OPHTHALMIC PROCEDURES

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Behind the Lenses
Taylor Jones
Ocean Lakes High School

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Executive Summary

I completed my academy senior mentorship during the summer of 2014 at Dominion Eye
Care Chesapeake. During that time, I was under the guidance of Dr. Christopher Fusco, O.D.
and Mrs. Meredith Fusco; Dr. Fusco is the main working optometrist and the business owner of
Dominion Eye Care Chesapeake, and Mrs. Fusco is the co-owner of the business and the
manager of the secretarial staff. Dr. Fusco graduated from Indiana University School of
Optometry in 1985 and provided eye care at many locations prior to founding his own practice in
1992. In addition to working with Dr. and Mrs. Fusco, I worked with Dr. Tobin, an optometrist,
Marie Pearson, an optician, Robin, an office assistant, and other staff members at Dominion Eye
Care Chesapeake. Although my original intentions for the mentorship were to follow the
optometrist, I spent a lot of my time with the practices optician making glasses; however, I also
got to observe examinations by the optometrist and pretest patients.
Since my experience included both the guidance of an optometrist and the guidance an
optician, I was given the opportunity to explore multiple facets of the eye care profession. An
optometrist is a medical professional who examines patients for vision or eye problems ranging
from nearsightedness and farsightedness to glaucoma. They also prescribe contact lenses and
glasses to correct vision errors. If a patient needs further treatment, the optometrist will refer the
patient to an ophthalmologist, another medical professional who directly treats eye diseases or
performs surgery on the eye. In order to become an optometrist, one must acquire a bachelors
degree and subsequently spend four years in an accredited optometry school. This time usually
includes becoming licensed by the state in which one plans to practice and completing a Doctor
of Optometry (O.D.) program. This program is very competitive; one must earn high, passing

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scores on the Optometry Admission Test or OAT, which is conducted by the Association of
Schools and College of Optometry, to be admitted into optometry school. Additional studies in a
residency program may also be required if one wants to specialize in other areas such as ocular
disease or pediatric optometry.
Contrary to the role of an optometrist, an optician cannot prescribe or examine a patient
for vision errors. An optician makes the correctional lenses that an optometrist prescribes for his
or her patients. While opticians are only required to have graduated from high school or passed
the General Education Development (GED) class, they often have an associates or bachelors
degree in opticianry to allow for career advancement. State licensure and certification are also
required to become an optician, depending on the state in which one resides; 22 out of 28 states
require opticians to have a license (the state of Virginia requires licensure). The most common
test used is the American Board of Opticianry or ABO; it is a written examination that requires
minimal competency and has a low passing score.
The following case studies explore three aspects pertaining to the eye care profession.
They are focused around ophthalmic procedures, or procedures pertaining to the eye.
Ophthalmic procedures include the work of ophthalmologists, optometrist, and opticians. Most
of these procedures are surgical and therefore carried out by an ophthalmologist. However, the
case studies that follow focus on the nonsurgical procedures accomplished by optometrists and
opticians. More specifically, the case studies flow from pre-testing and examination to the
production of products that are used to eradicate or reduce the effects of vision errors,
particularly the production of correctional lenses and contact lenses.

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Auto-Refraction

The eye focuses on an image using the cornea and crystalline lens1. When creating a
sharp image, a normal eye utilizes the following parts of the eye with specific jobs: the cornea is
the clear, front portion of the eye that acts as a window through which light passes; it initiates the
process of refraction (the process of bending light to focus an image on the retina). The light
rays are then able to pass through the pupil, the opening at the center of the iris, because of the
refractive powers of the cornea which bend the light rays to allow free passage. Similar to how a
shutter works in a camera, the iris enlarges or shrinks the image depending on how much light
enters the eye. The light rays then pass through the crystalline lens, a clear, flexible structure that
condenses or elongates in thickness to appropriately focus the light rays. Passing through the
vitreous, the dense, transparent gel-like substance within the eye, is the next step in creating an
image. Finally, the retina captures all of the light rays and brings them to a sharp focusing point;
however, this sharp image formation only occurs in a normal eye2.
If the cornea has a minor scar or shape irregularity, then vision can become impaired,
therefore making ones ability to see clear images directly affected by the condition of the
cornea. Apart from the corneas importance to focus, the crystalline lens plays an important role
in focusing an image because it is the part of the eye that changes in thickness in order to
appropriately focus light rays before they come to a sharp point on the retina2. Although these
eye problems and abnormalities cause vision problems, the main cause of irregular vision is
refractive errors.
Refractive errors are vision problems that occur when the shape of the eye hinders proper
focusing. Amongst the most common errors are myopia, hyperopia, astigmatism, and

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presbyopia. Myopia (nearsightedness) is a refractive error in which one can see close up but is
not able to see far away. On the other hand, hyperopia (farsightedness) is the exact opposite; it is
a refractive error in which one can see far away but cannot see close up. Both of these errors
occur due to an abnormality in the length of the eye; myopia is caused by the lengthening of the
eye while the shortening of the eye causes hyperopia. Astigmatism is a refractive error in which
one cannot create clear images on the retina due to an irregularity in the curvature of the cornea;
specifically, the cornea is shaped more like a football than like a sphere. Presbyopia is a
refractive error in which vision is not clear due to the loss of elasticity of the crystalline lens of
the eye, which usually becomes significant after the age of 45. Some of the symptoms that can
result from these refractive errors include the following; blurred or double vision, haziness, glare
or halos around bright lights, squinting, headaches, and eyestrain1. Auto-refraction (automated
refraction), therefore, is a very useful tool in aiding patients with refractive errors by quickly
assessing their refractive abilities and aiding optometrists in producing the best prescription for
their patients which can reduce or eliminate the symptoms experienced by the patient.
During my mentorship with Dominion Eye Care Chesapeake, I used an auto-refractor
while performing patient pre-examinations. Patients would rest their chins on a bar on the autorefractor. I subsequently adjust the position of the machine using a joystick to align a thin, bright
beam of green light to the patients pupil. The patient would then focus one eye on an image of a
prairie scene that is initially blurred. Holding down a button on the top of the joystick, the
machine begins to change the sharpness of the image of the prairie, going from a sharp image to
an image of medium sharpness to a blurred image and then back to a sharp image, repeating this
variation in sharpness until the test is complete. Three beeps sound to signify that three
measurements have been successfully recorded. The joystick is then used again to focus the

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machine on the other eye to repeat the process. Finally, a printout is generated to display a
machine-calculated prescription for the patient. Because I only had a basic understanding of
why auto-refractors are used, this pre-examination process left me wondering exactly how the
auto-refraction tests the refractive ability of the eye and yields an appropriate prescription.
Automated refraction, often referred to as auto-refraction, was developed over 20 years
ago. Auto-refractors are machines that measure the refractive ability of the eye through the
process of auto-refraction. When auto-refraction was first introduced, and earlier on in its
utilization, it was very unpopular amongst many optometrists. These optometrists were
concerned with what type of effect auto-refraction would have on the eye care profession; they
didnt know how accurate auto-refraction was and whether it would benefit them to use it instead
of already established methods. However, the use of auto-refraction has increased in popularity
over the years because it is fast, unbiased, reasonably accurate, and repeatable3.
An auto-refractor is comprised of an infrared source, a fixation target, and a Badal
optometer within the measuring head. A beam of infrared light, which is green in appearance, is
connected to the front of a rectangular mask so that it will line up with the pupil of a patients eye
during examination; the mask is shaped like a pair scuba goggles without the nose and is utilized
to block any surrounding light. Before the beam of light passes through the mask, it passes
through a beam splitter, which, as its name implies, divides the beam of light. The beam splitter
divides the light to remove the light reflected from the cornea and provides a passageway for the
split image on the patients retina. The light then passes through the Badal lens, which is just a
lens used to gather the light, and finally passes through the mask and into the patients eye.
Three meridians of the eye are measured using this machine to obtain the eyes refractive power.
Measuring the eye is executed utilizing the sine-squared function, a common function used in

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Calculus. The result is a sphero-cylindrical prescription; the range (x-values) for the sinesquared function is 0o-180o, and the maximum y-value in the period (range) becomes the
spherical prescription. In an eye without astigmatism, the sine curve will resemble that of a plain
sine curve, whereas the sine curve will appear to be shifted to the right or left in an eye with
astigmatism. In other words, if the patient has astigmatism, the maximum y, value in the period
will not occur at 0o and thus a cylindrical prescription comes into play (the cylindrical
prescription is zero for an eye without astigmatism because the maximum y-value occurs at 0o).
The degree at which the maximum occurs becomes the axis of the prescription3.
To increase the accuracy of the prescriptions collected, the auto-refractor tries to relax
accommodation (capability of the eye to alter its focus from near to distant objects) and maintain
magnification. To relax accommodation prior to objective refraction, auto-refractors use the
fogging technique; the fogging technique transpires when the image of the prairie starts out
blurry and continues to change in focus during the pre-testing. Using the Badal lens system
keeps the magnification of the target constant regardless to the location of the Badal lens because
there is a linear relationship between the distance of the Badal lens to the eye and the ocular
refraction within the meridian of the eye being measuerd3. These two specific portions of the
machine aid in increasing the accuracy of the prescriptions derived during the use of the auto
refraction, however, the prescriptions collected by the machine are hardly ever 100 percent
accurate.
Even though the machine successfully produced a prescription for each patients eyes, my
mentor, Mrs. Fusco, informed me that these prescriptions arent always exact. In other words,
the prescription that the optometrist ends up prescribing to his patients hardly ever perfectly
matched the prescription recorded by the machine. Mrs. Fusco also explained that the machine

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is still used in practices because it gives the optometrists a reference frame to start from when
beginning their examination and when prescribing correctional lenses for the patient, despite the
errors that make the machine-calculated prescription deviate from the final prescription.
Many elements of the machine play a role in how the machine-calculated prescription
isnt necessarily the same as the prescription the optometrist prescribes to a patient. The autorefractor shines a small beam of light, the infrared light source (approximately 800-900nm), into
the eye. The deeper layers of the eye reflect the light back at this specific wavelength, resulting
in a systematic error of roughly -0.50DS (spherical dioptres: the power of the spherical lens) that
had to be added in order compensate for ocular refraction using visible light. Small fluctuations
in accommodation, even while using the fogging technique, occur and can change the
prescription by up to 0.50DS. While averaging multiple readings counteracts this change, it does
not eliminate the innacuracy3. These fluctuations result in discrepancies between the prescription
derived by auto-refraction and the actual prescription needed by the patient to correct his or her
refractive errors. These discrepancies, however, can be overlooked because the main purpose of
auto-refraction is to acquire a quick and reasonably accurate reference frame for the eye care
professional when entering their eye examination and deriving the prescription used to correct
the patients vision.
Although these discrepancies are negligible considering the purpose of an auto-refractor,
some eye care professionals still question the benefits of using an auto-refractor to test the
refractive abilities of the eye as compared to retinoscopy. Retinoscopy is a method of identifying
refractive errors by illuminating the retina and noting the direction of the light movement on the
retina. There is not necessarily an answer to which method is better for examining a patient, but

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there are distinct differences in the types of information about the eye that are received from
auto-refraction versus retinoscopy.
Auto-refraction yields less information about the eye than retinoscopy. In autorefraction, the only results yielded by the auto-refractor are the prescriptions for the patients
eyes and the K-readings for both eyes. From the K-reading, the shape of the eye is determined,
which is necessary for fitting contacts. K-readings also determine whether or not the patient is a
candidate for laser eye surgery or has karetonus4 (a disorder in which the cornea thins, resulting
in visual distortion5). While auto-refraction only has one basic method, which is simply using an
auto-refractor to examine the eye, retinoscopy has many different methods and can be utilized to
uncover a wide variety information about a patients eye. Some of these methods are the
following: book, bell, dynamic (patient focuses on distant letters/images), MEM (monocular
estimate method: near retinoscopy), and stress point. The book technique is based on a childs
level of interaction with what they view. For example, the optometrist could examine the
response a child has to texts that vary in comprehension difficulty and try to lessen a negative
response by changing the power of the lens in the retinoscope. On a separate note, the bell
technique focuses on the patients ability to follow a moving object with their eyes at various
distances. By using the bell technique, the delay of accommodation is measured. Thus, a more
accurate prescription can be prescribed to reduce the lag as different prescriptions are tested on
the patient until the lag becomes unnoticeable. The stress point technique is a method of
retinoscopy in which the patient focuses on a stationary target at various distances. The color of
the object often changes colors when it is stopped. Although all of the techniques are unique in
their procedures, they all test multiple lens powers on the patient while running specific tests
until the results resemble those of a patient with 20/20 vision. In other words, the optometrist

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will change the power of the lenses in the retinoscope during testing until perfect vision is
achieved6. While these methods are very accurate, they can also be very time consuming when
finding the correct prescription for a patient as compared to auto-refraction.
Because retinoscopy is more time consuming and auto-refraction is less accurate, most
eye care professionals use a combination of the two methods to determine the refractive ability
of a patients eyes. Auto-refraction is used in pre-examination. The prescriptions achieved from
this process, although they arent completely accurate, give optometrists a reference point for
retinoscopy in examination. This greatly reduces the time consumed during retinoscopy because
the optometrist will already have an idea of whether the patient is nearsighted or farsighted and
whether the patient might have an astigmatism3,6. Although auto-refraction is not reliable enough
to prescribe patients on its own, it proves to be a benefit to the eye care profession when
combined with retinoscopy.

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Works Cited

1. U.S. National Library of Medicine. Refractive Errors [Internet]. Bethesda (MD): U.S.
Department of Health and Human Services; [2014 Oct 14, cited 2014 Oct 14]. Available
from: http://www.nlm.nih.gov/medlineplus/refractiveerrors.html
2. Warren C. How Does The Human Eye Work? [Internet]. Los Angeles (CA): National
Keratoconus Foundation; [2014, cited 2014 Oct 14]. Available from:
http://www.nkcf.org/how-the-human-eye-works/
3. Dave T. 2004. Automated Refraction. Design and applications [Internet]. [2004 Jun 4, cited
2014 Oct 16] 28-32. Available from:
http://www.optometry.co.uk/uploads/articles/ae331f5e9f3c12ab8e23e345f22b45d4_dave200
40604.pdf
4. Furniss M. 2014. Auto Refraction & Auto Keratometry [Internet]. Waterloo(ONT): [2014,
cited 2014 Oct 17]. Available from: http://www.waterloo-optometrist.ca/index.php?
page=auto_refraction
5. Warren C. About Keratoconus Eye Disease [Internet]. Los Angeles (CA): National
Keratoconus Foundation; [2014, cited 2014 Oct 19]. Available from:
http://www.nkcf.org/about-keratoconus/
6. Harris P, Hohendorf R, Kitchener G, Koslowe K, Lewis R. Retinoscopy [Internet]. Santa Ana
(CA): Optometric Extension Program Foundation, Inc.; [cited 2014 Oct 19]. Available from:
http://www.oepf.org/VTAids/Retinoscopy.pdf

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Producing Lenses and Glasses

Originally, lenses were made of glass, hence the origination of the name glasses.
However, while glass provided a scratch resistant surface, this heavy material was prone to
breakage. Polycarbonate lenses are now more commonly used for correctional lenses. Plastic is
also used for correctional lenses but not as frequently used as polycarbonate lenses.
Polycarbonate (thermoplastic polymers containing carbon groups and composed of bosphenyl A
and phosgene) lenses are very impact-resistant, thin, and light-weight compared to the other
materials used for lenses. Polycarbonate is also used in other products such as CDs, DVDs,
laboratory safety goggles, greenhouse sheeting, and cell phones. An advantage to using
polycarbonate lenses as opposed to plastic lenses is that they block 100% of ultraviolet (UV)
rays without a special coating, whereas plastic and glass lenses require a special coating for UV
ray protection. On the other hand, one benefit of using plastic to make lenses is that plastic
easily accepts tints with uniform grade colors1; however, this benefit doesnt compete with the
many benefits of using polycarbonate, therefore making the use of polycarbonate more
prominent in correctional lenses.
Although I did not make any lenses from scratch during my experiences at Dominion Eye
Care Chesapeake, I worked with two of the three materials described above; polycarbonate
lenses and plastic lenses. The polycarbonate lenses were either regular poly (polycarbonate)
lenses or poly AR (polycarbonate lenses with an anti-reflective coating) lenses. Though I dealt
with some plastic lenses, most of the lenses were poly or poly AR lenses; I only used plastic
when making two pairs of practice glasses and one pair of glasses for a customer, whereas the
other multitude of glasses I made used poly or poly AR lenses. The benefit of using poly AR

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lenses as opposed to poly lenses, as informed by my mentor, is that the anti-reflective coating
provides a clearer image for night driving and reduces strain from looking at a computer screen
for a prolonged period of time. Although the practice orders lenses from a laboratory, I was
curious as to how the lenses were actually made.
In creating a lens with a specific prescription, a lens blank (a hockey puck shaped
cylinder of lens material with one beveled edge) is selected. The beveled edge will have the
desired base curve and will be in the patients desired contact lens material, which is usually
polycarbonate2,3,4. The front surface of the lens is specific to the type of lens being created; a
unique front surface is given to single-vision lenses, bifocals, trifocals, and progressive addition
lenses4.
Both spherical (lens with a single power and no axis) and cylindrical lenses (lens with
two powers and an axis to correct astigmatism) are single vision lenses, and therefore start with a
similar lens blank. If the prescription calls for a cylindrical lens, which will look like a pipe cut
lengthwise when completed, a line defining 180o is marked on the front of the lens. An
additional line is drawn to match the second curves axis (this axis will be specific to the
patients prescription). To keep the front of the lens protected, since the front will not be
modified, a special tape is used to cover it; the front of the lens does not change because it starts
with a specific curvature or power. This initial power is measure in diopters (D) and usually
starts as a large positive power ranging from +6.00D to +8.00D. Depending on the original
power of the lens, a specific sized minus curve is generated out of the backside of the lens blank
to create a different lens power. For example, if the starting lens power is +6.00D and the
desired power for the completed lens is +2.00D, then a minus curve (rounded concave cutout) of
4.00D is shaved on the back of the lens. The concavity subtracts from the initial lens power, so

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the final power of this lens would be +2.00D. If a -2.00D power is desired for the completed
lens, on the other hand, then a minus curve of 8.00D is ground on the back of the lens blank;
when 8.00D is subtracted from the original power of the lens, +6.00D, the final lens power is
-2.00D. The lens cutting machine therefore uses basic mathematics to determine the size of the
concave curve needed to yield the desired power of the completed lens. For a spherical lens,
which looks like half of a ball, the back of the lens is simply shaved down without a curve2. This
is accomplished by setting the lens blank into a lens lathe and using computer settings to shave
layers of material off of backside until the desired thickness is achieved. If the original power of
the lens blank is +4.00D, then the final power for a spherical lens can only be +4.00 since no
additional curves are applied to lens blank4.
Once the generated curve is applied to the backside, the backside of the lens is rather
rough. This roughness gives it a frosted appearance, so the lens is then put on a fining machine4
or special sanding machine (cylinder machine). Water is used to keep the lens cool during both
the process of shaving down the lens blank and sanding down the lens because the lens could
break or disfigure if it overheats2. This process of smoothing rids the lens of any visible
scratches and leaves it crystal clear. Once the lens is smoothed, the process of polishing the lens
is concluded2,4.
After the lens is polished, a tint can be added to the lens or any special coatings required
or desired are added to the lens. Lenses are usually treated with a scratch-resistant coating, and
an anti-reflective coating, which is growing in popularity, if specified by the patient3. The
scratch-resistant coating makes it more difficult for the lenses to get damaged by abrasions while
the anti-reflective coating reduces the effects of glare associated with night driving and the use of

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technology. Now, the lenses, still maintaining the diameter of a hockey puck, are ready to be fit
for glasses2,4.
During my experiences at Dominion Eye Care Chesapeake, I did not deal with the
machinery used to turn lens blanks into prescription lenses or the special coatings and tints
applied to the lenses. The lenses are constantly ordered in bulk (or on rare occasion individually
for patients with less common prescriptions) from an online laboratory, so the lenses in their
inventory had already gone through the above process and were ready to be cut for glasses. I
used four pieces of machinery to cut the lenses. With the first machine, a lensometer, I checked
the prescription on the lenses to ensure that it matched both the prescription written on its
packaging and the patients prescription; to determine the prescription of the lens, the power (in
diopters) is adjusted using a knob located on the side until three thick lines (running vertically)
and three sets of three skinny lines (running horizontally) are clear and crisp. For cylindrical
lenses, I would also adjust the axis to create clean lines, which was achieved by moving a knob
located at the back of the lensometer. I would then lower a lever on the machine that marked the
lens with three dots forming an 180o angle. Moving the lens into the adjacent machine, which
was also used to trace the frames of the glasses, to block the lenses; I aligned the dots (previously
marked on the lens by the lensometer) with a straight line on the machines screen and placed a
block with an adhesive material on one side of the lens with the assistance of the machine. Next,
I move the lens into a different machine to cut the lens into the shape of the frames, placing the
block into a compartment which it locks into. The machine constantly sprayed water on the lens
as it shaved the lens down to the shape of the frame. After the lens is cut and I ensure that it fits
in the frame, I manually shave down the sharp, inner edges of the lens to prevent any accidents
from occurring if the patient were to fall and the lenses were to pop out. I would also manually

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shave down the lens if it didnt fit in the lenses and the block was already removed (if the block
was still intact, I would put the lens back into the machine to be shaved down further); this
additional shaving was usually required when trying to fit lenses for thick plastic frames because
the thicker frames were less malleable, thus making the tighter fit of the lens less feasible.
Lastly, I insert the cut lens into the glasses frames, clean the lens off, and prepare the glasses for
the patient to pick up. Although I understood how to make glasses and the process of making
glasses, I wasnt aware of the terms for the machines and the procedures, and I wasnt fully
informed in how the machines worked.
The four machines used when cutting lenses to fit frames are the following; a lensometer,
a blocker machine, a computerized lens edger, and a manual lens edger. The lensometer is
used to locate the optical center (the point that should align with the center of the patients
pupil) and it marks it. The blocker machine is then used to trace the frames and block the lens
using an adhesive: blocking the lens is essential to the next step in the glasses production
procedure because it ensures that the lens will not move while it is being cut to the shape of the
frames during the grinding and polishing process. The lens is then placed into a computerized
lens edger, or generator, using the blocks to lock the lens in place. This machine uses three
diamond cutting wheels that vary in surface appearance (one rough surface, one medium surface,
and one fine surface) to shape the lens to the specific frames, during which water constantly
spays on the lenses to keep the lens cool and to reduce the amount of unnecessary shavings
around the lens. Applied to the lens during this process is a beveled edge to ensure a tight fit into
the frames; bevel application is achieved by a triangular indent in each diamond cutting wheel.
If the frames are rimless frames, this beveled edge is not applied to the lens, which is achieved
by utilizing the flat portion of the diamond cutting wheels. The next process, which is to perform

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any additional grinding that is required, is done by hand using a manual lens edger. The
completed glasses are then prepared for the customer, which concludes the process of producing
glasses.4,5.
Although most of the glasses I made at Dominion Eye Care Chesapeake were accurate, a
few mishaps occurred. Some of the mistakes were of human error, while other mistakes were
simply out of my control. For example, if I did not properly align the lens on the blocker
machine, insuring that the line of the traced frame fit onto the lens, then the glasses would not cut
once moved to the next machine because a piece would be missing from the lens. Another
mistake that I could have made is not properly aligning the three dots on the line displayed on the
blocker machine; this error would result in a manipulate PD (pupillary distance, or the distance
between the centers of the pupils) and possibly an incorrect axis, which is important to making a
clear image for patients that require cylindrical lenses. An even less common manual error could
be mixing patients prescriptions; however, this mistake is avoided by the use of trays to hold the
frames, lenses, and patient information. When using the computerized lens edger to shape poly
AR or specialty lenses, it was common for the machine to lose grip of the block on the lenses.
While this clockwise or counterclockwise shift did not affect the prescription for patients with
spherical lenses, which dont have a specified axis, it tampered with the cylindrical lens
prescriptions by changing the axis. The cylindrical lenses, therefore, would require remaking
because the patient would not be able to see correctly if the axis is off by more than five degrees.
Though human errors can play a role in improper lens production, most of the errors that
occurred when making correctional lenses during my mentorship were systematic errors caused
by the machines.

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While glasses have progressed technologically, the process of making glasses is not
perfect. The factories and laboratories that create lenses and glasses also run into problems that
can alter the prescription of the glasses. When surfacing the lens blocks before cutting from the
backside, the surface can be contaminated by applying the surface tape with bare hands, which
will prevent the proper adhesion from occurring; thus, the lens could shift while being cut,
resulting in a distorted curve or a curve that is too large or small for the desired prescription.
Secondly, the fining pads used to finish the lenses wear down over time. Since the machine has
set times for shaving the lenses, the fining time could be insufficient if the fining pads are worn;
this shortened fining time could result in a less smooth lens or even deep scratches that are
unable to be removed during polishing. In polishing lenses, an overused polish will deteriorate
and fail to be effective. Another common mistake that occurs during finishing lenses is the
inability of the finishing pads to properly adhere; since the pads dont stay in place, it could
result in a lens that was edged off of the prescribed axis6. Amongst these occurrences are the
many ways that systematic errors can affect the final prescription of the lenses. However, these
errors are sometimes negligible and are very unlikely to occur with proper machine maintenance.
Overall, technology has made the process of producing lenses more accurate and less
time consuming, allowing eye care professionals to help more patients.

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Works Cited

1. Eyekit. Lens Materials Explained [Internet]. York (UK); [cited 2014 Nov 3]. Available
from: http://www.eyekit.co/information/lenses/lens-materials-explained.html
2. Broten B. 2000 Aug 21. How Corrective Lenses Work [Internet]: HowStuffWorks.com;
[cited 2014 Nov 5]. Available from:
http://science.howstuffworks.com/innovation/everyday-innovations/lens.htm
3. Zeiss C. How Lenses Are Made [Internet]: ZEISS; [cited 2014 Nov 5]. Available from:
http://www.zeiss.com/vision-care/en_us/better-vision/better-vision-with-zeiss/howlenses-are-made.html
4. Shawnee Optical. 23 Jun 2011. How The Lenses of Eyeglasses Are Made [Internet];
[cited 2014 Nov 5]. Available from:
http://www.eyeweareyecare.com/ArticleHowLensesEyeGlassesAreMade.html
5. Ling G. Eyeglass Lens [Internet]. 1: How Products Are Made; [cited 2014 Nov 5].
Available from: http://www.madehow.com/Volume-1/Eyeglass-Lens.html
6. Julie B. Bright Ideas for Avoiding Consumable Mistakes [Internet]: Jobson Medical
Information; [cited 2014 Nov 6]. Available from:
http://www.labtalkonline.com/articles/34368

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Contact Lenses

The use of contact lenses has become a popular way to correct refractive errors, which
are vision problems caused by the shape and condition of the eye. Over 30 million people in the
United States use contact lenses. They are not only convenient for sports, work, and other
activities, but they are also typically safe and effective1; as compared to eyeglasses, contact
lenses regularly provide better visual acuity, or sharpness of vision, and better peripheral vision,
which also makes contact lenses more desirable for many patients2.
Eye care professionals may prescribe contact lenses for many of the following common
eye problems: myopia, hyperopia, astigmatism, anisometropia, aniseikonia, aphakia, and
keratoconus. Myopia, or nearsightedness, is the inability to see distant objects more clearly than
close objects, while hyperopia, or farsightedness, is the inability to see close objects as clearly as
distant objects. Astigmatism is the condition of having an abnormally curved cornea, which
causes blurry vision; patients that are nearsighted or farsighted can also have astigmatism.
However, anisometropia occurs when the eyes have unequal refractive power: one eye may be
myopic while the other is hyeropic or one eye may be significantly stronger than the other.
Aniseikonia is diagnosed when one sees unequal images: the image in one eye appears larger or
smaller that the image in the other eye. Lastly, Aphakia is the lack of the crystalline lens after a
cataract removal, and keratoconus is a condition in which one has a conical-shaped cornea1,2,3.
Presbyopia (blurry vision caused by loss of elasticity in the crystalline lens, usually due to age),
although it usually requires a time-consuming procedure to fit and precisely align the contact
lenses, can also be treated with the use of contact lenses2. In order to correct the conditions or

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lessen the symptoms of the previously mentioned refractive errors, great detail goes into the
composition and structure of contact lenses.
Contact lenses are regularly made of plastic and are uniquely fitted to every eye. In my
personal experiences during my mentorship at Dominion Eye Care Chesapeake, I tested for and
recorded the K-readings (keratometry readings) for each patient during the pre-exam using the
auto-refractor machine, although the readings can also be obtained manually. Manual
keratometry involves a keratometer instead of an auto-refractor and requires the turning of
several knobs until a plus sign on the screen of the machine becomes clear to the patient. Kreadings detect the curvature of the patients cornea, which is essential to have when choosing
the most appropriate contact lenses for them. The curvature of the cornea also determines the
power of the cornea and measures for astigmatism, by detecting any irregular curvature of the
patients cornea. Although I did not get to experience the manufacturing process of making
contacts lenses, I became extremely curious as to how they are made and how the prescription is
put onto the lenses.
Contacts fall under three categories: soft contacts, rigid gas permeable contacts, and
hybrid contacts. Depending on whether the contact lenses are soft, rigid, or hybrid lenses, the
manufacturing process differs. Soft contacts, also called scleral lenses, are composed of
hydrophilic plastic polymers; these polymers are called hydrogels. Hydrogels become soft and
malleable when they absorb water without compromising their optical qualities. Rigid gas
permeable lenses, also referred to as RGP or GP lenses, are composed of oxygen-permeable
plastic polymers that contain fluorine and silicone. These lenses contain only a minute amount
of water and stay stiff on the eye. GP lenses cost more than the soft lenses, which are massproduced, because they are custom-made; customization is necessary for a comfortable fit and

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for contact lens success because they maintain their shape and do not form to the eye like soft
lenses. Hybrid contact lenses are a combination of both soft and rigid lenses. The rigid gas
permeable plastic composes the central optic zone (center of the lens), and the soft contact lens
material surrounds the rigid area in a peripheral fitting zone. Although these three types of
contact lenses are made out of plastic materials, they are all made using slightly different
methods2,4,5.
Two methods can be used to make soft contact lenses: a lathe cutting process or an
injection molding process. In lathe cutting, buttons, which are non-hydrated plastic disks, of
soft contact lens material are shaped using computer-controlled precision cutting tools after
being individually mounted onto spinning shafts. The cutting tool shapes both the front and back
of the contact lens. The lens is then removed and softened by hydration. Finally, the lens goes
through quality assurance testing. During injection molding, the soft contact lens material is
heated until it is in a molten state. Then, under pressure, the lens is injected into computerdesigned molds. After quickly cooling the lens, it is removed from the molds. Following
removal, the edges of the lens are smoothly polished. Before going through quality assurance
testing, the lenses are softened through hydration; they are usually placed in a balanced PH saline
solution. The lath cutting process was originally more time-consuming and required more steps
than the injection molding process; however, the lathe cutting process now takes less time
because it is mainly automated. The injection molding process, on the other hand, is still used
for most disposable contact lenses because it is faster and less expensive. One usually chooses to
wear soft contact lenses because they are more comfortable and harder to displace during sports
and active lifestyles; however, soft contact lenses do not correct all vision problems, and soft lens
vision clarity is generally less than that of GP contact lenses2,4,5.

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Gas permeable (GP) contacts, similar to soft lenses, are made with a computerized
precision lathe cutting process. The non-hydrated disks or buttons of hard contact lens
material are individually cut and mounted to spinning shafts for shaping. Unlike the process for
soft contact lenses, the GP lens is not hydrated after this step. The prescribing doctor generally
receives a shipment of the lenses in a dehydrated state. After receiving the shipment, the lenses
are then soaked in a GP contact lens care solution by the doctors office prior to the distribution
of the lenses to the offices patients; the solution increases the contact lenses wearing comfort by
conditioning the lens surface. The wearer, therefore, must keep the lenses hydrated not to
maintain shape but to ensure maximum comfort. One generally chooses to wear GP contact
lenses because they provide excellent vision compared to soft contact lenses and last
significantly longer than soft contact lenses; a pair of GP lenses can be worn for 1-2 years before
being replaced. However, GP lenses can shift from the center of the eye more easily than soft
contact lenses, and they are generally uncomfortable to the wearer until they get adjusted.
Overall, soft contact lenses and GP lenses have their own strengths and weaknesses2,4,5.
Combining the benefits and minimizing the disadvantages of soft and rigid gas permeable
contact lenses, hybrid lenses are a great alternative. Hybrid lenses, which are composed of GP
lens material and soft contact lens material, also use a process similar to that of the lathe cutting
process for soft contact lenses. However, there is one major difference: the plastic disks have a
non-hydrated soft contact lens perimeter and a center of GP lens material. The bonding of the
two materials is carried out using proprietary technology, which is used to prevent the separation
of the two materials once the cutting and hydration of the lenses has concluded. Choosing to
wear hybrid contact lenses allows one to not have to compromise comfort for crisp vision and
vice versa. Despite the benefits, many are hesitant to use hybrid contact lenses, including

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optometrists, because of difficulties that arose when inventing the hybrid contact lens; there were
many cases in which the contacts would stick to the cornea and cause discomfort, irritation, and
infection due to low oxygen permeability (low allowance for oxygen to pass through lens).
Although these cases did arise in the past, there are many current cases in which patients
experience improved vision and little to no irritation2,4,5.
While contact lenses do not protect the eye from blunt or sharp injury like eyeglasses,
they do have many other benefits. Because contact lenses move with the eye, they offer vision
correction that could feel and look more natural. Contact lenses also provide corrective vision
while not altering the appearance of the patient. On the other hand, the patient can also change
their natural eye appearance with the addition of color into the contacts. For patients with active
lifestyles, well-fitted contact lenses stay in place on the eyes and improve peripheral vision.
Unlike eyeglasses, contact lenses do not fog up when outdoors, when in low temperature
environments, or when playing sports. Contact lenses also allow the patient to wear nonprescription UV-blocking sunglasses, whereas eyeglasses with UV-blocking must be purchased
in the patients prescription1,2.
Although contact lenses have many benefits, they also present some complications. Most
of these complications are caused by incorrect care of the lenses by the user. Contact lens use
can become painful under the following conditions: when lenses fit poorly, when lenses dont
have enough moisture to remain floating above the cornea, when lenses are worn in non-ideal
environments like smoky or oxygen poor places, when lenses are improperly inserted or
removed, when lenses have a trapped foreign particle (dust, soot, etc.) stuck in between it and the
cornea, and when lenses are worn for a long time. The eyes can develop a contact-lens related
corneal infection, keratitis, when the lenses are poorly cleaned, worn overnight or for an

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extended period of time, cleaned with tap water, or worn on eyes with a compromised ocular
surface (example: a dry surface or poor corneal sensation). Besides keratitis, many other eye
infections can form from improper contact lens use.
A corneal ulcer is a potentially vision-threatening infection of the cornea that is
commonly found amongst contact lens users who dont properly take care of their lenses. This
infection is suspected when intense eye pain is experienced by the contact lens wearer and when
the wearer has redness in his or her eyes. Bacteria, viruses, fungi, and amebas can all cause
corneal ulcers, and the risk of getting an ulcer increases by a multiple of 15 when contact lenses
are worn overnight. If an ulcer is detected, contact lens use is stopped, and antibiotic drops are
diagnosed, but the treatment method for ulcers differs. If the patient responds poorly or doesnt
respond at all to any of the treatment, severe vision loss may be a result of the ulcer1,2,5. Vision
loss is the most severe effect of improper contact care, therefore, proper contact lens care is
essential to maintaining a healthy eye.
Due to the many infections and discomforts that can come from wearing contacts, great
care must go in to wearing, handling, and cleaning contact lenses. Simple tasks such as proper
hand washing with soap and water and drying them well before handling contact lenses can
decrease the chances of infection and discomfort. Other methods to decrease ones chances of
irritation are the following: taking off contact lenses before sleeping, keeping water away from
contact lenses, rubbing and rinsing lenses with contact lens disinfecting solution (never water),
cleaning contact lens cases with contact lens solution (never water), replacing contact lens cases
at least every three months, avoiding topping off solution by using fresh contact lens disinfecting
solution, and never mixing new solutions with old solutions. Taking into account these simple

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precautions and implementing them, will allow contact lens wearers to enjoy the benefits of
contact lens use and avoid experiencing any complications1,2,5.

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Works Cited

1. Centers for Disease Control and Prevention. Healthy Contact Lens Wear and Care [Internet].
Atlanta (GA): Centers for Disease Control and Prevention; [2014 Nov 3, cited 2014 Dec 4].
Available from: http://www.cdc.gov/contactlenses/\
2. Dhaliwal D, Hassanlou M. Contact Lenses [Internet]. Whitehouse Station (NJ): Merck Sharp
& Dohme Corp.; [2013 Sep, cited 2014 Dec 4]. Available from:
http://www.merckmanuals.com/professional/eye_disorders/refractive_error/contact_lenses.ht
ml
3. MedicineNet, Inc. [Internet]: MedicineNet, Inc.; [2013 Aug 28, cited 2014 Dec 4]. Available
from: http://www.medicinenet.com/
4. Heiting G. How Contacts are Made [Internet]. San Diego (CA): All About Vision; [2014 Feb,
cited 2014 Dec 4]. Available from: http://www.allaboutvision.com/contacts/faq/how-clsmade.htm
5. Weinstock F. Contact Lenses [Internet]: eMedicineHealth; [2008 Apr 8, cited 2014 Dec 4].
Available from: http://www.emedicinehealth.com/contact_lenses/article_em.htm

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Reflection

During my senior academy mentorship, I thoroughly enjoyed having the opportunity to

explore the eye care profession. I was constantly learning new information pertaining to the
eyes. Prior to starting my mentorship, I knew very little about the eye and how it works, and I
hardly knew anything about optometry and opticianry. Now, I can confidently say that I know
more about the anatomy of the eye and can answer basic questions about how a normal eye
forms a clear image on the retina as opposed to an eye with refractive errors. I also gained an
understanding of technical terms for different refractive errors like myopia and hyperopia.
Although I quickly learned a lot from this experience, everything didnt come easy. Learning
how to make glasses was fairly uncomplicated, but I initially struggled with neutralizing lenses.
I couldnt find the correct axis for cylindrical lenses, but I eventually improved with practice.
Overall the experience was thoroughly enjoyable and eye opening, but there were some
minor considerations. I didnt get to work a lot with the optometrist, which were my original
intentions of the mentorship; however, I got to spend a lot of my time with the practices optician
and make glasses which was a really cool, hands-on experience. The only other downside was
waking up early to head to the mentorship, but this is easily overlooked because waking up early
to go to work in the summer is just a part of life after high school.
Although Im not considering optometry as a future profession, this experience helped
me narrow down my choices. I enjoyed working with the optician and optometrists, but I
realized that certain eye diseases are unsettling. However, this experience definitely solidifies
my desire to work in the medical field in the future.