle wearer and the soft lens wearer should be con-
sidered candidates as well. If the spectacle wearer is motivated by the
improved cosmesis and visual freedom of a GP multifocal or bifocal
correction, success can be obtained. It is not uncommon for a contact
lens-wearing patient with presbyopia to comment how enjoyable it is

to be with friends of similar age but being the only one not wearing a
spectacle correction. Likewise, the soft lens wearer should not be dis-
carded as uninterested or unqualified. The quality of vision obtained
with the current generation of GP aspheric and translating designs is
an opportunity they should be provided. If the soft lens wearer insists
on staying in that modality (i.e., monovision or a soft bifocal design),
the GP option can be introduced. It is not unusual for some of these
patients to be refit into a GP design because of dissatisfaction with the
visual performance of the soft lenses. The concept of “20/happy,” in
which a patient has a reduction in best-corrected Snellen acuity (often
20/25 to 20/40) but the patient is satisfied, can sometimes be a mis-
nomer. There are patients who are extremely motivated to avoid spec-
tacle wear, which can be an ethical issue for practitioners to manage.
If the patient’s distance vision is reduced a few lines on the chart but
he or she is satisfied, should an effort be made to improve the vision?
This often results from soft bifocal lens wear and occasionally from
aspheric multifocal GP wear. The solution should be to attempt to
improve the patient’s vision with the best option available; for the soft
lens wearer, this could be some form of GP presbyopic design; for the
aspheric multifocal lens patient, this should be a translating design.
Candidates for GP bifocal and multifocal correction are summarized
in Table 12-1.
Table 12-1 Gas-Permeable Bifocal and Multifocal Candidates

Category Good Candidate Acceptable Candidate Poor Candidate
Refractive >1.25 D myopia; ≤1.25 D myopia emmetrope
Error >1 D hyperopia ≤1 D hyperopia
Tear Quality ≥10-second TBUT 6–9 second TBUT ≤ 5-second TBUT
Motivation/ Motivated not to Desires good vision Desires excellent
Expectations wear spectacles; at all distances vision at all
understands that but understands distances; does
compromise is vision compromise not desire any
possible is possible compromise
Mode of Current GP wearer Current spectacle or Current satisfied
Correction soft lens wearer spectacle wearer,
interested in a soft bifocal or
bifocal correction monovision
patient
GENERAL FITTING CONSIDERATIONS

When a patient has made the decision to be fit into GP lenses, the next
decision is to decide which specific multifocal or bifocal lens design is
most appropriate for fitting this patient. Regardless of the lens design,
there are several fitting guidelines that are important. When fitting a
patient with presbyopia into GP lenses, there is always a concern about
initial comfort, especially if this patient is a spectacle or soft lens
wearer. These patients can be reassured that GP presbyopic lens
designs are no less comfortable and may be more comfortable than
single-vision GP lens designs. This is true because all GP lens designs
for presbyopia are most successful if they exhibit little movement with
blinking in primary gaze.
The use of a topical anesthetic during the initial lens application—
as with new single vision wearers—is important as well. This has the
benefits of improved patient attitude toward adaptation, less likelihood
of discontinuation of lens wear, and reduced chair time.43,44 The anes-
thetic effect should be allowed to wear off during lens wear such that
the patient can experience realistic lens awareness. However, because
patients are often apprehensive about the initial experience of lens
application, topical anesthetic use can be invaluable.
During the fitting process, loose trial lenses—not the phoropter—
should be used for the overrefraction. This provides a more realistic
environment for patients with presbyopia. To confirm the overrefrac-
tion, the use of +/− 0.25/0.50-D flipper bars can be used binocularly at
the distances that are most important to the patient. If the patient
spends much of his or her time at a computer, this can be performed
in front of a terminal in the office.
Once the appropriate correction has been determined, the patient
can walk around the office and be encouraged to perform activities that
he or she customarily performs (i.e., look at a book, magazine, or a
computer screen; view off at a distance) and report any visual compro-
mise he or she experiences. This will assist in possible refinement of
the lens power(s).
Finally, for practitioners who are initiating GP bifocal and mul-
tifocal fittings, it is recommended they confer with their labora-
tory consultant on recommended lens designs. These advisors are
also invaluable for troubleshooting with these designs. There are
many bifocal and multifocal lens designs available from practically
every laboratory. A list of these laboratories along with their con-
tact information and lens designs is available in Tyler’s Quarterly,
Frames Contact Lens Quarterly, and the RGP Lens Institute web site
(www.rgpli.org).
These general fitting considerations are listed in Box 12-1.
Box 12-1 GENERAL FITTING CONSIDERATIONS FOR GAS PERMEABLE BIFOCAL AND
MULTIFOCAL LENSES
1. Explain the adaptation process to each patient; for new GP wearers,
emphasize that the initial comfort should be similar or possibly better than
for single-vision wearers.
2. Use a topical anesthetic at the initial application to relieve patient (and
practitioner) apprehension and accelerate the fit process.
3. Use loose trial lenses or flipper bars—not the phoropter—for refracting
over these lenses.
4. Once the lenses have been applied with the appropriate correction, have
the patient walk around the office and perform multiple visual tasks to
simulate his or her daily activities. They should report back with any
activities for which visual compromise was present.
5. The laboratory consultant is invaluable for providing lens design
recommendations and troubleshooting specific patients.
LENS DESIGNS
Aspheric Multifocal
Description and Patient Selection

There are many aspheric progressive designs that are currently avail-
able, and reports of high success rates (typically ≥ 75%) have been
claimed.8,9,43-45 These designs usually have a high eccentricity posterior
aspheric surface and spherical anterior surface. These designs use
simultaneous imagery with the patient viewing through the distance
and near powers at the same time. Therefore these powers are super-
imposed so the eye and brain attempt to select light rays most “in
focus” for either distance or near.39 However, for an aspheric lens
design to be successful, it should shift some—or translate—with down-
ward gaze to provide a greater amount of plus correction (Figure 12-2).
Aspheric multifocal lenses are a viable option for patients with early
presbyopia who do not have a highly critical distance demand. These
lens designs typically have a nominal add of approximately +1.00 D,
although as the add power increases away from the optical center, a
larger effective add can be obtained as the pupil size increases. Many
of the most recently introduced lens designs have been able to provide
higher add powers via a modification of the front surface with or a
reduction in the effective distance optical zone. Nevertheless, these
lenses rarely provide greater than a +1.75 D. Patients with high add
power presbyopia are not contraindicated for aspheric multifocal
Figure 12-2. Some translation of an aspheric multifocal lens design will optimize near
vision. (Courtesy Ursula Lotzkat.)
lenses; however, a “modified bifocal” approach is necessary. Typically

this can consist of overplussing the nondominant eye to optimize near
and intermediate vision in one eye with optimum distance and inter-
mediate vision in the other eye. It would be a misnomer to use the
term “modified monovision” to describe this concept because distance
vision is only mildly compromised in the “near” eye.
Patients who have been single-vision GP wearers are often excellent
candidates for aspheric multifocal lenses. The transition is often rapid
because both lens designs are thin and the fitting relationship is typically
similar to their previous lenses. In addition, these patients with early
presbyopia are satisfied with the improvement in their near vision.
Because these lens designs tend to provide optimum vision at an
intermediate—often arm’s length—distance, patients in occupations
where this distance is important benefit from a progressive design.
This includes accountants, electricians, plumbers, and those with
mechanical responsibilities.46 Especially important are those who
spend much of their time at a computer. If they spend ≥ 35% of their
waking hours at a computer, an aspheric multifocal lens design is
recommended.47
An important—but often overlooked—consideration is the athlete
with presbyopia. Numerous patients with presbyopia still play tennis,
basketball, racquet sports, and even soccer. Because a well-fitted

aspheric design will move little on the eye with blinking, it is much
less likely to decenter or dislodge with contact than a translating
design and less likely than with a single-vision lens design.
Several anatomic considerations are important in the decision-
making process. A small-to-medium pupil size is important, prefer-
ably ≤ 5 mm as measured during mesopic or normal room
illumination. Patients with a larger pupil size should be fit into
another lens design. Patients with a well-centered corneal apex are
good candidates, whereas a decentered apex—notably inferior—would
result in lens decentration in that region. The possible exception
would be patients with a superior decentered apex, although they
should be monitored to ensure that corneal distortion is absent in that
region. Lens adherence can also occur with a superior decentered lens.
Patients with steeper than average corneas are also good candidates
because a well-centered lens-to-cornea fitting relationship is more
likely to result. Patients who have a loose or flaccid lower lid or a low
lower lid should be considered for an aspheric lens design because
they are not good candidates for a translating design.
Lens Design, Fitting, and Problem-Solving

Material. The lens material selected should be one that optimizes
surface wettability. Therefore it would be similar as for a single-vision
patient. For patients with myopia, a low-Dk (i.e., 25 to 50) fluoro-
silicone/acrylate (F-S/A) lens material is recommended; for patients
with hyperopia, a higher-Dk material is indicated.37 Many of the lens
designs are available in a specific material as recommended by the
manufacturer.
Lens design and fitting. Fitting of an aspheric lens design is as sim-
ple—if not simpler—than a spherical GP lens design because there
are fewer design parameters to consider. Although the authors recom-
mend diagnostic fitting, especially when gaining familiarity with a
given design, Ames41 has experienced excellent success with empirical
fitting. With the importance of ordering these lenses warranted, he
averages a 50% reorder rate and indicates that it typically takes a max-
imum of two lenses per eye to either achieve success or recognize fail-
ure. The benefit of empirical fitting is to allow the patient to experience
acceptable-to-excellent vision with his or her initial GP multifocal
lenses.
All aspheric lens designs should exhibit good centration with little
(1 mm recommended) lens movement with blinking to maintain the
optimum distance correction in front of the pupil with distance gaze.
Most of the aspheric designs introduced in recent years are of lower
eccentricity than their higher e-value counterparts. The more tradi-

tional higher eccentricity lens designs, such as VFL3 (Conforma,
Norfolk, VA), are fit approximately 3 D steeper than K. Because the
lens design flattens at a high rate away from the optical center of the
lens, the fluorescein pattern should exhibit some apical clearance but
midperipheral alignment (Figure 12-3).
Lower eccentricity lens designs are typically fit between 0.75 and
1.50 D steeper than K. The actual base curve to be selected depends on
the specific lens design. Each laboratory used a different eccentricity
value in producing the fitting curve and the power addition effect.48 It
is important to adhere to the manufacturer’s recommended fitting
guidelines. It is recommended for the lenses to be well centered,
although slight superior decentration is often satisfactory, and exhibit
an alignment fitting relationship with fluorescein (Figure 12-4).
Fluorescein pattern evaluation should be performed with a combina-
tion of a cobalt filter with a yellow filter over the observation system.
If the lens is moving excessively, changing to a base curve radius
0.50 D steeper is recommended. Likewise, if the patient has against-
the-rule astigmatism, fitting steeper will assist in obtaining acceptable
centration.49
Problem-solving. Problems with aspheric lens designs include
decentration, insufficient add power, and glare.
Decentration. Decentration, especially if in combination with exces-
sive movement, typically results in variable acuity and overall visual
Figure 12-3. An optimum fitting high eccentricity lens design with apical clearance
and midperipheral alignment. (Courtesy Conforma Laboratory.)
Figure 12-4. An optimum aspheric multifocal lens-to-cornea fitting relationship.
discomfort. If the lens is decentering inferiorly with excessive move-

ment, as previously indicated, steepening the base curve radius by
0.50 D is recommended. Most likely, this is the most common param-
eter change made with aspheric designs. If the lens is inferior with
minimal to no movement with blinking, a flatter base curve radius is
recommended. Slight superior decentration is often acceptable and
may result in no compromise in vision. Moderate decentration, espe-
cially if in combination with limited to no movement, can result in
corneal distortion. Steepening the base curve by 0.50 D is recom-
mended. A secondary change would be to reduce overall diameter.48
Steepening the base curve radius and/or increasing the overall diame-
ter should resolve lateral decentration. However, moderate decentra-
tion, especially if in combination with a decentered corneal apex, is
best managed by using another type of lens design.
Insufficient Add Power. As described before, one of the limitations
of an aspheric lens design is limited add power. Patients with 1.50 D or
higher refractive add powers typically require a higher add power than
available in these designs. However, if patients have been successful in
this form of design or do not represent a good translating design can-
didate, efforts should be made to optimize the near vision. Several
options available to manage this problem are discussed below.
USE A HIGHER ADD ASPHERIC DESIGN. Several of the current lens
designs are available in multiple effective adds, typically via providing
increased plus power in a concentric zone on the front surface of the
lens. For example the Essentials Xtra lens (Blanchard, Manchester,

NH) is available in three effective add powers (Series I, Series II, and
Series III). A patient with a +1.75-D add may obtain satisfactory near
vision with little compromise at distance with a Series II add on one
eye (typically, but not always, the dominant eye) and a Series III add on
the other eye. In a recent study, 81% of patients exhibiting moderate
presbyopia were successful with the Series III lens.50
MODIFIED BIFOCAL. For patients with higher add requirements, the
aforementioned “modified bifocal” approach is recommended.
Overplussing the aspheric lens design on the so-called “near” eye by
0.25 to 0.75 D should optimize near vision with only mild compromise
of the distance vision.
LOW PLUS READING SPECTACLES FOR SMALL PRINT. A pair of +1.00-D
reading spectacles can be invaluable for occasional use when reading
small print. Likewise, it is important to educate all aspheric multifocal
lens wearers about the benefits of having high illumination when per-
forming all near tasks.
OTHER OPTIONS. If these two options are unsuccessful, a translating
lens design or monovision correction can be considered.
Glare. A problem with aspheric lens designs, notably during dim
illumination, is symptoms of glare. This often results from intermedi-
ate and near powers in front of the pupil while viewing at distance. If
the lens is decentered, it can be managed as previously described. If
the pupil size is larger than average, this design may not be optimum
for that patient. However, if it is a problem that appears to only occur
while driving at night, simply turning on the dome light may alleviate
the problem.51
Translating Designs
Description/Patient Selection
Translating lens designs are successful if the lower near section
shifts upward or translates such that most of this section is in front
of the pupil during downward gaze for reading (Figure 12-5). They are all
prism ballasted—typically between 1.5 and 3.0 䉭—with some of these
designs also truncated to optimize stability such that the lens positions
on or adjacent to the lower lid. Because of the center thickness of these
designs, a high-Dk lens material is required, and most of these lenses
are provided in lens materials such as Boston XO (Polymer Technology,
Bausch & Lomb, Rochester, NY), Paragon HDS100 (Paragon Vision
Sciences, Mesa, AZ), Menicon Z (Menicon/Con-Cise, San Leandro, CA),
and Fluorex 700 (GT Laboratories, Austin, TX).
Figure 12-5. A well-positioned translating bifocal with distance gaze (A) and with
downgaze gaze for near work (B). (Courtesy Dr. Irvin Borish.)
These designs are recommended for patients who have critical

vision tasks, either distance, near, or both. When they are optimally fit
and also translate properly, these designs provide uninterrupted vision
at distance and near from both eyes. In addition, these designs can
incorporate any add power such that patients with moderate-to-
advanced presbyopia should be able to achieve good near vision at
near. One traditional limitation has been the inability to provide an
intermediate correction, with the exception of a few trifocal lens

designs. However, this problem has lessened with the recent intro-
duction of several lens designs with an intermediate correction (to be
discussed). These lens designs are pupil independent, and as long as
the overall diameter is increased accordingly, they should be success-
ful for patients with a larger than average pupil size.
For translating lens designs to be successful, the lower lid tonicity
must be average to tight to permit translation. In addition, the lower
lid acts as a support system to move the lens vertically, allowing the
patient to use the bifocal segment.46 Therefore it needs to be posi-
tioned within 1 mm of the lower limbus. If the lower lid is positioned
greater than 1.5 mm above the lower limbus, it may be difficult to pro-
vide a sufficient seg height for acceptable near vision.
Translating bifocals are also successful for patients with flatter than
average corneas, for whom contact lenses tend to fall inferiorly.52 This
is also true for the thicker, anterior center of gravity hyperopic lenses,
which tend to fall quickly to the lower lid and exhibit little upward
movement with blinking, an important quality for translating bifocal
success. Patients with an inferiorly displaced corneal apex also are
good candidates because of the tendency of the lens to position over
the steepest region of the cornea.40 Finally, patients in need of either a
front toric design for residual astigmatism correction or a toric design
for high corneal astigmatism can obtain these corrections with most
translating designs. Patient selection for aspheric versus translating
lens designs is provided in Table 12-2.
These designs take many forms, including segmented (i.e., straight-
top, executive, crescent) and annular (or concentric).
Segmented Translating Designs

Current segmented translating designs have monocentric optics, elim-
inating the problem of image jump, which was common with first-
generation GP bifocal lens designs. Although there are few additional
design considerations with these lenses, they are not as complicated as
often perceived. Diagnostic fitting is important when fitting these
lenses such that factors to include seg position and translation can be
assessed. Diagnostic fitting sets are often available in +2.00-D and
−2.00-D distance powers with a +2.00-D add. In addition, both aver-
age seg height and prism amounts are included.
Translating designs are typically fit slightly flatter than K to allow for
a rapid descent of the lens to the lower lid. When evaluating the lens on
the eye, the seg line (or crescent) should be positioned at or within 1 mm
below the lower pupil margin (Figure 12-6). When in doubt, the lower
seg height should be ordered to minimize any possible interference
Table 12-2 Patient Selection: Aspheric Verus Translating Lens Designs

Category Recommended Design(s)
Quality of Vision TRANSLATING if critical vision demands at
distance or near; also recommended if patient
has amblyopia
Anatomical Considerations ASPHERIC if low lower lid or flaccid lower lid
tonicity
TRANSLATING if large pupil size (≥5 mm in
room illumination)
Add Power ASPHERIC if low add power and for those with
occupations in which computer use is >35% of
time or arm’s length distance is important,
although new translating designs with
intermediate correction can be used
TRANSLATING for high add powers, although
“modified bifocal” approach can be used with
aspheric designs
Corneal Topography ASPHERIC for steep corneas and well-centered
corneal apex
TRANSLATING for flat corneas and inferior
decentered corneal apex
Single-Vision GP Wearers ASPHERIC
Athletes ASPHERIC
Residual Cylinder; High TRANSLATING
Corneal Cylinder
with distance vision. The lens should be picked up slightly with blink-
ing, but the seg line should not move more than 1 mm into the pupil
during blinking. It is important to evaluate the seg position with the
patient viewing straight-ahead in normal room illumination. If the
patient is viewing slightly superiorly, the seg position will appear low,
and the resultant lens may have too high a seg line via overcompensa-
tion. Likewise, if the patient is viewing slightly inferiorly during the
diagnostic fitting process, the seg position can appear to be too
high, resulting in a lens that is ordered with an insufficient seg height.
Because the simple act of smiling can result in raising the seg
height, patients should be advised to be aware of this, particularly
when driving. If the patient has a slightly low lower lid, not only is a
larger seg height often indicated but also the overall diameter should
be increased to ensure that the upper edge of the lens is adequately
covering the pupil for optimum distance vision. If the patient has an
upswept lower lid and a truncated lens design has been prescribed, the
Figure 12-6. A well-centered crescent translating bifocal lens design with the seg
position near the lower pupil margin. (Courtesy Dr. Peter Kollbaum.)
RALS acronym (right add left subtract) can be used to align the trun-
cation with the lower lid or to align any rotated segmented translating
design.36 When the lens rotates to the practitioner’s right, this amount
can be added to the 90-degree position; if the lens rotates to the prac-
titioner’s left, the amount of rotation can be subtracted from 90
degrees. For example, if both lenses are rotating excessively toward the
nose, the lenses may be ordered with the prism at 105 degrees OD and
75 degrees OS.
It is also important to assess translation. While under the slit lamp,
the patient should be instructed to view inferiorly. When lifting the
upper lid, the lens should shift superiorly, and most of the segment
should be positioned in front of the pupil. This can be confirmed by
viewing the seg position in primary and down gaze with an ophthal-
moscope at arm’s length. In addition, the patient can hold appropriate
reading material at normal viewing distance and determine if his or
her near vision is uncompromised. The patient can then raise the
reading material to a straight-ahead position to ensure it is blurred
(i.e., patient viewing through superior distance power zone). Seg
height change, if necessary, can then be made according to the results
of these tests. It is also important for patients to know how to hold
reading material, where to look, and where to guide their eyes. It is
important that they realize the importance of dropping their eyes to
successfully view near material.53
Translating bifocal lens designs in common use include the X-Cel

Solution (X-Cel, Atlanta, GA), Solitaire II (Tru-Form, Euless, TX),
Tangent Streak Bifocal (Fused Kontacts of Missouri), and the Metro
Seg Crescent (Metro Optics, Austin, TX). In addition, there are several
translating designs that provide an intermediate correction. The
Tangent Streak Trifocal (Fused Kontacts of Missouri) has an interme-
diate region extending into the pupil in an executive-style seg. The
Llevations lens (Tru-Form) is a translating GP bifocal with an inter-
mediate aspheric zone.47 The Presbylite lens (Lens Dynamics, Golden,
CO) incorporates a spherical distance zone, spherical near zone, and a
triangle-shaped aspheric intermediate zone. It is nontruncated with
1.5 䉭.36 A large distance zone allows for up to 30 degrees of nasal rota-
tion with minimal effect on vision.39 The ESSential Solution
(Blanchard/X-Cel) has been recently introduced and appears to
combine the best qualities of successful aspheric multifocal and trans-
lating segmented lens designs. It incorporates the proprietary
Essential S-Form posterior surface aspheric geometry and the anterior
surface segmented prism ballast of the Solution GP bifocal lens (Lee
Buffalo, personal communication, July 2003). The benefits of this
design include full distance and intermediate corrections with 0.50- to
1.25-D additional add power provided by the segmented anterior
design.
Annular (Concentric) Translating Designs

These designs are prism ballasted with most translating designs using
a decentered central distance zone of approximately 4 mm, which is
decentered slightly superior in an attempt to be positioned directly in
front of the pupil during distance gaze but in close proximity to the
lower lid such that translation can occur with inferior gaze (Figure
12-7).39 This is surrounded by a near concentric periphery. Increasing
the central distance zone can result in improved distance vision but
degraded near vision; reducing the central distance zone can result in
improved near vision but degraded distance vision. A balance between
the two is critical for success.36 Any add power is available, and evalu-
ating the fit to ensure the distance zone is in front of the pupil on dis-
tance gaze and that translation occurs with inferior gaze is important.
These designs are typically fit similar to a segmented design (i.e., flat-
ter than “K”).
A new concentric annular design, the Mandell Seamless Bifocal
(Con-Cise), provides an aspheric transition zone between the distance
and near annular zones. It is a front surface concentric design with
central distance zone diameters ranging from 3.0 to 3.8 mm (average
= 3.4 mm) and an average overall diameter of 9.8 mm.36,39
Figure 12-7. An optimum fitting decentered annular design.
Problem Solving
Potential problems experienced when fitting a translating bifocal con-
tact lens include the following54:
●
Excessive lens rotation with blinking
●
Lens positioned superiorly
●
Poor lens translation
●
Poor distance vision
●
Poor near vision
●
Poor intermediate vision
Excessive lens rotation with blinking. For with-the-rule corneas,
excessive lens rotation is often associated with a base curve radius that
is too steep (Figure 12-8). A flatter than K base curve radius, in combi-
nation with a thick lens, tends to result in a rapid descent of the lens
to the lower lid after blinking, a desirable characteristic for a prism-
ballasted translating bifocal design. If, however, the lens is fit steeper
than K, the resulting lacrimal lens will assist in promoting lens cen-
tration. The result would be a lens that may not descend rapidly toward
the lower lid but rather will be subjected to the forces exhibited by the
upper lid, which can assist in promoting lens rotation. For against-the-
rule corneas, however, selecting a steeper base curve radius would be
recommended. As mentioned before, an upswept lower lid can also
promote rotation resulting in the need to order the prism ballast at
approximately 105 degrees OD and 75 degrees OS.
Lens positioned superiorly. When the lens is lifted too superiorly
with blinking such that the segment interferes with distance vision,
Figure 12-8. An excessively rotated translating bifocal lens design.
increasing the prism ballast by 0.50 䉭 is recommended (Figure 12-9).

A secondary change would be to flatten the base curve radius (always
in 0.50-D increments). Likewise, in offices with the capability of mod-
ifying the lens, all but the superior edge can be covered with tape, and
the superior edge can be thinned using an anterior bevel tool.
Poor lens translation. If the lens exhibits an absence of or only
intermittent translation (Figure 12-10), increasing the edge clearance
Figure 12-9. Excessive superior decentration with blinking. (Courtesy Paragon

Vision Sciences.)
Figure 12-10. Poor lens translation. (Courtesy Paragon Vision Sciences.)
can be beneficial. This can be accomplished easily in-office by using a

0.50-D flatter base curve radius. Flattening the peripheral curve radius
can also increase translation. Secondarily, increasing the amount of
prism or truncation can improve translation. If these changes do not
result in an improvement in lens translation, it is likely that the patient
has flaccid lower lids, and a different lens design is indicated.
Poor distance vision. Poor distance vision can be caused by the lens
being too high or moving excessively; for these patients, increasing the
prism ballast should be beneficial in positioning the lens lower and
providing greater stabilization. Inadequate coverage of the pupil,
which can result in distance vision complaints, can be managed by
increasing the overall diameter by, at minimum, 0.4 mm. If the seg
height is well into the pupil during blinking, simply ordering the lens
with a lower seg height should improve the problem (Figure 12-11).
Poor near vision. Poor near vision may be caused by the lack of
lens translation on inferior gaze. This problem can be addressed by
increasing lens edge clearance as discussed previously. Excessive rota-
tion, which can often be managed by flattening the base curve radius,
can also cause near vision problems. If the lens positions well and has
adequate translation, the problem can be caused by the segment
height being too low; for these patients, the lens needs to be reordered
with a higher segment height. Occasionally, patients need to be
reeducated to move their eyes inferiorly, instead of moving their head,
to read.
Figure 12-11. An excessively high seg height that may result in blurred vision at dis-
tance. (Courtesy Dr. Peter Kollbaum.)
Poor intermediate vision. Because most GP translating bifocals do

not have an intermediate correction, this can be problematic, espe-
cially for patients who spend much of their day at a computer termi-
nal. The use of overspectacles, with an intermediate correction
specifically at their working distance, can be beneficial. In addition,
the aforementioned translating designs that incorporate an intermedi-
ate correction are also recommended.
Troubleshooting translating bifocal lens designs is summarized in
Table 12-3.
Representative cases and their management are provided in Box 12-2.
RESOURCES
There are numerous resources that will assist in practitioner and
patient education.
The most valuable resource is the laboratory consultant. This is the
person who will recommend a given lens design, provide fitting infor-
mation, assist in troubleshooting, and play a valuable role in a practi-
tioner’s confidence level in fitting these lenses. The manufacturer
fitting guide for each lens design is always beneficial and typically
uncomplicated and straightforward.
There are also several resources available from the RGP Lens
Institute (RGPLI) that can be beneficial. The “GP Bifocal Fitting and
Table 12-3 Troubleshooting Translating Bifocal Lens Designs

Problem Management Options
Excessive rotation 1. Flatten BCR 0.50 D if WTR cyl; steepen 0.50 D
if ATR cyl
2. Offset prism if upswept lower lid; order prism
at 105 degrees OD and 75 degrees OS
Superior decentration 1. Increase prism by 0.50䉭
2. Flatten base curve radius by 0.50 D
Poor translation 1. Flatten BCR 0.50 D or flatten peripheral curve
2. Increase prism and/or truncation
3. Change to another lens design
Poor distance vision 1. Superior decentration: increase prism by 0.50 䉭
2. Inadequate pupil coverage: increase
OAD ≥ 0.5 mm
3. If seg height into pupil: reduce seg height
Poor near vision 1. Poor lens translation: manage as indicated
above
2. Excessive rotation: manage as indicated above
3. Too low seg height: increase seg height
4. Patient is dropping head, not eyes, to read:
educate patient appropriately
Poor intermediate vision 1. Overspectacles for intermediate distance
2. Select a GP translating bifocal lens with an inter-
mediate correction
Troubleshooting” video is a comprehensive dynamic guide to GP mul-

tifocal and bifocal patient selection, prefitting, fitting, and trou-
bleshooting. Video images of good-fitting and poorly fitting lenses,
with the latter followed by appropriate management, are provided. In
addition, a “Correcting Presbyopia” laminated pocket card is available
through the RGPLI and its web site (www.rgpli.org). This heavily illus-
trated card provides descriptions of the different designs along with
benefits, patient selection, and consultation information on one side
(i.e., patient-oriented) and fitting pearls and troubleshooting informa-
tion on the other side. The “GP Lens Management Guide,” also avail-
able from the RGPLI web site, has an extensive section on presbyopia
management with GP lenses. A consumer brochure on myopia and
presbyopia is also available from the RGPLI. In addition, the RGPLI
sponsors a monthly online symposium on GP lenses. Twice each year,
the topic is GP bifocal and multifocal lenses, and the faculty present
interesting cases that are discussed by all participants. The schedule is
available on the web site.
Box 12-2 CASE MANAGEMENT

Case One
Overview: A 52-year-old engineer who is tired of spectacle wear and desires to
consider contact lens wear.
Refractive Information: OD: −4.00 − 1.50 × 175; OS: −3.75 − 1.25 × 004 Add:
+2.00 D
Keratometry (sim K): 41.50 @ 180; 42.75 @ 090 OU
Anatomical Considerations: Lower lid 0.5 mm above lower limbus; 5 mm
pupil size in room illumination.
Lens Design: Patient was fit into the Solutions bifocal with the following
parameters: OU: 9.60 mm OAD; seg height at geometrical center; base curve
radii (BCRs): 8.18 mm (41.25 D) OD and 8.13 mm (41.50 D) OS; medium
prism. The seg position was at the lower pupil margin with good translation.
Troubleshooting: The patient complained of variable vision OS at the 1-week
follow-up evaluation. With slit-lamp evaluation, the left lens was rotated
approximately 30 degrees nasally. A flatter BCR equal to 8.23 mm (41 D)
was ordered and resulted in a more stable fit and more consistent vision.
Comment: The critical vision demands of an engineer would make a translating
bifocal lens the preferable option. The lower lid was positioned optimally for
a translating design, and the pupil size was borderline large for an aspheric
multifocal. It is important to fit these lenses flatter than “K” to optimize
translation and minimize rotation and upward movement with blinking.
Case Two
Overview: A 44-year-old housewife who also coordinates social functions and
is experiencing some difficulty reading (i.e., newspapers, books, menus)
with her single-vision soft lenses. She is wearing −6.25 DS Acuvue II
lenses OU.
+1.25 D
Keratometry: 44.75 @ 180; 45.75 @ 090 OU
Anatomical Considerations: Lower lid at lower limbus; 4 mm pupil size in
room illumination.
Lens Design: Patient was empirically fit into the Boston MultiVision
multifocal (Polymer Technology Corporation) with the following
parameters: 7.40 mm BCR; −7.00 D OU.
Troubleshooting: Both lenses decentered inferiorly with excessive movement
with blinking. The lenses were reordered in 7.30 mm BCR/−7.50 D OU,
which resulted in an improvement in centration and subjective satisfaction.
Comment: Aspheric multifocal lenses are an obvious choice with an absence of
critical vision for a patient with early presbyopia with steeper than average
corneal curvature values. These lenses are often successfully fit empirically;
however, when a change is necessary, it often pertains to steepening the BCRs.
Case Three
Overview: The patient is a 53-year-old secretary who has been wearing single-
vision gas-permeable (GP) lenses with reading glasses. Because she devotes
Box 12-2 CASE MANAGEMENT—CONT’D

most of her working hours at a computer terminal, she is unhappy with
her intermediate vision. In addition, she is tired of the frequent application
and removal of spectacles.
Refractive Information: The patient’s refractive information was the
following:
OD: −2.00 − 1.25 × 170; OS: −1.50 − 1.00 × 180 Add: +2.00 D
Keratometry: OD: 43.25 @ 180; 44.50 @ 090
OS: 43.00 @ 090; 44.25 @ 090
Anatomical Considerations: Lower lid is 1.5 mm below limbus; 3.5 mm pupil
size in room illumination.
Lens Design: The patient was fit into the Essentials Xtra lens with the
following parameters:
OD: 7.60 mm (44.37 D) −3.00 D; OS: 7.70 (43.87 D) −2.50 D Series II OU.
Troubleshooting: At the 1-week follow-up visit, the patient indicated that she
was happy with her distance vision but that her near vision was not sharp.
A +0.50-D overrefraction resulted in an improvement in near vision. The
left lens was reordered into a Series III lens with a −2.25-D power. This
solved the patient’s near vision problem.
Comment: This patient’s intermediate demand, in combination with a low
lower lid, makes an aspheric multifocal the lens of choice. However, the
moderate add demand is often not met with these designs, even in the so-
called “high add” designs. The Essentials multifocal lens is available in a
high add (Series III), and this, in combination with a “modified bifocal”
approach via overplussing the nondominant eye (OS in this case), will
often provide satisfactory near and intermediate vision.
Case Four
Overview: This patient is a 56-year-old electrician who was a previous soft
lens wearer but discontinued lens wear 10 years previously because of
blur at near and because his doctor indicated that “bifocal contact lenses
were not perfected yet.” Additionally, he was never entirely pleased with
his vision at distance with his soft lenses.
Refractive Information: The patient’s refractive information was as follows:
OD: +2.50 − 0.75 D × 172; OS: +2.75 − 0.75 × 010 Add: +2.25 D
Keratometry (sim Ks): 40.75 @ 180; 41.50 @ 090 OU
Anatomical Considerations: The lower lid is positioned at the lower limbus;
the pupil diameter is 4.5 mm in room illumination.
Lens Design: The patient was fit into the Presbylite lenses: OD:
8.28 mm (40.75 D) +2.50 D; OS: 8.28 mm, +2.75 D; 9.6 mm OAD and
1.5䉭 OU.
Troubleshooting: The first pair of lenses fit well, provided acceptable vision
at all distances, and translated well.
Comment: An electrician requires good vision at multiple distances.
Unfortunately, his case is not unique because many patients with
presbyopia are denied the opportunity to be fit into bifocal GP lenses
Continued

Case Four—cont’d
because of reluctance by the prescribing practitioner. The Presbylite design
is a segmented translating design with an aspheric intermediate zone.
Other designs that could also be used include the Mandell Seamless bifocal,
Llevations, ESSential Solution, and the Tangent Streak Trifocal.
Case Five
Overview: A 49-year-old accountant, who has been a long-term soft lens
wearer, has recently failed in his efforts to wear a series of soft lens
multifocal designs because of poor vision at near. He has made it clear
that spectacle wear—in any form—is not an option he desires.
Refractive Information: The patient had the following refractive information:
OD: −3.00 − 0.50 × 085; OS: −2.50 − 0.75 × 092 Add: +1.75 D
Keratometry: 42.50 @ 180; 42.00 @ 090 OU
Anatomical Considerations: His lower lid is 0.5 mm below the lower limbus;
his pupil diameter is 4.5 mm in room illumination.
Lens Design: The patient was fit into the Tangent Streak bifocal with the
following lens parameters: OD: BCR: 8.04 mm (42.00 D), OAD: 9.4/9.0
mm; 4.2 mm seg height; 2䉭, −3.00 D/+1.75 D add; OS: all parameters
same as OD with −2.50 D power.
Troubleshooting: At the 1-week visit, the patient complained of variable vision
at distance and poor vision at near. The lenses only intermittently
translated, and the seg height was positioned approximately 1.5 mm below
the lower pupil margin. The superior lens edge was right at the upper pupil
border. The lenses were ordered with BCR equal to 41.50 D (8.13 mm) OU
to improve translation, and a larger diameter of 10.2 mm with a 5.0-mm
seg height resulted in better pupil coverage—especially in dim
illumination—and greater near area in front of the pupil on down gaze.
Comment: This patient had critical vision demands, but having been a long-
term soft lens wearer, it is understandable that a soft bifocal lens would be
an option that he would initially desire. However, this is an excellent time
to “plant the seed” about a GP bifocal lens design. Ultimately, for vision
purposes, this was the design that was successful. Another important
factor is overall diameter on patients exhibiting a borderline low lower lid.
Although they may still be candidates for a translating design, it is not
uncommon for a larger than average overall diameter in combination with
a greater seg height to be necessary to provide complete lens coverage over
the pupil for distance viewing and a greater area of the near zone in front
of the pupil with downward gaze.
Case Six
Overview: This patient is a 43-year-old teacher who has been a long-time
single-vision GP wearer but is beginning to notice that her vision is
somewhat blurry while reading.

+1.00 D
Keratometry: OD: 43.50 @ 180; 44.75 @ 090; OS: 44.00 @ 180; 45.00 @
090
Anatomic Considerations: Lower lid is positioned 1 mm below lower limbus;
3.0 mm pupil diameter in normal room illumination.
Lens Design: This patient was fit into the Lifestyle GP (Lifestyle Company,
Inc., Morganville, NJ) with the following lens parameters: OD: BCR: 7.63
mm (7.8 mm EQ); −8.25 D; OAD: 9.0 mm; OS: BCR: 7.50 mm (EQ: 7.70
mm); −9.00 D; OAD: 9.0 mm.
Troubleshooting: This lens design resulted in an optimum slightly superior-
central fitting relationship with 1-mm movement with blinking. No changes
were necessary.
Comment: This is a good representative example of how easy it is to refit a
single-vision GP wearer into an aspheric multifocal lens when presbyopia
initially occurs. This is another benefit of fitting young people into GP
lenses such that they can obtain the visual benefits of contact lens
correction later in life.
SUMMARY
The key to successful GP presbyopia management is to take the initia-
tive to fit those first few patients. As in orthokeratology, keratoconus,
and other specialty fits, it is preferable to begin by fitting aspheric mul-
tifocal lenses on a few relatively straightforward patients. This could
consist of patients with early presbyopia, perhaps current single-vision
GP wearers in need of a near correction. As confidence is gained,
aspheric lenses could be fit on soft lens refits, new contact lens
patients, and patients with more advanced presbyopia. Segmented and
concentric translating diagnostic sets can then be obtained and used
with the appropriate patients.
A primary reason to position GP lenses first in the contact lens
management of the patient with presbyopia is the improvements in
lens design and manufacturing technology. Current designs have
reduced mass, improved initial comfort, sharper acuity over a wider
performance range, and increased add availability to meet the needs of
a “chronically mature” population.55 With new lathing technology,
greater design reproducibility, more wettable materials, and enhance-
ment of previous bifocal designs to provide better performance, GP
multifocal and bifocal designs have numerous benefits over their soft
lens counterparts. In addition, although the fees are higher (typically
2 to 2.5 times spherical lens fees), fitting these lens designs often
results in enthusiastic patients who refer others to the practice.
Monovision correction does not have this effect.
In summary, as described by Ames,41 GP presbyopic lens designs
put the “fit back in contact lens fitter” and can enhance the profes-
sional image of the practice. As mentioned earlier, many of these
patients are unaware of the availability and benefits of GP bifocal and
multifocal lenses and are therefore fit into spectacles, monovision cor-
rection, or a soft bifocal design. However, it is evident that these GP
lens designs can build the practice. Not only are patients with presby-
opia a relatively untapped group of patients who are willing to pay the
appropriate fee for a corrective alternative that will provide them with
visual freedom and good vision in general, but also the lens designs
themselves are not especially difficult to fit and the benefits to the prac-
tice and the practitioner can be tremendously rewarding.
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46. Hansen DW: Advanced multifocal fitting and management, Contact Lens
Spectrum 14(8), 1999.
47. Hansen DW: RGP bifocals and computer users—the real world, Contact Lens
Spectrum 11(2):15, 1996.
48. Hansen DW: A specialist’s guide to fitting RGP multifocals, Contact Lens
Spectrum 12(9):7S-12S.
49. Hansen DW: Coping with astigmatism using RGP multifocals, Contact Lens
Spectrum 12(12):18, 1997.
50. Businger U, Byrnes S, Baker R: An RGP multifocal for moderate to high presby-
opes, Contact Lens Spectrum 15(10), 2000.
51. Hansen DW: Multifocal contact lens expectations—be prepared, Contact Lens
Spectrum 14(1):18, 1999.
52. Hansen DW: Fitting flat and steep corneas with RGP multifocals, Contact Lens
Spectrum 13(6), 1998.
53. Hansen DW: Educate your new RGP bifocal patients, Contact Lens Spectrum
11(8):18, 1996.
54. Bennett ES, Luk B: Rigid gas permeable bifocal contact lenses: an update, Optom
Today June:34-36, 2001.
55. Hansen DW: What’s new with RGP bifocals, Contact Lens Spectrum 13(1):19, 1998.
13
Aphakia
BELINDA MING WAI LUK
ROBERT M. GROHE
T his chapter reviews the clinical considerations of aphakia

and the use of gas permeable (GP) contact lenses for patients
with aphakia. There are several postsurgical aphakic rehabilita-
tion options available, including conventional spectacles, daily- and
extended-wear contact lenses, and intraocular lenses (IOLs). Cataract
surgery has become one of the most commonly performed surgical
procedures; however, the number of patients with aphakia is decreas-
ing because of the increasing number of patients who undergo pri-
mary and secondary IOL implantation procedures. However, aphakia
remains one of the most challenging and important areas of contact
lens fitting because IOL implantation may be contraindicated in some
special cases. Consequently, the contact lens practitioner must remain
up to date on the various fitting techniques, postoperative complica-
tions, and care of GP lens–wearing patients with aphakia.
POSTOPERATIVE CONSIDERATIONS IN APHAKIA

Before discussing the specific applications of rigid GP materials for
patients with aphakia, a review of the postsurgical changes in the eye
is warranted. These changes present as special considerations for
treating patients with aphakia and can be divided into either optical or
physiologic ones.
Optical Considerations
Optical changes that occur postoperatively result from the disruption
and displacement of the nodal points of the eye from their preopera-
tive position. In the aphakic eye, the previously two separate nodal
points become coincident and lie 4 mm more anteriorly than in the
phakic eye. Other special optical considerations emerge as a result of
the high plus power correction that is required for patients with
aphakia.1
357
High Plus Power

The human eye has approximately 60 diopters of optical power, of
which the crystalline lens contributes approximately one third.2 The
final power required in an aphakic correction depends on the patient’s
preoperative refractive error, the eye’s axial length, and the postopera-
tive corneal curvature, which may have changed after surgery. Most
patients require more than +10 D in refractive correction after cataract
extraction, with 75% requiring between +11.75-D and +13.50-D correc-
tion in the spectacle plane.3 In the past, aphakic spectacles were a
common means of correcting postsurgical refraction, and they greatly
assisted the patients’ ability to function. However, because of the large
amount of high plus power, they also caused major optical problems.
These problems, as described below, are the reasons why contact
lenses present as better choices for the correction of patients with
aphakia.
Vertex Distance
The significant high plus power causes the vertex distance, which was
of minimal consideration preoperatively, to become an important fac-
tor. Small changes in the vertex distance can cause large changes in the
refractive correction required in the spectacle plane. In effect, visual
acuity through a pair of aphakic spectacles can be adversely affected by
small changes in the vertex distance, while the high mass of the high
plus power lenses makes it difficult for spectacles to stay in place.
The vertex distance also presents as a special optical consideration
in another way: the conversion of the spectacle refractive power to the
required contact lens power, taking into consideration the vertex dis-
tance. With high plus powers, there is a pronounced increase in the
amount of plus power compensation needed in a contact lens, and the
greater the lens power, the more the calculation is sensitive to errors
in vertex distance measurements. For example, a 1-mm vertex distance
measurement error can result in a 0.25- to 0.75-D error in the result-
ant contact lens power. Despite the most precise vertex distance
measurements, there may still be unintentional contact lens power
miscalculations. Therefore to arrive at the most accurate contact lens
power, the practitioner must use diagnostic lenses of high plus power
and the overrefraction to determine the required contact lens power.
Lens Aberrations
High power plus lenses, in aphakic spectacles, produce alterations in
retinal image size and in the patient’s visual perception.1 These result
from lens aberrations, the effects of which are significantly amplified
in the power ranges of aphakic spectacle lenses. Among the spectacle
Chapter 13 Aphakia 359
lens aberrations induced are spherical aberration, coma, distortion,

magnification, oblique and radial astigmatism, curvature of field or
power error, and axial and transverse chromatic aberrations. Lens-
induced aberrations lead to three primary problems in visual percep-
tion through aphakic spectacle lenses, which are described below.
Magnification. Relative image magnification resulting from high
plus power spectacle lenses, in the aphakic range, is approximately
20% to 33%.4,5 This can be effectively reduced by the use of contact
lenses. Although residual magnification of approximately 5% to 9%
still exists, this reduction in the amount of magnification results in an
improved visual, perceptual, and psychological status for the patient
(Figure 13-1).
Visual field complications. The large amount of relative image mag-
nification reduces the patient’s ability to use the peripheral field of
vision, creating a ring scotoma and the accompanying jack-in-the-box
effect (Figure 13-2).
The visual field may be reduced by up to 30% in aphakic spectacles.
Furthermore, patients will experience significant base-out prismatic
effects when viewing close targets, where their line of sight is nasal to
the optical center of the high plus power lenses (Figure 13-3). Contact
lenses reduce the peripheral visual field scotoma and the base-out pris-
matic effect because of the close lens apposition to the eye.
Distortion. Lens aberrations, resulting from spectacle magnifica-
tion from the center of the lens to the edge, produce distortion of the
image as perceived by the patient. The amount of distortion depends
Figure 13-1. Image magnification with spectacles and with contact lenses. Note disparity.
(From Grohe RM: Aphakia. In Bennett ES, Grohe RM: Rigid gas-permeable contact lenses,
New York, 1986, Professional Press Book/Fairchild Publications.)
Figure 13-2. The prismatic effect at the periphery of high plus spectacle lenses causes a blind
area in the visual field. (From Mandell RB: Contact lens practice, ed 3, Springfield, Ill, 1981,
Charles C. Thomas Publisher.)
on the dioptric power of the required correction (i.e., the greater the
power of the lens, the greater amount of aberration and distortion).
Because the amount of magnification is greatly reduced in contact
lenses, the amount of perceived distortion is also greatly reduced.
Physiologic Considerations
Fitting contact lenses postsurgically, the practitioner must consider
wound healing and recovery. Also, the majority of patients with
aphakia are elderly, and changes in corneal sensitivity and tear film
quality in this group of patients are important factors to assess before
fitting and evaluating GP contact lenses.
Figure 13-3. The induced base-out prism effect when looking inward from the optical center of
a high plus lens. (From Mandell RB: Contact lens practice, ed 3, Springfield, Ill, 1981,
Charles C. Thomas Publisher.)
Wound Healing
Because of the nature of the wound-healing process, the refractive and
keratometric status of the eye is variable during the recovery phase. An
extended recovery period may necessitate multiple power adjustments
and possible base curve fitting changes. As the eye heals and the cornea
returns to normal, the true postoperative status is more readily deter-
mined. Therefore the stability of the refraction and the keratometry
measurements can be used to judge when the patient has healed suffi-
ciently to tolerate GP fitting and contact lens wear, and to eliminate
excessive lens fit or power changes. The type of surgical procedure, the
postsurgical complications present, and the patient’s health are factors
determining recovery time. If a patient undergoes cataract extraction

without IOL implantation, the postsurgical recovery phase may last sev-
eral months. Patients who undergo phacoemulsification experience
faster healing and may be ready for a contact lens evaluation within 4 to
6 weeks. After undergoing intracapsular lens extraction, the recovery
period for healing can be as long as 12 weeks.6 Therefore a rigid diag-
nostic lens evaluation for the aphakic eye is contraindicated before a
minimum of 4 weeks’ postoperative recovery time.
Corneal Sensitivity
A majority of patients with aphakia are elderly. This factors into the GP
fitting consideration because as a patient ages, there is a slight loss of
corneal sensitivity. There is also an accompanying decrease in the
amount of corneal innervation after surgical incision. Cataract surgery
can result in a reduction of up to approximately 50% in corneal sensi-
tivity because of severed afferent sensory nerve fibers.7 Corneal dener-
vation is an important consideration because it may result in impaired
epithelial wound healing, increased epithelial permeability, and
decreased epithelial metabolic activity in more severe cases.8 Therefore
elderly patients with aphakia with a GP correction will require more
frequent follow-up care and more aggressive management of other-
wise minor corneal complications from contact lens wear.
Tear Film
As a patient ages, there is a reduction in the tear fluid volume, which
may result in corneal desiccation and staining.8 This will affect the
success of contact lens wear.
Photophobia
Many patients with aphakia complain of postoperative photopho-
bia. This is a result of distracting reflections, disturbing glare from
overhead fluorescent light fixtures, and halos or glowing of light
sources produced from removal of the crystalline lens, which has
served as an effective barrier to optical radiation before surgery. As a
neutral density filter, gray tints in aphakic contact lenses may be ben-
eficial in restoring a degree of comfort by filtering some light. In a
study by Chou et al,9 it was concluded that for hydrogel and GP poly-
mers, there was essentially no difference in the quality of ultraviolet
absorption as compared with spectacle lenses. However, it was sug-
gested that protective filters should still be prescribed whenever
appropriate because there is mounting scientific evidence that expo-
sure to ultraviolet radiation may play a role in retinal diseases, partic-
ularly age-related macular degeneration.2 There are several GP
materials that are now available with ultraviolet filtration, such as

FluoroPerm 30, FluoroPerm 60, FluoroPerm 90, FluoroPerm 151
(Paragon Vision Sciences), Paragon HDS (Mesa, AZ), Fluorex 300
(LifeStyle Company, Inc.), Fluorex 500, and Fluorex 700.10
PATIENT SELECTION
Patient examination and evaluation are necessary in determining the
suitability of a patient with aphakia for contact lens wear. A compre-
hensive examination should include the evaluation of the lids, lashes,
tear drainage system, conjunctiva and sclera, limbus, cornea and pre-
corneal tear film, pupil, retina, and accurate measurements of corneal
curvature and refractive status.
Lids, Lashes, and Blinking

Structural abnormalities such as ptosis, entropion, ectropion, punctal
closures, lid depressions or elevations, or ulceration should be noted
and diagrammed in the records. The lashes should be examined for
presence of trichiasis, lash deformation, and epithelial scaling around
the base of the eyelashes. Trichiasis and entropion can result in
corneal insult and abrasions. Any existing infections or inflammations
should be medically treated and eliminated before contact lens wear.
Lid tension should be evaluated because flaccid or excessively tight lids
will affect lens centration. The quality of blinking, as with any poten-
tial contact lens patient, is also important. If partial blinking is present,
the constant reinforcement of consistent and complete blinking is
indicated if GP lenses are to be worn. If blinking habits are not
improved, corneal desiccation or 3 and 9 o’clock staining may result.
Tear supplements or rewetting drops may also be necessary.
Conjunctiva, Sclera, and Limbus

It is important to carefully monitor existing blood vessels and chronic
capillary abnormalities. The bulbar conjunctiva should be examined
for any unusual looseness, tissue bunching, or swelling. The lids
should be everted and the palpebral conjunctiva examined for signs of
giant papillary conjunctivitis. Also, it is important to evaluate for the
presence of superior limbic keratoconjunctivitis, limbal neovascular-
ization, surgical incisions, residual suturing, and any bleb formation
along the limbus.
Cornea and Precorneal Tear Film

Any existing scars, dystrophies, and surgically rendered endothelial
changes should be noted. The use of fluorescein to evaluate the corneal
integrity, tear film break-up time (TBUT), tear volume, and viscosity is
essential. Although the use of GP contact lenses most likely will not sig-
nificantly compromise the cornea because of hypoxia, any existing
epithelial defects and tear film inadequacies may be exacerbated.
Pupils
The size, shape, and location of the pupil should be evaluated, making
special note of any key-hole pupil or encroaching iridectomy that is not
covered by the lids.
Ophthalmoscopy
A careful evaluation should be performed to rule out cystoid macular
edema and peripheral retinal holes, tears, or detachments. Any other
existing retinal abnormalities should also be noted.
Keratometry and Topography

Keratometry measurements should be made at regular intervals to
monitor the healing process and the stabilization of the corneal con-
tour. Any gross or sector distortion of the keratometer mires should be
diagrammed. Topography is valuable to evaluate postoperative
changes in corneal shape, which may result from tight sutures, and to
identify corneal irregularity.11
Refraction
Refraction of the aphakic eye should be performed with care to estab-
lish the baseline of the expected visual acuity.2 Variations in the actual
visual acuity attained through contact lenses can be explained by the
loss of spectacle magnification or the correction of irregular astigma-
tism by GP contact lenses. When performing the refraction, an accu-
rate measurement of the vertex distance should be made.
Thoroughness and accuracy in prefitting examination procedures
are essential and will aid in patient profiling. During the consultation
with the patient, the examination findings can be reviewed and dis-
cussed in terms of potential implications for lens selection and wear-
ing schedule. Although it is a subjective judgment, the practitioner
should attempt to estimate the patient’s ultimate goals, expectations,
and motivation for wearing contact lenses because these are influen-
tial factors in the patient’s success with contact lens wear.
LENS MATERIAL SELECTION

The ability of traditional GP lens materials to transmit oxygen, when
they are used to produce lenses in aphakic powers, is controversial.
In recent years, GP lens materials with hyperpermeability have been
developed; examples include Paragon HDS 100 (Dk = 100; ISO/ANSI

method), FluoroPerm 151 (Dk = 151; Revised Fatt method), and Boston
XO (Dk = 100; ISO/Fatt method; Bausch & Lomb, Rochester, NY).
(Figure 13-4)10,12,13 Although these materials may sometimes be unsta-
ble when used for myopic lens powers, thick aphakic lenses demon-
strate good stability; however, they may still need to be replaced more
frequently than low- to mid-Dk lenses. Considering the health benefits
of high oxygen permeability, it is advisable to fit patients with aphakia
with these materials.14,15
LENS DESIGNS
Contact lens practitioners have traditionally selected from two primary
designs for rigid aphakic contact lens fitting: single cut and lenticular.
Variations of both designs are available. Figure 13-5 illustrates the more
common variations of aphakic lens designs. The selection of a single-cut
or lenticular design is a function of lid position, pupil size, keratometry
Figure 13-4. Oxygen performance (EOP) over a range of thicknesses of three rigid gas-
permeable lens materials not yet approved for clinical use by the FDA. Each point is the aver-
age of six measurements: the dashed curved segments are extrapolations beyond the
thicknesses actually measured. (From Flynn WJ, Hill RM: The oxygen performance of hard
gas permeables, Contact Lens Forum 9(11):61-67, 1984.)
Figure 13-5. Common aphakic lens designs. (1) Single cut; (2) lenticular carrier; and (3) minus
carrier. (From Grohe RM: Aphakia. In Bennett ES, Grohe RM: Rigid gas-permeable contact
lenses, New York, 1986, Professional Press Book/Fairchild Publications.)
values, and lid tightness. The indications for single-cut and lenticular
designs are compared in Table 13-1 and are described in this section.
Single-Cut Designs
Because the optical zone can be manufactured large, a single-cut
design is the initial choice of design when the patient exhibits
extremely tight lids, steep corneas, or large or irregular pupils. Single-
cut lens designs also typically result in improvement in lens comfort
and reduction in lens-lid awareness for patients with unusual lid spas-
ticity or blepharospasm. This improvement in comfort may be attrib-
uted to the generally smaller size of single-cut design lenses and less
edge thickness, leading to decreased lower lid sensation.
An ideal single-cut lens will position centrally or slightly superiorly
after each blink. Pronounced inferior displacement should be
avoided. The fluorescein pattern should reveal minimum apical clear-
ance and smooth transition zone. Generally the initial base curve of
single-cut lenses is equal to flat “K” and steepened by 0.25 D for each
diopter of corneal astigmatism, except for patients with high corneal
Table 13-1 Indications for Aphakic Contact Lens Designs
From Grohe RM: Aphakia. In Bennett ES, Grohe RM: Rigid gas-permeable contact lenses, New
York, 1986, Professional Press Book/Fairchild Publications.
toricity, in whom bitoric lenses may be necessary. The secondary

curve radius is fit 1.0 mm flatter than the base curve, and the periph-
eral curve radius is 1.5 mm flatter than the secondary curve.14
Diameters of single-cut lenses commonly range from 7.5 to 9.0 mm.
Optical zone diameter, which can be manipulated by varying the sec-
ondary curve and peripheral curve widths, should be at least 6.5 mm
to avoid flare or diplopia. Table 13-2 provides a general fitting guide
for single-cut lenses.
Lenticular Designs
For patients without tight lids and steep corneas, the thickness and
mass of an aphakic lens result in an anteriorly positioned center of
gravity, resulting in inferior lens decentration. A lenticular design will
greatly reduce lens mass and center thickness. Lenticular carriers are
available in a couple of different configurations, including minus
Table 13-2 Single Cut Lens Fitting Guide

Flat K* Diameter OZD Peripheral Curve
42-43-50 8.5 7.5 10.5/0.45
44-45 8.0 7.0 10.0/0.45
45-50 7.5 6.5 9.5/0.45
From Mandell RB: Contact lens practice, ed 3, Springfield, III, 1983, Charles C Thomas.
*
Base curve: start with base curve = flat K. For each 1 D K, add −0.25 to base curve.
lenticular in the single or double lenticular forms. Each variation has

specific applications.
The minus lenticular design is the most commonly used lenticular
carrier for aphakic lenses as compared with the plano and plus lentic-
ular carriers. The lens tends to be thinner at the junction, with a
slightly greater peripheral edge thickness. The upper lid better retains
a lens with a minus lenticular carrier; therefore reduction in lens
movement and increased patient comfort are achieved.
Single lenticular carriers continue to be the most popular form of
aphakic design. Tables 13-3 and 13-4 provide the parameters for two
possible lenticular design aphakic diagnostic lens fitting sets. The
anterior optic cap should be approximately 1.5 mm smaller in diame-
ter than the overall diameter of the lens to provide sufficient lenticular
flange for the lid to pull the lens superiorly. The center thickness of the
lens is directly affected by the diameter of the optic cap: the larger the
cap, the greater the central lens thickness. The posterior optical zone
is generally slightly smaller than the optic cap.
For better consistency, performance, and lens reproducibility, it is
advisable to specify the anterior flange radius and the anterior optic
cap diameter when ordering lenticular aphakic lenses because the
radius and width of the anterior flange are significant factors in lens
comfort and positioning.14 An anterior flange width of at least 0.7 mm
is optimal for lid contact and superior lens positioning (Figure 13-6).16
An approximate flange radius that is between 1.0 and 3.0 mm flatter
than the base curve radius is recommended, creating a minus carrier-
shaped flange that provides the most desirable lid-to-lens relation-
ship.17 A well-designed minus carrier-shaped flange can be retained by
the upper lid, therefore maintaining a slightly superior lens position
while preserving good lens comfort (Figure 13-7). An excessively flat
flange radius will create an excessively thick lens edge, resulting in
increased lens awareness or excessive superior lens decentration. This
can be remedied by making the flange radius slightly steeper. The lens
may also decenter superiorly if the flange width is too wide; for these
patients, the flange width needs to be decreased or the optical cap
diameter should be increased.
The thickness of the lens at the junction of the optical cap and the
flange is marginally thin and therefore is prone to fracture if signifi-
cant stress is induced. To avoid local or annular polymer stress, a min-
imal thickness of 0.14 mm at the junction is recommended. Junction
thicknesses less than 0.12 mm may cause significant flexure and buck-
ling of the peripheral flange, resulting in lens decentration and possi-
ble edge fracture. For patients with extreme flange flexure, the lens
exhibits lens-cornea adhesion similar to a suction cup.18,19 Clinically,
Chapter 13
Table 13-3 Aphakia (Small Lens, Lenticular, Minus Carrier) Diagnostic Lens Fitting Set
Second Second Periph. Periph. Power Optic Anter.
Base Curve Curve Blend Curve Curve OZ Lens (Front Cap Curve
Curve OZR Radius Width Curve Radius Width Diam. Diam. Thick. Vertex) Diam. Radius
46.00 7.34 8.1 .3 9.0 10.0 .4 7.2 8.6 .33 +13.00 7.2 9.1
45.50 7.42 8.2 .3 9.0 10.0 .4 7.2 8.6 .33 +13.00 7.2 9.2
45.00 7.50 8.3 .3 9.0 10.0 .4 7.2 8.6 .33 +13.00 7.2 9.3
44.50 7.58 8.4 .3 9.5 10.5 .4 7.2 8.6 .33 +13.00 7.2 9.4
44.00 7.67 8.5 .3 9.5 10.5 .4 7.2 8.6 .33 +13.00 7.2 9.5
43.50 7.76 8.6 .3 9.5 10.5 .4 7.4 8.8 .35 +13.00 7.4 9.6
43.00 7.85 8.7 .3 9.5 10.5 .4 7.4 8.8 .35 +13.00 7.4 9.7
42.50 7.94 8.8 .3 9.5 10.5 .4 7.4 8.8 .35 +13.00 7.4 9.8
42.00 8.04 8.9 .3 10.0 11.0 .4 7.4 8.8 .35 +13.00 7.7 9.9
41.50 8.13 9.0 .3 10.0 11.0 .4 7.4 8.8 .35 +13.00 7.4 10.0
41.00 8.23 9.1 .3 10.0 11.0 .4 7.4 8.8 .35 +13.00 7.5 10.1
40.50 8.33 9.2 .3 10.0 11.0 .4 7.4 8.8 .35 +13.00 7.4 10.2
40.00 8.44 9.3 .3 10.0 11.0 .4 7.4 8.8 .35 +13.00 7.4 10.3
From Sarver MD: Contact lens syllabus University of California Alumni Association, 1973, cited in Mandell RB: Contact lens practice, ed 3. Springfield, III,
1981, Charles C Thomas.
Aphakia
369
370
Table 13-4 Aphakia (Modified Contour, Lenticular, Minus Carrier) Diagnostic Lens Fitting Set
Second Second Periph. Periph. Power Optic Anter.
SECTION IV
Base Curve Curve Blend Curve Curve OZ Lens (Front Cap Curve
Curve OZR Radius Width Curve Radius Width Diam. Diam. Thick. Vertex) Diam. Radius
46.00 7.34 8.1 .5 9.0 10.0 .4 7.6 9.4 .37 +13.00 7.6 9.1
45.50 7.42 8.2 .5 9.0 10.0 .4 7.6 9.4 .37 +13.00 7.6 9.2
45.00 7.50 8.3 .5 9.0 10.0 .4 7.6 9.4 .37 +13.00 7.6 9.3
44.50 7.58 8.4 .5 9.5 10.5 .4 7.6 9.4 .37 +13.00 7.6 9.4
44.00 7.67 8.5 .5 9.5 10.5 .4 7.8 9.6 .38 +13.00 7.8 9.5
43.50 7.76 8.6 .5 9.5 10.5 .4 7.8 9.6 .38 +13.00 7.8 9.6
43.00 7.85 8.7 .5 9.5 10.5 .4 7.8 9.6 .38 +13.00 7.8 9.7
42.50 7.94 8.8 .5 9.5 10.5 .4 7.8 9.6 .38 +13.00 7.8 9.8
42.00 8.04 8.9 .5 10.0 11.0 .4 8.0 9.8 .39 +13.00 8.0 9.9
41.50 8.13 9.0 .5 10.0 11.0 .4 8.0 9.8 .39 +13.00 8.0 10.0
41.00 8.23 9.1 .5 10.0 11.0 .4 8.0 9.8 .39 +13.00 8.0 10.1
40.50 8.33 9.2 .5 10.0 11.0 .4 8.0 9.8 .39 +13.00 8.0 10.2
40.00 8.44 9.3 .5 10.0 11.0 .4 8.0 9.8 .39 +13.00 8.0 10.3
From Sarver MD: Contact lens syllabus, University of California Alumni Association, 1973, cited in Mandell RB: Contact lens practice, ed. 3. Springfield,
III, 1981, Charles C Thomas.

Figure 13-6. Optimal 0.7-mm anterior flange creating superior lens positioning by interacting
with the upper lid. (From Grohe RM: Aphakia. In Bennett ES, Grohe RM: Rigid gas-
permeable contact lenses, New York, 1986, Professional Press Book/Fairchild Publications.)
minute arcuate adhesions will be observed because of flange flexure in

the flatter corneal periphery.20 In addition, the flange junction may act
as a reservoir for mucoprotein deposits, which can be removed by
applying a cotton swab soaked in abrasive surfactant cleaner. However,
care must be taken to apply the cotton swab parallel to the lens because
a perpendicular approach will create too much stress on the thin
flange junction (Figure 13-8).
Double lenticular designs are effective for difficult cases where the
lens edge is below the superior lid margin. GP lenses of 9.8-mm diam-
eter or larger can be readily stabilized with a double lenticular carrier.
However, it is even more important to maintain a minimal flange
junction thickness to avoid multiple annular fracture sites (Figure
13-9). In addition, when the flange junction zones of the anterior and
posterior bevels approximately coincide, a significant amount of flex-
ure because of lens profile thinning may occur that can lead to fracture
of a GP lens in the eye. To avoid this potential problem, the anterior
and posterior bevels can be designed such that the junction sites do
not coincide. This will result in a more uniform distribution of stress
Figure 13-7. Minus carrier lens is pulled by the lid into a superior position. (From
Mandell RB: Contact lens practice, ed 3, Springfield, Ill, 1981, Charles C. Thomas
Publisher.)
throughout the matrix of the lens, minimizing potential stress-related

fracture sites. Because of the possibility of eyelid-induced lens frac-
ture, double lenticular carriers should be used conservatively.
The flow chart shown in Figure 13-10 has been developed as a
method of differentiating design preferences in different cases.21
Single-cut and lenticular lens designs can be manufactured in GP
materials and are effective corrective options for patients with aphakia.
Diagnostic Fitting
Valuable information can be obtained from diagnostic lens evaluation
by assessing the lens performance on the eye and by performing an
Figure 13-8. The use of a Q-tip soaked with an abrasive surfactant cleaner, if applied correctly,
can eliminate deposit buildup at the flange junction of a lenticular rigid aphakic lens. (From
Grohe RM: Aphakia. In Bennett ES, Grohe RM: Rigid gas-permeable contact lenses, New
York, 1986, Professional Press Book/Fairchild Publications.)
overrefraction to accurately determine the power of the lens. These

pieces of information are essential for the prescription of a lens that
offers the optimal lens-to-cornea fitting relationship and to determine
the best potential visual acuity that can be obtained from GP contact
lenses. The overrefraction is best determined by using Halberg clips or
a trial frame. The diagnostic lens power should be within 4 D of the
predicted final value to provide more accurate information on the lens-
to-cornea fitting relationship and to minimize the effect of vertex dis-
tance in the refraction. If residual astigmatism is present and
significantly reduces visual acuity, it can be incorporated into specta-
cles to be worn over the contact lenses.
INTRAOCULAR LENS IMPLANTS VERSUS APHAKIC CONTACT LENS CORRECTION

Because of the aging population, the number of patients undergoing
cataract surgery continues to increase, and IOL implants are more
commonly used in cataract surgery than ever. This is primarily
because of the improvements in surgical techniques and quality of IOL
Figure 13-9. Lid and flexure forces can create fracture stress at the junction between the lens
flange and the optical zone. (From Grohe RM: Aphakia. In Bennett ES, Grohe RM: Rigid
gas-permeable contact lenses, New York, 1986, Professional Press Book/Fairchild
Publications.)
implants and the low incidence of complications with IOLs reported.

Therefore the number of patients with aphakia after cataract surgery is
rapidly decreasing. However, the fitting of aphakic contact lenses
remains an important part of a contact lens practice because IOL
implantation may be contraindicated in some patients and because
aphakic contact lenses are the best alternatives to IOLs with regard to
visual performance.14
A previous contraindication to IOL implants was a patient’s young
age because of the refractive power changes that are anticipated with
ocular growth. This has been overcome by considering the expected
rate of myopic shift that occurs in the developing eye when determin-
ing the IOL power. Therefore more recently IOL implantation has
become increasingly accepted for young children and even for
infants.14,22 Other contraindications to IOL implants include intraocu-
lar diseases, especially severe or recurrent uveitis; abnormal anatomy,
such as aniridia or compromise to the iris or corneal endothelium; and
any unforeseen intraoperative complication that may cause the sur-
geon to abandon IOL implantation.2
Contraindications to aphakic contact lenses include dexterity prob-
lems encountered in patients with arthritis, tremors, Parkinson’s dis-
Figure 13-10. A guide to differentiating aphakic lens design preference. (Courtesy Polymer
Technology, Inc.)
ease, and so on; chronic external pathologic conditions such as kerati-

tis sicca, blepharitis, and persistent epithelial defects of the cornea;
and intolerance to contact lenses. IOLs and aphakic contact lenses pro-
vide effective means of post–cataract surgery correction by providing
patient satisfaction and superior visual functioning compared with
spectacle correction. Table 13-5 consists of a comparison of all the dif-
ferent rehabilitation options for patients with aphakia in terms of the
factors that contribute to visual function, patient satisfaction, and
patient success with rehabilitation.
Complications resulting from IOL implants and contact lenses are
functions of the location of the lens in the eye. With IOLs there is a
slightly higher risk of complications internally, whereas aphakic con-
tact lenses may cause more complications in the external tissues of the
eye.23,24 Boxes 13-1 and 13-2 indicate the important advantages to apha-
kic contact lenses and IOLs.
SUMMARY
Aphakic GP lenses provide superior vision compared with spectacle
correction, and they are excellent alternatives when IOL implants are
contraindicated. Diagnostic lens fitting should be performed to obtain
376
SECTION IV
Table 13-5 Comparison of Aphakic Rehabilitation Options
Extended Wear
Hydrogel Contact Gas Permeable

Factor Aphakic Glasses Intraocular Lenses Lenses Contact Lenses
Magnification 25%-30% 1.5% 5%-7% 5%-7%
Adaptation/adjustment Long Short Short Slightly longer than for
period IOLs or hydrogels
Visual field Ring scotomas Normal Normal Normal
Coordination/manual Minimal None Significant Significant
dexterity needed
Cosmesis Poor Excellent Excellent Excellent
Endothelial integrity Not essential Mandatory Mandatory Mandatory
Handling Daily, necessary None Important Very important
Physiologic Few (long-term Seldom, but serious Anterior segment; Minimal
complications functional long-term
adaptation)
Pupil dilation Easy Difficult Easy Easy
Comfort Poor Excellent Excellent Good
Cost Minimal once Rx One-time significant Ongoing expense Minimal
stabilized expense
Chapter 13
Site of complications Facial, rare Internal External External
From Grohe RM: Aphakia. In Bennett ES, Grohe RM: Rigid gas-permeable contact lenses, New York, 1986, Professional Press Book/Fairchild
Publications.
Aphakia
377
Box 13-1 ADVANTAGES OF APHAKIC CONTACT LENSES

●
Possibly safer and more readily removed when needed
●
Rarely cause postoperative intraocular complications
●
Relative ease in changing power of the lens when required
●
A nonsurgical alternative to secondary IOL implants
●
Relatively low initial cost compared with surgery to implant IOL in an
already aphakic eye
Box 13-2 ADVANTAGES OF INTRAOCULAR LENS IMPLANTS

●
An alternative for patients with dexterity problems arising from
disabling systemic diseases such as arthritis and Parkinson’s disease
●
Eliminates need for patient handling
●
Lack of maintenance
●
Relatively quick return to normal vision
●
Stable visual acuity
●
Preferred for patients with chronic external pathological conditions such as
keratitis sicca, blepharitis, and persistent epithelial defects of the cornea
●
Significant reduction in costs generated from maintenance and multiple
contact lens replacements
important information about patient’s tolerance to lenses, potential

visual acuity, and lens parameters for best aphakic lens fit. The contact
lens practitioner has several aphakic lens designs available, and new
lens materials with hyper-Dk provide superior health benefits.
REFERENCES
1. Grohe RM: Aphakia. In Bennett ES, Grohe RM, editors: Rigid gas permeable contact
lenses, New York, 1986, Professional Press Books/Fairchild Publications, pp
411-429.
2. Weissman BA: Contact lens application in aphakia. In London R, Harris MG, edi-
tors: Mosby’s optometric problem-solving series: contact lenses for pre- and post-sur-
gery, St. Louis, 1997, Mosby, pp 67-96.
3. Borish I: Aphakia: perceptual and refractive problems of spectacle correction, J Am
Optom Assoc 54:701, 1983.
4. Boeder P: Spectacle correction of aphakia, Arch Ophthalmol 68:870-874, 1962.
5. Dyer JA, Ogly KN: Correction of unilateral aphakia with contact lenses, Am J
Ophthalmol 50(1):11-17, 1960.
6. Floyd G: Changes in corneal curvature following a cataract extraction, Am J

Ophthalmol 34(11):1525-1533, 1951.
7. Phillips LJ, Soltis GG: Intraocular lenses: an update, J Am Optom Assoc
54(8):697-700, 1983.
8. Kohlhaas M: Corneal sensation after cataract and refractive surgery, J Cataract
Refract Surg 24(10):1399-1409, 1998.
9. Chou BK, et al: Spectral transmittance of contact lens materials, Int Contact Lens
Clin 11(2):106-115, 1984.
10. GP materials and products guide. Available at www.rgpli.org. Accessed July, 2003.
11. Corbett MC, Rosen ES: Lens replacement: corneal topography in cataract surgery.
In Yanoff M, Duker JS, editors: Ophthalmology, London, 1999, Mosby, pp
4.15.1-4.15.6.
12. www.paragonvision.com/products_con3.html. Accessed July 2001.
13. www.bausch.com/us/resource/visioncare/bostonrgp/bostonxo.jsp#MATE. Accessed
August 2001.
14. Davis LJ: Aphakia. In Bennett ES, Henry VA, editors: Clinical manual of contact
lenses, ed 2, Philadelphia, 2000, Lippincott Williams & Wilkins, pp 477-492.
15. Bennett ES, Levy B: Material selection. In Bennett ES, Henry VA, editors: Clinical
manual of contact lenses, ed 2, Philadelphia, 2000, Lippincott Williams &
Wilkins, pp 59-74.
16. Polse KA: Lens design factors of aphakic gas-permeable lenses, J Am Optom Assoc
54(8):719-724, 1983.
17. Nelson G, Mandell RB: The relationship between minus carrier design and per-
formance, Int Contact Lens Clin 2:75-81, 1975.
18. Fatt I: Negative pressure under silicone rubber contact lenses, Contacto 23(1):6-8,
1979.
19. Fanti P: Silicone contact lens wear III: physiology of poor tolerance, Contact Lens
Intraocul Lens Med J 6(2):111-119, 1980.
20. Sevigny J: The Boston lens clinical performance, Int Contact Lens Clin 10(2):73-
81, 1983.
21. Polymer Technology Corporation: Fitting guide: clinical information and reference
for the Boston contact lens, Wilmington, MA. 1982.
22. Cassidy L: Pediatric cataract, Optom Today 9:27-31, 2001.
23. Bernth-Peterson P, Sorensen T: Intraocular lenses versus extended wear contact
lenses in aphakic rehabilitation, Acta Ophthalmol 61:382-391, 1983.
24. Bainbridge JW, Teimory M, Tabandeh H, et al: Intraocular lens implants and risk
of endophthalmitis, Br J Ophthalmol 82(1):1312-1315, 1998.
14
Gas Permeable Extended Wear
IVETTA SIEDLECKI
EDWARD S. BENNETT
W ith the increasing demands of a fast-paced society, the

extended-wear modality of lens wear has become not only
an added convenience for patients but also practically a
requirement by their lifestyles. With the introduction of higher oxygen-
permeable materials, this presents a safer alternative than previ-
ously thought. This chapter will address the benefits, applications, patient
selection, fitting, and care of extended-wear gas permeable (GP) lenses.
BENEFITS
GP lenses provide several advantages versus their hydrogel counter-
parts.1 Deposits on the lens can be easily removed by polishing.2 The
lenses provide superior optics with good stability. Table 14-1 compares
the benefits of GP lenses over hydrogel lenses.3 Complications associ-
ated with extended-wear GP lenses will be discussed later in the chapter.
Safety is one of the most important issues concerning GP extended-
wear materials compared with hydrogel lenses. Complications of
hydrogel lenses are primarily the result of four limitations to the lens
design and materials3,4: (1) insufficient oxygen transmission; (2) lens
surface deposition and contamination; (3) limbal compression and
seal-off; and (4) porous polymer composition.
Insufficient oxygen transmission can be manifested in several
ways, ranging from corneal edema and microbial keratitis to corneal
infiltrates and neovascularization.5,6 GP lenses can use dry monomers
to provide higher gas permeability.3
Lens surface deposits can create intolerance to hydrogel lenses and
distort vision. They have been associated with the development of
giant papillary conjunctivitis7 and increased bacterial adherence to the
lens.8 Lens deposits can be polished off the lens surface, often without
affecting the wettability or optical quality of the lens.
Limbal compression can induce complications such as conjunctival
hyperemia, neovascularization, corneal infiltrates, and keratoconjunc-
380
Chapter 14 Gas Permeable Extended Wear 381
Table 14-1 Comparison of Benefits of Hydrogel Versus Gas Permeable

Extended-Wear Lenses
Hydrogel GP
Parameter availability Limited Unlimited
Manufacturing reliability, verifiability Poor-good Good-excellent
Fitting expertise required Minimal Moderate
Visual performance Fair-good Good-excellent
Oxygen transmission Poor-fair Good-excellent
Initial comfort Good-excellent Poor-good
Long-term comfort Fair-good Good
Replacement frequency 1 week–1 year 1-3 years
Modification None In most cases
Dehydration Significant Minimal
Soilage Progressive Manageable
tivitis. These complications are most likely a result of limited exchange

in tears and decreased removal of debris away from the eye. The
smaller diameter of the GP lens allows more movement and therefore
much greater tear exchange with blinking.
PATIENT SELECTION
One of the first documented uses of extended-wear GP lenses per-
tained to contact lens wearers with aphakia.5,9 Patients with aphakia
often have poor digital dexterity and uncorrected vision; the use of
these lenses with replacement at regularly planned intervals provides
these patients with the full benefit of this modality.
To achieve successful GP lens wear, it is vital to screen patients
before placing them in an extended-wear modality. Similar to all situ-
ations concerning patients, extended wear is not the ideal option for all
contact lens wearers. Such as for those with contraindications for
extended-wear hydrogel lenses, patients with a history of diabetes,
microbial keratitis, pathologic dry eye, corneal dystrophy, or other
anterior segment pathology should avoid extended wear of their GP
lenses. Whether it is contaminated lens cases and solutions, inade-
quate disinfection, or simply a lack of good personal hygiene, studies
have correlated an increased risk for extended-wear complications
with poor lens hygiene.5 Smoking has also been implicated as a risk
factor for complications such as microbial keratitis; the mechanism as
of yet is unknown, although it could potentially be the result of char-

acteristics in the behaviors of smokers.10,11
The patient’s need for visual correction must be factored into the
decision of whether to embark on the continuous-wear pathway.
Patients with myopia with a low refractive error, who typically remove
their glasses to read, would be forced into full-time correction of their
prescription, which may not be optimum for their needs. However, the
improvement in visual quality for patients with anisometropia, high
myopia, and aphakia often makes them optimum candidates.
Vocation is also an important factor. Extended wear has been shown
to be ideal for firefighters.12 Although many studies and case reports
show GP lenses exhibiting some protection in industrial accidents,13
they do not replace the use of the appropriate eye protection such as
safety goggles.
A patient expressing interest in extended wear must be motivated to
be successful. Motivation can encourage a person to be compliant with
the care and handling procedures necessary for success. Patients must
be informed of the responsibilities associated with wearing extended-
wear lenses, and an understanding of their expectations for their
lenses should be gained before dispensing lenses. It is important that
their expectations are realistic and that they are comfortable with lens
handling and care. For example, patients with aphakia with decreased
dexterity must still be able to insert and remove their lens in the event
of an emergency or discomfort. If the patient would like GP lenses for
issues of dryness, extended-wear lenses may just exacerbate the issue.
It would be prudent to begin with daily-wear lenses and then progress
to extended-wear lenses when and if possible. In cases of orthokera-
tology, where lens wear is just during sleeping hours, a way to over-
come initial lens awareness with extended wear is to have the patient
remove, rinse, soak, and then reinsert the lenses just before going to
sleep because movement is minimized during sleep, making the
lenses more comfortable.3
ASSESSMENT
Careful assessment of patients before fitting them for extended-wear
lenses is necessary, similar to the fitting required for daily-wear lenses.
The patient’s health history is significant. As mentioned earlier, dis-
eases that represent poor wound healing (e.g., diabetes, immunocom-
promise) are indicative of a poor candidate for extended-wear lenses.
Although not an automatic contraindication, the use of oral antihista-
mines may exacerbate symptoms of dryness. In addition, patients with
irregular corneas, such as those with keratoconus, Fuchs’ dystrophy, or
a history of corneal surgery (i.e., penetrating keratoplasty, radial kera-

totomy), should be ruled out before proceeding with fitting into
extended-wear lenses.
A normal and healthy tear film is essential to a successful fit in
extended-wear lenses because of the less frequent removal and clean-
ing of the lenses. Excessive debris in a patient’s tears may be a sign
that this patient is more likely to build up deposits on his or her lenses.
Dryness may indicate discomfort with the extended-wear modality.
Signs of chronic blepharitis or hordeola may signal potential lid
problems with extended wear. Pterygia would be a contraindication
because of the vascularity associated with the advancing edge; in addi-
tion, it makes the corneal surface irregular and presents an area that
may not have adequate tear flow because of physical obstruction.
Pingueculae, conversely, may or may not predict success. These
patients will need to be carefully monitored to reduce the risk of
adverse reactions.
A comprehensive slit-lamp examination using fluorescein stain in
combination with a cobalt blue light and Wratten No. 12 filter to accu-
rately assess the cornea, conjunctiva, and tear film is necessary. The
presence of ghost vessels, neovascularization, or even limbal engorge-
ment may also be a significant finding, indicating increased risk for
complication with extended wear. These are all signs of hypoxia and
often indicate the need for higher oxygen-permeable (Dk) lens materials.
LENS MATERIALS
Although the extended-wear modality has typically represented a small
percentage of the lenses fit in the past, the development of lenses
approved for overnight wear, 7-day wear, and most recently 30-day
continuous wear is changing the mindset for contact lens fitters. Table
14-2 lists high- (51 to 99) and hyper- (>100) Dk lens materials approved
for extended wear.15 Menicon Z (Menicon Co., Ltd., Nagoya, Japan,
manufactured in the United States by Con-Cise Contact Lens Co., San
Leandro, CA) is the most recently Food and Drug Administration
(FDA)–approved lens. With a Dk of 163, it is currently the only GP lens
approved for 30-day continuous wear.16 A comparison of the Menicon Z
after 30 days of continuous wear with Acuvue (Johnson & Johnson
Vision Care, Inc., Jacksonville, FL) after 7 days of extended wear showed
equivalent performance between the two lenses.17 Many of the subjects
showed thinner corneas; the authors hypothesized this was possibly
because of a decrease in hypoxia-induced corneal swelling, GP-induced
reversible corneal epithelial compression, decreased epithelial slough-
ing, or long-term contact lens-induced keratocyte apoptosis.18
Table 14-2 Gas Permeable Extended-Wear Lens Materials

Lens Name Manufacturer Material Dk
High Dk
Alberta Lens “S” Progressive Optical Sulfocon A 53
Research
Boston EO Polymer Technology Enuflufocon B 58
Equalens II* Polymer Technology Oprifocon A 85
Fluorex 700 GT Laboratories Flusilfocon A 70
Fluorocon* CIBA Vision Corporation Paflufocon B 60
Fluoroperm 60* Paragon Vision Sciences Paflufocon B 60
Fluoroperm 92* Paragon Vision Sciences Paflufocon A 92
OP-6 Stellar Conact Lens, Inc. Lotifocon C 60
O-Perm F 60 Optical Polymer Research Oxyflufocon A 62
Paragon HDS† Paragon Vision Sciences Paflufocon B 58
Paraperm EW* Paragon Vision Sciences Pasifocon A 56
Hyper Dk
Boston XO Polymer Technology Hexafocon 100
Fluoroperm 151* Paragon Vision Sciences Paflufocon D 151
Menicon SFP Con-Cise Contact Lens Co. Melafocon 159
Menicon Z‡ Con-Cise Contact Lens Co. Tisilfocon 163-250
Paragon HDS 100* Paragon Vision Sciences Paflufocon D 100
*
Lens has been approved for 7-day continuous wear.
†
Lens has been approved for overnight wear.
‡
Lens has been approved for 30-day continuous wear.
The ideal extended-wear lens has a hyper-Dk for patients with

hyperopia. Holden and Mertz14 found the minimum requirement for
oxygen transmissibility to prevent corneal edema was 24.1 + 2.7 × 10−9
for daily wear and 87.0 + 3.3 × 10−9 for extended wear. It has been
found that higher-Dk lenses resulted in less corneal swelling after 1
month of continuous wear versus medium- or low-Dk materials.19 The
Berkeley Contact Lens Extended Wear Study (CLEWS) evaluated the
relationship of oxygen permeability for GP extended-wear lenses with
extended wear and the association to contact lens-associated ker-
atopathies (CLAKs).20 It was found that, although success rates for the
high- and medium-Dk GP wearers were the same, failure resulting
from CLAK was significantly higher for the medium-Dk lenses. It is
important to note the medium-Dk GP group complication rate was
low compared with hydrogel lenses of the same Dk. This would indi-
cate that hypoxia, although important, may not be the only issue.
However, when selecting a lens for extended wear, it is important for

the practitioner to select the highest Dk lens material available that
allows for stable, comfortable vision for the patient.
High-Dk silicone/acrylate (S/A) materials provide good oxygen trans-
mission, although protein and lipid deposition is more frequent on the
lens. Silicone, although highly permeable to oxygen, is hydrophobic and
exhibits poor flexural resistance (see Chapter 2). The development of
fluoro-silicone/acrylate (F-S/A) lens materials allowed for a reduced sili-
cone content, thereby decreasing the attraction for deposits and
decreased the likelihood of warpage. These lens materials can exhibit
optimum oxygen transmissibility and good surface wettability. Examples
of hyper-Dk extended-wear F-S/A lens materials include Boston XO
(Polymer Technology Corporation, Bausch & Lomb, Rochester, NY),
Paragon HDS 100 (Paragon Vision Sciences, Mesa, AZ), and Menicon
Z. The latter is a derivative of fluoromethacrylate in combination with
siloxanylstyrene and benzotriazol (the ultraviolet light absorber).21
LENS DESIGN AND FITTING

Philosophies for fitting GP extended-wear lenses vary from apical
clearance-to-alignment22,23 to alignment-to-flat24-26 lens-to-cornea fit-
ting relationships. The most important factor is that GP extended-wear
lenses are fit in a similar manner as daily-wear lenses. Because of a
greater likelihood of flexure-induced residual astigmatism—notably
with an apical clearance fitting relationship for patients exhibiting
moderate-to-high corneal astigmatism—a bitoric lens may be required
to help with centration and vision for patients with greater than 2 D of
corneal astigmatism.
The general recommendation is to select large diameters.23,25 The
lenses can tuck underneath the upper lid to increase lens comfort; the
large diameter can also cause a decrease in flare. The overall diameter
often ranges from 9.4 to 10.2 mm. However, as with daily-wear lens
designs, a smaller diameter (i.e., 8.8 to 9.0 mm) may be indicated for
patients in whom a large palpebral fissure negates the possibility of
achieving a lid attachment fitting relationship.
Selecting center thickness varies with Dk of the material.27 It should
be enough to minimize flexure without decreasing oxygen permeabil-
ity. Many F-S/A lens materials have a higher specific gravity than S/A;
this means that the F-S/A lens may need to be made thicker than its
S/A counterpart. However, improvements in lens polymer develop-
ment and manufacturing technology have resulted in lens designs
with center thicknesses only slightly greater than their lower-Dk
counterparts.
The edge lift for the lens needs to be higher than for daily wear to help
with tear flow and assist in minimizing adherence. Schnider28 recom-
mends edge lift between 0.15 and 0.20 mm. Studies report that lenses
with lower edge lift show more severe staining29,30 and that as edge clear-
ance decreases, lens adherence increases.31 Therefore a wide region of
definite 360-degree peripheral clearance with well-blended peripheral
curve radii is recommended to minimize staining and adherence.
Flexure plays an important role in the fitting of a lens for extended
wear. As mentioned earlier, the silicone component of GP lenses
makes them softer, more oxygen permeable, and less resistant to flex-
ure. As the oxygen permeability of the lens material increases, the lens
is typically more flexible. Studies report a practitioner should avoid fit-
ting an apical clearance lens-to-cornea fitting relationship to minimize
flexure.32-34 To determine if flexure is present, overretinoscopy and
overkeratometry must be performed during the examination, as dis-
cussed in Chapter 5.
It is also recommended that practitioners take advantage of the lab-
oratory consultants and obtain their advice for the ideal fit. They can
serve as a valuable resource when designing a GP extended-wear lens.
PATIENT EDUCATION
Good communication is essential for patient success with extended
wear. It is beneficial to attempt to minimize the potential for compli-
cations. As discussed earlier, when performing a comprehensive case
history, it is important to understand the patient’s motivations and
expectations concerning extended wear. It is also important to discuss
the risk and benefits, potential complications, and requirements for
compliant wear.
Instructional videotapes, booklets, and other resources can be used
to help educate the patients in handling, care, and management of
their lenses. Patients should be advised on insertion and removal,
cleaning and disinfection, and wearing schedule of the lenses. It
would be prudent to discuss discontinuing extended wear during ill-
ness or infections and address concerns regarding cosmetics and per-
sonal items such as hairspray.
FOLLOW-UP CARE
Progress Evaluations
Although some practitioners advocate initiating extended wear from
day 1, we recommend beginning lens wear with daily wear first and
then progressing to extended wear. For first-time lens wearers, it has

been suggested that it takes 8 days to achieve acceptable levels of com-
fort with regards to lens awareness.35
The extended-wear regimen requires careful and consistent follow-
up evaluation to maintain good ocular health. The patient should not
exceed the prescribed maximum wearing time, even if lenses are still
comfortable.
A thorough examination should be performed at every visit and
should include case history, visual acuity, overrefraction, overkeratom-
etry, and slit-lamp biomicroscopy with white and blue cobalt light with
lenses on and off. The case history should include any adverse reac-
tions, fluctuations in vision, changes in comfort or care regimen, sub-
jective symptoms of adherence, redness, lens verification and
condition, and the patient’s impression of lens fit and comfort.
Baseline visual acuity, overrefraction, and keratometry should cor-
relate with post–extended-wear results. A decrease in with-the-rule
astigmatism is expected because of the effect of GP lens wear on the
cornea with overnight wear (to be discussed in the Complications sec-
tion). Keratometry should be performed on lens removal; mire clarity
and distortion should be noted. Ideally, corneal topography evaluation
with a videokeratoscope would provide more detailed information
about corneal shape change, possible distortion, and unusual curva-
ture changes while also serving as an excellent tool for monitoring
topography change over time.
Patients should be asked to review their cleaning and care proce-
dures at the first follow-up visit; in addition, they should be asked if
they are experiencing any difficulty with insertion and removal. A ben-
efit of an initial daily-wear schedule is the opportunity to become pro-
ficient at handling because these procedures may occur much less
frequently once an extended-wear schedule is initiated.
The lids and conjunctiva should be carefully examined for hyper-
emia and chemosis. The corneal clarity should be evaluated for signs
of hypoxia, such as microcysts, folds, blebs, and edema. Corneal stain-
ing, if present, should be noted as to location and type (e.g., foreign
body, diffuse, arcuate).
The first follow-up visit should occur within the first week of wear-
ing the lens for daily wear. If no complications have presented, the
patient can initiate an extended-wear schedule. The first follow-up
evaluation should be the morning after sleeping in the lenses for the
first time; it is preferable to see patients within 2 hours of waking to
assess for hypoxia.3 If swelling or lens binding is present, the patient
should return to the clinic another day at midmorning to monitor for
changes. If swelling is still present, a higher-Dk lens material is
warranted. If the issue is lens binding, the patient may need to remain
in daily wear. Assuming findings are normal, the patient should then
schedule follow-up evaluations at 1 week, 2 weeks, 1 month, 3 months,
and every 3 months from there. It is advisable to recommend the
patient remove the lenses overnight, at minimum, one night a week
for cleaning and disinfection.
Most manufacturers have preferred cleaning and disinfection regi-
mens. It is important to adhere to their recommendations because
materials are becoming more complex. Frequent lens replacement
may help to minimize deposit- and warpage-related problems.
Furthermore, Woods and Efron36 suggested a regular replacement
interval of every 3 to 6 months might also prevent other adverse reac-
tions such as lens binding.
Complications
The most common complications associated with extended-wear GP
lenses are hypoxia, lens binding, poor lens wetting, decreased vision,
ptosis, and dryness. Most of these can be addressed with simple
changes to the lens or lens materials. However, complication rates for
the extended-wear GP modality are low, especially compared with
hydrogel lenses.37-39
Hypoxia, as addressed earlier, can manifest itself through signs
such as corneal edema, striae, endothelial polymegethism, and
increased myopia. Oxygen delivery to the eye through the lens depends
on lens material, lens thickness, the tear pump, and tightness of the
lids during sleep.40 This is customarily managed by refitting in a
higher Dk or different lens material.
Lens adherence is not uncommon and most likely occurs in 100%
of extended-wear lens patients on a transient basis.41 Typically, the lens
will be decentered, and tears will be concentrated at the periphery of
the lens because of the relative absence of tear exchange (Figure 14-1),
while debris will be trapped behind the lens (Figure 14-2). Although
the patient may be asymptomatic, areas of indentation may be appar-
ent with staining (Figures 14-3 and 14-4). Lens binding may cause
superficial punctate keratitis, corneal distortion, spectacle blur, and
even microbial keratitis.42 The Fisher-Schweitzer pattern may also be
apparent. A corneal mosaic pattern, the Fisher-Schweitzer pattern is
not one of epithelial cell loss but rather occurs secondary to lens com-
pression on the cornea.3 Usually disappearing within a few hours of
waking, it may be related to the rigidity or swelling of the cornea.
Blinking, digital pressure, or artificial tears may initiate movement of
the lens.43 Lens-to-cornea adherence without lens movement was
noted for the first time in 1979 with silicon rubber lenses.44 It was
Figure 14-1. Trapped fluorescein at the periphery of an adherent lens.
described as a suction effect from the contact between the lens and the
eye; it was suggested that poor quality tear film or surface hydropho-
bicity and the negative pressure of the lens against the eye contribute
to this effect. More specifically, they hypothesized that tears between
the lens and cornea produce adherence from the shear forces exerted
by the high pressure.45 The action of the lids forces the tears from
underneath the lens, with the midperipheral portion of the lens being
the first area of the lens to contact the cornea, eventually progressing
to corneal seal-off. Large overall diameters with low edge lift and a flat
Figure 14-2. Trapped debris that can form a mucoprotein “glue” to aid in adherence.
Figure 14-3. Adherence ring or imprint after lens removal.
base curve radius have been implicated. Management includes advis-

ing the patient to clean both surfaces of the lens on removal. In addi-
tion, the patient should be advised to wait as long as 30 to 60 minutes
on awakening to remove the lens and to do so after first instilling
rewetting drops followed by mild digital manipulation of the lower lid
into the lower edge of the lens to break any existing seal that may be
present if the lens is bound. Improving the lens-to-cornea fitting rela-
tionship may reduce the problem as would advising the patient to
resume a daily-wear schedule. Considering a wider flatter peripheral
curve and a smaller overall diameter would be beneficial. Because
some patients will exhibit adherence with any lens design, in a few
occasions, changing them to a soft lens material would be indicated.
Figure 14-4. The adherence phenomenon.

Poor lens wetting can be a sign of either pitch remaining on the

lens or that the patient is not properly cleaning and disinfecting
the lenses. To remove the pitch polish, a laboratory solvent or cleaner
is indicated. Poorly wetting lenses can manifest through blurry or
foggy vision or feelings of dryness or discomfort. With this problem,
reviewing proper techniques for cleaning and disinfecting the lenses
would be appropriate (see Chapter 7). A different solution regimen
(i.e., switch from multipurpose solution to separate cleaner and soak-
ing solution) should be considered. Regular use of a liquid enzyme is
imperative for GP extended-wear patients.
A trend toward corneal flattening during the first month of wear
has been shown in several studies.43,46,47 As mentioned earlier, spher-
icalization results during the first month. A significant increase in
myopia or astigmatism or a decrease in best-corrected visual acuity
may warrant a change in lens material or design.
Ptosis has been correlated to extended-wear GP lenses after a
2-month period of wear.48 It is important to note the ptosis resolved in
all cases after discontinuing lens wear.
Reduced vision can be attributed to several different problems. It is
important to ask the patient when is the vision reduced. Is it all the
time? Is it when the patient first wakes up or at the end of the day? Do
rewetting drops help? Does blinking help? Is there discomfort in com-
bination with the reduced vision? Does it appear as a fog, or are letters
not sharp? These symptoms can be related to any one or combination
of numerous possible causes: poor wettability, a dry environment, lens
deposits, incomplete blinking, or poor-fitting lenses. Warpage of the
lens can cause blurred vision. Verifying the base curve radius with a
radiuscope will confirm warpage caused by the resulting toricity. Lens
deposits can also interfere with vision; extended-wear lenses tend to
deposit more readily than daily-wear lenses. Handling and care will
need to be reviewed with the patient in both of these cases.
Dryness can decrease vision, comfort, and overall success with
extended-wear lenses. Desiccation of the cornea with GP lenses mani-
fests through 3 and 9 o’clock staining. Its mechanism of occurrence
may be that the GP lens prevents the upper lid from completely wet-
ting the surface of the cornea adjacent to the edge of the lens, espe-
cially in the areas around the 3 and 9 o’clock hour regions.
Management of this problem can often result by improving centration
if the lens is decentered inferiorly or changing to a more wettable lens
material. In addition, flattening the base curve radius, increasing axial
edge lift, increasing the overall diameter, changing the material, or
changing to an aspheric lens design may be beneficial.49
As discussed in Chapter 9, vascularized limbal keratitis (VLK) has

been reported in extended- and daily-wear GP lens wearers.50 In VLK,
extensive staining is present in the corneal epithelium, limbus, and con-
junctiva with superficial and deep vascularization of the cornea in the
exposed peripheral 3 and 9 o’clock regions. If allowed to progress, areas
of the corneal epithelium may become heaping and hyperplastic, then
forming an infiltrate and worsening to a corneal erosion (Figure 14-5).
These patients will have sensitive corneas with increased lens
awareness and localized pain; they will complain of reduced wearing
time because of their corneal sensitivity. Patients will subjectively com-
plain of a red eye and the visible appearance of a “white spot” on the
eye. Because of the risk of infiltration and erosions, not to mention the
discomfort, it is necessary to monitor patients for signs of VLK. An
association may occur between VLK and GP lens designs with steep
fitting, large diameters, and low edge lifts.3 Likewise, VLK has been
observed predominantly in S/A lens wearers.50 Depending on the
severity of the condition, a patient will not be able to wear his or her
lenses for 2 days to 2 weeks. A combination antibiotic-steroid, such as
TobraDex (Alcon, Fort Worth, TX), will assist in reducing the inflam-
mation and the risk of infection. Modifications of the lens to flatten
base curve radius, decrease the diameter, or increase the edge lift will
typically need to be performed. Drops, such as artificial tears or decon-
gestants, can be used to improve comfort while the cornea is healing.
Figure 14-5. Vascularized limbal keratitis.

SUMMARY
With the high oxygen transmissibility of new lens designs, the GP
extended-wear modality is a safer and more comfortable alternative
than before. The most important concern for eye care practitioners is
the health and visual needs of the patient. With careful screening, this
is a modality that can aid in building a successful practice.
REFERENCES
1. Fonn D, Holden BA: RGP vs. hydrogel lenses for extended wear, Am J Optom
Physiol Opt 65(7):545-551, 1988.
2. Maehara J, Kastl P: Rigid gas permeable extended wear, CLAO J 20(2):139-143, 1994.
3. Schnider C, Bennett E, Grohe R: Rigid extended wear. In Bennett ES, Weissman
BA, editors: Clinical contact lens practice, Philadelphia, 1991, Butterworth-
Heinemann, pp 56-1 to 56-14.
4. Bennett ES, Ghormley NR: Rigid extended wear: an overview, Int Contact Lens
Clin 14(8):319-332, 1987.
5. Brennan NA, Coles MLC: Extended wear in perspective, Optom Vis Sci
74(8):609-623, 1997.
6. Chahine T, Weissman B: Peripheral corneal furrow staining: a sign to discon-
tinue hydrogel contact lens use, Int Contact Lens Clin 23(6):229-233, 1996.
7. Fowler SA, Greiner JV, Allansmith MR: Soft contact lenses from patients with
giant papillary conjunctivitis, Am J Ophthalmol 8:1956, 1987.
8. Aswad M, Barza M, Kenyon K, et al: Bacterial adherence to extended wear soft
contact lenses, Invest Ophthalmol Vis Sci 27(suppl):166, 1989.
9. Gurwood AS: Prescribing contact lenses for aphakes, Contact Lens Spectrum
10(11):17-23, 1995.
10. Poggio EC, Glynn RJ, Schein OD, et al: The incidence of ulcerative keratitis
among users of daily-wear and extended-wear soft contact lenses, N Engl J
Med 321:779-783, 1989.
11. Cutter GR, Chalmers RL, Roseman M: The clinical presentation, prevalence, and
risk factors of focal corneal infiltrates in soft contact lens wearers, CLAO J
22:30-37, 1996.
12. Kartchner MN: Fight fires with contacts? Contact Lens Forum 10:13, 21, 23-25,
27-30, 1985.
13. Rengstorff RH: Eye protection from contact lenses, J Am Optom Assoc 45(3):
274-275, 1974.
14. Holden BA, Mertz GW: Critical oxygen levels to avoid corneal edema for daily- and
extended-wear contact lenses, Invest Ophthalmol Vis Sci 25:1161-1167, 1984.
15. Thompson TT: Tyler’s Q 20(2):52-56, 2003.
16. Gleason W, Tanaka H, Albright R, et al: A 1-year prospective clinical trial of
Menicon Z (tisilfocon A) rigid gas permeable contact lenses worn on a
30-day continuous wear schedule, Eye Contact Lens 29(1):2-9, 2003.
17. Gleason W, Albright R: Menicon Z 30-day continuous wear lenses: a clinical com-
parison to Acuvue 7-day extended wear lenses, Eye Contact Lens 29(1S):S149-
S152, 2003.
18. Pall B, Barr J, Szczotka L, et al: Corneal thickness results in the Menicon Z
30-day continuous wear and Acuvue 7-day extended wear contact lens clini-
cal trial, Eye Contact Lens 29(1):10-13, 2003.
19. Ichijima H, Imayasu M, Tanaka H, et al: Effects of RGP lens extended wear on
glucose-lactate metabolism and stromal swelling in the rabbit cornea, CLAO
J 26(1):30-36, 2000.
20. Polse KA, Graham AD, Fusaro RE, et al: The Berkeley contact lens extended wear
study: part I and II, Ophthalmology 108(8):1381-1399, 2001.
21. www.menicon.com, April, 2003.
22. Swarbrick HA, Holden BA: Rigid gas permeable lens binding: significance and
contributing factors, Am J Optom Physiol Opt 64(11):815-823, 1987.
23. Yamane S: Fitting RGP lenses for extended wear, Contact Lens Forum 13:24-27,
1988.
24. Jones L, Woods CA: Contact lens fitting and design, Optician 203:16-22, 1992.
25. Lebow KA: Clinical evaluation of the Boston Equalens for cosmetic extended
wear, Contact Lens Spectrum 2:47-53, 1987.
26. Morgan P: Advanced contact lens fitting. Part one: extended wear RGP lenses,
Optician 5595:20-26, 1997.
27. Bennett ES, Sorbara L: Lens design, fitting, and evaluation. In Bennett ES, Henry
Lippincott Williams and Wilkins, pp 75-124.
28. Schnider CM, Terry RL, Holden BA: Clinical correlates of peripheral corneal des-
iccation, Invest Ophthalmol Vis Sci 29(suppl):336, 1988.
29. Solomon J, Snyder R, Klein P: A clinical experience with extended wear RGP
lenses, Contact Lens Spectrum 1:49-50, 1986.
30. Andrasko GJ: Clinical implications of 3 & 9 o’clock staining. Presented at the
First Annual RGP Lens Institute Symposium, St Louis, MO, July 1989.
31. Swarbrick HA, Holden BA: Rigid gas permeable lens binding: significance and
contributing factors, Am J Optom Physiol Opt 64(11):815-823, 1987.
32. Harris MG, Chu CS: The effects of contact lens thickness and corneal toricity on
flexure and residual astigmatism, Am J Optom Arch Am Acad Optom
49(4):304-307, 1972.
34. Pole JJ: The effect of base curve on the flexure of Polycon lenses, Int Contact Lens
Clin 10(1):49-52, 1983.
35. Morgan P, Maldonado-Codina C, Efron N: Comfort response to rigid and soft
hyper-transmissible contact lenses used for continuous wear, Eye Contact
Lens 29(1S):S127-S130, 2003.
36. Woods CA, Efron N: Regular replacement of extended wear rigid gas permeable
contact lenses, CLAO J 22(3):172-178, 1996.
37. Fonn D, Holden BA: RGP vs. hydrogel lenses for extended wear, Am J Optom
Physiol Opt 65(7):545-551, 1988.
38. Schnider CM: An overview of RGP extended wear, Contax May:10-12, 1987.
39. Weissman BA, Remba MJ, Fugedy E: Results of the Extended Wear Contact Lens
Survey of the Contact Lens Section of the American Optometric Association,
J Am Optom Assoc 58(3):166-171, 1987.
40. Koetting RA, Castellano CF, Nelson DW: A hard lens with extended wear possi-
bilities, J Am Optom Assoc 56:208-211, 1985.
41. Swarbrick HA, Holden BA: The incidence of RGP lens adherence: experimental
vs. clinical findings, Invest Ophthalmol Vis Sci 30(3, suppl):166, 1989.
42. Kenyon E, Polse KA, Mandell RB: Rigid contact lens adherence: incidence, sever-
ity and recovery, J Am Optom Assoc 59(3):168-174, 1988.
43. Polse KA, Sarver MD, Kenyon E, et al: Gas-permeable hard contact lens extended
wear: ocular and visual responses to a 6-month period of wear, CLAO J 13:
31-38, 1987.
44. Bennett ES, Grohe RM: How to solve stuck lens syndrome, Rev Optom 124(12):
51-52, 1987.
45. Swarbrick HA: A possible etiology for RGP lens binding (Adherence), Int Contact
Lens Clin 15(1):13-19, 1988.
46. Henry VA, Bennett ES, Forrest JF: Clinical investigation of the Paraperm EW rigid
gas-permeable contact lens, Am J Optom Physiol Opt 64(5):313-320, 1987.
47. Sevigny J: Clinical comparison of the Boston IV contact lens under extended
wear vs. the Boston II lens under daily wear, Int Eyecare 2(5):260-264, 1986.
48. Fonn D, Holden BA: Extended wear of hard gas-permeable contact lenses can
induce ptosis, CLAO J 12(2):93-94, 1986.
49. Holden BA, Terry R: How to succeed with extended wear, Rev Optom 126:81-86,
1989.
50. Grohe RM, Lebow KA: Vascularized limbal keratitis, Int Contact Lens Clin
16(7&8):197-209, 1989.
15
Contact Lenses After Refractive
Surgery
HELEN J. CHANDOHA
JOSEPH P. SHOVLIN
MICHAEL D. DEPAOLIS
“I wanted refractive surgery so I wouldn’t have to wear contact lenses or

glasses!”
W ith the ever-increasing popularity of vision correction sur-

gery, practitioners are sometimes faced with a disappointed
and frustrated patient after refractive surgery. In addition to
being psychologically difficult for the patient to return to contact
lenses, it is a noteworthy challenge for the practitioner to fit these
patients. Traditional prescribing guidelines cannot be used because
the corneal surface has now been altered in shape and function. Thus
the practitioner must understand the healing process of the cornea
after refractive surgery, use the pretopography and posttopography
measurements, and be creative with diagnostic contact lens fitting. A
conservative approach should always prevail in postrefractive fitting
(i.e., always do what is in the patient’s best interest without regard to
financial benefit).
Reasons for contact lens application include glare, photophobia,
undercorrection or overcorrection, induced irregular astigmatism, loss
of best spectacle visual acuity, anisometropia, and aniseikonia.1 This
chapter will describe postrefractive surgery fitting for the aforemen-
tioned reasons. It will include radial keratotomy (RK), photorefractive
keratotomy (PRK), and laser-assisted in situ keratomileusis (LASIK). A
discussion of the rationale for contact lens use, options, and demand-
ing fitting considerations will be described for each of the refractive
surgery techniques.
RADIAL KERATOTOMY
Although not seen as a primary means of refractive surgery today, we
are encountering post-RK patients who are now manifesting ani-
396
Chapter 15 Contact Lenses After Refractive Surgery 397
sometropia, resulting in diplopia and disturbed binocular fusion, or

diurnal fluctuation of vision. The Prospective Evaluation of Radial
Keratotomy (PERK) study found that 35% of its RK patients experience
anterior corneal curvature increases (steepening) during the day
caused by corneal hydration and arteriole pulse, which distends on the
globe.2 This often requires a stronger myopic correction for evening
use. Irregular astigmatism can also impact the post-RK patient
because of incision depth and healing rates. Two other reasons for fit-
ting contact lenses involve glare, resulting from a small optical zone
(OZ) (Figure 15-1), width of the incision scars and pupil size, and
hyperopic shifts or rarely myopic regressions. This final reason is once
again from inadequate incision depth or aggressive stromal wound
healing.3
Contact Lens Fitting

When looking at a post-RK topography, the desired corneal flattening
to reduce myopia may not always be depicted. Areas of steepening
adjacent to flattening are asymmetric, accounting for residual myopia,
hyperopia, or induced astigmatism. Thus contact lenses can be bene-
ficial in masking the irregular corneal surface. OZ decentration can
sometimes only be appreciated with use of corneal mapping and often
explains contact lens decentration. However, the cornea’s anatomic
and physiologic changes can increase the risk of neovascularization
(Figure 15-2), epithelial defects, corneal edema, infiltrative keratitis,
Figure 15-1. Exceedingly small optic zone in a radial keratotomy patient experiencing
significant glare. Unfortunately, the patient had three enhancements.
Figure 15-2. Stromal hematoma in a patient with an eight-incision radial keratotomy

and significant neovascularization.
and ulcerative keratitis.4 Therefore patients with limbal injection,

severe vascularization, significant corneal staining or edema, anterior
chamber reactions,5 inclusion plugs, or cysts in the incisions6 (Figure
15-3) should not be fitted with contact lenses because they are at risk
for developing ulcerative keratitis.
It is best to fit a post-RK patient who has a stabilized topography
and refraction.3,4 This may be difficult to determine because of diurnal
Figure 15-3. Sixteen-incision radial keratotomy showing inclusion cysts.

fluctuations. Nevertheless, within 2 to 3 months after surgery, the fluc-

tuations usually stabilize.7 In some patients, the fluctuations can occur
for an indefinite period, depending on the level of steroid use after the
surgery.5 Other factors include length of incision and depth. This was
identified in the PERK study to be the cause of hyperopic shifts; longer
incisions were associated with a greater hyperopic shift. Therefore
mini-RK incisions were instituted to prevent the latter. However, this
caused a smaller amount of myopia to be corrected.8
The contact lens of choice is the gas permeable (GP) lens. There is
greater oxygen transmissibility, fewer lens surface deposits, and an
irregular astigmatism-compensating tear film.
The following contact lens parameters should be used.
Base Curve
According to DePaolis et al,4 it was determined that an initial contact
lens base curve (BC) should be based by subtracting one third of the
refractive error reduction from the preoperative flat keratotomy. For
example, the preoperative keratotomy readings are 43.00 × 44.00, and
the RK myopic reduction is 2.00 D. To select an initial BC, one would
take (43.00 – ¹⁄₃[2.00]), or 42.30. Modifications are then based on flu-
orescein evaluation, vision, and lens stability. Given the flat central
curve and steep “knee” periphery,3 another method of determining BC
is to calculate the flattest dioptric meridian of this transition zone
(approximately a 3-mm radius).7
When a cornea is altered by incisional surgery (e.g., central flattening),
an ideal pattern appearance would be an unavoidable moderate-to-
significant central clearance, alignment–mild touch in the midperiphery,
and some mild-to-moderate edge clearance for good tear exchange.
Standard multicurve designs often reveal excess edge clearance and
increased movement; therefore aspheric lenses should be considered
because of their junctionless curves and ability to mask astigmatism.
Goldberg9 describes an RK-aspheric ellipsoidal back surface design with
an eccentricity of 0.6. He recommends fitting 1.75 D steeper than the flat-
test preoperative keratometry reading and selecting an overall diameter
2.0 mm larger than the BC radius to minimize decentration.
Unfortunately, prescribing practitioners do not always have access
to the original preoperative keratometry readings. Lee and Kastl10
addressed this issue. They found the preoperative keratometric read-
ings are not necessary. Applying diagnostic lenses and observing fluo-
rescein patterns could achieve an optimal post-RK GP lens fit. Most
lenses were between 9.2 and 10.0 mm in diameter. BCs ranged from
36.00 to 42.50 D and were usually steeper than the postoperative flat-
ter meridian keratometric reading.
Optical Zone Diameter

A smaller zone will decrease tear pooling in the larger flattened central
zone of the RK cornea. If not designed this way, the stagnant tear pool-
ing with debris can cause variable vision, dimple veiling, and hypoxia.
Overall Lens Diameter

Because of apical displacement and a large overall central corneal plateau,
a larger diameter, 9.5 to 11.5 mm, should be used. A larger diameter lens
facilitates lid attachment with midperipheral corneal fitting. However, the
practitioner must monitor the lens-to-cornea fitting relationship as the
diameter of the lens increases. The curvature may not match the post-RK
cornea and may cause decentration and lens adherence.
Peripheral Curves
Peripheral curves are selected based on lens position and diameter.
They should not be so steep as to obstruct tear flow given the midpe-
ripheral topography. The curves should not be too flat as to prevent
proper circulation of tears.11 To compensate for this, reverse-geometry
GP lenses (steep peripheral and flatter central curves) were developed
to conform to the corresponding corneal shape. Reverse-geometry
lenses generally have secondary curves 3 to 6 D steeper than their cen-
tral curves. This design prevents pooling of tears or lens bearing and
promotes stability. Examples include OK Series (Contex Inc., Sherman
Oaks, CA), RK-Bridge (Conforma, Norfolk, VA), and the NRK Lens
(Lancaster Contact Lens, Inc., Lancaster, PA). In fact, many regional
laboratories with DAC (DAC Vision, Garland, TX) lathing capabilities
can fabricate these lenses. A study in Singapore by Lim et al12 showed
how 11 patients (13 eyes) who had RK, PRK, and penetrating kerato-
plasty (PKP) wore the reverse-geometry lens (Menicon Plateau Lens,
Clovis, CA). The authors found the fluorescein pattern of the plateau
lens fit (central bearing, midperipheral pooling, followed by bearing
and peripheral edge lift) provided patients with good visual acuity
without complications. An advantage of the plateau design is its abil-
ity to incorporate a front toric configuration, which is beneficial to the
residual astigmatism of the postsurgical corneas. It should be noted
that any changes made to the OZ of a reverse-geometry lens have an
opposite effect when compared with a conventional lens. Unlike a
spherical lens, smaller OZs result in a tighter fitting relationship with
reverse-geometry lenses.
Lens Materials and Lens Thickness

As one would expect, a thin and moderate-to-high oxygen transmissi-
bility lens will prevent corneal edema. In RK patients with decreased
endothelial function (Figure 15-4), edema may be slower to resolve.3

Fluoro-silicone/acrylate (F-S/A) materials provide good oxygen trans-
mission and deposit and flexure resistance.4 Lens flexure and adher-
ence, however, are possible when prescribing a thin lens.
Hydrophilic soft contact lenses are a good second option for post-
RK fits. These lenses are prescribed if the patient is unable to tolerate
a GP lens and if the RK incisions do not extend to the limbus. RK inci-
sions to the limbus can initiate neovascularization. A proper candidate
for this type of lens is a compliant patient who uses proper lens
hygiene. The Harrison postrefractive surgery lens (Paragon Vision
Sciences, Mesa, AZ) is a good option for the post-RK cornea. Lenses
with high oxygen flux are preferred. The Focus Night & Day lens (Ciba
Vision, Duluth, GA) provides excellent oxygen transmission to these
surgically altered corneas and may also result in acceptable acuity.
Patients exhibiting residual astigmatism with a GP lens may be fit
with a toric soft contact lens. Despite corneal instability with variable
astigmatic axis and power, a soft postrefractive surgery lens (Harrison
postrefractive lens, Paragon Vision Sciences) follows the contours
of the “new” cornea. This corrective lens has a flat BC and steep
peripheral curves providing good vision and centration, respectively.4
Therefore as long as peripheral corneal edema has resolved (usu-
ally 6 months after surgery), a soft contact lens can be used with
caution.5
Figure 15-4. Significant endothelial morphology showing large areas of cell

enlargement along the incision line of a radial keratotomy cornea.
PHOTOREFRACTIVE KERATECTOMY
In PRK, a 193-nm argon fluoride excimer laser removes corneal
epithelium and stroma (a process called photoablation),8 often affect-
ing only the anterior 10% of central corneal depth without altering the
peripheral cornea for treating refractive errors. A smoother transition
through the ablation zone should provide the practitioner with an eas-
ier contact lens fit. A 6- to 12-month post-PRK forestallment should be
given to facilitate corneal healing with refractive and topographical sta-
bilization.13 Regression of the initial refractive response is directly cor-
related with intended myopic correction. For example, with a larger
intended correction, there is a greater amount of regression and longer
time for stabilization to occur.14 Because the corneal curvature often
steepens 1 to 2 weeks postoperatively,3 early contact lens intervention
may be difficult.
Regardless, there are reasons for fitting post-PRK patients. They
include residual ametropia caused by laser programming errors,
aggressive corneal wound healing, abnormal collagen synthesis, and
epithelial hyperplasia. Central corneal thickening by approximately
5 μm may result in 1.0 D of refractive regression.15 Another indication for
contact lenses is irregular astigmatism caused by aggressive corneal
healing or central island effect (area of corneal steepening)(Figure
15-5). A decentered ablation zone (Figure 15-6) resulting from poor
Figure 15-5. Prominent “central island” effect after photorefractive keratotomy.

Figure 15-6. Markedly decentered optic zone in a photorefractive keratotomy patient.
patient fixation or inconsistent surgical technique can also result in

irregular astigmatism and decreased acuity. Finally, stromal haze from
type III collagen deposition by active keratocytes and sulfated keratan8
can decrease best-corrected visual acuity. Although topical corticos-
teroids can help diminish the haze, contact lenses can provide further
visual comfort. One must be wary when addressing haze with reabla-
tions because the haze itself can lead to an overestimation of the
amount of myopia, which can result in an overcorrection.8

Postoperative discomfort is lessened with the use of a bandage contact
lens along with topical nonsteroidal antiinflammatory drugs
(NSAIDs).16 By the third or fourth postoperative day the disposable
contact lens is removed because the epithelium has then healed.
Although using disposable contact lenses for this purpose is consid-
ered “off-labeled,” the Food and Drug Administration (FDA) has
approved the ProTek (Ciba Vision, Atlanta, GA) for this purpose.4
Newer generation silicone hydrogel lenses are also attractive for use
after refractive surgery.
In certain post-PRK eyes, a loss of preoperative spectacle visual acu-
ity has been reported. For this reason, better vision is often obtained
with GP lenses.17,18 Schipper et al18 discussed cases where 13 eyes were
fitted with an aspheric GP lens (Boston Equalens, Bausch & Lomb)

after PRK, with best fits showing apical clearance, midperipheral
alignment, and peripheral clearance.
The ideal pattern for patients after PRK is less apical pooling than
after RK, mild midperipheral touch whenever possible, and some
clearance peripherally for adequate tear exchange.
Base Curve
An initial GP BC approximately 0.50 D flatter than the flat preopera-
tive keratometry reading has been recommended as a starting point.4
Corneal topography must be used to determine if the ablation zone is
decentered because this could be the reason for not obtaining a stable
lens fit in some patients. Patel et al19 studied the shape of the corneal
apical zone after excimer PRK. They found the average post-PRK
corneal contour to have the appearance of steepening ellipses from the
apex toward the edge of the ablation zone.
Optical Zone Diameter

Because the flat ablation zone of the cornea promotes pooling of fluo-
rescein, a smaller OZ in the contact lens should be used.
Overall Lens Diameter

Traditional GP lens diameters are often prescribed because of the rel-
atively unchanged midperipheral area of the cornea.20 Centration of
the contact lens is obtained using lid attachment with an average lens
diameter of 9.0 to 10.5 mm.4
Peripheral Curves
Because the transitional zones are smooth in the ablation zone, stan-
dard peripheral curves can be used.4 Reverse-geometry contact lenses
are rarely indicated.
Lens Materials and Lens Thickness

Oxygen-permeable materials are necessary, and an F-S/A material is
preferred.4 A standard lens thickness is sufficient and will not result in
significant lens flexure. This will provide patient comfort, good vision,
and ease of lens handling.
Hydrogel Soft Contact Lenses

Because wound healing is relatively fast after PRK and the corneal
trauma is more superficial compared with RK, corneal edema, infec-
tious keratitis, and neovascularization are not commonly associated
with soft lenses. To be clinically prudent, a disposable contact lens
worn daily is best. Because central vaulting with excess tear pooling
can occur,17,18 a flat BC with a larger lens diameter for better centration
should be prescribed. A thin central thickness is also recommended.
With soft lenses, a spherocylindrical overrefraction should be per-
formed. This will determine whether a soft toric contact lens or GP
lens is indicated for residual astigmatism. If the spherocylinder refrac-
tive error ratio is ≤ 3:1, then GP lenses are the better option.21 GP lenses
are also preferred if there is irregular astigmatism or if significant
astigmatism is found. Conversely, if the patient has against-the-rule
corneal cylinder, soft toric contact lenses provide better centration.21
If spherical aberrations are of concern, a newer aspheric soft lens
should be prescribed. This lens category includes Frequency 55
Aspheric (Cooper Vision, Rochester, NY) and the Specialty Choice AB
(Specialty Ultravision, Campbell, CA).22 Concern is generally at night
for most but can be a factor for patients with large pupils even during
the day. Complaints consistent with aberrations warrant some alter-
ation in lens approach.
LASER-ASSISTED IN SITU KERATOMILEUSIS (LASIK)

This refractive lamellar surgical technique alters the anterior curva-
ture of the cornea by removing stroma while leaving Bowman’s layer
and epithelium intact.8 Given this procedure, more surgeons are
selecting LASIK because of the postoperative advantages: shorter
recovery time with less pain, fewer follow-up visits and medications,
and predictable refractive outcome. When a flap complication occurs,
resulting in epithelial defects or ingrowth (Figure 15-7), diffuse lamel-
lar keratitis (DLK), or inaccurate ablation to the stroma bed, an over-
correction or undercorrection with irregular astigmatism may ensue.
In these scenarios, contact lenses can provide visual relief to the post-
operative patient. Overcorrections occur in 5% of patients after
LASIK, and undercorrections occur in 15% of patients with myopia.23
Decentered ablation, central islands, and irregular astigmatism are
also possible.

Even though post-LASIK bandage contact lenses are occasionally pre-
scribed for therapeutic reasons (e.g., loose flaps or epithelial defects on
the flap), their use does have risk. Potential bandage lens complica-
tions include epithelial distortion, edema, possible infection, and
delayed improvement in vision.24
Because LASIK is relatively new to the refractive surgeon’s arma-
mentarium, it is likewise novel to the contact lens fitter. A few articles
Figure 15-7. Interface ingrowth of epithelium in a laser-assisted in situ keratomileusis

patient who experienced multiple epithelial defects after the procedure.
have been written about such post-LASIK contact lens fits, and each
will be explained.
To design a post-LASIK contact lens, corneal topography must
again be analyzed. According to DePaolis et al,4 one should use the
sagittal topographic maps to determine the diameter of the flat zone.
To determine the midperipheral corneal curvature, the tangential
maps should be used. Because this area has a high dioptric variability,
using data averaged from the sagittal map is beneficial to determine
the initial BC. Fluorescein evaluation assists in finalizing the BC. The
authors also recommend the BC formula for post-RK fitting (subtract
one third of the refractive error reduction from the preoperative flat
keratotomy value). If the patient’s fluorescein pattern has sharp
demarcation within the transition between central and peripheral
curve area, an aspheric GP lens should be used with lid attachment.
For an unusually shaped cornea, a gradual fluorescein transition is
desired. An aspheric design can sometimes provide a more gradual
rate of flattening effect. This results in a more acceptable midperiph-
eral pattern. Another option would be a reverse-geometry system. This
will decrease bearing at the transitional zones and increase edge lift.
To determine the secondary curves in a reverse-geometry lens, the pre-
scriber should average the dioptric value of the data points at the tran-
sition zone on the sagittal map corresponding to the 0, 90, 180, and
270 meridians.5
The lens diameter should promote lid attachment (9.5 to 11.5 mm).
This will decrease cornea (more specifically the corneal flap) bearing,
thus promoting vaulting. Consequently, the OZ diameter should be
2.5 mm smaller than the overall diameter to diminish debris entrap-
ment, hypoxia, and poor vision. The material should provide optimal
oxygen transmissibility, resist lens deposits (FSA material), and be
thin enough for comfort and centration.
Szczotka and Aronsky25 advocate post-LASIK GP lens fitting when
necessary, largely because of the lacrimal lens’s ability to neutralize
irregular astigmatism and enhance oxygen transmission and tear
exchange. They state that use of corneal topography makes it difficult
to determine the initial BC because of the oblate corneal shape after
surgery. The authors recommend diagnostic lens fitting with an initial
lens BC to be 1.00 to 1.50 D steeper than the flat postoperative kerato-
metric reading. This will promote the vaulting pattern and midperiph-
eral alignment advocated by DePaolis et al. For optimal centration, the
overall lens diameter should range from 9.2 to 10.5 mm with the OZ
1 to 4 mm smaller than the lens diameter. Therefore the posterior con-
tact lens OZ should vault the LASIK ablation zone and thus be large
enough to provide full pupillary coverage in dim illumination. Most
OZs are 6 to 8 mm in diameter compared with the 4.5- to 9.0-mm
ablation zones from the excimer laser.23,26,27 Reverse-geometry lenses
(Figure 15-8) are preferred for those patients with oblate corneal
Figure 15-8. A well-centered reverse-geometry lens on a post–laser-assisted in situ

keratomileusis cornea.
shapes caused by the sharp curvature of the corneal cap made by the
microkeratome. When deciding on peripheral curves, the authors rec-
ommend using the axial map, measuring the “knee” of the transition
zone, and averaging the midperipheral curves by placing the cursor at
these sites. They then select the secondary curves equal to or slightly
flatter than the average at the transition zones. The BC can be selected
to be 1 D steeper than the flat keratometric reading or, if more than 2 D
of corneal astigmatism remains, an average of the keratometric read-
ings.28 Although they advocate use of GP lenses, Szczotka and
Aronsky25 also use soft contact lenses 4 to 12 weeks after surgery for
those patients who cannot tolerate GP lenses. The Harrison post-
refractive lens (Paragon Vision Sciences) functions like a reverse-
geometry lens. Patients with residual astigmatism can be difficult to fit
with soft toric contact lenses because of poor lens-to-cornea contours.
Chou et al29 evaluated the long-term efficacy of contact lens fitting
after myopic keratomileusis. They found postoperative keratometry
readings to be more beneficial, ranging from 7.9 to 9.2 mm, with use
of fluorescein patterns with associated OZ diameters ranging from 5.6
to 6.7 mm. They used larger lens diameters to decrease movement,
with incremental increases of 0.2 mm. Of greater interest is their find-
ing of soft contact lens fitting. A patient from this prospective evalua-
tion who was fitted with a soft lens developed epithelial hyperplasia
and increased myopia. Another patient (not in this study) who was fit-
ted with a soft contact lens 4.5 months after myopic keratomileusis
developed tight lens syndrome on the third day of the soft contact lens
fitting. This changed her undercorrection from 1.50 D before soft con-
tact lens wear to 5.50 D as a result of corneal steepening.
Effects From Postrefractive Contact Lens Fitting

Regarding post-RK fitting, a study by Shivitz30 found 48% of eyes hav-
ing undergone radial incisions and fitted with hydrogel soft contact
lenses developed neovascularization. However, because RK no longer
uses incisions to the limbus, there is less risk for a neovascular stimu-
lus. In fact, the same study found only two eyes fitted with GP lenses
developed a neovascular response.
Other problems after post-RK fitting are recurrent corneal erosions
caused by basement membrane changes, and inclusion cysts along the
incision lines.2 An already decentered lens resulting from a decentered
postsurgical corneal apex can enhance the poor optical quality from
soft contact lenses. As in normal GP lens wear, corneal molding can
develop, causing central corneal steepening or compression.2
It has been found that there is no increase in PRK corneal haze or
epithelial staining associated with lens fitting.31 The impetus for neo-
vascular growth is less the result of the excimer laser’s ability to ablate
with minimal collateral tissue involvement. Although refractive out-
comes have not been affected thus far,31 the use of GP lenses compared
with soft contact lenses does not seem to alter corneal integrity.
Finally, the practitioner must be aware of post-LASIK contact lens
wear complications. These concerns relate to flap hypoesthesia and ocu-
lar surface drying. These two conditions can delay contact lens wear for
up to 6 months or longer after the surgery.4 Of interest are the effects on
the corneal endothelium. Reports have been recorded of improvements
in endothelial cell density, most likely because of discontinuation of con-
tact lens use.25 However, no such studies have adequately addressed
what occurs to the endothelium with a post-LASIK contact lens.
To provide the optimum corneal homeostasis, a GP lens should be
used first when fitting postrefractive corneas. This will stabilize the
altered corneal layers and provide additional oxygen for the eye’s res-
piratory needs.32 However, if the patient cannot tolerate this type of
lens because of edge sensation, the patient should be fitted with a soft
contact lens.
SUMMARY
It is difficult for patients after refractive surgery to return to corrective
contact lens wear, especially when they had hoped to be free of them
all together. They often revert to poor lens hygiene, predisposing them-
selves to additional ocular infection. Appropriate discussions of the
risks, benefits, and especially outcomes (good and bad) of refractive
surgery must be addressed with prospective candidates during their
refractive surgery consultation. This will help avoid patient disap-
pointment should contact lenses be required postoperatively.
REFERENCES
1. Binder PS: Optical problems following refractive surgery, Ophthalmology 93:739,
1986.
2. Aquavella JV, Shovlin JP, DePaolis MD: Contact lenses and refractive surgery. In
Harris MG, London R, editors: Problems in optometry, Philadelphia, 1990, JB
Lippincott, pp 685-703.
3. Astin CLK: Refractive surgery and contact lenses. In Hom MM, editor: Manual of
contact lens prescribing and fitting, Boston, 2000, Butterworth-Heinemann,
pp 363-380.
4. DePaolis M, Shovlin JP, Henry VA: Postsurgical fitting. In Bennett ES, Henry VA,
editors: Clinical manual of contact lenses, ed 2, Philadelphia, 2000, Lippincott
5. DePaolis MD, Shovlin JP, Ryan RA: The state of refractive surgery: a clinician’s
guide to post-op care, Rev Optom 132:93-96, 1995.
6. MacRae S, Rich L, Phillips D, et al: Diurnal variations in vision after radial kera-
totomy, Am J Ophthalmol 107:262-267, 1989.
7. Szczotka LB: Contact lenses for the irregular cornea, Contact Lens Spectrum 13:21,
1998.
8. Kaufman H, Barron BA, McDonald MB, et al: Companion handbook to the cornea,
ed 2, Boston, 2000, Butterworth-Heinenmann.
9. Goldberg JB: The RK-aspheric RGP corneal lens of for radial keratotomy, Contact
Lens Spectrum 8(3):23-24, 1993.
10. Lee AM, Kastl PR: Rigid gas permeable contact lens fitting after radial kerato-
tomy, CLAO J 24:33-35, 1998.
11. Shovlin JP, Kame RT, et al: How to fit an irregular cornea, Rev Optom 124:88-98,
1987.
12. Lim L, Siow KL, Sakamoto R, et al: Reverse geometry contact lens wear after pho-
torefractive keratectomy, radial keratotomy or penetrating keratoplasty,
Cornea 19(3):320-324, 2000.
13. Waring GO, Bourque L, Cartwright CS, et al: Summary of initial results of the
prospective evaluation of radial keratotomy (PERK) study, Ophthalmol Forum
3:177-185, 1985.
14. Gartry DS, Kerr-Muir MG, Marshall J: Excimer laser photorefractive keratec-
tomy—18 month follow up, Ophthalmology 99:1209-1219, 1992.
15. McDonnell PJ: Excimer laser corneal surgery: new strategies and old enemies,
Invest Ophthalmol Vis Sci 36(1):4-8, 1995.
16. Aquavella JV, Shovlin JP, Pascucci S, et al: How contact lenses fit into refractive
surgery, Rev Ophthalmol 1:36, 1994.
17. Astin CL, Garty DS, McG Steele AD: Contact lens fitting after photorefractive
keratectomy, Br J Ophthalmol 80:597-603, 1996.
18. Schipper I, Businger U, Pfarrer R: Fitting contact lenses after excimer laser
photorefractive keratectomy for myopia, CLAO J 21:281-284, 1995.
19. Patel S, Marshall J, Fitzke F, et al: The shape of the corneal apical zone after
excimer photorefractive keratectomy, Acta Ophthalmol 72:588-596, 1994.
20. Bufidis T, Konstas AGP, Pallifaris IG, et al: Contact lens fitting difficulties
following refractive surgery for high myopia, CLAO J 26(2):106-110, 2000.
21. Bennett ES: RGPs and soft torics: making the right decision, Contact Lens
Spectrum 14(3):19, 1999.
22. Jackson JM: Management of irregular corneal astigmatism, Contact Lens
Spectrum 15(12):23-27, 2000.
23. Perez-Santonja JJ, Bellot J, Claramonte P, et al: Laser in situ keratomileusis to
correct high myopia, J Cat Refract Surg 23:372, 1997.
24. Pallikaris I, Siganos D: Laser in situ keratomileusis to treat myopia: early experi-
ence, J Cat Refract Surg 23:39-49, 1997.
25. Szczotka LB, Aronsky M: Contact lenses after LASIK, J Am Optom Assoc 69:775-784,
1998.
26. Danasoury MA, Waring GO, Maghraby AE, et al: Excimer laser in situ ker-
atomileusis to correct compound myopic astigmatism, J Refract Surg 13:
511-520, 1997.
27. Tsai RJ: Laser in situ keratomileusis for myopia of -2 to -25 diopters, J Refract Surg
13(suppl):S427-S429, 1997.
28. Menicon plateau fitting guide, Clovis, CA, 1986, Menicon U.S.A.
29. Chou A, Swinger CA, Cogger SK: Fitting contact lenses after myopic ker-
atomileusis, J Cat Refract Surg 25:508-513, 1999.
30. Shivitz IA: Fitting contact lenses after radial keratotomy, Contact Lens Forum
13:38-39, 1988.
31. Astin CL: Contact lens fitting after PRK, Ophthalmic Physiol Opt 15(5):371-374,
1995.
32. Mizutani Y, Matsutaka H, Takemoto N, et al: The effect of anoxia on the human
cornea, Acta Soc Ophthalmol Jpn 9:644-649, 1987.
16
Contact Lenses and Myopia
Progression
JEFFREY J. WALLINE
A pproximately 25% of the U.S. adult population has myopia,1 yet

only 2% of children entering elementary school are near-
sighted.2 Approximately 15% of teenaged children become
myopic between the ages of 6 and 14 years, and myopia progression
generally continues until approximately age 15 years for girls and 16
years for boys.3 Therefore slowing the progression of myopia in chil-
dren could ultimately impact the lives of approximately 42 million peo-
ple in the United States.
People with myopia greater than −6.00 D are at greater risk for
sight-threatening anomalies such as retinal detachments, pathologic
myopia, posterior subcapsular cataracts, early onset nuclear sclerosis,
primary open-angle glaucoma, and corticosteroid responsiveness.
Patients with −1.00 to −3.00 D spherical equivalent myopia are four
times more likely to experience a retinal detachment than patients
without myopia, and patients with greater than −6.00 D spherical
equivalent myopia are 10 times more likely to experience a retinal
detachment than patients without myopia.4 Patients with less severe
myopia have better uncorrected visual acuity than people with
moderate-to-high myopia, and they are able to wear thinner spectacle
lenses that are more comfortable and cosmetically more appealing.
Patients with −3.00 D myopia obtain more predictable refractive sur-
gery results than patients with −6.00 D myopia5; thus control of
myopia at a young age may have a profound effect on the correction of
myopia later.
Gas permeable (GP) contact lenses provide clear, comfortable vision
with relatively few ocular health risks and are a standard management
option for correcting myopia. Although GP contact lenses are used to
correct myopic refractive error, they may also provide a therapeutic
effect and retard the progression of myopia.
412
Chapter 16 Contact Lenses and Myopia Progression 413
PREVIOUS STUDIES OF MYOPIA CONTROL WITH RIGID CONTACT LENSES

Previous review articles have suggested that rigid contact lenses retard
the progression of myopia in children,6-8 and several studies have
attempted to substantiate this effect.9-13 The first report was by
Morrison in 1956.14 He fitted more than 1000 patients with myopia
between the ages of 7 and 19 years with polymethylmethacrylate
(PMMA) contact lenses and claimed that no patients experienced
myopia progression after 2 years. The contact lenses were fitted 1.50 D
to 2.50 D flatter than the flattest keratometry reading, so an orthoker-
atologic effect may have influenced the halt of myopia progression. In
1959, Morrison reported to an audience at the annual American
Academy of Optometry meeting that he attempted to fit children with
alignment-fitted rigid contact lenses. He said, “Now and then, an
increase in minus is noted, usually slight in amount.”15 Other anec-
dotal clinical reports with similar results soon followed.16-18
Two studies compared the effects of PMMA contact lenses with
spectacles on myopia progression in children. In 1975, Kelly et al19
reported that only 62% of 57 patients younger than 15 years progressed
at least −0.25 D during a 4-year period. Of the 84 spectacle wearers
who were examined at 10 years of age and again at 14 years of age, 73
(85%) experienced myopia progression. The subjects in Kelly’s study
were not randomly assigned to treatment groups, and the contact
lens wearers were likely to have reached the age of cessation for
myopia progression during the study, thereby potentially affecting the
results.
Stone13 conducted a study of 80 children fitted with PMMA contact
lenses and 40 children wearing spectacles. The rigid contact lenses
were fitted with the base curve “just steeper” than the flattest ker-
atometer reading. It was found that the average rate of progression
was −0.10 D per year for contact lens wearers compared with −0.35 D
per year for the spectacle wearers. It was also found that both groups
of subjects showed corneal flattening during the 5-year period, 0.10 D
on average for the contact lens wearers and 0.02 D for the spectacle
wearers. Axial length was not measured, but it was concluded that the
effects of the contact lenses on the progression of myopia could not be
entirely the result of corneal flattening, and Stone was the first to sug-
gest that contact lenses may influence the axial growth of the eye.
Grosvenor et al9,11 conducted the first study of the effects of GP
rigid—as opposed to PMMA—contact lenses on myopia progression.
After 3 years, the contact lens wearers progressed −0.48 D and the
spectacle wearers progressed −1.53 D, indicating a significant effect of
GP contact lenses (p < 0.01). Three-year data on corneal curvature and
axial length were not available for the control group of single vision
spectacle wearers, who were selected from a pool of subjects partici-
pating in a study of myopia control with bifocal spectacles. Although
valid comparisons using the 3-year data were not available, the 2-year
data illustrate the potential effects of rigid contact lens wear on axial
elongation of the eye.
A GP contact lens myopia control study was also conducted in
Singapore.10 Subjects were randomly assigned to wear GP contact
lenses or spectacles. One hundred five children were fitted with GP
contact lenses, but only 45 children (42.9%) wore their contact lenses
regularly through the end of the study. After 3 years, the spectacle
wearers progressed an average of −0.78 D per year, and the contact
lens wearers progressed −0.42 D per year, a clinically and statistically
significant difference (p < 0.0005). The investigators measured the
axial length and found a significant difference in annual axial growth
between the contact lens wearers (0.22 mm) and the spectacle wearers
(0.31 mm). Previous hypotheses regarding slowed axial growth in rigid
contact lens wearers were finally validated, but the significance of the
conclusions from the study is still limited because the study is com-
promised via a differential loss to follow-up evaluation and incomplete
ocular component measurement.
Baldwin20 conducted the largest study that failed to find an effect of
rigid contact lenses on myopia progression. Seven- to 13-year-old chil-
dren with myopia were fitted with rigid contact lenses or spectacles
and followed for slightly less than 1 year. The mean rate of myopia pro-
gression extrapolated to 1 year was −0.53 D for the rigid contact lens
wearers and −0.45 D for the spectacle wearers. The study may have
failed to find a positive effect for rigid contact lenses because the sub-
jects were followed for less than 1 year and because the patients were
not randomly assigned to treatment groups. The patients chose the
treatment best suited to their needs, so the rigid contact lens group ini-
tially had more females, greater myopia, steeper corneas, and longer
axial lengths. All of these factors are related to higher amounts of
myopia and greater progression of myopia, so the rigid contact lens
group is expected to experience a greater change in myopia.
Limitations of Previous Studies

Many previous studies have shown that rigid contact lenses may slow
the annual progression of myopia (Table 16-1), but all of the studies
failed to provide proper attention to important confounding variables
(Table 16-2). Although earlier work produced intriguing results for sci-
entists and clinicians, the studies contained many problems that chal-
lenged the significance of the findings. The faults of the previous
Table 16-1 Mean Annual Rate of Myopic Progression for Rigid Contact Lens
Wearers and Spectacle Wearers Participating in Myopia Control
Studies
Rigid Contact
Lenses (D) Spectacles (D) Significant Effect?
Baldwin20 −0.53 −0.45 No
Stone13 −0.10 −0.35 Yes
Perrigin11 −0.16 −0.51 Yes
Khoo10 −0.42 −0.78 Yes
studies can be summarized in four categories: (1) differential loss to

follow-up evaluation, (2) inadequate control group, (3) incomplete ocu-
lar component measurements, and (4) inadequate or poorly selected
entry criteria.
Many GP contact lens myopia control studies have suffered from
differential loss to follow-up evaluation.9,10 Adaptation to the initial dis-
comfort of rigid contact lenses is more difficult than adjusting to spec-
tacle wear for the majority of people. Many subjects drop out of the
rigid contact lens group because of an inability to adapt to rigid contact
lenses.9,10 The absence of data from these subjects compromises the
validity of the results. For example, the inability to adapt to rigid con-
tact lens wear may be associated with a higher rate of myopia progres-
sion. Eliminating subjects who were not able to adapt to rigid contact
lens wear would also eliminate subjects whose myopia progressed
faster. The result would be a false impression that rigid contact lenses
Table 16-2 Limitations of Previous Rigid Contact Lens Myopia Control Studies
Subjects
Adequate Older
Control Axial Length Contact Lens Than
Author (yr) Group Measurement Subject Losses 16 Years
Khoo (1999)10 No Yes 47% No
Grosvenor (1989)9 No* No† 44% No
Stone (1976)13 No No Unknown Yes
Morrison (1960)15 No No Retrospective Yes
Kelly (1975)19 No No Unknown Yes
Baldwin (1969)20 No Yes 30% No
*
Historical control group only.
†
No 3-year axial length data for the control group.
slow the progression of myopia, when, in reality, subjects assigned to

wear rigid contact lenses whose myopia progresses faster were simply
lost to follow-up evaluation. Subjects lost to follow-up review poten-
tially impact the implications of study results.
To make valid conclusions regarding the effect of rigid contact
lenses on myopia progression in children, two treatments should be
compared, and the treatment groups must be equal with respect to
known and unknown confounding variables that may alter myopia
progression. For example, the two treatment groups must have an
equal distribution of initial refractive error because one would expect
a group with higher initial refractive error to progress more rapidly. A
randomized clinical trial is considered the “gold standard” design to
compare treatments because it helps to ensure equal distribution of all
potential confounding factors between the two treatment groups. The
study conducted by Khoo et al10 is the only randomized clinical trial
conducted to examine the effects of GP contact lenses on myopia
progression.
Previous studies lacked a control group,14 used self-selected groups
of contact lens wearers,13,19,20 or used a historical control group.11
Although the study conducted by Khoo et al10 has been the only ran-
domized clinical trial to examine the effects of GP contact lenses to
date, the differential loss to follow-up evaluation mitigates the effects
of randomization. The study by Grosvenor et al9,11 used a historical
control group of single vision spectacle wearers participating in a bifo-
cal myopia control study. Matching the spectacle wearers to the contact
lens subjects based on age, gender, and initial refractive error limited
the number of control subjects, and complete ocular data were not
available for the control subjects after 3 years. The absence of an ade-
quate control group makes comparisons difficult, thereby reducing the
impact of the conclusions.
Positive results in many studies fail to exclude alternate possibilities
that may explain the effect. For example, the Houston Contact Lens
Myopia Control Study and Stone’s study found that rigid contact
lenses slow the progression of myopia and that corneal flattening
measured by keratometry does not explain all of the effect. However,
neither study was able to definitively identify other mechanisms that
may retard myopia advancement. They hypothesized that slowed axial
growth may explain part of the treatment effect but did not rule out a
change of the central corneal curvature that was not measured by ker-
atometry. Thorough measurements of the ocular components in a con-
trolled trial will allow better understanding of the effects of rigid
contact lenses on myopia progression.
Inadequate or poorly selected entry criteria may also affect the

results of the study. Goss and Winkler3 showed that children with
myopia tend to experience myopia progression until age 15 years for
girls and age 16 years for boys. Previous studies have included subjects
who may be expected to cease myopic progression,13,21,22 which limits
the ability to detect a potential treatment effect. None of the studies lim-
ited the participants to subjects who were able to adapt to rigid contact
lens wear, therefore leading to differential loss to follow-up evaluation.
Generalizability to a large population is not affected by eliminating chil-
dren who cannot adapt to rigid contact lens wear because only children
who can adapt to rigid contact lens wear are able to benefit from the
potential treatment effect. Choosing appropriate entry criteria for a
study is critical to the validity significance and generalizability of the
conclusions.
Although we have a multitude of anecdotal evidence and clinical
study results that show myopia progression in children is slowed by
rigid contact lenses, problems encountered by the previous studies
limit the significance of the outcomes.
GP LENS BENEFITS
GP contact lenses subjectively provide clearer vision than soft contact
lenses, especially when worn to correct astigmatism caused by corneal
toricity. GP contact lenses also allow improved tear flow and oxygen
under the contact lens, thereby providing ocular health benefits to the
long-term contact lens wearer. Anecdotally, GP lenses are easier to
handle because they cannot invert or fold as soft contact lenses do, and
less contact time with the eye is necessary to allow the lens to settle.
Children with myopia may also benefit from a reduction in the pro-
gression of myopia because of the influence of rigid contact lens wear.
The Contact Lens and Myopia Progression (CLAMP) Study, an ongo-
ing study of myopia control with GP contact lenses, limited partici-
pants enrolled to subjects who were able to wear rigid contact lenses at
least 40 hours per week and reported that they were “usually comfort-
able” or “always comfortable.” Of the 148 children who were fitted with
GP contact lenses, 116 (78.4%) were able to adapt to rigid contact lens
wear.23
Children with myopia represent a relatively untapped population of
potential contact lens wearers (Figure 16-1). The 78.4% success rate is
higher than that reported for adults (69.6%).24 Although children are
successful contact lens wearers, the fitting and dispensing of contact
lenses is different for children than for adults.
Figure 16-1. Eight- to 11-year-old children can be successful gas permeable contact lens
wearers.
FITTING CHILDREN WITH GP CONTACT LENSES

The contact lens fitting can be traumatic for a young child because it
is a new experience. When communicating with a young patient, a
direct approach is often best but is not universally appropriate. While
the practitioner prepares to insert a contact lens, he or she may tell the
child, “I am going to put a contact lens in your eye. It will feel like get-
ting an eyelash or a piece of dust in your eye. After you wear the lens
for 1 or 2 weeks, you probably won’t feel it in your eye any more.” The
practitioner should limit questions before putting the contact lens in
the eye and not wait too long before inserting the contact lens because
anxiety is a major factor in the child’s ability to initially tolerate a con-
tact lens. As soon as the practitioner inserts the contact lens, he or she
should tell the child that it is already in the eye. Generally the child is
surprised at how easy it is to put the contact lens in the eye.
Bennett et al25 reported the use of topical anesthetic at the fitting
and dispensing visits improves adaptation to rigid contact lens wear.
To prevent putting an additional drop in a child’s eyes, the drop of
anesthetic should be placed in the contact lens before insertion. After
instilling the drop on the contact lens, the practitioner can place a fin-
ger in the contact lens to displace most of the liquid, but the anesthetic
effect still occurs. The anesthetic improves the child’s disposition and
the practitioner’s ability to evaluate vision and lens fitting with fluo-
rescein because of reduced tearing.
Children often squirm to avoid having the contact lens inserted in
the eye. The practitioner can avoid chasing the child by having the
child fixate on a target while he or she firmly holds the eyelids open
and stabilizes the head. A quick insertion of the contact lens will make
the entire fitting process much easier for the child and the practitioner.
There are few differences between an adult and a child when decid-
ing the lens parameters to order. Most children can be fitted with a
9.2-mm diameter contact lens and a 7.8-mm optic zone diameter.
Some practitioners like to fit children with smaller contact lenses
because the palpebral aperture is smaller, and some practitioners like to
fit children with larger diameter contact lenses because they may fall out
of the eye less often. The philosophy a practitioner chooses is an indi-
vidual decision, but a 9.2-mm diameter may be a good compromise.
The base curve for the initial trial lens is based on keratometry read-
ings and the standard fitting guide found in contact lens textbooks (Table
16-3). It may be difficult to get accurate keratometry readings from a
child fidgeting in the chair, but the practitioner can be more sure the
readings are correct if the two eyes have similar readings, the keratome-
try readings are similar to simulated keratometry readings from a
corneal topographer, or two measurements of the same eye are similar.
Because of tearing and time constraints, a refraction performed over
the rigid lens to determine the final power may not be necessary. An
alignment-fitted contact lens should result in a refraction that is equal to
the spherical component of the manifest refraction, so an empirical
power determination is appropriate given a suitable fitting relation.
DISPENSING GP CONTACT LENSES TO CHILDREN

Depending on the child’s motivation, the dispensing visit may be excit-
ing or scary. One way a practitioner can alleviate some of the anxiety is
Table 16-3 Guide to Determine the Base Curve From Keratometry Readings
Corneal Toricity Base Curve
Spherical 0.50 D flatter than flat K
Up to 0.75 D 0.25 D flatter than flat K
0.87 D to 1.37 D Fit on flat K
≥1.50 D 0.33 times the toricity steeper than flat K
to instill a drop of topical anesthetic at the dispensing visit. The drop

will again help alleviate some of the child’s fears and allow for a more
proper assessment of the fit and prescription of the contact lens.
Insertion and removal training takes more than 15 minutes, so corneal
sensation will return to normal levels by the time the child leaves the
practitioner’s office.
Children have a fast-rising learning curve when it comes to han-
dling GP contact lenses. They regularly lose or break at least one lens
during the first week, but the number of lost or damaged lenses
decreases dramatically after 2 weeks. The practitioner should consider
ordering a spare pair of contact lenses with the initial order. Most
lenses will fit appropriately and provide good vision, and a contact
lens lost during the early stages dramatically extends the adaptation
period.
When checking the refraction over the contact lenses, the child may
accept +0.50 D to +1.00 D of additional sphere power without a reduc-
tion in acuity. When this happens, the practitioner should ask the child
to blink hard, and then he or she should recheck the power immedi-
ately. The practitioner will probably find that the child will no longer
accept the plus power. Even if the child accepts up to +1.00 D over the
contact lens power at the initial dispensing visit, the practitioner
should wait to recheck the power after 1 week. The acceptance of addi-
tional plus power may be because of excess tearing, so after 1 week of
adaptation, children typically experience poorer vision with a +0.25 D
overrefraction.
SUCCESSFUL GP CONTACT LENS WEARERS

Approximately four of every five children adapt to GP lens wear.
Knowing how to predict which children can successfully wear contact
lenses will save the practitioner and the child many problems.
Young girls are typically more mature than boys of a similar age.
Although maturity plays a role in the success rate of GP contact lens
wearers, 8- to 11-year-old boys and girls are equally successful at adapt-
ing to rigid contact lens wear. However, more girls attempt to wear
contact lenses, and they may account for three fifths of the patients
who are able to adapt to rigid lens wear.
Maturity is primarily an issue at the fitting visit rather than the dis-
pensing visit. Some 8-year-old subjects are not able to distinguish the
initial discomfort from pain. They are not able to comprehend that the
sensation of the eyelids rubbing on the edge of the contact lenses is
temporary, so they cry or refuse to wear contact lenses. A child’s abil-
ity to handle or care for GP contact lenses is not dependent on the
child’s age. Nearly all of the 8- to 11-year-old children can insert,

remove, and care for contact lenses without assistance from their
parents.
It is often believed that the motivation to wear lenses must belong
solely to the contact lens wearer. When young lens wearers are
involved, parents must also be motivated. Once outside of the office,
parents must encourage the child to insert the contact lenses every day
and help with problems that may be encountered during the adapta-
tion period. Parents must also be willing to allow the child to learn
alone and must tolerate the additional time necessary to insert or
remove lenses.
In-office indicators of success include the child’s ability to tolerate
eye drops and holding of the eyelids by the practitioner. Children who
run to “mommy” for a hug between each eye drop or are not able to
answer the practitioner’s questions on their own are less likely to
become successful GP contact lens wearers.
Occasionally a successful contact lens wearer may experience a
traumatic situation, such as inserting the lens without rinsing off all of
the soaking solution. This single event may cause a mental block that
is difficult for the child to overcome. The child may want to insert the
contact lenses but be unable to because he or she subconsciously fears
it will hurt again. When a parent reports that the child does great once
the contact lenses are worn, but the child does not like to put them in,
it is typically because of a mental block. The mental block may be
because of one traumatic event or irritation on insertion caused by
solution allergies. The eye care practitioner’s reassuring affirmation
and individual coaching or changing solutions often helps the child
overcome the mental block.
If the child is not able to overcome a mental block after changing
solutions and coaching from an experienced practitioner, dispensing
topical anesthetic may be considered. A child who cannot insert a con-
tact lens alone will often insert the contact lens on the first attempt
after instillation of a drop of topical anesthetic. Because of the poten-
tial abuse of topical anesthetic, several constraints on dispensing
should be discussed with the parents (Box 16-1).
Unfortunately, no universal predictors of success exist. Children
may become successful GP lens wearers despite initial signs that indi-
cate the child may not be a good candidate. Fortunately, two thirds of
the children who could not adapt to rigid lens wear did not report to
the 1-week check. Most children who are not able to wear rigid lenses
realize it in a relatively short period, which is beneficial to the practi-
tioner because it reduces time and resources necessary for the child to
learn to care for contact lenses.
Box 16-1 CONSTRAINTS TO DISCUSS WITH PARENTS WHEN DISPENSING TOPICAL

ANESTHETIC
The bottle of anesthetic should be in the parent’s possession only.
Limit the administration of anesthetic to one drop per eye per day.
The child must attempt insertion for 5 minutes per eye before anesthetic
installation.
Weekly examinations are necessary until the child is able to insert contact
lenses without anesthetic.
If the child is not able to insert contact lenses without anesthetic after 2
weeks, then the child will not be able to wear rigid contact lenses.
The bottle of anesthetic must be returned to the practitioner at the end of the
trial.
SUMMARY
GP contact lenses are a standard treatment option for patients with
myopia, and they may provide a therapeutic affect by slowing the pro-
gression of myopia. They also provide good vision with relatively few
ocular health risks or side effects. The benefits of rigid contact lens
wear greatly outweigh the potential risks and irritations associated
with contact lens wear, and young children represent an untapped
population of prospective contact lens wearers.
REFERENCES
1. Sperduto RD, Seigel D, Roberts J, et al: Prevalence of myopia in the United States,
Arch Ophthalmol 101:405-407, 1983.
2. Blum H, et al: Vision screening for elementary schools: The Orinda Study, Berkeley,
CA, 1959, University of California Press.
3. Goss DA, Winkler RL: Progression of myopia in youth: age of cessation, Am J
Optom Physiol Opt 60:651-658, 1983.
4. The Eye Disease Case-Control Study Group: Risk factors for idiopathic rheg-
matogenous retinal detachment, Am J Epidemiol 137:749-757, 1993.
5. O’Brart DP, Corbett MC, Lohmann CP, et al: The effects of ablation diameter on
the outcome of excimer laser photorefractive keratectomy. A prospective,
randomized, double-blind study, Arch Ophthalmol 113:438-443, 1995.
6. Goss DA: Attempts to reduce the rate of increase of myopia in young people—a
critical literature review, Am J Optom Physiol Opt 59:828-841, 1982.
7. Hirsch M: The prevention and/or cure of myopia, Am J Optom Arch Am Acad
Optom 42:327-336, 1965.
8. Birnbaum MH: Clinical management of myopia, Am J Optom Physiol Opt 58:
554-559, 1981.
9. Grosvenor T, Perrigin J, Perrigin D, et al: Use of silicone-acrylate contact lenses

for the control of myopia: results after two years of lens wear, Optom Vis Sci
66:41-47, 1989.
10. Khoo CY, Chong J, Rajan U: A 3-year study on the effect of RGP contact lenses
on myopic children, Singapore Med J 40:230-237, 1999.
11. Perrigin J, Perrigin D, Quintero S, et al: Silicone-acrylate contact lenses for
myopia control: 3-year results, Optom Vis Sci 67:764-769, 1990.
12. Stone J: Contact lens wear in the young myope, Br J Physiol Opt 28:90-134, 1973.
13. Stone J: The possible influence of contact lenses on myopia, Br J Physiol Opt
31:89-114, 1976.
14. Morrison RJ: Contact lenses and the progression of myopia, Optom Weekly
47:1487-1488, 1956.
15. Morrison R: The use of contact lenses in adolescent myopic patients, Am J Optom
Arch Am Acad Optom 165-168, 1960.
16. Dickinson F: The value of microlenses in progressive myopia, Optician 133:263-
264, 1957.
17. Bier N: Myopia controlled by contact lenses, Optician 135:427, 1958.
18. Silbert M: Comments on myopia control by contact lenses, Optom Weekly 53:961-
963, 1962.
19. Kelly TS, Chatfield C, Tustin G: Clinical assessment of the arrest of myopia, Br J
Ophthalmol 59:529-538, 1975.
20. Baldwin WR, West D, Jolley J, et al: Effects of contact lenses on refractive corneal
and axial length changes in young myopes, Am J Optom Arch Am Acad
Optom 46:903-911, 1969.
21. Keller J: Myopia control with RGPs in children, Contact Lens Spectrum 11:45-48,
1996.
22. Bier N, Lowther G: Myopia Control Study. Effect of different contact lens refrac-
tive corrections on the progression of myopia, Optom Today 38-40, 1988.
23. Walline JJ, Mutti DO, Jones LA, et al: The Contact Lens and Myopia Progression
(CLAMP) Study: design and baseline data, Optom Vis Sci 78:223-233, 2001.
24. Polse KA, Graham AD, Fusaro RE, et al: Predicting RGP daily wear success,
CLAO J 25:152-158, 1999.
25. Bennett E, Smythe J, Henry V, et al: Effect of topical anesthetic use on initial
patient satisfaction and overall success with rigid gas permeable contact
17
Orthokeratology
JOHN M. RINEHART
EDWARD S. BENNETT
OVERVIEW
Orthokeratology is a process that uses specially designed gas permeable
(GP) contact lenses to temporally reshape the corneal contour.1 The pur-
pose of orthokeratology is to reduce or modify myopia and astigmatism
by applying GP lenses that have a curve that is flatter than the cornea.
Because the curvature of the cornea changes in response, myopia is
reduced, and uncorrected vision improves. Once the desired effect is
achieved, a retainer lens is worn part-time to maintain the effect. The
usefulness of orthokeratology for a given patient will depend on the
magnitude of change achieved, versus a target goal, and how lasting the
effect is. The goal of this procedure is to allow patients to see sufficiently
to perform daily tasks without the need for correction for, at minimum,
part of the day.2 This process has also been termed “contact lens corneal
reshaping” and “corneal refractive therapy (CRT).”
HISTORICAL OVERVIEW
Early Fitting Philosophies
The principles behind orthokeratology were initiated by George Jessen
in 1962.3 His technique—termed “orthofocus”—used the principles of
the liquid lens and flat-fitting polymethylmethacrylate (PMMA) lenses
for corrections in his patients. However, with all of the pressure placed
on the apex of the cornea, this approach can often result in an unsta-
ble fitting relationship and discomfort.4,5 Likewise, Nolan6,7 fit his
patients with a much flatter than “K” base curve but altered wearing
time to achieve the desired effect. The wearing time was initiated at 4
hours and increased 30 minutes per day up to 10 hours. He also
restricted the amount of initial myopia to a maximum of 2.25 D. These
early approaches to orthokeratology also defined the process as one
that would correct myopia and hyperopia.8,9 Two pioneers of orthoker-
424
Chapter 17 Orthokeratology 425
atology, Stuart Grant and Charles May,10,11 adopted a less-aggressive

and more common-sense approach consisting of large-diameter
PMMA lenses fit up to 0.50 D flatter than K. New lenses were pre-
scribed when the cornea flattened by 0.50 D, when there was plus
acceptance through the lenses, or both. Retainer lenses were then pre-
scribed when 20/20 uncorrected and corrected vision, if possible, was
achieved. Therefore the process as described by early orthokeratolo-
gists consisted of a series of lenses typically fit during a period of sev-
eral months or as long as 1 year.
During the 1970s, numerous reports—often anecdotal—were pub-
lished pertaining to PMMA applications in orthokeratology.12-20 It also
became understood that this process was a temporary one, and once
the endpoint occurred, retainer lens wear was necessary to maintain
the refractive error reduction. Typically, wearing time with retainer
lenses was gradually reduced to determine the minimum amount of
contact lens wear required to maintain the desired effect.21,22 There
was much variance in the amount of retainer wear that was needed
(i.e., between several hours once or twice a month and several hours
daily), and therefore this required patient compliance with the
restricted wear schedule. Because corneal sensitivity increases as rigid
lens wear decreases, it also initiated the likelihood of some lens aware-
ness during retainer lens wear.
Early Clinical Studies

Although there have been numerous reports pertaining to orthokera-
tology in-office success, most of these early reports were anecdotal.
According to Leach,5 only four controlled prospective clinical studies
that pertained to early orthokeratology lens designs were published.
The first controlled clinical study pertaining to orthokeratology was
performed by Kerns and was published in a series of articles.23-30 In
this study, he evaluated 36 eyes that were fitted 0.12 to 0.37 D flatter
than K in the orthokeratology group, 26 eyes that were fitted with con-
ventional, alignment fitting contact lenses, and 6 eyes that were fitted
with spectacles. The patients were followed for 1000 days and then
discontinued lens wear for 60 days. The results showed large variance
in effect. An average reduction in myopia of −0.77 D was present after
10 months of lens wear with an additional 0.40 D present after an
additional 20 months of wear. An increase in with-the-rule (WTR)
astigmatism occurred in more than 50% of the experimental group. It
was Kerns’ belief that an increased likelihood of induced WTR astig-
matism resulted when a lens fitted greater than 0.50 D flatter than K
was used. On discontinuation of lens wear, visual acuity and corneal
curvature tended to regress toward prefitting values.
Binder et al31 compared a group of orthokeratology patients, who

were fit 0.75 D to 2.50 D flatter than K, with a group of cosmetic rigid
lens wearers for a 40-month period. The study group was divided into
three response groups. The “no response” group consisted of patients
who essentially reported no change and typically consisted of
those with the highest level of initial myopic refractive error (mean =
−3.95 D). Those in the “variable response” group and “good response”
categories had lower initial levels of myopia (means = −1.98 D and
−2.03 D, respectively). An average reduction in myopia of −1.60 D was
found in the orthokeratology group. The authors reported a highly
variable response, increases in WTR astigmatism, and absence of pre-
dictive variables.
The most valid study of the four and the only one to be randomized
and masked was the Berkeley Orthokeratology Study led by Ken
Polse.32-35 Forty subjects were fit approximately 0.30 D flatter than K,
and 40 subjects were fit to achieve an alignment fitting relationship.
PMMA was the initial material used, although some subjects were fit-
ted into the Polycon GP lens material if hypoxia was observed. Subjects
were monitored for 1.5 years. A mean refractive change of 1.01 reduc-
tion in myopia was observed with the experimental group compared
with 0.54 D with the control group; however, the results were variable.
Most of the change occurred within the first 4 months with little
change noted for the duration of the study. The level of unaided vision
was unstable during periods of nonwear with much fluctuation. After
discontinuation of lens wear, it took approximately 90 days for the
maximum amount of regression toward the baseline to occur; this
value was within 0.2 D of the original mean sphere. It was concluded
that although orthokeratology was safe, it was not predictable, results
were variable, more patient visits were required, and little reduction in
myopia occurred. The results of this study led to fewer practitioners of
orthokeratology during the 1980s than in the previous decade.
The fitting method developed by Roger Tabb was investigated and
reported by Coon.36,37 To avoid increasing WTR astigmatism, the
“Tabb” method was based on an apical clearance fitting relationship.
The base curve radius (BCR) was fit slightly steeper than K, and the
optical zone diameter was decreased if necessary to ensure a tear reser-
voir behind the lens. A positive correlation was found for refractive
and visual acuity changes. In addition, this was the first study to report
on a change in corneal shape factor toward sphericity and central
corneal thinning accompanied by peripheral corneal thickening.
Although WTR astigmatism did not increase as a result of this study,
the mean reduction in myopia was only 0.50 to 0.75 D by the conclu-
sion of this approximately 2-year study.
Box 17-1 POSSIBLE COMPROMISES AND ADVERSE EFFECTS WITH TRADITIONAL

ORTHOKERATOLOGY LENS DESIGNS AND FITTING APPROACHES
●
Reduction in myopic refractive error was only 0.50 to 1.50 D
●
Increases in with-the-rule astigmatism and possible corneal distortion,
particularly in flat-fitting lenses
●
Daily fluctuation in the quality of unaided visual acuity
●
Visual problems at near because of accommodative system changes
●
Regression of refractive error toward prefit level
●
Lack of predictability as to amount of individual refractive error change
●
Need for—and variability of—retainer wear; the potential of lens awareness
during retainer lens wear
●
Patient inconvenience during the orthokeratology treatment period
●
Uncertainty as to how corneal change correlates with refractive change
It was evident that these early studies did show a reduction in myopia
but also exhibited numerous results that were not positive and tended to
dissuade practitioners from adopting this approach. These included
variable unaided vision, little reduction in myopia, unpredictability of
outcome, increased WTR astigmatism, possible corneal distortion, need
for retainer lens wear that was often variable but could be as long as a
few hours of wear during the day, and regression of myopia toward the
prefit level. These results are summarized in Box 17-1.
Early Reverse Geometry Designs

The aforementioned problems necessitated several changes in lens
design, corneal curvature evaluation, and lens and retainer wear sched-
ule if orthokeratology was to be embraced by practitioners and benefi-
cial to interested patients. The first step toward modern orthokeratology
was the introduction of reverse geometry lenses. This term derives
from the fact that the secondary curve is reversed from the traditional
design; instead of becoming progressively flatter, the secondary curve is
steeper than the base curve, followed by a much flatter peripheral curve
radius. This concept was first mentioned by Fontana38 in 1972,
although it pertained to a one-piece bifocal design that had a secondary
curve radius 1.00 mm steeper than the base curve.
The steeper secondary curve allows for improved centration, mini-
mizing the astigmatic and induced corneal distortion resulting from
decentration. In addition, it allows space for the corneal tissue to redis-
tribute toward the midperiphery as the central cornea exhibits flatten-
ing. It also allows for tear exchange under the lens and minimizes
peripheral bearing.
The first reverse geometry lenses in common use for orthokeratol-

ogy were reported by Wlodyga and Bryla39 in 1989. They introduced
the concept of “accelerated orthokeratology” using reverse geometry
lenses manufactured by Nick Stoyan of Contex Laboratories (Sherman
Oaks, CA). The most popular design, the OK-3 lens, was an excellent
forerunner of current designs because it had a large overall diameter
(i.e., approximately 10 mm) with a small optical zone of 6 mm. A wide
reverse curve, 3 D steeper than the BCR, was present with a thinner,
flat peripheral curve (Figure 17-1). This type of design was termed a
“three-zone lens.” The retainer lens could conceivably have a less rad-
ical secondary curve (i.e., 2 D steeper than the BCR) or a larger optical
zone (i.e., 6.5 mm).
Using the Wlodyga-Bryla method and the OK series of lenses,
Horner et al40,41 found up to 3.00 D of myopia reduction. This
occurred in approximately half the time of conventional orthokeratol-
ogy, typically in a 4- to 6-week period, with stabilization in approxi-
mately 3 months. It was evident that orthokeratology had entered a
new and potentially exciting era in the 1990s.
MODERN ORTHOKERATOLOGY
New Developments
In the 1990s interest in orthokeratology increased dramatically because
of several factors. These included newer four-zone and similar
7.60/1.0
8.20/6.0
.7
7.6 P.S.B.C.
6.0 Diameter of P.B.C.
1.0 Diameter of P.S.B.C. (Tear reservoir)
.7 Aspheric edge lift design
Figure 17-1. OK-3 lens design. (From Wlodyga RJ, Bryla C: Corneal molding; the
easy way, Contact Lens Spectrum 4:58-65, 1989.)
advanced orthokeratology lens designs, corneal topography applica-

tions, overnight lens wear, and consumer interest in myopia reduction.
Lens Designs
Perhaps the first four-zone lens design to become popular in the
United States was the DreimLens (DreimLens, Inc., Melbourne, FL)
developed by Dr. Tom Reim and first reported by Hom.42 The primary
advantage claimed for this lens was the ability to reduce myopia by
more than 2.50 D.43-46 It was believed that a patient with 4-D myopia
should be able to maintain clear, uncorrected visual acuity during all
waking hours. In addition, the change in refractive error would occur
more rapidly, typically in a matter of weeks often using only one pair
of lenses, not a series. Modern orthokeratology pioneers John
Mountford, Roger Tabb, John Rinehart, Jim Reeves, Sami El Hage,
Jerry Legerton, Jim Edwards, Rob Breece, and others soon introduced
their designs.
Cross-section and schematic diagrams of a four-curve lens are
shown in Figures 17-2 and 17-3. Each curve and zone of a four-curve
reverse geometry lens has a specific purpose and relationship to the
cornea it opposes and the other curves of the lens. The fitting
Power curve
Base curve
Reverse curve
Alignment curve
Peripheral curve
Figure 17-2. Cross-section view of a four-curve reverse geometry lens.
Base Curve Radius

Range 5.6-6.5mm
Reverse/Relief Curve
Range 0.5-0.75mm
Alignment/Fitting Curve
Range 0.8-1.6mm
Peripheral Curve
0.4mm
Figure 17-3. Schematic diagram of a four-curve reverse geometry lens.
relationship of this type of lens on the cornea has been compared to a

“bottle cap” (Figure 17-4).47,48
The back optical zone radius (base curve) is designed to create the
forces necessary to impart the desired corneal changes. As a general
rule, the flatter the lens-to-cornea fitting relationship, the deeper the
tear layer, and the greater the hydraulic forces exerted on the cornea.
There are limits to the magnitude of change for any given cornea.
Making the base curve flatter does not automatically create a greater
reduction in myopia.
The purpose of the alignment and fitting curve is to control lens
centration and movement. Much like the base curve-to-cornea fitting
relationship of a traditional spherical GP lens controls centration and
movement, the relationship of this zone to the cornea controls move-
ment and centering characteristics in reverse geometry lenses. To
illustrate the similarities further, a traditional spherical lens design
Figure 17-4. The similarity between a four-zone design and a bottlecap. (From Bennett ES:
Rebirth of Ortho-K, Rev Contact Lenses May:36-39, 2001.)
that has an excessively flat lens-to-cornea fitting relationship will not

center properly and will tend to move excessively. Likewise, a reverse
geometry lens with an excessively flat alignment and fitting curve-to-
cornea fitting relationship will exhibit poor centration and excessive
movement. Any lens—spherical or reverse geometry—that has too
steep a relationship to the midperipheral cornea will not allow suffi-
cient lens movement to ensure proper tear circulation. This relation-
ship will most often result in a low-riding lens that can seal off,
making it difficult to maintain good corneal physiology.
The peripheral curve of a four-zone reverse geometry lens functions
the same as with traditional lens designs. The most common width
will be 0.4 mm in combination with a radius of 10.5 to 12.5 mm.
Because these designs are commonly prescribed for nightwear only,
the peripheral tear reservoir does not need to be as large as with tradi-
tional spherical GP lenses because minimal tear circulation will occur
in the closed-eye environment. However, it is important that there is a
sufficient tear reservoir to provide tear circulation and allow lens
movement on awakening.
The reverse and relief curve functions to connect the optical zone to
the alignment and fitting zone in such a way as to not alter the ideal
lens-to-cornea fitting relationship. A reverse and relief curve radius
that is excessively steep will increase the tear layer depth at the center
of the cornea, thus altering the forces exerted on the cornea. The most
likely result of this relationship is to decrease the magnitude of myopia
reduction. Conversely, a reverse and relief curve that is too flat will
alter the relationship of the alignment and fitting zone to the cornea.
In this case, the result will be to lose centration and therefore reduce
the quality of the orthokeratologic effect by creating a decentered
treatment zone.
Corneal Topography Applications

The importance of obtaining more information about corneal shape
was determined by May,49 Freeman,50,51 and others using early topog-
raphy instruments such as the Reynolds corneascope and the Wesley-
Jessen photoelectric keratoscope (PEK). Wlodyga and Bryla39
introduced the concept of a “reduction factor” (RF) based on the shape
factor of the cornea. The shape factor was determined by subtracting a
temporal keratometer reading from the central horizontal keratometer
reading.
Horner et al52-54 first reported the use of videokeratography (VKG)
in orthokeratology. Sami El Hage, a pioneer in corneal topography
evaluation, formed the International Controlled Kerato-Reformation
Society (ICKRS), which, although now defunct, was instrumental in
promoting VKG-assisted modern orthokeratology lens designs.5,55

Other reports also described corneal topography use and benefits of
newer advanced designs in orthokeratology.56-61
The benefits of VKG in orthokeratology are numerous. This instru-
mentation has played an important role in the understanding of the
mechanism behind how orthokeratology reduces myopia.62 In addition,
it helps rule out poor candidates for orthokeratology by identifying
patients with displaced corneal apex (poor candidates because of the
importance of good centration), higher than predicted corneal astigma-
tism, corneal distortion, subclinical keratoconus, and any other form of
corneal irregularity or pathology.48 In addition, it is invaluable for the
monitoring of corneal change during the orthokeratology process.
Mountford45,46,63-68 has published extensively on the applications of
corneal topography to orthokeratology, including prefitting, fitting,
and problem-solving applications. The BE lens design (Precision
Technology, Vancouver, Canada) from Mountford and Noack is topog-
raphy based. This will be discussed in a later section of this chapter. An
important contribution by Mountford pertained to predicting how
much myopia reduction can result based on initial corneal shape. He
had previously determined that patient response to orthokeratology
could not be predicted by such factors as ocular rigidity or central or
peripheral epithelial fragility.68 Based on his study of corneal eccen-
tricity change in orthokeratology, however, Mountford46 developed the
following equation pertaining to the amount of refractive error change
as determined by initial corneal eccentricity: y = 0.21x, where y =
eccentricity and x = refractive change (in D). If this was rounded to y =
0.2x, the following can be predicted48,69: For an average corneal eccen-
tricity value of 0.5, a reduction in myopia of 2.50 D would be predicted;
for high corneal eccentricity, such as 0.6, the potential reduction
would be 3.00 D; and for low eccentricity, such as 0.4, it would be 2.00
D. Therefore the amount of myopia reduction is often limited to
approximately 4 D based on initial corneal shape.67
It is important to mention that the 0.21x value is the linear rela-
tionship, but in reality the relationship is nonlinear, and the real value
is E = 0.16Rx + 0.10.46 So under the linear system, a 3.00-D Rx change
needs an E of 0.63; in the real case, it is only 0.58.
An important factor in corneal topography application in orthoker-
atology is the accuracy of the VKG instrument. According to
Mountford,67 the accuracy depends on the following factors.
●
The assumptions made about the corneal shape of the algorithm
being used
●
The accuracy of the focusing and alignment systems
●
The stability of the tear film
As a result of these factors, for any given corneal topography read-

ing, one of four outcomes is possible: (1) the reading is accurate; (2)
the reading overestimates the corneal elevation or sag; (3) the reading
underestimates the corneal elevation or sag; or (4) the reading is totally
inaccurate. Nevertheless, the use of a corneal topography instrument
is all but essential in orthokeratology practice for the benefits
described in this and succeeding sections of this chapter.
Overnight Orthokeratology
The wearing of GP lenses for the purpose of overnight retainer wear
was first reported by Nolan in 1977.70 However, the lens material rec-
ommended at that time was cellulose acetate butyrate (CAB), which
had a Dk value of approximately 4. Grant71 reported that if GP lens
materials were safe for overnight wear, then the retainer effect could
occur while the patient was sleeping, and a variable daily-wear retainer
schedule was unnecessary. Several other potential benefits have been
reported from overnight wear, including the following2,56,71:
●
Lesser adaptation time because lens awareness is reduced in the
closed-eye environment
●
Increased effectiveness because there is increased eyelid pressure
from closed eyes and rapid eye movement during sleep
●
Problems with wind and dust are avoided
●
Less risk of lens loss
●
Convenience for the patient because (theoretically) no optical
devices are required during the day
●
Better ocular health because the overall wearing time of the lenses
is less
●
Progression of myopia may be retarded or stopped if used in
children
In recent years overnight lens wear, during the orthokeratology
process itself and as a retainer when the endpoint has been reached, has
become the recommended method for lens wear, and the lens materi-
als used are often hyper-Dk (≥100) lens materials that are approved by
the Food and Drug Administration (FDA) for extended wear. It is
important to note that in June 2002, Paragon Vision Sciences (Mesa,
AZ), with the CRT lens, became the first manufacturer to receive
approval from the FDA for overnight corneal reshaping.
Consumer Interest in Myopia Reduction

As Walline reported in Chapter 16, there has been a greater awareness
of and consequently increased consumer interest in myopia reduction.
It is certainly evident that some of this interest has resulted from the
advancements made in lens design and wear mode (i.e., overnight).
Another important factor is the presence of orthokeratology and

corneal reshaping as a temporary, reversible method of myopia reduc-
tion as compared with refractive surgery.72 In a web survey of 1000
consumers performed by AllAboutVision.com, 84% would prefer
orthokeratology to laser-assisted in situ keratomileusis (LASIK) if
given the choice.73 In addition, 93% reported to be likely or very likely
to try orthokeratology. Beta research of 471 completed telephone inter-
views of consumers also was dramatic.74 Reporting on their interest of
CRT using a scale of 1 (low) to 10 (high), 74% reported interest at, at
minimum, a level of 5, and 50% reported an interest of 7 or greater.
Practitioners have also become much more aware of orthokeratology.
In a survey of 895 contact lens fitters, it was evident that they were
aware of the safety, effectiveness, and potential practice benefits of this
modality (Box 17-2).73 Likewise, according to Paragon Vision Sciences
market research, as many as 15 to 20 million people could have more
interest in CRT than in daily- and extended-wear lenses.75 In addition,
by the end of 2003, more than 3000 practitioners should be certified
to fit CRT lenses alone and with other designs pursuing FDA approval
for overnight orthokeratology; this number should increase.
Box 17-2 CONTACT LENS FITTER SURVEY
From Norman CW: Is there a sustainable market for orthokeratology in North America?
Presented at the Global Orthokeratology Symposium, Toronto, Ontario, Canada, August 2002.
Mechanism
There have been numerous theories to account for the corneal and
refractive changes that occur in orthokeratology, although the most
widely accepted would pertain to that of corneal “sphericaliza-
tion.”30,47,76,77 The most valid explanation to date has been provided by
Swarbrick et al.63,76,78 They have found that the changes in anterior
corneal topography in orthokeratology are achieved through central
corneal thinning and midperipheral thickening.76 The central thin-
ning was primarily epithelial in origin, whereas the midperipheral
thickening appeared to be in part stromal in origin, although whether
the midperiphery changes in thickness significantly is still in ques-
tion.78,79 Essentially the corneal topography changes are limited to the
anterior cornea as opposed to an overall bending of the cornea.
The importance of the presence of a tear film behind reverse geom-
etry lenses has been reported to be essential to provide the forces nec-
essary to create the corneal tissue redistribution necessary in
orthokeratology.46,66,79 The flat BCR that is selected applies central
positive compression to the thin layer of tear film between the anterior
cornea and the posterior lens surface. Although with fluorescein appli-
cation an apical bearing relationship is visible, a thin tear layer of 10
microns is present.66,80 The steep reverse curve provides the negative
or tension force that accentuates the midperipheral corneal steepen-
ing. The difference in force (in theory) between the positive compres-
sion and tension force exerts a tangential stress on the cornea such
that a squeeze film force is established, which results in the flow of
epithelium until equalization of force under the lens is obtained
(Figure 17-5). The redistribution of tissue creates a reduction in sagit-
tal depth and causes the cornea to approach sphericalization with a
resultant reduction in myopia.
Because refractive change appears to be related to central corneal
thinning, an analogy could be made to refractive surgery, in which the
amount of refractive error reduction is related to the treatment zone.
Munnerlyn’s formula for refractive surgery is ablation depth = RD2/3,
where ablation depth is equivalent to epithelial thinning, R is the
refractive change required, and D is the diameter of the treatment
zone.81 Because Swarbrick and Alharbi78 have found a maximum
change of 20 μg in epithelial thickness, this value can be entered into
the equation to determine the treatment zone of the contact lens. If
only 2 D of refractive error reduction is required, a 5.5-mm treatment
zone should be sufficient to result in this effect. However, if a 6-D
myopia reduction were desired, a treatment zone of 3 mm would be
necessary. This would almost always be impractical because the
patient’s pupil diameter—particularly in low illumination—will be
Tissue
movement depth
in microns
Preradius r1
Postradius r2
Treatment diameter
Figure 17-5. The Mountford squeeze film force concept.
greater (often much greater than this), and the patient’s unaided vision
would be compromised by haloes and flare.66
Efficacy
Numerous studies have been conducted pertaining to the efficacy of
orthokeratology lens designs. In its FDA study, which ultimately resulted
in approval for daily-wear orthokeratology, Contex reported on 110 eyes
that had completed, at minimum, 3 months of orthokeratology.82 Myopia
reduced by an average of 1.69 D with 39% achieving 20/20 or better
unaided visual acuity. The most common complaints were blurred vision
(20% of eyes) and variable vision (17% of eyes). Lui and Edwards83-85 also
reported on the efficacy of daily-wear orthokeratology during a 100-day
period. A control group of standard GP lens wearers were compared
with a subject group wearing reverse geometry orthokeratology lens
designs. The mean overall reduction was −1.50 D in the orthokeratology
group and 0.01 D in the control group. Uncorrected LogMAR visual acu-
ity improved several lines during the first 30 days for the orthokeratol-
ogy group but not significantly after that.
The results of overnight orthokeratology studies have resulted in

greater and more rapid reduction in myopia than daily-wear studies.
The first such study was reported by Mountford,46 who evaluated 60
patients wearing reverse geometry lenses overnight and found an aver-
age reduction in myopic refractive error equal to −2.19 D. Nichols et al79
evaluated 10 subjects who underwent overnight orthokeratology during
a 60-day period. The mean change in unaided visual acuity (high-con-
trast LogMAR) was 5.5 lines on the chart or an improvement from a
baseline average of 20/66 (Snellen equivalent) to 20/19. The mean
change in subjective refraction was a reduction in myopia of 1.83 D.
Most of the myopia reduction occurred the first 7 days.
Rah86 reported the first 6-month data of the Lenses and Overnight
Orthokeratology (LOOK) study. The results of this study showed that
74.1% of eyes evaluated had 20/20 or better high-contrast unaided
visual acuity, whereas 96.3% had 20/25 or better. At 1 month, 89% of
subjects were within 1 D of their target (i.e., desired) refractive error.
Legerton87 reported the FDA Overnight Clinical Trial with the Paragon
CRT lens. After 9 months, it was concluded that the uncorrected visual
acuity was 20/20 or better in 67.4% of eyes and 20/40 or better in
94.3% of eyes. At the conclusion of 9 months, 91.7% of the subjects
completing the study described their unaided vision as good, very good,
or excellent. Additionally, 69.4% of subjects were able to achieve a
refractive endpoint within 0.50 D of their desired target; 91.8% were
able to achieve an endpoint within 1 D of their desired target. In addi-
tion, in a testimony to the fact that the newer generation of lens designs
precludes the need for a series of lenses to reach the desired effect, only
2.54 lenses per patient were needed. Although the average reduction in
myopia with overnight orthokeratology reported in these studies is
approximately 2 D, the important factor is how close patients come to
their target value (i.e., typically a slightly hyperopic outcome of +0.50 to
+0.75 D is desired). In other words, many subjects may only require a
low (0.75 to 1.50 D) reduction, some a moderate reduction (i.e., 1.75 to
2.50 D), and some a high reduction (i.e., 2.50 to 4.50 D). For example,
Siedlecki et al88 found an average reduction in myopia (spherical equiv-
alent) of −1.42 D for patients with less than −2.50 D of refractive error
and −2.89-D reduction for patients with a refractive error equal to or
greater than −2.50 D. Subramanium et al89 reported similar findings
when the subjects were divided based on refractive error.
A common outcome of the overnight orthokeratology studies was a
rapid reduction in myopia. Swarbrick and Alharbi78 found refractive sta-
bilization after only 10 days of overnight orthokeratology. It has been
found that significant central corneal flattening and improvement in
unaided visual acuity can occur after just 10 minutes of lens wear.63
The effect of modern orthokeratology lens designs on astigmatism

has also been studied.90,91 Mountford90 has reported that the mean
reduction in WTR astigmatism is 50% over the central 2.00-mm
chord. The maximum reduction was 1.50 D with little effect on limbus-
to-limbus and against-the-rule astigmatism. However, little effect has
been demonstrated for patients who manifest a relatively low amount
of baseline astigmatism.91
Patient Selection and Evaluation
Good and Poor Candidates

Patients with low-level myopia who are motivated for a reversible, non-
surgical means of reducing nearsightedness are good candidates for
orthokeratology.1 Many patients are motivated by an occupational or
recreational need or requirement.56 Airline employees, military per-
sonnel, police officers, and firemen are among the patients who may
request orthokeratology as a means of meeting an unaided visual acu-
ity requirement. Likewise, patients who want to participate in recre-
ational and athletic endeavors without correction are typically good
candidates.
It is important to determine whether orthokeratology is feasible
with the patient’s refractive error and unaided visual acuity require-
ments and also to emphasize the importance of retainer contact lens
wear. Prospective candidates should be aware that orthokeratology is
not permanent and that their resulting vision may be variable. The
importance of monitoring acuity and complying with unaided visual
requirements should also be emphasized. The patient should consult
with the (potential) employer regarding vision requirements before
undertaking orthokeratology. Prospective candidates must be given a
realistic overview of the expectations in terms of how much myopia
may be reduced, the cost, and the timeframe along with the patient’s
availability for visits. Although the cost (often between $1000 and
$2500) and the number of visits are often reduced because of the more
rapid changes occurring with reverse geometry lens designs, patients
need to be advised that as many as 10 to 12 visits may be necessary for
monitoring and design changes during a 6-month or greater period.
Likewise, the patients’ goals should be considered. Whereas 20/20
unaided visual acuity is often desirable, it may not be the required end-
point of therapy for a patient with severe myopia who desires an
improvement in unaided vision. The range of refractive errors most
likely to be limited to nighttime retainer wear is up to 4.50 D of myopia
and 1.50 D WTR astigmatism. Patients with severe WTR astigmatism
(i.e., >1.50 D) and those exhibiting irregular or against-the-rule astig-

matism are not good candidates as is someone with a decentered
corneal apex. As mentioned before, patients with a smaller astigmatic
area (Figure 17-6) are better candidates than those with limbus-to-lim-
bus astigmatism (Figure 17-7). Patients with presbyopia are typically
not good candidates, although some orthokeratologists provide mono-
vision orthokeratology to motivated patients with presbyopia.
The most difficult issue to address is the patient’s motivation,
expectations, and lifestyle. The patient who is demanding perfect
vision with minimal retainer wear is not a good candidate for ortho-
keratology. Not everyone is looking for 20/20 unaided acuity. The par-
ents of a young patient with progressive myopia may be attempting to
stabilize or slow the progression of the myopia. The patient with
severe myopia (> –6.00) may simply want to read without the need to
hold a book 6 to 7 inches from his or her face. Many people will want
independence from their glasses or contact lenses for sports, such as
swimming or jogging, or activities where dust is a significant problem.
Another factor that can adversely affect orthokeratology is lifestyle.
Figure 17-6. An example of a patient with a more centralized astigmatic region.

Figure 17-7. A patient with limbus-to-limbus astigmatism.
If work schedules or other commitments do not allow for proper fol-

low-up care, the patient should not be accepted into a program of
orthokeratology. Without proper monitoring, the procedure will take
longer, and the best possible outcome may not be achieved.
As with any procedure to reduce refractive errors, pupil size must
be considered. Patients with pupils larger than 5.0 mm in normal
room illumination should be advised of potential problems with glare
and poor performance in dim light conditions. An orthokeratology
patient with a treatment zone smaller than his or her pupil will tend to
be dissatisfied with the procedure.
Patients with eyes that are deeply set with loose lids are also not
good candidates for two reasons.67 The first negative outcome would
be superior decentration, resulting in induced corneal distortion and a
decentered treatment zone. The deep-set eye makes obtaining a valid
corneal topography reading more challenging.
What About Young People?

Walline92,93 has reported that, at minimum, 80% of children can adapt
to GP lenses. In the pilot Children and Overnight Orthokeratology
(COOKI) study, Walline and Rah93 studied children with a mean age of
10.4 years wearing Paragon CRT lenses for overnight orthokeratology.
They found that 87.3% of the children rated the lenses as either com-
fortable or usually comfortable; 84.1% rated their unaided vision as
either perfect or pretty good; and 90.2% indicated they either never
had a problem or usually did not have a problem with handling. The
incidence of initial staining observed was high; however, there were no
lasting adverse effects, and the staining resolved 80% of the time.
Reim et al94 evaluated more than 450 eyes of children with a mean age
of 12.5 years during a 3-year period wearing the DreimLens. After 3
months, the average refraction had decreased from −3.32 D to −0.31 D.
From that period onward, myopia increased approximately 0.13 D per
year with a resultant myopic refractive error of −0.67 D after 3 years.
It is apparent that children are good candidates, although because the
axial length of the eye continues to grow, promises of emmetropia are
not realistic. However, it is also apparent that further well-designed
clinical trials are necessary to determine the effect of overnight ortho-
keratology on axial length, corneal topography, refractive error,
unaided visual acuity, and eye health.
What About Current GP Lens Wearers?

It has been recommended that current GP lens wearers may not be good
candidates for orthokeratology because of the sphericalization of the
cornea that has already occurred from long-term rigid lens wear.4
Subramanium et al89 evaluated GP lens wearers versus nonwearers to
determine if there were significant differences in visual outcome, refrac-
tive error reduction, and corneal topography change during a 1-month
period of overnight orthokeratology. The GP lens-wearing group discon-
tinued lens wear for 3 weeks before initiating overnight orthokeratology.
The results of this study found essentially no change in the amount of
myopia reduction between the two groups (i.e., −2.64 D reduction for
previous non-GP wearers and −2.66 D for previous GP wearers).
However, unwanted induced astigmatism resulting from an increase in
existing baseline WTR astigmatism was greater in degree and frequency
in the GP group. In addition, the refractive change was more predictable
in the non-GP group from the baseline myopia factor alone, accounting
for most of the variability. Other factors such as corneal eccentricity,
duration of previous GP wear, and induced astigmatism were more
likely to affect the visual outcome with the previous GP-wearing group.
It was concluded that, although GP and non-GP groups attained func-
tional visual acuity—on average—better than 20/30 after orthokeratol-
ogy, the visual and refractive outcome appears to be better and more
predictable in the non-GP group. The bottom line is that GP wearers are
candidates for overnight orthokeratology; however, patients need to

understand that their response is less predictable, and more lens
exchanges may be necessary to achieve the final outcome. Good, poor,
and borderline candidates are provided in Table 17-1.
Screening For Good Candidates

With the cost and time involved (for patients and practitioners), the
use of telephone and in-office screenings can help identify good can-
didates while minimizing the time and frustration that can result for
patients who were not good candidates but were fit into this modality
nevertheless.
Telephone Screening. For patients who inquire about the viability of
orthokeratology for them, a telephone screening can serve as an initial
method of eliminating patients who are not candidates, saving them
money and time. The following, at minimum, should be discussed at
the telephone screening:
Table 17-1 Good, Borderline, and Poor Candidates for Orthokeratology

Good Borderline Poor
≤3.50 D myopia 3.75-4.50 D myopia > 4.50 D myopia
<1.50 D WTR cyl 1.50-2 D WTR cyl >2 D WTR cyl
New CL wearer Current GP wearer Irregular or ATR cyl
Young, progressive Low “e” value (unless High myope with
myope <2 D myope) low “e” value
Occupational need for Loose lids &/or deep-set
better unaided VA eyes
Small pupil size Medium pupil size with Large (>5 mm room
moderate myopia illumination
≥7 mm dim
illumination)
Motivated Unmotivated for CL
wear
Realistic expectations Unrealistic expectations
History of compliance Poor history of
compliance
Good eye health (no Poor response to
history of dry eyes, overnight trial
anterior segment Dx)
Recreational/athletic Cost or visit schedule is
benefits problematic
WTR cyl, With-the-rule astigmatism; CL, contact lens; GP, gas permeable; ATR cyl, against-the-
rule astigmatism; VA, visual acuity.
●
Contact lens history: if GP wearer, the patient will need to
discontinue lens wear while also understanding possible
compromises in effectiveness
●
Age: typically rule out patients with presbyopia; young patients with
progressive myopia can be encouraged, with the knowledge that it is
premature to indicate overnight orthokeratology will result in
emmetropia at this time
●
Refractive status
●
Need for a temporary correction during the treatment phase (often
daily disposable lenses)
●
Need for an overnight retainer
●
Costs involved and typical visit schedule, including trials and
possible lens exchanges
In-office Screening. A quick in-office screening can further deter-
mine if the patient is a good candidate. This can consist of, at mini-
mum, the following tests:
●
Manifest refraction (cycloplegic if young person)
●
Slit-lamp evaluation: rule out anterior segment pathology and dry
eyes
●
Corneal topography: important to correlate corneal eccentricity with
refraction and to rule out corneal distortion and decentered apex
If a telephone screening was not performed, the information that
would ordinarily be asked at that time can be performed (e.g., contact
lens history, expectations, fees, visit schedule, retainer, and temporary
correction).
The Evaluation
Initial evaluation of a potential orthokeratology patient is essentially
the same as that for any potential contact lens patient. The exception
is that corneal topography evaluation at the initial examination and
during the follow-up period is important. The instrumentation needed
for evaluation and follow-up review of orthokeratology patients is pro-
vided in Box 17-3. After passing the screening evaluation(s), the fol-
lowing should be performed (some tests may have already been
performed at the in-office screening):
●
Case history: includes ocular and medical history; inquiry should be
made as to the patient’s reasons for desiring orthokeratology
●
Visual acuities: aided, unaided, and best-corrected acuity (Snellen is
acceptable; high- and low-contrast acuity charts or contrast
sensitivity testing would be preferable)
●
External evaluation: evaluate pupil size, vertical fissure, and
horizontal visible iris diameter; also observe whether the patient’s
eyes are deeply set
Box 17-3 RECOMMENDED EQUIPMENT FOR AN ORTHOKERATOLOGY PRACTICE

1. Corneal topography (VKG) instrument
2. Lens diameter gauge: to measure lens diameter
3. Handheld (reticule) magnifier: to measure the widths of the zones on the
lens
4. Thickness gauge: to measure center thickness and edge thickness
5. Lensometer: to verify the lens power and assess the quality of the lens
optics
6. Radiuscope: to verify the base curve radius and assess the quality of the
optics of the base curve
7. Yellow Wratten filter: to increase contrast during fluorescein pattern
evaluation
8. Snellen acuity chart (minimum): high and low contrast/contrast sensitivity
charts
●
Biomicroscopy:
●
The cornea should be inspected for signs of trauma, dry eye
syndrome, and limbal staining
●
The tears should be assessed for quantity (i.e., phenol red thread
or Schirmer) and quality (i.e., tear break-up time)
●
Abnormal lid structures that may interfere with blinking or tear
exchange should be ruled out
●
The meibomian glands should be inspected and expressed
because meibomian gland dysfunction will result in poor tear
quality and reduced lens comfort; this condition must be
successfully managed before considering orthokeratology
●
Determine the rate of the patient’s blink and its quality; too slow
a rate or incomplete closure will likely yield poor results
●
Evaluate the endothelial layer for possible dystrophies, significant
polymegethism, and blebs
●
Evaluate for corneal scarring, elevations, and vascularization
●
Evert upper lids and inspect for signs of papillary hypertrophy
and GPC; also rule out loose lid tension
●
Ophthalmoscopy
●
Keratometry and corneal topography
●
Tonometry
●
Visual analysis
●
Patient or parent consultation: includes an in-depth discussion of
the positive and negative implications of orthokeratology for this
patient
●
Assess the patient’s motivation
●
Are the patient’s goals realistic for the correction?
●
Does the patient have a positive attitude; is the patient
enthusiastic?
●
Does the patient’s schedule allow him or her to keep the
appointments? (This can be a time-consuming procedure for the
first 3 weeks)
●
Discuss fees with patient or parents
●
Total fee and how it is to be paid
●
Refund policy
●
Guarantee policy: it is important to not make any guarantees
beyond the fact that the practitioner will always attempt to obtain
the best possible results
It is not possible to predict the exact result that will be achieved for
any orthokeratology patient; therefore it is important to be conserva-
tive with the prognosis. The entire patient, not just the eyes, should be
evaluated. A patient’s eyes may be perfect for the procedure, but the
patient’s expectations may not be compatible and vice versa. Both of
these potential patients should be discouraged from the program.
Authors’ Fitting Philosophy

There are many common factors for lens design and fitting, regardless of
the lens design or fitting philosophy of a given manufacturer’s lens. The
lens designs have a large overall diameter (often 10 to 11 mm), a small
optical zone (depends on the amount of refractive error and pupil size
among other factors, but it tends to average approximately 6 mm), and a
steep reverse or secondary curve. Likewise, several important factors are
essential for an optimum fitting relationship. Good centration, minimal
movement with blinking, and a “bulls-eye” fluorescein pattern are impor-
tant and will be discussed further in this section of the chapter.
Initial Lens Selection

There are two methods used to design the initial lens for an orthoker-
atology patient: empirical fitting and diagnostic lens fitting. Empirical
lens designing is less time consuming initially. It is also a less exact-
ing method to design lenses. When lenses are designed empirically,
the first lens fit is a diagnostic lens. It emphasizes the laboratory’s abil-
ity to fabricate an accurate lens and the practitioner’s ability to obtain
reliable data. If so, although more lens exchanges should result, a suc-
cess rate similar to diagnostic fitting can be achieved.88,95 Diagnostic
fitting requires more time initially, but it is more exact. A proper diag-
nostic fitting will evaluate the exact corneal eccentricity, the exact lid
pressures, and the exact tear formulation of the patient.
Diagnostic Fitting. The goal is to achieve centration with approxi-

mately 1 to 1.5 mm of movement.96 The key factor is sagittal depth, and
this is best determined through the use of diagnostic lenses of known
sagittal depth. The area beneath the optical zone and reverse and relief
curve is not the primary factor in lens centration and movement. The
alignment and fitting zone is the controlling factor for lens centration
and movement.
The initial diagnostic lens is selected based on an estimate of the
eccentricity of the cornea.
●
Low eccentricity (0.0 to 0.3): select an alignment curve that is 0.25
D flatter than K
●
Normal eccentricity (0.31 to 0.55): select an alignment curve that is
0.50 D flatter than K
●
High eccentricity (0.56 to 0.70): select an alignment curve that is
0.75 D to 1.00 D flatter than K
The following steps are important in diagnostic fitting:
1. Verify the BCR and power of the diagnostic lens before placing it
on the patient’s eye
2. Allow the lens to settle on the eye for 10 to 15 minutes before
evaluating the performance
3. Instill a small amount of fluorescein
4. Using the yellow Wratten filter to enhance the fluorescein pattern,
evaluate the lens positioning and movement
5. The ideal lens will be the one with the lowest sagittal depth that
centers
●
If the lens positions too high or moves excessively, increase
sagittal depth by steepening the alignment curve radius (i.e.,
instead of BCR)
●
If the lens positions too low or does not move, decrease sagittal
depth by flattening the alignment curve radius
●
It is preferable to have the lens position slightly low as opposed
to slightly high
6. Overrefraction: use this value to do a calculated central K and to
verify the necessary lens power
To calculate the BCR, add 0.75 D to the desired amount of myopia

reduction, and then subtract this value from the flat K reading. For
example,
●
Subjective refraction: –3.50 − 1.00 × 180
●
Flat K: 43.75 D
●
Target change in myopia: 3.50 D + 0.75 D = 4.25 D
●
Base curve: 43.75 D − 4.25 D = 39.50 D (8.54 mm)
The power resultant of the lens will be +0.75 D. This will allow
for some regression toward myopia to occur on awakening and
subsequent lens removal. It should be seldom necessary to use a
BCR that is more than 5.00 D flatter than the central keratometric
reading.
It is now necessary to calculate the reverse and relief curve radius.
The perfect reverse and relief curve radius will maintain the lens-
cornea relationships (i.e., sagittal depth) that have been determined
through diagnostic fitting and base curve calculations. The computa-
tions necessary to determine the proper radius of curvature are labori-
ous and virtually impossible to do without the aid of a quality
mathematics computer program.
The peripheral curve radius and width complete the back surface of
the lens. Most frequently, the peripheral curve width will be 0.4 mm
with a radius ranging from 10.50 to 12.25 mm. Figure 1 again shows
the final lens configuration.
Empirical Lens Design Procedures. The procedure to design the ini-
tial lens empirically is similar to that of the diagnostic lens fitting
except for the determination of the sagittal depth. The empirical
method necessitates estimating the proper lens sag. Three possible
methods of estimation include the following:
1. Using the flat central keratometer reading for the radius of the
alignment and fitting curve
2. Using flat K reading and corneal eccentricity to estimate the radius
of the cornea in the midperiphery
3. Using topography, the radius of the temporal cornea can be
measured approximately 4 mm from the corneal apex, and this
value can be used for the radius of the alignment and fitting curve;
even if the most optimum corneal topography exists, it will not
consider lid pressures and tear quality and quantity
The radii of the remaining curves (base curve, reverse and relief
curve, and peripheral curve) are determined using the same method
described in the section on diagnostic lens fitting.
Characteristics of a Good Fitting Relationship

Some fitting philosophies are base curve driven, and the initial lens is
selected using a nomogram or computer-driven software program.
Whether it is via one of these philosophies or the authors’, there are
several common ingredients to an optimum fitting relationship.
Good Centration. As mentioned before, these modern orthokeratol-
ogy lens designs have been developed to help ensure good centration and
little movement on the eye. With the small optical zone and treatment
zone diameters necessitated in these designs, it is essential that the

central cornea be treated using this process. A decentered treatment
zone can result in induced astigmatism and ghosting or haloes in dim
illumination.2
Central Bearing. Central bearing of approximately 4 to 5 mm is
optimum; absence of or minimal touch would be representative of a
steep-fitting lens, often resulting in undertreatment of inadequate
myopia reduction.
Dense Paracentral Pooling. A dense 360-degree narrow (1 to 1.5
mm) ring of paracentral pooling should be present. This ring should
exist just beyond the area where the reverse zone reapproaches the
cornea.
Peripheral Touch and Edge Clearance. As determined during the ini-
tial diagnostic fitting, selection of the appropriate alignment curve
should result in midperipheral bearing of lens to cornea. Absence of
midperipheral bearing accompanied by central touch would be indica-
tive of excessive apical bearing, which can possibly result in overtreat-
ment and corneal distortion, especially if the lens is decentered
superiorly. A narrow but definite region of peripheral pooling should
also be present.
Therefore the fluorescein pattern should exhibit a bulls-eye appear-
ance with central touch, deep paracentral clearance, midperipheral
touch, and mild peripheral clearance. Figure 17-8 demonstrates the flu-
orescein pattern of a well-centered, properly fit orthokeratology lens.
Lens Material
Lenses that are to be used for overnight orthokeratology must be
approved for extended wear. This will provide the best possible oxygen
supply to the cornea during sleep. For overnight orthokeratology, the
material should have a Dk of, at minimum, 100 and exhibit good sta-
bility and wettability. Lens materials in common use include Paragon
HDS 100 (Paragon Vision Sciences) and Boston XO (Polymer
Technology Corporation, Rochester, NY).
Other Lens Designs and Fitting Philosophies

There are many lens designs in use today. Most of these lens designs—
like that of the primary author—use sagittal depth as the basis of fitting
and troubleshooting. It is important to emphasize that this may not rep-
resent a comprehensive list and that modern orthokeratology is
dynamic; new lens designs and lens design parameter changes occur
on a regular basis. This section is based on a comprehensive review
article by Luk et al.97 Table 17-2 presents a summary of these designs
and design software.
Figure 17-8. A desirable bulls-eye fluorescein pattern. (Courtesy Paragon Vision Sciences.)
Paragon CRT Lens

The lens design most commonly used and, at press time, the only
orthokeratology lens design approved by the FDA for overnight ortho-
keratology is the Paragon CRT lens (Paragon Vision Sciences).
Paragon has coined the term “corneal refractive therapy” as a more
accurate representation of the nonsurgical corneal reshaping and
myopia reduction. Practitioners who are interested in fitting CRT
lenses are required by Paragon to be certified after attending a CRT-
fitting seminar.
The CRT lens design—like the authors’ philosophy—is based on
sagittal height. However, this design differs from other modern ortho-
keratology designs because with standard designs, the four zones con-
sist of curves of different widths and radii of curvature; with the CRT
design, the reverse zone and the alignment zone are not curves. The
reverse zone, called the return zone, is still much steeper than the base
curve, but it is a sigmoid. It is not a curve that can be defined by a radius
of curvature. The alignment zone, called the landing zone, is a plano
curve (i.e., a straight line), which is defined by the negative angle that it
makes with a horizontal line. Like the alignment zone with other
Text Continued on p.453
450
Table 17-2 Modern Orthokeratology Lens Designs and Software
Company Designer Product Contact Information
ABBA Optical Inc. Lee Dickerson Reversible Corneal 2230 Central Park Court
SECTION IV
Therapy Stone Mountain, GA 30087
1-800-331-2015
www.abbaoptical.com
Advanced Corneal Roger L. Tabb, O.D., Nightmove Refractive 2363 S.W. Cedar Hills Blvd.
Engineering, Inc. F.A.A.O., F.I.O.S. Lens Portland, OR 97225-4534
503-646-5194
Fax: 503-643-9751

E-mail: [email protected]
www.nightmovepm.com (not available yet)
Contex Inc. Nick Stoyan Contex OK Contact Lens 4505 Van Nuys Blvd
Sherman Oaks, CA 91403
818-788-5836
Fax: 818-788-5078
www.oklens.com
Correctech, Inc. Robert Breece, O.D., Correctech Orthokeratology 1325 Progress Drive
Susan Herndon, O.D. Contact Lens71 Front Royal, VA 22630
540-636-7976
Fax: 540-635-8846
DreimLens Thomas R. Reim, O.D. DreimLens 1900 S. Harbor City Blvd.,
International LLC Ste. 217
Melbourne, FL 32901
1-877-OK-DREIM
Fax: 1-877-DREIM-FX
www.DreimLens.com
Chapter 17
Euclid Systems George E. Gladys, Emerald design Jade design 2810 Towerview Road
Corporation Randy DeWoolfson, Herndon, VA 20171
Joann Simonsen 1-800-477-9396
Fax: 703-471-7577
www.euclidsys.com
EyeDeal Software & Thomas K. Geimer OrthoTool 2000 software 575 West Sierra, Ste. 220
Design Fresno, CA 93704
559-438-9013
www.eyedealsoftware.com
EyeQuip Jim Edwards, O.D. WAVE Contact Lens 5150 Palm Valley Road,
Design Software Ste. 305
Ponte Vedra Beach, FL 32082
1-800-303-8676
Fax: 904-280-1888
www.eyequip.com
Fargo Jim Day, O.D. G.P. Specialists 3518 W. Cactus Road, Suite A
Phoenix, AZ 85029
800-366-2522
Orthokeratology
Fax: 602-843-2245
Gelflex Laboratories Don Ezekiel Gelflex EZM 3 Hutton St.
Orthokeratology Lenses Osborne Part
Western Australia 6017
61 89 443 4944
Fax: 61 89 443 4147
451
Continued
452
Table 17-2 Modern Orthokeratology Lens Designs and Software—cont’d
Company Designer Product Contact Information
E-mail: for clinical assistance
SECTION IV
[email protected]
www.gelflex.com
Metro Optics, Inc. Alvis Blackburn Orthofocus 11034 Shady Trail, Ste. 106
Dallas, TX 75229
1-800-442-3032
Fax: 214-351-4405
www.metrooptics.com

Paragon Vision Jerome A. Corneal Refractive Therapy 947 East Impala
Sciences Legerton, O.D., Mesa, AZ 85204-6619
F.A.A.O. 1-800-528-8279
Fax: 480-926-7369
www.paragonvision.com
Precision Technology John Mountford, BE Lens 866 E. Cordova St.
Services Dip.App.Sc, F.A.A.O, Vancouver, B.C.
F.V.C.O, F.C.L.S.A., V6A 1M4
Don Noack 604-215-1467
Fax: 604-215-1476
R & R Lens Design James W. Reeves, O.D., R & R Design 501 Central Ave.
F.I.O.S Great Falls, MT 59401
John M. Rinehart, O.D., 406-761-6841
F.A.A.O. E-mail: [email protected]
13260 N. 94th Drive #420
Peoria, AZ 85381
623-974-2020
From Luk B, Bennett ES, Barr JT: Fitting orthokeratology contact lenses, Contact Lens Spectrum 16(10):22-32, 2001.
designs, the landing zone is intended to be tangent to or in alignment

with the midperipheral cornea and assists in lens centration (Figure
17-9). This series of curves and angles is designed to optimize the con-
trolled redistribution of corneal tissue during overnight lens wear.98
Practitioners can select from two different systems to fit these
lenses: a 24-lens diagnostic fitting set with a Palm Pilot calculator pro-
gram (Palm, Inc., Milpitas, CA) or a 100-lens inventory. The latter is
sufficient to provide the majority of patients with lenses the same day.
In fitting this lens design, the initial diagnostic lens will be chosen with
a base curve equal to that which would, in theory, provide the target
power. For example, if the goal is to achieve a low hyperopic endpoint
(i.e., +0.50 to +0.75 D), if the flat K (or simulated K) reading is 43.37 D,
and if the spherical power is −3.50 D, the CRT initial selector will
recommend a diagnostic lens of 39.25 D (i.e., 4.12 D flatter than K,
which should result theoretically in a refractive error equal to +0.62 D).
This lens will have an average return zone depth (RZD) of 0.550 and a
landing zone angle equal to 33 degrees. Ideally the lens will exhibit
wider midperipheral pooling and slight central bearing at dispensing
Figure 17-9. With the CRT lens design, the landing zone should be tangent to or in alignment
with the midperipheral cornea. (Courtesy Paragon Vision Sciences.)
and then gradually “land” or result in definite midperipheral bearing

and the desired bulls-eye fitting relationship (Figure 17-10). Once again,
lens changes should concentrate on the midperiphery; if the lens
decenters superiorly or exhibits apical bearing but no midperipheral
bearing, the RZD is too shallow and should be increased to 0.575.
Conversely, if the central clearance or “bridging” exists, the RZD is
too deep and should be reduced to 0.525. The landing zone angle can
be varied to facilitate edge clearance and centration.
BE Lens Design
The BE lens design is designed by John Mountford and Don Noack
and is manufactured (in North America) by Precision Technology
Services. The fitting of the BE lens design is based on the theory that
the sagittal height of the contact lens must match the sagittal height of
the cornea, allowing for the tear film layer. Sagittal height of the cornea
is determined with an equation that requires the following informa-
tion: the apical radius of the cornea, the elevation of the cornea, and
chord length (i.e., the total diameter of the lens to be fitted; often this
is 11.0 mm). The software program for this design is available with the
Medmont topographer (Medmont, Camberwell, Victoria, Australia).
The apical radius can be determined with this topography software
program. From this information, the treatment zone diameter can be
determined. As previously mentioned, this will decrease as the refrac-
tive change desired increases (Table 17-3).99 The final apical radius and
Figure 17-10. The CRT lens should exhibit wider midperipheral pooling and slight central bear-
ing at dispensing and then gradually “land” or result in definite midperipheral bearing and the
desired “bulls-eye” fitting along with the appropriate edge lift. (Courtesy Paragon Vision
Sciences.)
Table 17-3 Relationship Between Desired RX Change, Treatment Zone Diameter,

and Final Apical Radius for a 7.80-mm Apical Radius, 0.50
Eccentricity, 11.5-mm Corneal Diameter Patient
From Mountford J, Noack D: BE optimal orthokeratology. In Precision Technology Services Ltd.

fitting guide, 2001.
treatment area are determined after inputting the initial apical radius,
the eccentricity and elevation data, and the horizontal visible iris diam-
eter (HVID), all of which can be derived from the topography program.
The following example demonstrates how the trial lens is derived99:
Example:
With a spectacle Rx = −3.75 − 0.50 × 180; an apical radius (Ro) = 7.43
mm, an elevation = 1.5733 mm, a standard lens diameter = 11.0 mm,
and an HVID = 11.5, the screen will appear as:
Initial Ro: 7.43
Eccentricity: 1.5733
(or sag at tangent)
HVID: 11.5
Lens diameter: 11
Refractive change: −3.8
Final Ro: 8.109
Treatment area: 3.832
Extra refractive −0.50
change:
New final Ro: 8.208
New treatment area: 3.58
In this example, the calculated Rx change is 3.80 D. Allowing for an
overcorrection of 0.50 D, −0.50 D is added to the “extra refractive
change” box. The new apical radius and treatment diameter will be dis-
played. Ultimately, the following trial lens information will appear as
follows.
Lens required: Right
Trial set diameter: 11.0
Ro: 7.43 Eccentricity: 0.620 Diameter: 11.0

Effective corneal sag: 1.5733 Treatment zone: 3.58
Lens order: BOZR: 8.18
TRF: 79400850
“1/4 Tangent” Tangent: 54.11 Tear lens power: −4.16
Diameter: 11.0 Expected refractive change: 4.3
Lens power required ____
Calculated lens Apical clearance: 0.0032 Effective sag: 1.5765
pressure: 6.174
TRIAL LENS FIGURES
Calculated trial 8.15 Tangent 53.87
lens BOZR
Trial lens pressure
factor 0.498 Apical clearance 0.0114
Trial lens effective sag 1.5846 Chord of sag 9.41
Expected power change (+/− 0.50 D) 0.54
The BE design is topography driven. The type of topography map

desired is a bulls-eye with central flattening and midperipheral steep-
ening. If the topography pattern shows superior flattening and inferior
arcuate steepening (because of a flat-fitting superiorly decentered
lens), a “smiley face” topography pattern will be present. Conversely, a
steep-fitting lens will show inadequate treatment centrally, and the
topography pattern will exhibit a “central island.” Each of these pat-
terns will be discussed in the problem-solving section of the chapter.
When a smiley face or central island pattern is inputted into the BE
program, a new lens design will then be calculated.
R & R Lens Design

This design was developed by the author (John Rinehart) with Jim
Reeves. They have often provided training sessions in association with
continuing education meetings and schools and colleges of optometry.
These programs are intended to educate the practitioner (or future
practitioner) about the lens design process, the purpose of each curve
of the lens, and how these curves affect the lens-to-cornea fitting rela-
tionship and lens performance. As mentioned previously, it is a
process that is based on sagittal height and depends on achieving a
proper fit in the midperiphery. The intent is to train practitioners such
that they have the knowledge to design and troubleshoot orthokeratol-
ogy lenses. Therefore R & R lens design is not intended to be simply a
design but rather a system that the practitioner can manipulate to
achieve the best possible results. The practitioner has the freedom to
select the lens material of choice (hyper-Dk is recommended) and the
GP laboratory. Lenses are fit from a 14-lens diagnostic fitting set. The
lens design can be either four- or five-curve reverse geometry and is
available in diameters of 10.0 mm, 10.6 mm, and 11.0 mm. The
10.6-mm diameter is recommended most often.
A training CD for this system is being developed and should be
ready before the publication of this text.
Contex OK Series
As mentioned before, the Contex three-zone lens was the first to receive
FDA approval for daily wear. Since then, Contex has developed several
modern orthokeratology lens designs. The Contex OK lens is fit based
on the central K reading, manifest refraction, and corneal eccentricity
value obtained from topography. The lenses are labeled with the K
value, the desired refractive change, and a peripheral fit size. For exam-
ple, for a patient with a K reading of 43.00 D and a refractive error of
−2.00 D, the initial diagnostic lens should be labeled 43.00 D/–2.00 D,
which will have a BCR of 40.25 D (i.e., the base curve is automatically
adjusted for the desired refractive change). The peripheral fit size is
determined based on the corneal eccentricity value from topography
data: XXL (extra, extra loose; e = 0.8), XL (extra loose; e = 0.7), L (loose;
e = 0.6), S (standard; e = 0.5), T (tight; e = 0.4), XT (extra tight; e = 0.3),
and XXT (extra, extra tight; e = 0.2). After selecting the initial diagnos-
tic lens from clinical data, the final lens determination will be based on
fluorescein pattern evaluation and lens centration.
DreimLens
The DreimLens, designed by Dr. Thomas Reim, is available in the
Boston XO lens material and, as mentioned earlier, is a four-zone
design. The BCR of the central zone is calculated from the flat central
K reading and the amount of refractive error to be corrected. The stan-
dard fitting zone, alignment zone, and peripheral zone parameters
have been clinically and theoretically determined to work together to
provide the best results for the majority of patients. Therefore the
DreimLens is often ordered empirically based on the patient’s ker-
atometry readings and refraction. It is emphasized that the fluorescein
pattern should only be used for gross observations because clinically
significant differences in lens parameters (e.g., base curve, diameter)
can result in a similar fluorescein pattern.
The Fargo Lens

The Fargo lens, designed by Jim Day, is a four-zone lens manufactured
by G.P. Specialists (Phoenix, AZ). The Fargo lens is designed with the
original K readings and spectacle Rx and the eccentricity or temporal
K reading. The eccentricity and the elasticity characteristics of the

cornea may affect the final design.
There are three ways to order lenses: (1) original K and spectacle Rx
plus e-value or temporal K; (2) fit with a trial lens; and (3) dispense and
fit from a 112-lens inventory set.
The overall lens diameter ranges from 10.0 to 11.2 mm.
Emerald and Jade Lens Designs

The Emerald and Jade designs (Euclid Systems Corporation, Herndon,
VA) are manufactured with the EPT manufacturing system, which
offers a polish-free lens finish that is intended to eliminate inconsis-
tencies in posterior sagittal depth from polishing. The Emerald is a
four-zone lens. The Jade design is more advanced and uses a conic
model of the cornea and information about corneal eccentricity and
patient’s refraction to calculate the appropriate reverse curve. The
Euclid system includes the lens designs and the Euclid ET-800 corneal
topographer. The overnight orthokeratology lenses are manufactured
in the Boston Equalens II material.
Correctech Lens Design

The Correctech lens (Correctech, Inc., Front Royal, VA) is a four-zone
reverse geometry lens designed by Dr. Robert Breece. Patient data are
provided to the laboratory, and the lenses are manufactured on an
empirical basis. As previously indicated, this design has been success-
ful in lieu of a diagnostic fitting.88,95 The Correctech lenses are manu-
factured in the Boston Equalens II material.
Reversible Corneal Therapy Lens Design

The reversible corneal therapy lens (ABBA Optical, Stone Mountain,
VA) is a standard four-curve reverse curve lens manufactured in the
Paragon HDS 100 material. Base curve determination is accomplished
by fitting the lens flatter than K using the desired refractive error
change +0.75 D. The overall lens diameter is 10.6 mm. The alignment
curve radius is 0.25 D flatter than K. A consultant calculates the
reverse curve radius when the lens order is placed.
EZM Lens Design

EZM lenses (Gelflex Laboratories, Australia) are made in the Boston
XO lens material. The lens is available in either a 10.6- or 11.2-mm
overall diameter depending on the patient’s intrapalpebral aperture
size. The lens is fenestrated at a 120-degree interval to prevent lens
adhesion during overnight wear. Gelflex developed a computer calcu-
lator program to aid practitioners in determining the initial trial EZM

lenses by incorporating corneal topography data and the overall lens
diameter requested. Once the initial trial lenses are determined,
Gelflex recommends performing an overnight trial to determine
whether the patient is a fast or slow responder and whether the initial
trial lens choices were correct. If on the following morning,
the response appears to be poor and the result of a poorly fitted lens,
the patient will need to return for another trial with different
lenses.
Nightmove Lens Design

The Nightmove lenses (Advanced Corneal Engineering, Inc., Portland,
OR) were developed by orthokeratology innovator Dr. Roger Tabb.100
These lenses are manufactured from the Boston Equalens II lens
material. The lens design is a reverse geometry back surface construc-
tion with as many as nine curves, including the base curve, the reverse
curve, a variable number of alignment curves, and the peripheral
curve.
WAVE Contact Lens Design Software

The WAVE (EyeQuip, Ponte Vedra Beach, FL) program uses the math-
ematics of wavelet theory from topographic data and creates a digital
signal to describe the cornea, which is used to create the lens design
with an emphasis to match the periphery of the lens to the peripheral
cornea. This results in a lens that should exhibit good centration,
according to the manufacturer. The final lens design can be e-mailed
directly to the Optoform lathe (Precitech, Inc., Keene, NH) at Custom
Craft contact lens laboratory (Las Vegas, NV). The WAVE program,
which designs various GP spherical and special designs, is integrated
into the Scout topographer software and is included with the Keratron
topographer as standalone software (EyeQuip).
OrthoTool 2000
OrthoTool 2000 (EyeDeal Software & Design, Fresno, CA) is a GP
design, tear film modeling, and manufacturing software. It performs
the optical calculations from keratometry readings and spectacle
refraction to display complete lens parameters, manufacturing data,
the cross-section of the lens, thickness profile, and the tear film thick-
ness across the lens diameter. The contact lens practitioner can choose
from 12 different contact lens designs, such as standard spherical
designs, thin, ultrathin, aspheric, or bitoric lenses, and several reverse
geometry lens designs.
Lens Dispensing and Follow-Up Care
Dispensing
The initial lenses are dispensed after ordering the lenses using empir-
ical or diagnostic fitting; if dispensed during the fitting process, a 1-day
trial is recommended. The initial dispensing of an overnight orthoker-
atology lens is not different than that of any other GP lens design. In
addition to measuring visual acuity and evaluating the fluorescein pat-
tern, the patient must be taught insertion and removal of the lenses.
The patient should be instructed to place the lens on the eye 15 to 20
minutes before going to bed. Lens removal is especially important
because these lenses tend to fit tight and also typically adhere during
sleep. Because of this, the patient should wait, at minimum, 30 min-
utes before removing the lenses in the morning. Before removal, the
patient should apply wetting or rewetting drops and gently nudge the
lower lid into the lower edge of the lens to break any seal or suction
that may be present. The method of removal should not simply consist
of one finger at the lateral canthus but should consist of the upper and
lower lid margins pinned against the sclera and then pulled laterally as
recommend in Chapter 7.
Proper use of care products must be included in the instructions.
Because these are high- or hyper-Dk lens materials, the lenses should be
cleaned gently in an up-and-down manner in the palm of the hand on
removal. Patients must also understand their lens-wearing schedule.
Patients should also be educated about what to expect during the
treatment phase. They will typically experience some lens awareness
initially, but usually within a few nights they are not aware of any sen-
sation when they go to bed. However, it is not uncommon for patients
to experience some glare around lights and mild ghost images because
of the immediate impact these lenses have. This should stop when
patients adapt to the lenses. As mentioned before, a significant effect
can occur within 10 minutes.62 Patients should be aware that their
unaided vision should be much improved even after one night; how-
ever, the overall program could last 1 month or longer, especially if lens
changes are necessary.
It is common to perform 1- to 3-day trials with an overnight ortho-
keratology lens design. When fitting from a large diagnostic fitting set
or an inventory, overnight trials are a good alternative to better deter-
mine if the patient will be successful while also quickly determining
what, if any, lens design changes are necessary. All lenses are typically
+0.50 to +0.75 D in power but vary, at minimum, in base curve; inven-
tories allow variance in reverse curve (or RZD) and alignment curve
(or landing zone angle).
Follow-Up Visits
The patient should then be observed at day 1. This visit should occur soon
after awakening in the morning. If possible, the patient should return
wearing his or her lenses so that the fluorescein pattern can be evaluated.
A bulls-eye pattern should be observed. On lens removal, corneal topog-
raphy should be performed to determine if the topography map exhibits
a bulls-eye appearance as well (Figure 17-11). The appearance of this map
is not unlike a postoperative refractive surgery patient with the central
blue flatter treatment area surrounded by a dense steeper red-colored
region, which is surrounded by a flatter peripheral region. A central
island from excessive apical clearance (or bridging; Figure 17-12) or a smi-
ley face pattern from a lens that exhibits excessive localized apical bearing
often accompanied by superior decentration (Figure 17-13) can result.
The patient can then be observed from 3 to 7 days after dispensing.
If the topography map is not quite a bulls-eye at the day 1 visit, it may
Figure 17-11. A bulls-eye fluorescein pattern (A) accompanied by a bulls-eye topogra-

phy map (B).
Figure 17-12. An apical clearance fluorescein pattern accompanied by a “central island”

topography map. (Courtesy Craig Norman.)
take a few more days to determine if the treatment effect will be opti-
mal or if a new lens, with either a flatter base curve or alignment curve,
needs to be trialed.
The next evaluation should be after 1 week; afterward the patient
can be evaluated at the end of 2 weeks of wear, at the end of 1 month
of wear, and then every month for 3 months or when the cornea is sta-
ble. Expect stability within the first month for most patients. The fol-
low-up schedule is modified depending on the patient’s response to
the initial orthokeratology therapy. Each time a new lens design is dis-
pensed, the patient should be evaluated the next day. A patient should
Figure 17-13. An apical bearing fitting relationship accompanied by a “smiley face” topography
map. (Courtesy Craig Norman.)
never be allowed to continue to wear a lens that is too tight. A tight lens
will cause deleterious consequences in optics and physiology.
The typical follow-up visit will include the following:
1. Question the patient about comfort and improvement of unaided

visual acuity
2. Always measure and record acuity with and without the lenses
3. Overrefraction
4. Evaluate the fluorescein pattern
5. Evaluate corneal health
6. Subjective refraction
7. Keratometric readings or topography
8. Lens inspection including verification of all (verifiable) lens

parameters
9. Clean the lenses as necessary
10. Modify or order new lenses as necessary to maintain the desired
fitting characteristics
11. Review progress and the intended-wearing schedule with the
patient
12. Schedule the patient’s next appointment
Superficial punctate staining, if present, is most often observed at

the early visits. Typically it is diffuse and will resolve over time. If the
staining is coalesced or the patient is symptomatic (i.e., lens aware-
ness, burning, foreign body sensation), the staining should be resolved
before trialing another lens. Typically this is the result of a flatter than
desired fitting relationship.
One of the traditional problems with orthokeratology was how to
correct residual refractive error during the treatment phase.
Fortunately, the introduction of disposable lenses has resulted in a
viable option for most orthokeratology patients during this phase.
Daily disposable lenses, in particular, are recommended because of the
rapid reduction in refractive error that typically results with modern
designs worn overnight. At each follow-up visit until the treatment
phase is completed (often approximately 1 month unless lens changes
are needed), the patient can be given lenses ranging from the current
refractive error to slightly less myopic powers.
Retainer Wear
Once the target refraction (i.e., +0.50 to +0.75 D) or the best possible
endpoint has been achieved, a retainer wear program can be initiated.
The average amount of regression of the orthokeratology effect has
been found to be between 0.50 and 0.75 D per day.63 Therefore a
retainer program could be as simple as maintaining a nightly wearing
schedule. However, this will be dictated by the patient’s acuity. If the
patient is wearing the lenses only at night and acuity is good in the
evening, every-other-night retainer wear can be attempted. Because the
amount of regression can exhibit individual variance, some patients
can ultimately go to an every-third-night retainer wear. A well-
informed patient should be able to monitor and modify his or her
retainer wear safely.
Problem Solving
Overnight orthokeratology problems are rarely sight threatening
and are typically remediated with changes in lens design and
patient education. However, these changes should be made promptly.

They can include objective clinical signs pertaining to the lens-to-
cornea fitting relationship and corneal physiologic change, and sub-
jective symptoms pertaining to reduced vision and glare and ghosting
of images.
Lens-to-Cornea Fitting Relationship

Smiley Face and Central Island Topography. As mentioned before,
the presence of a smiley face topography map is typical of a lens that
is fitted too flat. Because lenses that are too flat tend to decenter supe-
riorly, the inferior region will be steeper. Changing to a steeper align-
ment curve or base curve should help remediate this problem,
or—depending on the manufacturer or designer’s recommendation—
the lens sag can simply be increased. Likewise, if a central island is
present, this is representative of significant undertreatment and a
steeper than desired fitting relationship. Changing to a flatter align-
ment curve or base curve should result in a more desirable effect, or—
depending on the manufacturer or designer’s recommendation—the
lens sag can simply be decreased.
Decentration
Superior Decentration. This typically results from a flat-fitting lens
and should be managed as mentioned for a smiley face problem.
Inferior Decentration. This is generally not a significant problem
(assuming the lens moves properly), unless the lens is fixed low or if
the patient experiences ghosting. Because the peripheral cornea is flat-
ter than the central cornea, the lens may exhibit a heavy touch in the
superior quadrant of the alignment zone, causing the lens to be forced
down. This can also result in a “frowny face” topography plot. The
solution would be to decrease lens sag, which can often be accom-
plished by flattening the alignment curve by 0.50 to 1.00 D.
Lateral Decentration. Lateral decentration can be managed simi-
larly to a spherical lens design by using a larger diameter. In addition,
the width of the alignment zone can be increased. On occasion, lateral
decentration can be caused by the patient sleeping on his or her side,
and the patient should be questioned about this if the lenses are posi-
tioned laterally.
Lens Movement
Tight Fit. This can be caused by back surface deposits, particularly
if movement decreases over time. Patient education about cleaning the
back surface of the lens and to supplement the lens care regimen with
a liquid enzyme would also be recommended. If this becomes a
chronic problem and does not appear to be deposit related, changing
to a flatter alignment curve and possibly peripheral curve radius
should be beneficial. A higher-Dk lens material, if possible, has also

been recommended.101
Loose Fit. If excessive movement is present, increasing the lens sag
by steepening the alignment curve will often be beneficial.
Corneal Physiologic Change

Corneal staining, as mentioned before, has more of a tendency to
occur during the initial part of the treatment and is typically diffuse
punctate. If coalesced, notably at the day 1 visit, it is often an exces-
sively flat-fitting lens that would require a steeper alignment zone or
BCR. If it occurs over time, it is often the result of a deposited back
surface, and patient education about compliance with the care and
cleaning regimen should be emphasized.
Reduced Vision
Reduced unaided vision—or best correction with manifest refrac-
tion—can be the result of several causes. If the lens is undertreating
the cornea, a more aggressive approach will be necessary (i.e., flatter
alignment curve or base curve). If the lens is decentered, resulting in
a decentered treatment zone, it should be handled as recommended in
the section on decentration. If the patient is experiencing poor reten-
tion of the reduced refractive error, the patient will need to increase the
retainer wear schedule.
Glare and Ghosting

It is not unusual for the patient to experience these symptoms during
the first few days of the treatment. If they persist, they could be the
result of decentration and therefore a decentered treatment zone
(Figure 17-14). If the patient experiences these symptoms, the practi-
tioner should confirm with topography that there are no central
Figure 17-14. Decentration of an orthokeratology can often lead to glare. (Courtesy

Craig Norman.)
islands. If all optical considerations are considered and fixed, the

patient’s pupils may be significantly larger than the area of the cornea
that has been treated. If possible, the optical zone should be increased,
although this may compromise the orthokeratology effect.
An overview of overnight orthokeratology problem-solving proto-
cols is provided in Table 17-4. Because of the design and terminology
differences with the Paragon CRT lens, the problem-solving protocol
for this design is provided in Table 17-5.102
COMPLICATIONS
It is apparent from overnight orthokeratology studies to date that this
process does not appear to result in a greater complication rate than with
other types of contact lens materials and wearing modes. As mentioned
before, lens binding is not uncommon because contact lenses worn dur-
ing sleep will adhere. It is important for the patient to use rewetting
drops on awakening to help initiate movement. The presence of persist-
ent adherence and associated epithelial imprinting and possible staining
should alert the clinician to change the lens design or material to attempt
to loosen the fit. Corneal staining, when present, is typically in the form
of mild central superficial punctate keratitis.93 Albeit rare, corneal ulcer
as an adverse reaction has been reported in China.103
An interesting finding—although to date not classified as an
adverse event or significant complication—has been the documenta-
tion of the so-called “Rah ring.” Rah et al104-105 have documented a
series of overnight orthokeratology patients—all wearing their lenses
from 6 months to 2 years—in whom an arcuate ring in the corneal
epithelium, presumably iron based as in the Hudson-Stahli line,
Fleischer’s ring, and other similar pigmented entities, has resulted
(Figure 17-15). This finding was more prominent in patients with dark
irides and in those with higher baseline refractive errors. It does not
appear to affect visual acuity, and patients have been able to remain in
overnight orthokeratology. Although overnight orthokeratology to date
appears to be relatively safe, there is a need for a well-controlled long-
term study to evaluate the safety of this modality.
INCORPORATING ORTHOKERATOLOGY INTO A PRACTICE

Promotion
It is important to emphasize that overnight orthokeratology is an off-
label use of lens materials that are approved for extended wear, but the
lens design has not been approved. At the time of this writing, only
Text Continued on p.471
468
Table 17-4 Problem-Solving Guide
Problem Possible Cause Solution
SECTION IV
“Smiley face” Flat-fitting relationship Increase sagittal height
topography Superior decentration Steepen base curve
Central island topography Apical clearance Decrease sagittal height
Flatten base curve
Superior decentration Flat-fitting relationship Increase sagittal height
Steepen base curve

Inferior decentration (“frowny face” Steep-fitting relationship Decrease sagittal height
topography)
Lateral decentration Decentered corneal apex Increase diameter
Patient sleeping on side Patient education
Tight fit Back surface lens deposits Patient education about cleaning
Steep-fitting relationship Decrease sagittal height
or flatten periphery
Higher Dk material
Loose fit Flat-fitting relationship Increase sagittal height
Corneal staining Flat-fitting relationship Increase sagittal height
Back surface lens deposits Patient education about cleaning
Reduced vision Undertreatment Decrease sagittal height
Decentration Treat as managed under decentration
Poor retention Increase retainer schedule
Glare/ghosting Decentration Treat as managed under decentration
Pupil size > treatment zone Increase treatment zone (if possible)
Chapter 17
Table 17-5 Paragon CRT Problem-Solving Guide
Orthokeratology
Continued
469
470
Table 17-5 Paragon CRT Problem-Solving Guide—Cont’d
SECTION IV
From Paragon CRT professional fitting and information guide, Mesa, AZ, 2002, Paragon Vision Sciences.
Figure 17-15. The “Rah” ring.
one lens design was approved; however, several other designs have
been submitted for FDA approval. For use of nonapproved designs,
the guidelines for promoting and advertising orthokeratology, as pro-
vided in Box 17-4, are important.106 It is especially important to note
that practitioners should avoid making exaggerated and unsupported
claims of safety or effectiveness. Likewise, claims of permanence or
the use of testimonials should be discouraged.
However, it is evident that patients are interested in a nonsurgical
method of potentially lessening their reliance on spectacles or contact
lens correction during the day. Orthokeratology has great potential as
an in-office modality that can be highly profitable while potentially
increasing a patient’s quality of life. Gerber107 has indicated that ortho-
keratology may represent the most profitable modality available to
optometry. The important factor is marketing the potential benefits
it provides, such as convenience, freedom, peace of mind, and self-
confidence. This is provided in Table 17-6.
West108 presents the Paragon CRT option to all of his current
patients and emphasizes that the practitioner should not prejudge a
patient’s interest, ability to afford the procedure, and ability to com-
prehend how it works. Certainly it can be promoted in an office
newsletter and also via a brochure; the latter can include what ortho-
Box 17-4 GUIDELINES FOR ADVERTISING AND PROMOTING ORTHOKERATOLOGY

●
The main responsibility of the Federal Trade Commission (FTC) is to
protect consumers from unfair and deceptive acts or practices in advertising
and promotion. The main responsibility of the Food and Drug
Administration (FDA) is to promote public health.
●
In an FDA Public Health Notification: Illegal Promotion of Contact Lenses
dated September 25, 1998, the FDA states, “A licensed practitioner may
individually design and prescribe an RGP Orthokeratology lens for a
particular patient within the scope of his/her patient. However, eye care
practitioners who promote Orthokeratology in their practice should avoid
making exaggerated and unsupported claims of safety or effectiveness.”
●
The practitioner who is advertising orthokeratology is responsible for all
statements, regardless of who creates the advertisement. All information
must be accurate and must not deceive the patient.
●
Claims of safety and efficacy must be supported by competent and reliable
scientific evidence. Advertising that claims a specific result, by the
individual practitioner, must be documented unambiguously. If the
promotion claims a specific result using a particular technique, it is
necessary that the orthokeratologist is using the exactly same protocol.
●
As a general guide, advertisements using testimonials should be avoided.
Far too many variables exist from patient to patient for any testimonial to
be considered a typical result.
●
Claims of permanence must be avoided. It is important that there be a
prominent mention of the need for retainer lens wear.
●
The best advertisement of orthokeratology is honest, unambiguous, and
without deception. One can apply the common person standard: the
average person will understand the advertisement and not be misled in
any fashion by the content.
From Rinehart J: Guidelines for advertising and promoting orthokeratology, Contacto 40(1):7-13,
1999.
keratology is, how it works, its benefits, the follow-up care involved,
retainer wear, potential limitations, and a “Q & A” section. If the office
has a web site, this would be a viable addition to the other services
listed. Likewise, just as is commonly performed in refractive surgery
practices, educational seminars on this procedure can educate the
community and build an orthokeratology practice. One staff member
could serve as the primary educator and handle informational calls
and in-office sessions. It would be advisable for this to be someone
who has been through the process.
Fees
The fees for orthokeratology are competitive with refractive surgery.
The fees tend to vary greatly; generally the all-inclusive fees range
between $750 and $2500. The average fees tend to range from $1100 to
Table 17-6 Marketing the Rewards for Choosing Orthokeratology
From Gerber G: Marketing techniques for the successful orthokeratology practice. Presented at
the Global Orthokeratology Symposium, Toronto, Ontario, Canada, August 2002.
$1400.80 West108 purposefully downplays the role of materials, explain-

ing that if the fee for orthokeratology was $1500, $250 is for lens mate-
rials and $1250 is for the initial fitting, dispensing, and follow-up visits
for 6 months. He also recommends being flexible in the payment
process; financing can be provided so patients can pay on a monthly
basis. This fee information can be provided as part of an informed con-
sent that describes the process to the patient (Appendix 17-1).
Resources
There are several resources that will help practitioners increase their
confidence and expertise with orthokeratology. There are numerous
workshops performed by Paragon Vision Sciences (CRT), John
Mountford/Precision Optics (BE), John Rinehart and Jim Reeves, and
others. The Annual Global Orthokeratology Symposium is a compre-
hensive program that combines workshops with contemporary clinical
presentations and the most current research. Organizations such as
the Orthokeratology Academy of America and the International
Orthokeratology Society are in the process of developing educational
programs. Likewise, the orthokeratology newsletter (www.ortho-
k.net/profess.htm) and the British Orthokeratology Society
(www.boks.org.uk) are useful resources. The RGP Lens Institute has
two monthly online symposia every year dedicated to orthokeratology
with faculty including Roger Tabb, John Rinehart, Harue Marsden,
Marjorie Rah, and Jeff Walline. The online schedule is posted at
www.rgpli.org. Publications such as a new text from John Mountford
and A Guide to Overnight Orthokeratology available from Polymer
Technology Corporation are also valuable resources.
SUMMARY
Orthokeratology is rapidly becoming an important part of eye care
practice and an invaluable application of GP lenses. As more con-
trolled research is performed, it is likely that orthokeratology will

become an important modality for myopia control for children and
adults.
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appendix
17-1
Sample Orthokeratology Agreement
and Informed Consent
Hartsdale Vision Health Center
1355 West Main Street – Anywhere, USA 12345
(555) 123-4567
This document pertains to an ortho-k pretreatment evaluation about
orthokeratology and care of ortho-k lenses, which I have read and
understood. All questions that I had were answered by Dr. ( ). This
program involves my wearing specially designed gas-permeable lenses
overnight that reshape my cornea overnight in order to provide accept-
able unaided distance vision during my waking hours. I understand
that the ortho-k effect is temporary and reversible and that it may be
necessary to wear my retainer lenses during waking hours to maintain
satisfactory distance vision, especially if I failed to wear these lenses as
advised. I also understand that the quality of my unaided vision is
dependent on wearing these lenses as prescribed by my doctor and on
how much internal astigmatism is present in my eyes, which is not
always predictable. If I do not find the results acceptable, the process
will be reversed by my wearing rigid, gas-permeable, or soft contact
lenses for about one to three weeks.
BENEFITS: These lenses have been designed to provide excellent
visual acuity and oxygen transmission to the eye. The lens design is
believed to provide a reduction in the refractive error of a treated eye
with a resultant improvement in the unaided visual acuity. This
change is believed to be completely reversible and temporary in
nature.
RISKS: While no harmful health risks to your eyes are anticipated
from using the lenses, as with any contact lens, there are potential
risks of irritation to the eye, infections, or corneal ulcers. Transient dis-
torted vision that is not corrected with spectacle lenses may occur after
removal of the lenses. No harmful effects are expected from any of the
examination procedures used in the fitting process. If you develop any
unusual symptoms or prolonged discomfort, removing the lens
should, in most cases, provide immediate relief. In addition, you
should contact your eye care practitioner immediately.
481
In the event it is determined that use of these lenses presents new

risks or the possibility of undesirable side effects, you will be advised
of this information so that you may determine whether or not you
wish to continue as a volunteer patient in this investigation.
ALTERNATIVES: Currently available alternatives to ortho-k lenses
are spectacles or other types of soft, conventional hard, or gas-perme-
able contact lenses or surgical vision correction. Dr. ( ) or his/her staff
can discuss these alternatives with you.
FEE SCHEDULE
Initial consultation: Includes comprehensive evaluation of refrac-
tive status, corneal topography, and determina-
tion of diagnostic lens parameters. $175.00
(payable at time of examination)
Diagnostic lens trial: Includes evaluating the refractive changes over
a period of three to five hours resulting from
the wearing of diagnostic lenses. $200.00
(payable at time of examination)
Treatment program: $625.00 (includes all visits for three months)
Retainer lenses: $300
Total: $925.00 ($300.00 payable in advance and
$625.00 payable by fourth-week scheduled
visit)
Refund policy: Should you wish to discontinue the treatment
on or before the fourth-week scheduled visit,
the balance of $625 will be credited or, if paid
by cash or check, refunded.
I have read all of the above information regarding lenses. I understand
what I have read, and the circumstances have been explained to me.
Although it is impossible for my eye care practitioner to inform me of
every possible complication, he/she has answered all of my questions
to my satisfaction and has assured me that he/she will advise me of
new risks if they develop and will answer any further inquiries I may
have about this treatment or wearing this type of lens. Should any
complications occur, I agree to contact Dr. ( )
immediately at (555) 123-2020 during daytime or (555) 123-4321 after
hours.
(please print)
Name ________________________________________________
Practitioner ____________________________________________
Address ______________________________________________
Date __________________________________________________
Phone ________________________________________________
Signature ______________________________________________
Appendix 17-1 Sample Orthokeratology Agreement and Informed Consent 483
If patient is under 18 years old, parent or guardian signature is

required.
Signature parent/guardian ________________________________
Relationship to minor __________________________________
Signature witness ______________________________________
From Cannella A: A guide to overnight orthokeratology, Rochester, NY, 2002, Polymer

Technology Corporation.
18
The Internet and Gas Permeable
Lenses
MILTON M. HOM
T he Internet has exerted a growing influence in many of our daily

lives. The same can be said for contact lens practitioners. For
information access, the Internet is unmatched because of its
availability, speed, and capacity. The use of the Internet for contact lens
information was named the contact lens event of 1997.1
There are generally two categories of Web sites geared for contact
lenses: patient and practitioner. The Web has appeal for contact lens
marketers. The demographics of the contact lens wearer and computer
user are similar. Contact lens companies usually design patient sites.
One philosophy is that contact lens companies can reach patients
directly through the World Wide Web. The Web is perceived to be a
more cost-effective supplement to journal advertising than consumer
advertising.2 For practitioners and optometry students, the available
Internet sources are increasing. Other practitioner-directed Internet
endeavors include chat rooms and e-mail lists.2
RGPLI ONLINE EDUCATION

One resource with a gas permeable (GP) focus is the RGP Lens
Institute (RGPLI) monthly educational session on the second Tuesday
of every month at 9:00 PM eastern time. Formerly in the “Review
Online” chat room of America Online, it has moved to its own Web site
(www.rgpli.org). Edward Bennett, OD, MS, moderates the session.
One advantage of moving to the Web site is the capability of view-
ing cases online. The speaker can write the pertinent information
about the case for review by the participants. Images such as fluores-
cein patterns and topographies can be displayed and archived.
The practitioners log into the system and are able to see the names
of the other participants on the screen. Participants type in their ques-
tions or comments, and the text appears on everyone’s screen.2 The
484
Chapter 18 The Internet and Gas Permeable Lenses 485
time it takes for comments to be seen by others depends on connec-

tion speed and Internet traffic. Many of the speakers are well known
and offer great information.
The format for the session is divided into two sections. The first
hour is dedicated to the topic. The remaining time becomes an open
forum. The participants can present cases, ask questions, or introduce
a new topic. Benefits of the session are uninhibited exchange of infor-
mation and speed. One optometric expert has compared this format to
one big conference because of the spontaneity and instantaneous feel.
Another expert likened this experience to “going out for coffee with an
expert after the lecture. It’s great for face-to-face learning, but it’s
much more relaxed.”2
OPTCOM LIST
Any discussion about optometry and the Internet would not be com-
plete without mentioning the Optcom list or Optcom Online
Community. Originally a mailing list, it is offered through
the Optometric Computing site (www.optcom.com), which is also the
official site of the Southern Council of Optometrists. Walt Mayo, OD,
a pioneer in the field of technology for optometrists, moderates the
list.3
Before the Internet became commonplace, Dr. Mayo founded the
Optnet Bulletin Board System in the 1980s and early 1990s. A hand-
ful of optometrists would log onto the system and exchange ideas and
news. Much of the same networking and sharing of information goes
on today on the Optcom list. The Optnet System subsequently evolved
and found a place on the Internet. The Optcom list has a membership
of approximately 1500 optometrists. The advantage of the Internet is
the worldwide access. There are optometrists all over the world form-
ing the optometric online community created by Dr. Mayo.
One problem he faced in the beginning was lack of sponsorship.
At the outset, Dr. Mayo financed the Optcom list himself. He devoted
a great deal of time and money to develop online optometry.3
Since that time, the Southern College of Optometrists has gained
ownership.
The Optcom list has evolved and has been available in four forms:
mailing list, digest, newsgroup, and Web board. The mailing list is the
original format. Messages are sent to the subscribers as e-mail as
they are posted. The digest format sends the subscriber a packet of
messages. There is also an option to have the digest sent in a com-
pressed (zip) format. The newsgroup and Web board are no longer
available.
E-COMMERCE FOR PATIENTS

The Internet has accounted for millions of ophthalmic electronic com-
merce (e-commerce) in 1999.4 Much of it was the Internet sale of con-
tact lenses to patients. 1-800 CONTACTS had total sales of almost
$100 million with the Internet sales accounting for $18.7 million.5
Half of contact lens wearers get their lenses from nontraditional
sources, such as mail order. Two of every five patients get their lenses
from a practitioner other than the doctor who prescribed them.4 In
2003, 1 of 10 patients replaces his or her lenses over the Internet. This
number is expected to increase.6 Buying online offers convenience,
one-stop shopping, and, many times, lower costs.
The manufacturers state that selling to Internet and mail order com-
panies is not their policy. Through the tracing of bar codes, the manu-
facturers have shut down accounts that resell the product. Over the
years, companies have claimed to have closed down dozens of accounts.
Some have adopted a “no slit lamp, no product” policy. However, com-
panies like 1-800 CONTACTS have huge inventories. The mail order
and online companies are thought to receive their lenses from the gray
market, overseas sales, and diverted product from eye care professionals
who chose to resell their product. 1-800 CONTACTS purchased 38% of
its contact lens inventory from a single source in 1999, and its top three
suppliers accounted for 68% of that inventory.5
Some experts have predicted that the move toward patients pur-
chasing lenses on the Internet will directly benefit GP practitioners. If
the patients acquire lenses through a list of Web sites and 1-800 num-
bers, experts believe that practitioners will be out of the soft lens
replacement business. The indirect benefit is that practitioners will
refocus on GP lenses.4
GP INFORMATION SEARCH
There is a wealth of information available on the Internet. One author
likens it to a library with 1 billion books. The problem is finding where
the information is located. It is as if all of the books are piled on the
floor. Additionally, many “books” disappear within months, and thou-
sands of new ones appear daily.7
Search Engines
Most people use search engines to locate Web pages. The problem
with search engines is that even the best ones only document 20% of
all the pages on the Internet.7 Search engines also have a difficult time
discerning the meaning of the key word. An example is the word “bill,”
which would generate thousands of hits but not necessarily what is
being sought. The word bill may be a legislature bill, a bill on a duck,
or a dollar bill. Another disadvantage is the ability to search only hyper-

text markup language (HTML). If the pages have built-in security, it is
likely the search will miss the pages. A commonly used search engine,
such as AltaVista (www.altavista.com), indexes medium-sized sites
more completely than large or small sites.7
One method to avoid the bias of one search engine is to use several
engines. Other search engines commonly used are Yahoo
(www.yahoo.com), InfoSeek (www.go.com), Lycos (www.lycos.com), and
Google (www.google.com). Google is fast becoming the standard search
engine on the Internet. Google lists the results by the number of links to
a particular page. The “official” Web page usually is listed first.
In the past, I found the search engine Dogpile (www.dogpile.com)
to be the most useful for difficult to find information. Dogpile enlists
the help of several search engines. When a key word is entered,
Dogpile gives the top results of several of the most commonly used
search engines. It is like using multiple engines with only one stop.
Web pages of manufacturers are highly useful for information
about RGP lenses. Depending on the site, many manufacturers have
fitting guides, parameters, and educational resources on their Web
sites. Web pages of organizations, such as the RGPLI (www.rgpli.org),
are dedicated to RGP education (see Chapter 19). The RGPLI site also
hosts the RGPLI monthly chat.
Usenet
Usenet and the newsgroups are other areas of the Internet that can be
searched. Newsgroups are messages posted by users pertaining to a
particular topic or interest area. In the past, the Optcom list could be
subscribed to as a newsgroup.
One newsgroup open to everyone is sci.med.vision. Some practi-
tioners do not like sci.med.vision because some members display an
anti–eye care practitioner stance. Most participants are patients hon-
estly seeking information about their eyes. However, there are several
vocal members who can be argumentative and impolite. The numbers
of these disenfranchised members are few; however, they sometimes
post the majority of the messages. I personally find sci.med.vision an
interesting forum to occasionally read because it gives me the pulse on
what patients are thinking today.
Newsgroups themselves are difficult to read. They are somewhat
organized by thread (message subject), but many times the thread
wanders away from the original topic. However, the newest informa-
tion can be found first in the newsgroups. It can sometimes be bewil-
dering to find things because of the inherent disorganization. Web
pages are more organized, but the information needs to be processed
before it appears on the site. Newsgroups are almost spontaneous in
their ability to post information. Searching Usenet can be done with a

search engine such as Google (under groups).
PubMed
Another more conventional search engine is PubMed (http://www.
ncbi.nlm.nih.gov/PubMed/). This engine searches the medical litera-
ture and is current. Formerly, literature searches were only available in
libraries or on expensive CD-ROM collections. PubMed makes litera-
ture searches accessible from the Internet. The US-based optometry
journals that PubMed searches are peer reviewed: Optometry and
Vision Science and Optometry (formerly Journal of the American
Optometric Association). PubMed is the best search engine for leading
someone to peer-reviewed studies related to GP lenses. Because
the majority of contact lens information has been written in non–
peer-reviewed journals, PubMed has limited use.
Archive by Archive
A journal-by-journal archive search is effective to find valuable contact
lens information. Contact Lens Spectrum (www.clspectrum.com),
Optometric Management (www.optometric.com), Primary Care
Optometry News (www.slackinc.com), and Review of Optometry
(www.revoptom.com) all have archives on their Web sites. The major
disadvantage of the archives is only recent years are available. Finding
older issues will still require a trip to the library. Another disadvantage
is the lack of viewable pictures that appeared in the article. Despite
these disadvantages, an archive-by-archive search is a useful tool.
RGPLI.org
The RGPLI offers many resources on their Web site (www.rgpli.org).
A database of RGP lenses is available in searchable form. There is a
directory of GP laboratories and a listing of GP materials. With regard
to the RGPLI on-line symposia, the schedule and summaries can be
found here. The resources described in Chapter 19 are available on the
Web site. The optometry schools and colleges workshop schedule and
areas to sign up for the student and practitioner newsletters are listed.
Links to the RGPLI consumer site (www.contactlenses.org) and other
sites are also listed.
Contact Lens Today

CL Today (www.cltoday.com) is the weekly Internet newsletter devoted
to contact lenses. The subscription is free. Although an archive search
is not offered at this time, the best fitting tips can be found on CL
Today.
Continuing Education Sites

Continuing education on the Internet is growing. There are several
sites available, although most of the sites do not have GP contact lens
classes.
Visioncarece.com
Visioncarece.com is an online continuing education site sponsored by
Boucher Communications (BCI). The courses on the site are Council
on Optometric Practitioner Education (COPE) approved. There are
classes available on contact lenses. The user takes the class and
answers questions online for continuing education credit hours. The
certificate is e-mailed back to the doctor in minutes. The classes are
available to an eye care practitioner 24 hours a day, 7 days a week.
CONSUMER SITES
Allaboutvision.com
Allaboutvision.com is a consumer site offering information about all
aspects of vision. The article on GP lenses is a useful reference for
patients. Pertinent topics such as adaptation and benefits are covered.
Contactlenses.org
Contactlenses.org is the consumer site sponsored by the Contact Lens
Manufacturers Association (CLMA). The site concentrates on oxygen-
permeable lenses. Some questions answered include what are oxygen-
permeable lenses; how do oxygen-permeable lenses compare with soft
lenses; and can oxygen-permeable contact lenses control myopia in chil-
dren? There are other sections comparing contact lenses and glasses,
teens and parents, bifocal contact lenses, athletes, and refractive surgery.
REFERENCES
1. Barr JT: The contact lens event of the year, Contact Lens Spectrum 13(1):15, 1998.
2. Gilfor M: Contact lenses in cyberspace, Contact Lens Spectrum 12(1):30, 1997.
3. Top 10 ODs of the decade, Optometric Manage 34(12):9, 1999.
4. Murphy J: 2010 an optometric odyssey: episode I: E-business: the next e-volution
of your practice, Rev Optometry 137(1):50, 2000.
5. Goodwin J: Mail order: public benefit or public health threat? Optometric Manage
35(9):30, 2000.
6. Quinn KA: Contact lenses and e-commerce, Rev Contact Lenses 140(3):129-130,
2003.
7. Maino DM: It’s all on the web...if you can find it, Rev Optometry 134(5):29, 1997.
19
Gas Permeable Lens Educational
Resources
MILTON M. HOM
URSULA LOTZKAT
EDWARD S. BENNETT
M any educational resources have been developed for gas

permeable (GP) lenses. Traditional sources are books, arti-
cles, and manufacturer materials. In recent years, technology
has expanded the capabilities of GP educational resources. Videotapes,
CD-ROMs, and Internet resources have emerged. Chapter 18 dis-
cussed the Web, chat rooms, and mailing lists in greater detail.
TEXTS
Current Texts
Other than the first edition of this book, there are no other books exclu-
sively dedicated to GP lenses. However, some books from the authors do
have extensive coverage of GP lenses, including the following:
Manual of Contact Lens Prescribing and Fitting with CD-ROM, Second
Edition
Milton M. Hom
Butterworth-Heinemann, 2000
ISBN 0-7506-7215-3
Description: The CD-ROM included with this book has more than
90 video clips depicting GP fitting and cases. The CD-ROM adds
eight multimedia chapters to the book. The screen text has been
reformatted into chapters included in this book. In all, there are
19 chapters dedicated to GP lenses. The late Rodger Kame wrote the
foreword.
Clinical Manual of Contact Lenses, 2nd edition

Edward S. Bennett
Vinita Henry
490
Chapter 19 Gas Permeable Lens Educational Resources 491
Lippincott Williams & Wilkins, 2000

ISBN 0-7817-1951-8
Description: This 639-page text includes extensive chapters
on every important GP category, including material selection, lens
design and fitting, problem solving, care and patient education, modi-
fication, verification, orthokeratology, presbyopia, astigmatic correc-
tion, keratoconus, postsurgery, extended wear, and aphakia. Each
chapter is concluded with numerous cases and a clinical proficiency
checklist.
Clinical Contact Lens Practice

Edward S. Bennett
Barry A. Weissman
Lippincott Williams & Wilkins, 2004
Description: This comprehensive contact lens text, once published in a
loose-leaf format (last updated in 1998) will soon be available in a
hardback edition.
Other Current Texts

Contact Lens Practice
Nathan Efron
ISBN 0-7506-4690-X
Description: Contact Lens Practice is positioned as the successor to
Phillips and Speedwell’s Contact Lenses. There are seven chapters of
this large book exclusively covering GP lenses.
Clinical Manual of Specialized Contact Lens Fitting

Terry Scheid
ISBN 0-7506-9924-8
Description: Six of the eight chapters are entirely or mostly devoted to
GP lenses.
Clinical Cases in Contact Lenses

Ron Watanabe
ISBN 0-7506-9044-5
Description: Almost 60% of the cases in this book are about GP lenses.
Legacy Texts
Many of these texts are older but are still currently available.
Contact Lens Problem Solving

Edward S. Bennett
Series Editor: Richard London
Mosby, 1995
ISBN 0-8151-0424-3
Description: The book covers contact lenses from a problem-solving
approach. Seven of the nine chapters contain notable GP cases and
information. The clinical pearls highlighted in each chapter are useful.
Contact Lenses with CD-ROM, 4th Edition

Anthony Phillips
Lynne Speedwell
ISBN 0-7506-1819-1
Description: Contact Lenses has been the cornerstone text for Europe
and the rest of the world for many years. Eight hundred eighty-eight
pages in length, it offers a comprehensive look at contact lenses. The
orthokeratology chapter by John Mountford is a classic. The 5th edi-
tion is forthcoming.
Medical Contact Lens Practice

Ian A. Mackie
ISBN 0-7506-0939-7
Description: Contact lenses within a medical practice is the approach of
this book. Well illustrated, the book provides good coverage of GP
lenses. Chapters are devoted to keratoconus, grafts, aphakia, presby-
opia, and torics.
Clinical Management of Myopia

Theodore Grosvenor
David A. Goss
ISBN 0-7506-7060-6
Description: The book is not a contact lens book. Its main focus is myopia.
However, there is a detailed chapter devoted to myopia management
with GP lenses written by the researchers who pioneered this area.
Contact Lenses For Pre- and Post-Surgery

Michael G. Harris
Richard London
Mosby, 1997
ISBN 0-8151-1400-1
Description: Michael Harris wrote this beneficial text on contact lens

management of surgical corneas. Included are chapters on kerato-
conus, aphakia, grafts, and refractive surgery.
Specialty Contact Lenses: A Fitter’s Guide

Carol A. Schwartz
WB Saunders, 1996
ISBN 0-7216-4747-2
Description: This is the only book with three chapters dedicated to GP
lenses for management of astigmatism. There are chapters on back
toric, front toric, and bitoric GP lenses. The bitoric chapter features Joe
Benjamin’s “Rigid Bitoric Form 1040” worksheet.
Anterior Segment Complications of Contact Lens Wear, 2nd Edition

Joel A. Silbert
ISBN 0-7506-7116-5
Description: The book covers general complications related to contact
lens wear. A good portion of the book includes GP lens complications.
Out-of-Print Books
Complications of Contact Lens Wear
Alan Tomlinson
Mosby, 1992
ISBN 0-8016-6309-1
Description: Tomlinson’s classic book introduced the area of complica-
tions. The chapter “Abrasions secondary to contact lens wear” by
Jeffrey Dougal is a milestone in GP lens complications.
VIDEOTAPES
The videotape series by the Contact Lens Manufacturer’s Association
(CLMA)/RGP Lens Institute (RGPLI) is the most commonly used in
schools and colleges of optometry in the United States. There is a
series of 12 tapes available from the RGPLI. It is also called The GP
Professional Advantage Video Series. Here are the tapes available in the
series:
1. GP Fitting & Evaluation

Learn vital basics with examples of various lens-to-cornea relation-
ships and effects of base curve radii, optic zone, diameter, peripheral
curves, and blends; also, examples of varying standard and non-
standard design parameter fits are discussed. Workbook available.
2. GP Problem Solving: Part I

Case management and recommendations with common issues:
adhesion, flexure, warpage, corneal desiccation, poor surface wet-
tability, and problem solving in six common categories.
Workbook available.
3. GP Problem Solving: Part II
Covers how to recognize and diagnose common hydrogel- and
polymethylmethacrylate-(PMMA) induced problems and how to
successfully refit patients into GP lenses. In addition, case man-
agement, examples, and recommendations are provided. GP lens
decentration, including inferior, superior, and lateral decentra-
tion, is reviewed with numerous examples, including patients
with keratoconus. Workbook available.
4. GP Modification & Verification
Essentials of in-office GP lens verification using inside views
through various instruments are discussed. Step-by-step essen-
tials of in-office GP lens modification, changing peripheral
curves, polishing edges, and so on are covered. Workbook avail-
able.
5. Advanced GP Fitting
Diagnostic fitting and evaluations of a variety of toric and irregu-
lar corneal conditions, such as keratoconus, are reviewed. Learn
how to design lenses for various stages of these conditions.
Diagnostic fitting, evaluation, and design for all forms of GP toric
lenses are discussed. Advanced fitting and fluorescein patterns
are provided. Workbook available.
6. Keratometry, Lensometry & Radiuscope
Staff training covering the operating fundamentals of ophthalmic
instruments, including verification, set-up, calibration, and
recording, is reviewed. Instrument-specific through-the-instru-
ment views are used along with many practical examples and
tips.
7. Reception Room Promotional Video
Three-minute loop provides patient education. It is complimen-
tary from the RGPLI.
8. Reception Room Promotional Video
This 1-hour continuous-loop video is ideal for staff training and
patient education; it presents the benefits of GP lenses to patients
using easy-to-understand language, colorful graphics, and ani-
mation.
9. GP Care & Handling
This important patient education video shows patients the in-
depth fundamentals of how to insert, remove, clean, and care for
their GP lenses.
10. Building Your Practice with GPs

This most important video covers ways to take advantage of the
loyal and profitable RGP market. This video covers optimizing
GP use, profits, and selling points. It is complimentary from
the RGPLI.
11. Contact Lens Biomicroscopy
This video presents the foundation of performing biomi-
croscopy in a clinical environment. It includes instrument set-
up and illumination and shows clinical examples with an
emphasis on contact lens-related imagery.
12. GP Bifocal Fitting & Troubleshooting
Released in November 1998, the newest video to the series uses
slit-lamp images to highlight important prefitting factors,
aspheric multifocal fitting and troubleshooting, and segmented
translating bifocal fitting and troubleshooting.
OTHER GP LENS INSTITUTE RESOURCES

The RGPLI is the educational arm of the CLMA. The CLMA members
comprise contact lens laboratories and material, solution, and equip-
ment manufacturers in the United States and abroad. They are dedi-
cated to providing practitioners with educational and practice-building
resources that enable them to fully benefit from the many advantages
of GP (oxygen-permeable) contact lenses. These include the following:
1. GP Lens Product Directory

The GP Product Directory is a summary of current GP products
available from CLMA member laboratories. The products are organ-
ized under the following headings: spherical GP designs, aspheric
GP designs, toric GP designs, multifocal-simultaneous GP designs,
multifocal-translating (segmented) GP designs, keratoconus GP
designs, reverse geometry GP designs, corneal refractive therapy,
and orthokeratology. Also included is a list of GP materials, solu-
tions, and accessories available from associate CLMA members. On
the rgpli.org Web site, there is a searchable version of the GP
Product Directory; practitioners can search for any of the GP lens
products that a CLMA member laboratory manufactures.
2. GP Lens Management Guide
Fitting and troubleshooting tips for single-vision sphere, multifo-
cal, toric, and keratoconus GP lenses are discussed. The guide
includes illustrated problem-solving tips.
3. Fluorescein Pattern Identification Card
This is a handy laminated card that is a quick and easy reference
for use in the practitioner’s office. It includes 14 helpful fluorescein
patterns, 5 fitting pearls, and a quick guide to design changes. The

card fits in a jacket pocket.
4. Correcting Presbyopia Tips Card
This pocket size card offers practical tips for presenting and fit-
ting patients with presbyopia with GP lenses. Also included are
eight common troubleshooting suggestions.
5. GP Fitting, Evaluation and Problem Solving (Hom/Bennett)
This CD-ROM covers basic fitting and troubleshooting for the cli-
nician. It features video clips captured from the extensive RGPLI
video library. The CD-ROM is divided into two sections: fitting
and evaluation, and problem solving. Topics covered in the
fitting and evaluation section include fluorescein pattern reading
of spherical and toric corneas. Topics covered in the problem-
solving section include inferior and lateral decentration, corneal
desiccation, adherence, and wettability problems. A GP Bifocal
CD-ROM has also recently been introduced.
6. Blueprint for a Successful GP Practice
Presenting GP lenses effectively, proven fitting strategies, mas-
tering GP lens design, problem-solving techniques, and more are
covered (Supplement to the July 1995 issue of Review of
Optometry; it has been revised and should be available soon after
this book goes to press).
7. Resources on the Web
There are also numerous resources on the rgpli.org Web site,
which were discussed in Chapter 18. A monthly on-line sympo-
sium on a GP topic of interest is chaired by reputable clinicians
in the given topic area (e.g., orthokeratology, presbyopia, torics,
irregular cornea, problem solving). In addition, clinical modules
in such areas as spherical design and fitting and bifocal/multifo-
cal design and fitting have been developed.
RESOURCES FOR STUDENTS

The RGPLI annually presents a 1-day grand rounds seminar and
workshop at every school and college of optometry in North America.
Likewise, several of the major button and fabricating CLMA mem-
ber laboratories provide annual seminars and workshops to students.
The RGPLI also offers student membership and provides many of its
resources complimentary to students, and all resources are compli-
mentary to educational institutions. The International Association of
Contact Lens Educators (IACLE) has a comprehensive and dynamic
10-volume curriculum on contact lenses that is used to educate
students and practitioners all over the world. A significant amount of

this information pertains to GP lenses.
RESOURCES FOR PATIENTS

The following patient brochures have been developed by the CLMA
and RGPLI:
1. Patient Education Brochure

This eight-page brochure was developed to help educate patients
about the features and benefits of GP lenses, including important
information on myopia, presbyopia, astigmatism, and more. It
answers the most common questions and addresses well-known
perceptions about GP lenses with key facts.
2. GP Care & Handling
Tips on proper hygiene, lens insertion and removal, and caring
for GP lenses are provided.
3. GP Lens Care Tips Card
A wallet-sized reminder card for patients outlines GP lens care
and handling tips.
4. Web sites
As discussed in Chapter 18, there are several excellent consumer
educational Web sites with an emphasis on GP lenses, including
www.contactlenses.org and www.allaboutvision.com.
OTHER RESOURCES
Other educational resources, which are product specific, are available
from button manufacturers and CLMA member laboratories. In addi-
tion, there are some excellent resources from contact lens organiza-
tions, including the following:
●
Contact Lens Society of America (CLSA):
1. Contact Lens Manual
2. Advanced Contact Lens Manual
3. Photo Atlas C/D
●
Contact Lens Association of Ophthalmologists (CLAO)
1. CLAO Pocket Guide to Contact Lens Fitting
Index
A Alkylsiloxanylmethacrylate, copolymers
Ablation zone, 407 of, 34
Abrasion, epithelial, in hypoxia, 11 Allaboutvision.com, 489
Abrasive surfactant, 141 Allergy in keratoconus, 224-225
Acanthamoeba keratitis, 150 Anatomic measurement, 66-69,
Acidosis, stromal pH and, 18-19 67f-69f
Actual astigmatism, 287-290 in presbyopia, 329-330, 329f
Adaptation to lens, 150-152, 151b Anesthetic, topical
nonsteroidal antiinflammatory drugs for child, 421, 422b
in, 90-91 in diagnostic lens fitting, 87
Adenosine triphosphate, 10 in empirical lens fitting, 90-91
Adherence Annular translating lens, 344
in extended wear, 388-391 Anterior bevel, 166-167
in keratoconus, 251 Antibiotic-steroid therapy for
Against-the-rule astigmatism, 100, 288 vascularized limbal keratitis,
Age 200
progressive myopia and, 62 Antiinflammatory drug for lens
type of lens and, 53-54 adaptation, 90-91
Algorithm for videokeratoscopy, Aperture, palpebral
118, 119 in lens fitting, 96-97
Alignment fitting, 93 measurement of, 67-68, 69f
Page references followed by “f” indicate figures, by “t” indicate tables, and by “b”
indicate boxes.
499
500 INDEX
Aphakia, 357-378 Astigmatism (continued)

corneal sensitivity and, 362 front surface toric GP lens for,
fitting of lens in, 372-373 292-293, 295-299, 295f, 296f,
intraocular vs. contact lens in, 373-374 298f
lens design for, 365-372 periballast lens for, 299
lenticular, 367-368, 369f-370f, soft toric lens for, 292
371f-374f spherical GP lenses for, 290-291
single-cut, 366-367, 366f, 367t spherical soft lenses for, 291-292
lens materials for, 364-365, 365f Atopy in keratoconus, 224-225
optical changes in, 357-360, 359f, 360f Axial edge lift, 102f
patient selection and, 363-364
photophobia in, 362-363 B
tear film in, 362 Back surface toric lens, 302-305, 305f
wound healing in, 361-362 Bacterial immunologic reaction, 14
Apical bearing in keratoconus, 241-242, Bandage contact lens, 403
242f Base curve, 100, 101t
Apical clearance in keratoconus, in child with myopia, 419, 419t
242-243, 243f in irregular cornea, 133-134
Archive search, 488 in keratoconus, 247
Aspheric lens in orthokeratology, 446-447
after photorefractive keratectomy, 405 of post-radial keratotomy lens, 399
for high astigmatism, 300-302 of post–photorefractive keratectomy
in keratoconus, 257-259, 259t lens, 404
multifocal, 334-339 verification of, 177, 179-181, 179f, 180f
decentration and, 337-339, 338f BE lens, 432, 454-456, 455t
lens design and fitting of, 336-337 Bearing
material for, 336 in keratoconus, 241-242, 242f
patient selection for, 334-336, 335f, in orthokeratology, 448
342t Benzalkonium chloride, 139-140
Astigmatism, 61, 286-323 Benzyl alcohol, 139
after radial keratotomy, 401 Berkeley Orthokeratology Study, 426
calculation of, 70-71 Bevel, anterior, 166-167
high, 300-316 Bifocal lens, 324-354. See also Multifocal
back surface toric lens for, 302-305, lens
305f Binder orthokeratology study, 426
bitoric lens for, 305-316. See also Biomicroscopy
Bitoric lens evaluation with, 71-72, 71f
spherical and aspheric design for, in keratoconus, 233-235, 234f, 235f
300-302, 301f in orthokeratology screening, 444
orthokeratology study of, 426 Bitoric lens
residual, 286-299 case histories with, 321-323
after radial keratotomy, 401 for extended wear, 385
calculated and actual, 287-290 for high astigmatism, 305-316
INDEX 501
Bitoric lens (continued) Care system (continued)

diagnostic fitting of, 311-313 patient education about, 146-150, 148f,
ease of fitting of, 306 149f
empirical fitting of, 307-311, 307f-310f preservatives in, 139-140
materials and designs for, 313-316, reviewing compliance with, 196b
315f, 316t, 317b rewetting solutions in, 140
optical principles of, 306-307 wetting solution in, 138-139
in keratoconus, 263 Case, lens, 149
Blending of peripheral curve, 173-175, 175f Case history, 213-222
Blepharitis, 383 Cellulose acetate butyrate lens, 35-36
Blink rate, 68 Center of gravity, 104, 104f
Blinking Center thickness, 184
in aphakia, 363 for extended wear, 385
microbial keratitis and, 13 in lens fitting, 104-105
with multifocal translating lens, 345, Central bearing, 448
346f Central corneal clouding, 207-208
Blurred vision, 192-196, 196b Centration in orthokeratology, 447-448
flexure and, 192 Chat room, RGPI, 484-485
incorrect power causing, 193 Child
power change causing, 194 myopia in
reduced surface wettability and, 193, gas permeable lens for, 417-422
193f, 194-195, 195f, 196f rigid lens for, 412-417, 415t
warpage causing, 194 orthokeratology in, 440-441
Booklet, patient education, 154-155 Chromosomal disorder, keratoconus in,
Borderline dry eye, 63 226
Boundary layer effect, 31 Circular prism-ballasted front surface
Bowman’s layer in keratoconus, 224-225 toric lens, 292-293, 294t, 295-297,
Bulls-eye fluorescein pattern, 449f 295f, 296f
CLAK, 384
C Cleaning
Calculated residual astigmatism of extended-wear lens, 388
circular prism-ballasted lens and, 293 patient education about, 147-148
spherical GP lens and, 291 types of solutions for, 140-142
Calculation of astigmatism, 70-71 Clearance
Captive bubble method of wetting angle in keratoconus, 242-243, 243f
measurement, 38, 38f, 39f in orthokeratology, 448
Carbon dioxide, partial pressure of, 3t CLEK fitting set for keratoconus, 254t
Care system, 138-142 CLEK lens, 253-255
cleaner in, 140-142 CLMA Laboratories keraconus lens
combination solutions in, 140-141 design, 273t-285t
enzymatic, 141 Clouding, central corneal, 207-208
laboratory-approved, 141 Collaborative Longitudinal Evaluation of
surfactant for, 140 Keratoconus, 63, 225
502 INDEX
Color scale, 125-126, 126f Copolymer

in videokeratoscopy, 120b properties of, 34-36
Combination cleaning solution, 141-142 types of, 48-50
Comfort factor, 106f Cornea
in keratoconus, 250-251 in aphakia, 362
reduced, 199-201, 199f-201f biomicroscopic evaluation of, 72
Comparator, projection, 182-184, 183f, curvature of, 99
184f desiccation of, 196-198, 197f, 198f
Compliance, 155-156 extended-wear lens and, 387, 388-389,
Complications 392
of extended wear, 388-393 flattening of, in radial keratotomy and,
of orthokeratology, 467 397
Compression, limbal, 380-381 irregular, 63
Computerized corneal topography. See base curve selection and, 133-134
Videokeratoscopy, computerized computerized videokeratoscopy for,
Concentric translating lens, 344 132-135
Conditioning of lens, 149 LASIK and, 407
Cone-shaped sponge, 170 in photorefractive keratectomy, 402
Conjunctiva in aphakia, 363 physiological response of, 2-23
Conjunctivitis, papillary hypoxia and, 9-23. See also Hypoxia,
contact-len–induced, 71-72, 71f corneal
giant, 63 oxygen requirement and, 3-4, 4f, 5t,
Connective tissue disease, 226 6t, 7-9, 7f-9f
Consent for orthokeratology, 481-483 on progress evaluation, 191
Consumer Internet site, 489 reshaping of, 424-483. See also
Contact-lens assiciated keratopathy, 384 Orthokeratology
Contact lens fitter survey, 434b scarring of, in keratoconus, 234-235,
Contact Lens Manufacturers 235f
Association, 48 topography of, 69-70
educational resources of, 495-496 lens material and, 52-53
keratoconus lens design of, 273t-285t multifocal lens and, 330
Contact Lens Today, 488 orthokeratology and, 431-433
Contact-lens–induced papillary Corneal exhaustion syndrome, 20
conjunctivitis, 71-72, 71f Corneal warpage syndrome, 236-237
Contactlenses.org, 489 Correctech lens, 458
Contex OK lens, 457 Coulometric technique, 31
Continuing education Internet site, Cup, suction, 160, 172-173
489 Curvature
Contraindications axial, 121-122, 122f
to aphakic lens, 374-375 in lens fitting, 99
to extended-wear lens, 381 tangential, 121, 122f
to gas permeable lens, 64 Curvature map in videokeratoscopy,
Coon orthokeratology study, 426 120b
INDEX 503
Curve Design, lens (continued)

base, 100, 101t philosophy about, 94, 96
in child with myopia, 419, 419t tetracurve, 97f
in irregular cornea, 133-134 Desquamation in microbial keratitis, 13
in keratoconus, 247 Detachment, retinal, 412
of post-radial keratotomy lens, 399 Diagnostic fitting, 86-89, 89b
of post–photorefractive keratectomy in aphakia, 372-373
lens, 404 of bitoric lens, 311-313
verification of, 177, 179-181, 179f, in keratoconus, 246t
180f in orthokeratology, 446-447
front, verification of, 181 Diagnostic fitting set
peripheral, 96, 97f, 100, 102-103, 103b of circular prism-ballasted lens, 294t
blending and flattening of, 173-175, for keratoconus, 254t
175f-177f Diameter
of post-radial keratotomy lens, 400 extended wear and, 385, 389-390
of post–photorefractive keratectomy large, 99-100
lens, 404 in lens fitting, 87, 96
Cyst, inclusion, 398 optical zone
after radial keratotomy, 400
D in keratoconus, 247-248
Daily-wear lens, 152 in lens fitting, 87, 96
Data in videokeratoscopy of post–photorefractive keratectomy
acquisition of, 118 lens, 404
display of, 120-128, 122f-129f verification of, 185, 185f, 186f, 187
Decentered lens, fluorescein and, 93-94 of post-LASIK lens, 407
Decentering gas permeable lens, of post–photorefractive keratectomy
superior, 237-238 lens, 404
Decentration of post–radial keratotomy lens, 400
in keratoconus, 251 Difference map, 126-127
with multifocal lens Digital cleaning, 147-148
aspheric, 347-348 Disinfectant
translating, 345, 346f diagnostic lenses stored in, 87, 89
Deep stromal vascularization, 22-23 for extended-wear lens, 388
Degeneration, pellucid marginal, 238, patient education about, 149-150
238f, 239f Dislodgement of lens in keratoconus,
Dense paracentral pooling, 448 251
Dermatitis, keratoconus and, 225 Dispensing of lens
Descemet’s membrane, 225 to child, 419-422, 422b
Desiccation, corneal, 196-198, 197f, 198f orthokeratology, 460
Design, lens Display, data, in videokeratoscopy,
for extended wear, 385-386 120-128, 122f-129f
for orthokeratology, 429-431, 429f, Disposable contact lens, 403
430f Distance, vertex, 110-111
504 INDEX
Distance vision, 347 Edge (continued)

Distortion thickness of, 184
in aphakia, 359 verification of, 182-184, 182f, 183f
hypoxia and, 16-17 Edge effect, 31-32
keratoconus vs., 17, 17f-18f Edge lift for extended wear, 386
Dk measurement Edge polishing, 164-167, 165f, 166f
of Polycon lens, 34 Edge sponge tool, 165
significance of, 30-32 Education, patient, 142-156
Double lenticular design in aphakia, about lens options, 78-82, 81b, 82b
371-372 on adaptation, 150-152, 151b
Down’s syndrome, keratoconus in, 226 on compliance, 155-156
DreimLens, 457 cosmetics and, 152-153
Drug on extended wear, 386
antiinflammatory, for adaptation, on keratoconus, 239-240, 240t
90-91 on lens care, 146-150
for vascularized limbal keratitis, 200 on lens insertion, 143-144, 144f
Drum tool, 162, 173 for multifocal lens, 331-332, 332t
Dry eye preparatory procedures for, 142-143
borderline, 63 on recentration, 145-146
evaluation of tear film and, 72-75, on refitting of soft lens, 208
73f, 74f on removal of lens, 144-145, 145f, 146f
questionnaire about, 76b on swimming, 153-154
Dryness Educational resource, 490-497
corneal desiccation causing, 196-198, of RGPL Institute, 495-496
197f, 198f textbooks, 490-493
with extended-wear lens, 392 videotapes, 493-495
Duozone lens for keratoconus, 255-256 Ehlers-Danlos syndrome, keratoconus
Durability of lens, 60 in, 226
Electrode in Dk measurement, 31
E Elevation, corneal, 121
E-commerce, 486 Elevation map, 123-124, 123f
Edema Emerald lens, 458
overnight, 16f Empirical design in orthokeratology,
stromal, 14-23, 16f 447
distortion in, 16-17, 17f-18f Empirical fitting
endothelial response to, 17-20, 19f of bitoric lens, 307-311, 307f-310f
hyperemia and vascularization in, topical anesthetic in, 90-91
21-23 EMZ lens, 458-459
hypoesthesia and, 20-21, 21f Endothelium
striae and folds, 15-16 polymegethism of, 19-20, 19f
Edge stromal edema affecting, 17-20, 19f
comfort and, 199 Enzymatic cleaner, 142
in orthokeratology, 448 Enzyme solution, 149
shape and design of, 105 EOP, 32
INDEX 505
Epithelium Eyelid
abrasion of, 11 anatomy of, 53-54
in keratoconus, 224-225 in aphakia, 363
metabolism of, 10 extended wear and, 387
Equipment lid attachment fitting relationship
for lens modification, 160-162, and, 98f
161f Eyelid tension, 68-69
vendors of, 163b
for orthokeratology, 444b F
Equivalent oxygen percentage, 32 False fluorescein pattern, 93-94
Ethylenediamine tetraacetate, 139 Family history of keratoconus, 225
Evaluation, 64-76 Fargo lens, 457-458
anatomic measurements in, 66-69, Fees for orthokeratology, 472-473
67f-69f Ferritin, 225
in presbyopia, 329-330, 329f Film
of binocular vision status, 75-76 mucoprotein, 194-196, 195f
biomicroscopic, 71-72, 71f tear
case history in, 64-65, 65b-66b evaluation of, 72-75, 73f, 74f
of corneal topography, 69-70 wettability and, 36
of daily-wear lens, 152 Finger polishing, 166, 167f
determination of good candidate and, Fissure, large, 99f
77, 78f Fitting, lens
fluorescein in, 91-94, 92-94, 94f alignment, 93
for multifocal lens, 328-330, 329f base curve radius in, 100, 101t
for orthokeratology, 443-445, 444b center thickness in, 104-105
patient education in, 78-82, 81b, comfort factors in, 106f
82b computerized videokeratoscopy in,
of patient’s motivation, 76-77, 77b 117-135. See also Videokeratoscopy,
progress evaluation, 191 computerized
of refraction, 69 diagnostic, 86-89, 89b
of tear film, 72-75, 73f, 74f edge shape and design in, 105
Exhaustion syndrome, corneal, 20 fluorescein evaluation in, 91-94, 94f,
Extended-wear lens, 63-64, 380-393 95t
assessment for, 382-383 in keratoconus, 241-247
benefits of, 380-393 laboratory in, 112-113, 113b
complications of, 388-393, 389f, lenticular design in, 105, 107
390f, 392f overall and optical zone diameters in,
design of, 385-386 96-100, 97f-99f
follow-up care for, 386-388 parameter changes in, 107, 107t
hypoxia and, 59 peripheral curve radii and width in,
materials for, 383-385, 384t 100, 102-103, 103b
patient education for, 386 philosophy about, 94, 96
patient selection for, 381-382 power determination in, 108-111, 109f,
Eyelashes in aphakia, 363 111f, 112f
506 INDEX
Fitting of lens Fluorocarbon lens, 35

after refractive surgery Fold, stromal, 15-16
laser-assisted in situ keratomileusis, Foreign body, 199, 199f
405-408 Formula, Munnerlyn, 435-436
photorefractive keratectomy, 402-405 Four-curve lens, 429-431, 429f, 430f
radial keratotomy, 396-401 Front curve radius, verification of, 181
in aphakia, 372-373 Front surface toric lens, 292-293,
bitoric, for high astigmatism, 306, 295-299, 295f, 296f, 298f
307-311, 307f-310f
in child, 418-419 G
for extended wear, 385-386 Gas-to-gas technique, 31
multifocal, 333, 334b Geometry, reverse, 134
aspheric, 336-337 after LASIK, 407-408
in orthokeratology, 447-448 early lenses with, 427
Flat sponge tool Giant papillary conjunctivitis, 63
characteristics of, 162-163 Glare, in multifocal lens, 339
for edge polishing, 165-166 Gravity, center of, 104, 104f
for surface polishing, 169-170 Guide, Mandell-Moore bitoric lens,
Flattening 307-311, 308f, 309f
corneal Guidelines, lens handling, 147b
extended wear and, 391
radial keratotomy and, 397 H
of peripheral curve, 173-175, 175f Handling of lens
Fleischer’s ring, in keratoconus, 233 by child, 420
Flexible lens, 63-64 guidelines for, 147b
Flexlens piggyback lens, 261 Hardness, 42
Flexure, 40-42 Healing in aphakia, 361-362
blurred vision caused by, 192 Health, ocular, 59
extended wear and, 386 HEMA, 36
Fluorescein, 91-94, 94f Hematoma after radial keratotomy, 398
application of, 91-92 Hereditary disorder, keratoconus as, 225
bulls-eye pattern of, 449f High astigmatism
corneal curvature determined with, 122 back surface toric lens for, 302-305,
instruments for evaluation with, 92 305f
interpreting patterns of, 95t bitoric lens for, 305-316. See also
in tear break-up time evaluation, Bitoric lens
72-73, 73f spherical and aspheric lens for,
technique of evaluation with, 92-94 300-302, 301f
Fluorine, 33 High Dk lens material, 51, 52t
Fluoro-silicon/acrylate lens, 385 High plus power in aphakia, 358
Fluoro-silicone/acrylate Homeostasis, corneal, 409
characteristics of, 49-50 Hordeola, 383
properties of, 34-35 Horizontal visible iris diameter, 67, 68f
INDEX 507
Hydrogel lens In-office screening for orthokeratology,

after photorefractive keratectomy, 443
404-405 Inclusion cyst, 398
hypoxia and, 59 Incorrect power, 193
microbial keratitis and, 13 Induced residual astigmatism, 286-287
Hydrophilic soft lens, 401 Infection, microbial keratitis, 13
Hydrophobicity, 36 Inflammation, 14
Hyper-Dk lens material, 51-52, 52t, 59 Information, online, 240t, 484-489
Hyperemia, 21, 22 Informed consent for orthokeratology,
Hyperopia 481-483
extended-wear lens material Insertion of lens
and, 384 disinfection before, 150
fitting data for, 112f teaching patient about, 143-144, 144f
Hypertrophy, papillary, 71-72, 71f Interleukin in keratoconus, 225
Hypoesthesia, polymethylmethacrylate Intermediate vision with translating
lens and, 20 multifocal lens, 348
Hypoxia International Controlled Kerato-
corneal, 9-23 Reformation Society, 431-432
epithelial metabolism in, 10-14 Internet, 484-489
epithelial abrasion and, 11 consumer sites on, 489
immunologic reactions and, 14 e-commerce on, 486
microbial keratitis and, 11, 13-14 information search on, 486-489
microcysts and vacuoles and, 11 keratoconus site on, 240t
sterile ulcer and, 12f Opticom list on, 485
superficial punctate staining and, RGP Lens Institute on, 484-485
10-11 Intraocular lens, 373-374
stromal edema in, 14-23, 16f Intraocular pressure in keratoconus, 234
distortion in, 16-17, 17f-18f Inventory, lens, 87, 88t, 89b
endothelial response to, 17-20, 19f Iris, diameter of, 67, 68f
hyperemia and vascularization in, Irregular cornea, 63
21-23 base curve selection and, 133-134
hypoesthesia and, 20-21, 21f computerized videokeratoscopy for,
striae and folds, 15-16 132-135
extended wear and, 388 base curve selection and, 133-135
hydrogel lens and, 59 fitting using, 132-133, 133f, 134f
refitting of lens and, 207-208
J
I Jade lens, 458
Immune reaction Journal-by-journal Internet search, 488
in corneal infection, 14
keratoconus and, 225 K
Impact resistance, 42 KBA lens, 256-257
Implant, intraocular lens, 373-375 Keratectomy, photorefractive, 402-405
508 INDEX
Keratitis Keratoconus (continued)

Acanthamoeba, 150 ophthalmoscopy in, 228-229, 228f
ulcerative, 59 patient education about, 239-240, 240t
vascularized limbal, 200 penetrating keratoplasty for, 264
extended-wear lens and, 392-393 PMMA lens related to, 226-227
Keratoconjunctivitis, 225 progression of, 235-236
Keratoconus, 223-285 refractive changes in, 228
atopy and, 224-225 soft lens for, 263-264
biomicroscopy in, 233-235, 234f, 235f spectacles for, 240
classification of, 237b symptoms of, 227
computerized videokeratoscopy in, systemic condition causing, 226
132-133, 134 videokeratography in, 231-232, 231f
corneal distortion vs., 17, 17f-18f visual acuity in, 228
differential diagnosis of, 236-239, Keratoglobus, 239
239f Keratometry
family history of, 225 in aphakia, 364
gas permeable lens for, 241-259 in child with myopia, 419, 419t
apical bearing of, 241-242, 242f for extended wear, 387
apical clearance of, 242-243, 243f in keratoconus, 229-231, 229f, 230t
aspheric, 257-259, 259t Keratopathy, contact-lens associated, 384
benefits of, 241 Keratoplasty, penetrating, 132, 133f
bitoric, 263 Keratorefractive surgery, 134
CLEK design of, 253-255 Keratoscope, photoelectric, 431
CLEK fitting set for, 254t Keratoscopy. See Videokeratoscopy,
design of, 247-249, 248t computerized
diagnostic fitting set for, 246t Keratotomy, radial, 396-401
Duozone, 255-256 Kerns orthokeratology study, 425
fitting process for, 245, 247
KBA, 256-257 L
lens material of, 249 Laboratory-approved cleaner, 142
McGuire, 255 Laboratory in lens fitting, 112-113, 113b
Ni-Cone, 257 Laser-assisted in situ keratomileusis,
piggy-type, 259-262, 260f, 262f 405-409
problem solving in, 249-252, base curve selection and, 134
252f corneal elevation after, 124f
Rose K, 252-253 effects of lens fitting after, 408-409
scleral and semiscleral, 262-263 LASIK, 405-409
Soper cone, 255 Lens aberration in aphakia, 358-359
three-point touch fitting of, 243, Lens adaptation, 150-152, 151b
244f, 245 nonsteroidal antiinflammatory drugs
histopathology of, 223-224 in, 90-91
keratometry in, 229-231, 229f, 230t Lens awareness, 199
lens-induced change versus, 127-128 in refitting lens, 206
INDEX 509
Lens care, 138-142, 146-150. See also Care Marginal degeneration, pellucid, 238,
system 238f, 239f
Lens case, 149 Marketing of orthokeratology, 467,
Lens fitting, empirical, 89-91 471-472, 473t
Lens-induced corneal molding, 127 Mascara, 153
Lens inventory, 87, 88t, 89b Material, lens
Lens rotation with translating bifocal after radial keratotomy, 400-401
lens, 345 age and, 53, 55
Lens surface deposit, 380 in aphakia, 364-365, 365f
Lens-to-cornea evaluation, fluorescein, for bitoric lens, 313-316, 315f, 316t, 317b
94 comparing properties of, 43, 44t-46t,
Lens-to-cornea relationship in 46
keratoconus, 241-245, 242f-244f copolymers as, 34-36
Lenticular design, 105, 107 corneal topography and, 52-53
in aphakia, 367-368, 369f-370f, Dk measurement of, 30-32
371f-374f for extended wear, 383-385, 384t
Lid attachment fitting relationship, flexure of, 40-42
98f fluoro-silicone/acrylate, characteristics
Lid tension, 68-69 of, 49-50
Lid-to-cornea relationship, normal, 98f hardness of, 42
Lift, axial edge versus sagittal, 102f high Dk, 51
Light transmittance, 42 hyper-Dk, 51-52
Limbal compression, 380-381 impact resistance of, 42
Limbal hyperemia, hypoxia and, 22 in keratoconus, 249
Limbal keratitis, vascularized, 200 low Dk, 51
extended-wear lens and, 392-393 luminous transmittance of, 42
Limbus, in aphakia, 363 multifocal, aspheric, 336
Local anesthetic, in diagnostic lens occupation as consideration in, 53
fitting, 87 in orthokeratology, 448
Low Dk lens material, 51, 52t polymers as, 32-34
Loyalty, patient, 60-61 for post–photorefractive keratectomy
Luminous transmittance, 42 lens, 404
refits and, 53
M refractive error and, 52
Macrolens, 262-263 selection of, 48, 52t, 54f
Magnification in aphakia, 359, 359f silicone/acrylate, characteristics of,
Magnifier, projection, 183f, 183m 184, 48-49, 49f
184f specific gravity of, 43
Mandell-Moore bitoric lens guide, styrene, 50
307-311, 308f, 309f wettability of
Map, corneal topography, 231-232, 231f clinical observations of, 38-40, 40f
Map display, videokeratoscopy, 120b, wetting angles and, 36-38, 37f, 38f,
121-128, 122f-129f 39f
510 INDEX
McGuire lens, 255 Multifocal lens (continued)

Measurement annular, 344, 345f
Dk, 30-32 patient selection for, 339-341, 340f,
equivalent oxygen percentage, 32 342t
Membrane, Descemet’s, 225 problem with, 345-348, 345f-348f,
Menicon Z, 35, 383 349t
Metabolic acidosis, stromal pH and, segmented, 341-344, 343f
18-19 Munnerlyn formula, 435
Metabolism, epithelial, 10 Munson’s sign, in keratoconus, 235, 236f
Methylmethacrylate, 33-34 Myopia, 412-422
Microbial keratitis, 11, 13-14 benefits of gas permeable lens for,
Microcyst, 11 417
Mnemonic, PEDAL, 14 dispensing lens to child for, 419-420
Modification of lens, 159-175 fitting child for, 418-419
equipment for, 160-162, 161f fitting data for, 111f
vendors of, 163b orthokeratology and, 62-63, 433-434,
procedure for, 163-175, 178t 434b
edge polishing in, 164-167, 165f, in presbyopic patient, 75-76
166f previous studies of, 412-417, 415t
repowering and, 169-173 progressive, 62
surface polishing in, 167-169, 169f success with lens for, 420-421
Modified bifocal, 339 topical anesthetic and, 421-422
Monovision lens in presbyopia, 326-328
Motivation of patient, 76-77, 77b N
for extended-wear lenses, 382 Near vision with multifocal lens, 347
for orthokeratology, 439-440 Neovascularization after radial
of parent, 421 keratotomy, 398
Mountford squeeze film force concept, Newsgroup, Internet, 487
436f Newsletter, Internet, 488
Mucin layer, wettability and, 37 Ni-Cone lens, 257
Mucoprotein film, poor acquired, Nightmove lens, 459
194-196, 195f Nonabrasive surfactant, 141
Mucus strand, microbial keratitis and, 13 Nonsteroidal antiinflammatory drug,
Multifocal lens, 324-354 90-91
aspheric, 334-339, 335f, 338f Novalens, 35
case histories of, 350b-353b
evaluation for, 75-76 O
fitting of, 333, 334b Occupation, type of lens and, 53
good candidates for, 332t Ocular health, 59
patient education about, 331-332 Online information, 240t, 484-489
prefitting evaluation for, 328-330, 329f Ophthalmoscopy
resources for, 348-349 in aphakia, 364
translating, 339-348 in keratoconus, 228-229, 228f
INDEX 511
Optical zone diameter Orthokeratology (continued)

after radial keratotomy, 400 overview of, 424
in keratoconus, 243, 245, 247-248 patient selection for, 438-445, 439f,
in lens fitting, 87, 96-100, 97f-99f 440f, 442t
of post–photorefractive keratectomy child and, 440-441
lens, 404 current gas permeable lens wearer
verification of, 185, 185f, 186f, 187 as, 441-442
Opticom list, 485 evaluation of, 443-445
Orthokeratology, 62-63, 424-483 screening in, 442-443
complications of, 467 problem solving in, 464-467,
corneal topography applications of, 468t-470t
431-433 promotion of, 467, 471-472, 473t
dispensing of lens in, 460 resources for, 473
efficacy of, 436-438 retainer wear and, 464
equipment for, 444b OrthoTool 2000, 459
fees for, 472-473 Overall diameter in lens fitting, 87,
follow-up visits for, 461-464, 96-100, 97f-99f
461f-463f Overnight edema, 16f
history of, 424-428, 427b, 428f Overnight orthokeratology, 433. See
informed consent for, 481-483 Orthokeratology
initial lens selection for, 445-447 Overrefraction, spherocylindrical, 143
lens design for, 429-431, 429f, 430f, Oxygen
450t-452f equivalent oxygen percentage and, 32
BE, 454-456, 455t insufficient transmission of, 380
Contex OK, 457 lens materials and, 50-52, 52t
Correctech, 458 requirement for, 3-4, 4f, 5t, 6t, 7-9, 7f-9f
DreimLens, 457 transmissibility of, Dk measurement
Emerald and Jade, 458 denoting, 30-32
EMZ, 458-459 Oxygen partial pressure, 3t, 7
Fargo, 457-458 Oxygen permeability, 5t-6t, 7-8
listing of, 450t-452t extended wear and, 384, 386
Nightmove, 459 measurement errors of, 46t
OrthoTool 2000, 459
Paragon CRT lens, 449, 453-454, P
453f Package, lens modification, 162
R & R, 456-457 Pad, polishing, 170
reversible corneal therapy, 458 Palm test of edge quality, 182-183, 182f
WAVE software, 459 Palpebral aperture size
lens fitting in, 447-448 in lens fitting, 96-97
lens material for, 448 measurement of, 67-68, 69f
mechanism of, 435-436, 436f Papillary conjunctivitis, giant, 63
myopia reduction and, 433-434, 434b Papillary hypertrophy, classification of,
overnight, 433 71-72, 71f
512 INDEX
Paracentral erosion, 252 Periballast lens, 299

Paracentral pooling, 448 Peripheral curve
Paragon CRT lens, 449, 453-454, 453f blending and flattening of, 173-175,
Parameter change in lens fitting, 107, 175f-177f
107t in lens fitting, 96, 97f, 100-101, 103b
Parent of child with contact lens, 421, of post-radial keratotomy lens, 400
422b of post–photorefractive keratectomy
Partial pressure lens, 404
of carbon dioxide, 3t Peripheral touch in orthokeratology, 448
oxygen and carbon dioxide, 3t Permeability, oxygen, 5t-6t, 7-8
Patient education, 142-156. See also measurement errors of, 46t
Education, patient pH of stroma, 18-19
Patient evaluation, 64-76. See also Phenol red thread test, 74, 74f
Evaluation Philosophy about lens fitting, 94, 96
Patient loyalty, 60-61 Photodiagnosis of keratoconus, 228-229,
Patient selection, 58-64 228f
astigmatism and, 61 Photoelectric keratoscope, 431
borderline dry eye and, 63 Photophobia in phakia, 362-363
flexible and extended wear lenses and, Photorefractive keratectomy, 402-405
63-64 Physical property of lens, 44t-45t
irregular cornea and, 63 Physiological residual astigmatism, 286
ocular health and, 59 Piggyback lens
for orthokeratology, 438-445, 439f, hypoxia and, 8-9
440f, 442t in keratoconus, 259-262, 260f, 262f
child, 440-441 Pinguecula, 383
current gas permeable lens wearer, Placido system, 118, 119f
441-442 PMMA lens. See Polymethylmethacrylate
evaluation of, 443-445 lens
screening in, 442-443 Polarographic electrode, 31
orthokeratology and, 62-63 Polish, lens, 162
presbyopia and, 61-62 Polishing
profitability and, 60-61 edge, 164-167, 165f, 166f
progressive myopia and, 62 finger, 166, 167f
quality of vision and, 58-59 surface, 167-169, 169f, 170f
soft lens refits and, 63 Polishing pad, 170
stability and durability of lens and, 60 Polyaminopropyl biguanide, 139
PEDAL mnemonic, 14 Polycon, 34
Pellucid marginal degeneration, 238, Polymegethism, 208
238f, 239f endothelial, 19-20, 19f
Penetrating keratoplasty Polymer, 32-34
computerized videokeratoscopy after, Polymethylmethacrylate lens, 2
132, 133f corneal distortion and, 17
lens fitting after, 134 hypoesthesia and, 20
INDEX 513
Polymethylmethacrylate lens (continued) Problem with lens (continued)

keratoconus related to, 226-227 translating multifocal, 345-348,
for myopia, 413-414 345f-348f, 349t
othokeratology, 424-425 Profitability, 60-61
refitting of, 53, 63, 201, 206-209 Progress evaluation, 191
Polyquad, 139 for extended wear, 396-398
Polyvinyl alcohol, 138-139 Progressive myopia, 62
Pooling, paracentral, 448 gas permeable lens for, 417-422, 418f
Power rigid lens for, 412-417, 415t
of aspheric multifocal lens, 338-339 Projection magnifier, 183, 183f, 184, 184f
change in, 194 Prolate profile lens, spherical, 134
incorrect, 193 Promotion of orthokeratology, 467,
tear lens, 108-109 471-472, 473t
Precorneal tear film, 363-364 Pterygia, 383
Presbyopia, 61-62 Ptosis, extended-wear lens and, 391
bifocal correction for, 75-76 PubMed search engine, 488
monovision correction for, 326-328 Punctate staining, in hypoxia, 10-11
multifocal lens for, 324-354. See also Pupil
Multifocal lens in aphakia, 364
single-vision contact lens and reading diameter of, 66-67, 67f
glasses for, 326 in lens fitting, 97
type of lens and, 53
Preservative, types of, 139-140 Q
Prism-ballasted lens for residual Quality of vision, 58-59
astigmatism Quaternary ammonium compound,
front surface toric, 292-293, 294t, 139-140
295-297, 295f, 296f
truncated, 297-299, 298f R
Problem with lens R & R lens, 456-457
blurred vision as, 192-196, 193f, 195f, Radial keratotomy, lens fitting after,
196f 396-401
case histories of, 213-222 base curve for, 399
dryness as, 196-198, 197f, 198f lens diameter for, 400
in keratoconus, 249-252, 252f lens materials and thickness, 400-401
monovision in presbyopia, 327-328 optical zone diameter for, 400
multifocal, 337-339 peripheral curves and, 400
aspheric, 337-339 Radius
in orthokeratology, 464-467, 468t-470t base curve, 100, 101t
overview of, 202t-206t in keratoconus, 247
progress evaluation in, 190-192, 191b verification of, 177, 179-181, 179f,
reduced comfort as, 199-201, 180f
199f-201f front curve, 181
refitting for, 201, 206-209 peripheral curve, 96, 97f
514 INDEX
Radius tool, 161-162 Resource

for blending and flattening peripheral for multifocal lens, 348-349
curve, 173-175, 175f for orthokeratology, 473
Radiuscope, 177, 179-181, 179f Respiratory acidosis, 18
Reading glasses, single-vision contact Retainer wear, 464
lens with, 326 Retinal detachment in myopia, 412
Receptor, interleukin, in keratoconus, Reverse geometry lens, 134
225 after LASIK, 407-408
Reduced comfort, 199-201, 199f-201f design of, 429-431, 429f, 430f
Reduced vision with extended wear lens, early, 427
391 tear film and, 435
Refitting of soft lens, 201, 206-209 Reversible corneal therapy, 458. See also
general considerations in, 53 Orthokeratology
patient education about, 208 Rewetting solution, 140
polymegethism and, 208 RGLI.org, 488
process of, 209 RGPL Institute
reasons for, 63, 207-208 educational resources of, 495-497
Refraction Internet chat room of, 484-485
in aphakia, 364 Rigid lens
evaluation of, 69 hypoxia and, 2-8
in keratoconus, 228 microbial keratitis and, 13
in lens fitting, 97, 108-111, 109f, 111f, for myopia, previous studies of,
112f 413-415, 415t
in lens for child, 420 Ring, adherence, in extended wear, 390
multifocal lens and, 330 Ring placido system, 118, 119f
orthokeratology and, 435 Rinsing of lens, 148
Refractive error Risk factor, for microbial keratitis, 13
lens material and, 52 Rose K lens, 252-253
patient selection and, 58-59 Rotation with translating bifocal lens,
Refractive surgery, 396-409 345, 346f
laser-assisted in situ keratomileusis, Rounded sponge tool, 171-172
405-409
Munnerlyn’s formula for, 435-436 S
photorefractive keratectomy, Safety, of extended-wear lens, 380
402-405 Sagittal edge lift, 102f
radial keratotomy, 396-401 Scale, color, 125-126, 126f
Removal of lens, 144-145, 145f, 146f Scarring, corneal, in keratoconus,
Repowering, 169-173, 171fm 172f 234, 235 235f
Reshaping of cornea, 424-483. See also Sclera in aphakia, 363
Orthokeratology Scleral lens in keratoconus, 262-263
Residual astigmatism, 286-299. See also Screening
Astigmatism, residual for keratoconus, 232
Resistance, flexure, 41 in orthokeratology, 442-443
INDEX 515
Search engine, 486-488 Spherical lens (continued)

Segmented translating multifocal lens, prolate profile, 134
341-344, 343f soft, 291-292
Semiscleral lens in keratoconus, Spherocylindrical overrefraction, 143
262-263 Spinner, 161, 171-172
Sensor, coulometric, 31 Sponge tool, 160-161
Sessile drop method of wetting angle cone-shaped, 170
measurement, 37, 37f flat
Sign, Munson’s, 235, 236f characteristics of, 162-163
Silicon/acrylate lens, 385 for edge polishing, 165-166, 166f
Silicone, 32-33 for surface polishing, 169-170
Silicone/acrylate, 34, 48-49, 49f rounded, 171-172
Silicone elastomer lens, 35 Sports, large-diameter lens for, 99
Single-cut aphakic lens, 366-367, 366f, Squeeze film force concept, 436f
367t Stability of lens, 60
Single-vision contact lens, 326 Stability polymer, 33-34
Slit-lamp examination Staining
for extended-wear lens, 383 in keratoconus, 251-252
wettability and, 38-40 superficial punctate, 10-11
Slit scanning system, 119 Sterene-hydroxyethylmethacrylate,
Soft lens 36
after photorefractive keratectomy, Sterile ulcer, 12f
404-405 Striae
after radial keratotomy, 401 stromal edema and, 15-16
keratoconus related to, 226-227 Vogt’s, 233, 233f
refitting of, 63 Stroma in keratoconus, 225
for residual astigmatism, 291-292 Stromal edema, 14-23, 16f
toric, 292 distortion in, 16-17, 17f-18f
SoftPerm lens, 261-262 endothelial response to, 17-20, 19f
Software module, lens fitting, 130-132 hyperemia and vascularization in,
Solution 21-23
preservative, 139-140 hypoesthesia and, 20-21, 21f
rewetting, 140 striae and folds, 15-16
wetting, 138-139, 150 Stromal hematoma, 398
Solvent, as preservative, 139 Stromal vascularization, 22-23, 23f
Soper cone lens, 255 Styrene, 50
Specific gravity, 43 Suction cup
Spectacles, single-vision contact lens for blending and flattening peripheral
with, 326 curve, 173-175
Spherical lens characteristics of, 160
gas permeable for repowering, 172-173
for high astigmatism, 300-302, 301f Superficial punctate staining, 10-11
for residual astigmatism, 290-291 Superficial vascularization, 22
516 INDEX
Superior decentering gas permeable Thickness, lens (continued)

lens, 237-238 for post–photorefractive keratectomy
Superior position of translating bifocal lens, 404
lens, 345-346 Thimerosal, 140
Surface, lens Three-point touch fitting in keratoconus,
deposit on, 380 243, 244f, 245
polishing of, 167-169, 169f, 170f Tool
verification of, 182-184 bevel, 162
wettability of for blending and flattening peripheral
poor acquired, 194-196, 195f curve, 173-175, 175f
reduced, 193, 193f drum, 162, 173
Surfactant radius, 161-162
abrasive, 141 spinner, 161
nonabrasive, 141 sponge, 160-161, 165-166, 166f
Survey, contact lens fitter, 434b Topical anesthetic
Swelling, extended wear and, 387-388 for child, 421, 422b
Swimming, 153-154 in empirical lens fitting, 90-91
Swirl staining pattern, 251-252 Topography, corneal, 69-70
Symptom, adaptation, 151b in aphakia, 364
lens material and, 52-53
T multifocal lens and, 330
Tear break-up time, 72-73, 73f orthokeratology and, 431-433
Tear film Toric lens
in aphakia, 362, 363-364 after photorefractive keratectomy, 405
evaluation of, 72-75 circular prism-ballasted front surface,
extended wear and, 389 292-293, 294t, 295-297, 295f, 296f
extended-wear lenses and, 383 front surface, 292-293, 295-299, 295f,
microbial keratitis and, 13 296f, 298f
multifocal lens and, 330 Touch, peripheral, 448
reverse geometry lens and, 435 Traditional piggyback lens, 260-261,
wettability and, 36 260f
Tear lens power, 108-109, 109f Translating multifocal lens, 339-348
Tears, volume of, 73-74 annular, 344, 345f
Telephone screening for orthokeratology, patient selection for, 339-341, 340f,
442-443 342t
Tension, lid, 68-69 problem with, 345-348, 345f-348f
Terminology in videokeratoscopy, 120b segmented, 341-344, 343f
Tetracurve lens design, 97f Transmissibility
Textbook, 490-493 of carbon dioxide, 4
Thickness, lens of oxygen, 3
after radial keratotomy, 400-401 Transmittance, luninous, 42
center, 104-105 Truncated prism-ballasted lens,
edge or center, 184 297-299, 298f
INDEX 517
U Visioncarece.com, 489
Ulcer, sterile, 12f Visual acuity
Ulcerative keratitis, 59 extended wear and, 391
Usenet, 487-488 in keratoconus, 228, 251
with new lenses, 143
V with translating multifocal lens,
Vacuole, 11 347-348
Vascularization, 21-23, 23f Visual field in aphakia, 359, 360f
Vascularized limbal keratitis, 200 Vocation, extended-wear lenses,
extended-wear lens and, 392-393 381
Vendor, modification equipment, 163b Vogt’s striae, 233, 233f
Verification, 175-187 Volume, tear, 73-74
of base curve radius, 177
of diameters and peripheral curve W
widths, 185, 185f, 186f, 187 Warpage, 194
of edge quality, 182-184, 182f, 183f keratoconus vs., 236-237
of lens power, 181-182 WAVE software, 459
Vernal keratoconjunctivitis, 225 Wearing schedule, 152b
Vertex distance, 110-111 Website, 488-489
in aphakia, 358 Wettability, 35-40
Videokeratography clinical observation of, 38-40
in keratoconus, 231-232, 231f in extended wear, 391
in orthokeratology, 431-432 measurement of, 37-39, 37f-39f
Videokeratoscopy, computerized reduced, 193, 193f
data acquisition in, 118-119, 119f Wetting agent, 138-139
data displays in, 120-128, 122f-129f Wetting angle measurement
fitting irregular cornea using, 132-133, captive bubble method of measuring,
133f, 134f 38, 38f, 39f
base curve selection and, 133-135 sessile drop method of, 37, 37f
for lens fitting, 128-130, 130f Wilhelmy plate method of, 38,
software module in, 130-132 39f
Videotape, educational, 493-495 Wetting solution, insertion of lens
Visible iris diameter, 67, 68f with, 150
Vision Wilhelmy plate method of wetting angle
after photorefractive keratectomy, measurement, 38, 39f
403-404 With-the-rule astigmatism, 100
with extended wear lens, 391 orthokeratology and, 426
quality of, 58-59 Wound healing in aphakia, 361-362

Edward S. Bennett, OD, MSEd, And Milton M. Hom, OD (Eds.) - Manual of Gas Permeable Contact Lenses (2004)

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11830 Westline Industrial Drive

MANUAL OF GAS PERMEABLE CONTACT LENSES ISBN 0-7506-7335-4

Optometry is an ever-changing field. Standard safety precautions must be followed, but as

Previous edition copyrighted 1986

International Standard Book Number 0-7506-7335-4

Publisher: Linda Duncan

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

EDWARD S. BENNETT, OD, MSED ROBERT M. GROHE, OD

JOHN M. RINEHART, OD LORETTA B. SZCZOTKA-FLYNN, OD, MS

G as permeable (GP) lenses are an important and underutilized

assistance provided by Project Manager David Stein was invaluable in

S ome 50 years ago, Smelser et al1,2 demonstrated that oxygen is

Today, it is pleasing to see that the technological advances of rigid lens

patients have themselves chosen to wear their lenses overnight, then

HOW MUCH OXYGEN IS NEEDED

Table 1-1 Oxygen and Carbon Dioxide Partial Pressures

0.10 0.20 0.30 0.40 0.50

CO2 transmissibility is directly related to the O2 transmissibility for

Holden et al Fatt & Ruben Tranoudis & Benjamin Technology

Table 1-2 Oxygen Permeability (Dk) of Rigid Lens Materials*—cont’d

Oxygen Carbon dioxide

A different way to consider the required Dk/t for corneal health is

must be made considerably thicker than the more common intralim-

CORNEAL RESPONSES TO HYPOXIA

REDUCED EPITHELIAL METABOLISM

Superficial Punctate Staining

However, superficial punctate staining of only a mild degree in con-

Microcysts and Vacuoles

Figure 1-5. A and B, Sterile ulcer.

Bacterial Immunologic Reactions

stroma, secondary to a hypoxia-related increase in anaerobic metabo-

Stromal Striae and Folds

Striae and folds remain a beneficial diagnostic indicator of corneal

Figure 1-7. Corneal distortion (warpage) versus keratoconus. A and B, Distortion

decrease as much as 5% during wear of an O2-impermeable contact

can occur if there is a decrease in the pH of the stroma because of

wear does not significantly alter endothelial cell density,54 it appears

Corneal Exhaustion Syndrome

Overnight wear of rigid lenses of even hyper-Dk material could be

HYPEREMIA AND VASCULARIZATION

Deep Stromal Vascularization

rigid lenses are advocated for the management of vascularization sec-

T he original rigid lens material was polymethylmethacrylate

materials into the following five categories based on oxygen transmis-

Dk values have been lowered.9 Some of the companies have resorted

One property of silicone is hydrophobicity.5 This hydrophobicity

Methylmethacrylate and Stability Polymers

dimethacrylate. Addition of cross-linkers can make the polymer more

is polymerized, the hydroxyl groups are replaced with acetyl and

poorer quality of wetting. The different in vitro methods are sessile

Sessile Drop Method

Captive Bubble Method

Wilhelmy Plate Method

CLINICAL OBSERVATIONS OF WETTABILITY

Advancing contact angle Receding contact angle

flexes, a portion of corneal astigmatism is not masked and becomes

LUMINOUS (LIGHT) TRANSMITTANCE

Table 2-1 Physical Properties Comparison Chart