Abstracts of The Congreo

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Contact Lens and Anterior Eye (2000) 23, 142-176
@ 2000 British ContactLensAssociation www.nature.com/clae
Abstracts of the 24th BCLAAnnual Clinical Conference Birmingham 2000

WHICH REFRACTIVE PROCEDURES WILL SURVIVE IN THE NEW MILLENNIUM? M McDonald The new millennium has begun, and there is no doubt that excimer laser surgery will continue to dominate our field for several years to come. It will have to share the stage, however, with several other modalities. Intracorneal ring segments (Intacs) for the treatment of low degrees of myopia has obtained approval in the United States. The clinical trials data are impressive, with 73% greater than or equal to 20/20, 81% greater than or equal 20/25, and 97% greater to or equal to 20/ 40 uncorrected at 24 months postoop in US Phase II (n=62). The reversibility and rapid return of excellent best corrected and uncorrected vision are big advantages. A small but definite piece of the refractive surgery pie will be served by Intacs, appealing to those patients who treasure reversibility above all. Gel injection adjustable keratoplasty, under development by Drs Gabriel Simon and Jean Marie Pard, is based on the same principle as the intracorneal ring segments. Several challenges must be addressed: the surgeon does not exactly know how much gel is inserted (there is always some loss during insertion), and intra-operative videokeratography and/or refractometry are necessary as ways to monitor the corneal curvature and/or refraction at the time of surgery. More work is needed to address these two issues. Advanced Corneal Systems of Irvine California is revisiting the concept of orthokeratology but with one important difference: the cornea is first 'destabilized' by injections of hyaluron-idase. The corneal shape is altered with a series of ever-flatter contact lenses, and the cornea is then cured with another medication when the ideal refraction is obtained. US clinical trials are set to begin this year. Holmium thermokeratoplasty will have a limited but important r61e in the new millenium, for correction of lower degrees of hyperopia and for the correction of overcorrected myopic PRK (and possibly LASIK) patients. An intriguing new method of applying thermal energy to the cornea is with radio frequency energy. The Refractec unit is being used in Mexicali, Mexico by the Drs Antonio Mendez and Antonio Mendez Noble, and in a multi-centre U.S. clinical trial as well with encouraging clinical results for the treatment of hyperopia. The Artisan (OPHTEC), NuVita (Chiron Vision), and STAAR phakic intraocular lenses will have an important r61e in the correction of high refractive errors in the new millennium, as long as pupil ovalization, cataract formation, and secondary glaucoma can be kept to a minimum during clinical trials. An emerging field in refractive surgery is the correction of presbyopia by manipulation of the ciliary body/zonular/lenticular relationship. Both of the current approaches (anterior ciliary sclerotomy as championed by Dr Spence Thornton, and scleral expansion bands as popularised by Drs. Ronald Schacher and Sheldon Hertzig) are based on the principle of putting the zonules on stretch once again, to compensate for the increased size of the mature lens. Investigations into both procedures are at such an early stage that it is difficult to accurately predict what r61es they will play in refractive surgery in the new millennium.
Address for Correspondence Refractive Surgery Center, EENT Institute, 2626 Napolean Avenue, New Orleans, LA 70115, USA
CONTACT LENS APPLICATIONS FOLLOWING REFRACTIVE SURGERY DISASTERS BA Weissman The majority of patients undergoing refractive surgery appear to be subjectively pleased with results; although this figure may be somewhat overly optimistic, refractive surgeons typically report the prevalence of 'poor visual results' at the 1% level. Refractive surgery procedures include both those which modify corneal curvature (e.g. ILK, AK, HexK, ALl(, LASIK, Intacs etc.) and those which modify intraocular optics (e.g. dear lens extraction, phakic IOLs etc.). When considering only those procedures which modify the corneal surface, poor optical results usually occur secondary to irregular corneal astigmatism or spherical aberration.
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Similar irregular corneal surfaces occur secondary to keratoconus, trauma, infection (e.g. HSK) and other surgeries (e.g. penetrating keratoplasty). Contact lens (CL) care is similar for all irregular corneal surfaces, regardless of aetiology. Rigid gas permeable contact lenses are the mainstay of treatment for all the various problems which cause irregular corneal astigmatism, including refractive surgeries. Occasionally standard design spherical RGPs, with standard diameters and peripheral curve systems, may be effective. More commonly, however, the clinician can increase effectivity by appropriate use of unusually steep or flat peripheral systems and relatively large diameter CLs, because of the distortion of normal corneal surface topography. Use of reverse geometry peripheral curves, and the various bitoric lens designs, are also occasion-
ally helpful in establishing mechanically and optically effective rigid CLs. Both standard and toric hydrogel CLs, or less usual hybrid designs (e.g. piggyback or SoftPerm etc.) rarely may prove helpful. Refractive surgery patients, in particular, elect these procedures primarily to eliminate need for spectacles and CLs. Such patients are usually unhappy if they find that CLs, and particularly RGP CLs, are not only advisable but necessary for optimum vision post surgery. Thus the clinician must also be prepared to deal with the patient's psychological disappointment. The procedures, and CL options, and the complications will be reviewed.
Address for Correspondence 2567 Amherst Avenue, Los Angeles, CA90064, USA
REFRACTIVE SURGERY FROM AN OPTOMETRIC PERSPECTIVE
J Craig
For some, refractive surgery has become a viable alternative to spectacle or contact lens correction of ametropia. Reasons for seeking treatment vary, but often include intolerance to a current mode of refractive correction and the desire for better unaided vision. The r61e of the optometrist within the refractive surgery setting can be an interesting and varied one. Pre-operative patient assessment; psychological as well as ophthalmic, is essential for the recruitment of suitable individuals. A questionnaire has been designed specifically for establishing patients' motives for undergoing excimer laser treatment, in order that appropriate counselling can be given and realistic expectations set. Intra-operatively, involvement can range from preparing the refractive parameters necessary for programming the laser to assisting the surgeon during the procedure itself. In addition the excimer laser can be used both to correct refractive error and, therapeutically, to treat a multitude of pathological conditions, thus the procedure varies from case to case. A selection of the procedures performed in recent years at the Corneal Diseases and Excimer Laser Research Unit in Dundee will be described. In terms of the ideal post-operative care, patients require, not only refraction, but also corneal topographic evaluation, measurement of contrast sensitMty, and an assessment of functional, psychological, and satisfaction outcomes. Over 300 patients have been treated at the centre in Dundee, for myopia, hypermetropia, astigmatism or corneal pathology, many with funding from the National Health Service. Aspects of management and outcome will be discussed on the basis of personal research and published results, in conjunction with the potential for research in this ever-evolving field. Newer imaging techniques such as in-vivo confocal microscopy and slit-scanning elevation topography allow the effects of refractive surgery on the cornea to be observed in considerably more detail than previously possible. The results of these and other investigations which may dictate the future direction of refractive surgery developments in the continued search for the ultimate management of ametropia will be discussed in the presentation.
Address for Correspondence Discipline of Ophthalmology, University of Auckland, Private bag 92019, Auckland 1001, New Zealand
VIDEOKERATOSCOPY IN CONTACT LENS PRACTICE
L Carney
The availability of videokeratoscopes has provided contact lens practitioners with extensive and detailed information about corneal topography. But how effective has this information been in advancing outcomes in patient care and changing contact lens practice? In answering this question, several underlying features need to be considered. Firstly, how valid are these corneal topography measurements? Using a range of test surfaces, we can establish that there is no simple answer to this question, since outcomes for different instruments depend on the specific test conditions and the analysis procedures used. Secondly, what is the most effective model for describing corneal topography in a way which is useful in contact lens practice and which informs contact lens design? Thirdly, how valuable are the contact lens f i ~ g
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programs incorporated with videokeratoscopes? These need to be evaluated not only in terms of the fitting strategy which is employed but also against the background of the established accuracy of corneal topography measurements and other known influences on contact lens fittings. Fourthly, what can corneal topography measurements tell us about visual function? Recently established inter-relationships between corneal topography, retinal image quality and visual function give us insights into management strategies for corneal abnormalities,
whether pathological or surgically induced. And finally, can we use corneal topography measurements to improve visual performance through optimised contact lens design? Each of these questions will be considered based on current practice and likely future developments.
Address for Correspondence Queensland School of Optometry, Victoria Park Road, Kelvin Grove, Queensland 4039, Australia
CONTEMPORARY ORTHOKERATOLOGY P Caroline The technique of orthokeratology can be defined as the reduction or modification of refractive errors through the application of modern, reverse geometry, rigid contact lenses. Today, orthokeratology is accomplished through a single or series of lenses, which flatten the central radius of the cornea thereby reducing myopia and improving unaided visual acuity. The modern renaissance of orthokeratology has been dramatically influenced by the introduction of: 1. New 'reverse geometry' lens designs which produce rapid and dramatic alterations in corneal curvature. 2. Advances in new high Dk, RGP lens materials for enhanced physiologic response. 3. Advances in corneal mapping techniques to aid in more accurate first fit lens selection and improved post-fitting patient management. 4. New concepts related to the physiology of tissue displacement providing a clearer understanding as to how orthokeratology works. These evolutionary advances have dramatically changed the modern practitioners' view of orthokeratology. Today, the procedure has moved from a speciality practised by only a handful of practitioners, to a technique that can be successfully incorporated into almost any practice.
Address for Correspondence 13606 Blazer Trail, Lake Oswego, Oregon 97035-1358, USA
CONT.42IINATION OF HYDROGEL CONTACT LENS DISINFECTION SYSTEMS C Lakkis A number of infectious and inflammatory complications potentially pathogenic bacteria gain access to the eye of microbial origin have been linked to the wear of is vital if we are to promote safe and successful contact contact lenses. Ulcerative keratitis is the most serious of lens wear. This presentation will provide an overview of contact these, with the condition sometimes causing scarring of the cornea and resulting in permanent vision loss. lens related complications of microbial origin and Inflammatory reactions occur more commonly than discuss the incidence and contributing factors to infectious complications but whilst they do not generally microbial contamination of hydrogel contact lens disinresult in vision loss, temporary or pemmnent cessation fection systems. The types and levels of contamination that are observed with various disinfection systems will of lens wear may be a consequence. A wide range of micro-organisms has been impli- be considered and both clinical and bacterial factors cated as causative agents in infectious and inflamma- contributing to contamination will be discussed. In tory contact lens related complications. Whilst the addition, the adequacy of current ISO/FDA testing pathogenesis of these complications remains unclear, procedures for regulatory approval of disinfection particularly for inflalmnatory reactions, bacterial con- systems will be examined and suggestions for reducing tamination of the eye appears to play a significant r6le. contamination will be provided. Lens handling, and contamination of the lens, lens case and lens care solutions have been implicated in Address for Correspondence increasing the ocular inoculum of micro-organisms University of California, Berkeley School of Optometry, during lens wear. A thorough understanding of how #688 Minor Hall, Berkeley CA 94700-2020, USA
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THE FUTURE OF CORNEAL TOPOGRAPHY IN THE CONTACT LENS PRACTICE P Caroline
Current corneal topography assessment techniques are 3. The refractive corneal surgery practice undergoing considerable evolution in both hardware 4. The modern contact lens practice and in the software algorithms used to calculate and Special emphasis will be directed towards uses for display corneal curvature. It is therefore prudent that topography assessment in the contemporary contact eye care professionals stay abreast of these dynamic lens practice. New techniques will be presented on changes, especially in light of the many new contact lens sagittal height analysis through videokeratography and designs and refractive surgery options being presented the r61e of sagitta in the fitting RGP and soft contact to our patients. lenses. Throughout this lecture we will focus on the future of corneal topography assessment as it relates to: Address for Correspondence 1. The normal cornea 13606 Blazer Trail, Lake Oswego, Oregon 97035-1358, 2. The pathologic cornea USA
RGP LENSES AND THEIR ROLE IN SLOVCING MYOPIC PROGRESSION A Canella
Myopia is said to be the most common ocular disorder Research Institute. The common thread of these study affecting mankind. While the epidemiology varies by results shows that despite study shortcomings, use of country and culture, one fact remains, myopia is rigid contact lenses appears to play a key r61e in the increasing world-wide. This presentation is a review prevention of myopic progression. Key to this preof myopic progression citing past studies such as sentation is the significance and impact of the various Sperduto et al., The Framingham Offspring Study, findings as they relate to the use of rigid contact lenses Yupik Eskimo Study, Singapore Army recruits by Tay to mitigate and to halt myopic progression in children. et al., Israeli Study, Melbourne Visual Impairment More critical is how eye care practitioners and contact Project. Previous landmark myopia studies utilising lens fitters will process this information and begin to rigid contact lenses such as Morrison 1956, Stone formulate communication strategies to educate parents 1976, and Grosvenor 1991 will be comprehensively and prospective patients on the course of myopia and reviewed with regard to their findings as well as their the rationale behind the use of RGP lenses to slow or significance in identifying trends. Current studies such stop its progression. as CY Khoo et al., 1997, the Contact Lens And Myopia Progression (CLAMP) Study being done at Ohio State Address for Correspondence University, and the Singapore Myopic Treatment Study Polymer Technology Corporation, 100 Research Drive, (CL-MTS) being conducted at the Singapore Eye Wilmington MA 01887, USA
A NOVEL ASPHERIC SURFACE FOR CONTACT LENSES W Sammons
Aspheric surface designs in contact lenses have, usually, two main objectives. Placed on the back surface, they provide opportunities to create favourable relationships with the corneal shape and, on the front, they produce variation in power needed, for example, in multifocal presbyopic correction. Whichever modality is intended, aspheric surfaces are usually quite simple mathematical functions with smooth, continuous derivatives, yielding the required smooth curvature profiles. The conic section, for example, provides a whole family of aspheric surfaces classified by the distinguishing parameter of eccentricity. However, these and some other mathematical surface representations lack the ingredients to produce really effective curvature variation, especially for
presbyopic correction, and the subject of this paper is the evolution of a whole new class of functions which do possess this ability. They differ radically from those normally used in a critical way. These are functions which describe the co-ordinate surface shape smoothly and continuously, but their derivatives give rise to singularities, near which rapid changes of slope and curvature arise. Choosing the location of the singularities therefore results in a very powerful technique for designing almost limitless curvature variations, which produce sensitive power changes across the lens. Surface designs based on this mathematical formulation have been successfully applied in contact lens manufacture to give lenses with unique multifocal properties. Function parameters
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allow the designer a choice of surface either for presybyopic correction, or to correct spherical aberration and enhance normal vision.
Address for Correspondence 11 Stillions Close, Windmill Hill, Alton, Hants GU34 2RX
CORNEAL ASPHERICITY AND RGP LENS WEAR S Klyce

We developed the corneal asphericity index (CAD, which indicates the asphericity of the central cornea using the TMS-1 videokeratoscope and used the CA[ to evaluate both normal corneas and corneas with rigid gas permeable (RGP) lens induced warpage. The CA[ (mean_+ standard deviation) for the 22 control corneas was 0.33 + 0.26, which indicates that the normal central cornea has a prolate shape. The average CAI for the 24 corneas with RGP lens induced warpage was significantly lower (-0.15+0.36, P=0.0001). These data suggest that some corneas have abnormal asphericity in the central cornea when warpage occurs with RGP lenses. CA[ is useful for the quantitative assessment of asphericity and topographic abnormalities in the central cornea caused by contact lens induced warpage.
Address for Correspondence 2858 at 6th Street, New Orleans LA 70115, USA
MEASURING NON-SPHERICAL OPTICAL SURFACES C Woods

Introduction: More lens designs for the presbyopic market are emerging. The use of novel designs to generate varifocal optics in contact lenses is increasing. A number of designs incorporate aspheric shapes, of known p-values on the front and back surface of contact lenses. Frequently the radius of curvature quoted by the manufacturer is a nominal reference making verification of these lenses difficult. Could a videokeratoscope or a radiuscope verify these complex surfaces? Methods: This study assesses whether clinical equipment can verify these complex surfaces for a range of concave surfaces of known curvatures (7.30 mm to 8.10 mm) and known p-values (p=0.0 to p=l.0). Results: The videokeratoscope was able to describe the p-value for the surface to a high degree of accuracy (_+0.15 [2 SD]) but did demonstrate bias, according to discrepancy analysis (mean difference=0.048 + 0.02 [2 SE]). The degree of accuracy for the measurement of the radius of curvature of the concave surface was also very high (_+0.014) without any demonstration of bias (mean difference=-0.07, 0.022). The radiuscope was able to verify the radius of curvature to a high degree of accuracy (+0.072) without bias (mean difference=0.008 + 0.01). However, verification of the p-value by utilising Baker's equation demonstrated a poor degree of accuracy (+0.574) and a bias (mean difference=0.134, _+0.078). These results for the measurement of the p-value for the radiuscope were statistically significantly different from that of the known measurement (P=0.0375) and that for the videokeratometer (/'--0.0050). Conclusion: To determine the degree of asphericity of a concave optical surface to an acceptable degree of accuracy a videokeratometer can be used in preference to a radiuscope. Both instruments demonstrated a high degree of accuracy when measuring the radius of curvature.
Address for Correspondence The Victorian College of Optometry, Cns Keppel and Cardigan Streets, Carlton 3053, Victoria, Australia
NEOVASCULARIZATION: THE SUPERFICIAL AND THE DEEP BA Weissman

As an optometry student in Berkeley in the early 1970s, I was taught that contact lenses were fairly benign devices. I learned that commonly encountered physiological complications were limited to various manifestations of hypoxia generated corneal oedema, 3/9 ('juxtapositional') corneal staining, and conjunctival injection. The most common complications of all were unsuccessful fits and lens soilage. This was in the days when all rigid CLs were PMMA and early soft lenses were just appearing on the scene.
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Subsequently, as a clinician in various academic environments (first in northern California, then Jerusalem, and eventually Los Angeles), I learned that severe reactions could occur. GPC, for one example, was a new disease; its natural history and treatment were being uncovered as I entered clinical practice. I have spent much of my subsequent academic career interested in microbial corneal infection. At Hebrew University/Hadassah hospital in Israel, I also saw several eyes with vascularized corneas, some
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attributed to various ocular diseases, but some clearly associated with contact lens wear. Isaac Michaelson was still alive then, the former Chair of the Development, and a giant of a man. While some of his research interest was in the study of those diseases which caused retinal neovascularizafion (e.g. diabetes), he had used a corneal model (with David Maurice) to support his idea that some angiogenic biochemical messenger (his 'factor X') was probably produced by stressed tissues: retina or cornea. Hearing his ideas and reading his papers, and seeing some patients with this complication of CL wear, initially caught my interest. Perhaps it was also because these vessels are so easily observed and interesting - even pretty - at the biomicroscope. In between other long-term projects which you might recall reading at some time, I have returned to this topic from time to time over the past 20 years with various students and colleagues. Cogan proposed in 1949 that the lack of vasculatnre in the normal cornea was due to the compactness of the stroma - but many of us have observed corneas swollen from endothelial dysfunction which do not vascularize for years. Contact lens practitioners have also noted that pannus associated with 3/9 staining progresses from the timbus to where the CL begins, and then stops; clearly this process is not due to hypoxia leading to stromal swelling at all. NV is now known to be the final common pathway of a great variety of corneal problems, and probably represents a healing effort on the part of the tissue when the normal balance of negative and positive mediators of angiogenesis is upset. It is now also clear that NV is the result of a cascade of cellularly derived biochemical mediator interactions (and that leukocytes as well as local tissues are involved) which can be elicited by a large variety of anterior segment insults. One of these mediators, Vascular Endothelial Growth Factor (VEGF), may be Michaelson's factor X and is known to be upregulated by hypoxia among other things. CL wear is known to cause both superficial (common) and deep (very rarely) stromal NV. Superficial NV, also called 'pannus', usually follows either (1) chronic '3-9' or 'juxtapositional' epithelial staining, which we know is a consequence of chronic limbal desiccation, or (2) hypoxia associated with the daily wear of low Dk (thick-edged high minus optically powered, or SoftPerm) hydrogel CLs or extended wear of any CL. Deep
stromal vessels may follow (1) very severe 3-9 staining (called pseudopterygium or vascularized timbal keratitis), (2) hypoxia from daily wear of very low Dk CLs (e.g. 'SoftPerm') or extended wear, and (3) has also been associated with keratoconus. Because NV is typically a 'silent' complication, in that patients are subjectively unaware of the problem until the clinician makes the observation; clinical management may first consist of enhanced professional observation. When NV is noted, the clinician must make a judgement whether intervention or continued observation, perhaps at a more frequent interval, is warranted. Photographic documentation is very helpful in following such patients and assists in appropriate timing and monitoring of intervention if elected. Intervention may consist of changing the patient from an extended wear to a daily wear schedule. Patients who develop pannus due to extended wear or use of thick edged hydrogels may be re-fitted into modest to high Dk RGPs (or perhaps one of the new high Dk silicone hydrogel designs); patients who develop NV from 3-9 stain may benefit from being dispensed standard hydrogel CLs, or new RGPs with larger diameters and higher edge lifts to address limbal desiccation. The clinician should always consider discontinuing purely cosmetic CL wear. Following planned intervention, the clinician should continue to monitor the patient's course to be sure that the blood vessels both become less inflamed and cease growth. It gives one some satisfaction to see the progress we have made as a field over almost three decades of professional life. When I entered this profession, we barely recognised any complications to CL wear at all. Over the past several years we as a profession have better learned recognition, diagnosis and now management and treatment. We are also participating in the grand adventure to learn some of the basic physiological interactions which allow these complications to occur, and hopefully we will be able to prevent many of them in the future. In the near future, specifically, enhanced understanding of the aetiology and treatment of the various forms of ocular NV (e.g. diabetes, macular degeneration as well as corneal) may allow more effective pharmacological intervention of NV.
Address for Correspondence 2567 Amherst Avenue, Los Angeles, CA 90064, USA
DRY EYE AND CONTACT LF~NS WEAR L Carney

Improvements in contact lenses and contact lens maintenance over recent years have led to significant gains for practitioners and patients alike. Despite this, satisfactory management of contact lens patients exhibiting dry eye signs and symptoms remains difficult. Indeed, management of dry eye in any patient, whether or not they are contact lens wearers, represents a considerable challenge. Dry eye is a highly prevalent condition amongst contact lens wearers. Prescribing contact lenses for a patient with recognised dry eye can exacerbate the condition, and for a patient with a marginal condition it can induce dry eye problems. Thus dry eye and contact lens wear are a combination which remain a challenge
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to practitioners and are a major source of contact lens intolerance. Yet there are some reasonable guidelines for approaching management of these patients. It is now clear that the dry eye condition can have many causes, and this has led to an improved dry eye subtype classification. Understanding its relationship to the
broader ocular surface diseases, including conjunctival, corneal and limbal epithelium changes, informs not only classification but also its management.
Address for Correspondence Queensland School of Optometry, Victoria Park Road, Kelvin Grove, Queensland 4059, Australia
OBSERVING AND MEASURING OCULAR ERYTHEMA. WHAT DO WE MEAN BY REDNESS? E Papas
Background: Observation of erythema plays a central r61e in the assessment of the status of the anterior segment. Traditional subjective quantification methods, such as grading scales, are widely used despite a lack of validation. The recent application of more objective systems has occurred without consideration of those aspects of the visual scene ufilised by human observers during the subjective judgement process. The purpose of this study was to establish objectively measurable characteristics of the conjunctival vasculature that correspond with the judgement of erythema by human observers. Methods: Colour images of bulbar conjunctiva from 21 different subjects were digitally analysed to extract variables characteristics of the scene. These data were compared with the subjective judgements of a panel of seven trained observers who independently rated erythema, in the same images, using a 0-4 grading scale.
Results: Strong associations (r 2> 0.9) between subjective grading and objective measures were found for morphometric variables describing the density of vessels on the ocular surface. Associations for variables describing colour in the scene were substantially
weaker.
Conclusions: Judgements of erythema made by human observers rely primarily on morphology rather than colour. This result has important implications for: (i) Design of both subjective and objective measurement systems (ii) Training of clinical observers (iii) Approach to data analysis
Address for Correspondence CRCERT, Level 4, Northwing, Rupert Myers Building, University of New South Wales, Kensington, Australia NSW 2052
CLINICAL EVALUATION OF TORIC SOFT LENS REPRODUCIBILITY G Young
Purpose: Frequent replacement toric soft contact lenses are becoming increasingly popular. The wider range of prescription variables with toric lenses means that lens reproducibility is harder to control than with spherical lenses. The purpose of this study was to assess the effect of lens reproducibility on the clinical performance of three different brands of frequent replacement tofic soft lenses. Method: This was a three-visit, randomised, repeated measures study in three parts. In each part, subjects were pre-adapted to the test lens prior to three assessment visits. At the assessment visits subjects wore 12 toric test lenses in succession (four lenses per visit) in one eye. All 12 lenses were of the same labelled power. The other eye wore a single lens which was removed and reinserted between assessments a total of 12 times. The three frequent replacement toric soft lenses evaluated were: Acuvue Toric (etafilcon A), Focus Toric (vifilcon A), and FreshLook Toric (phemfilcon A). A range of vision, lens fit and subjective variables were measured at each assessment. A statistical analysis tested for differences in variance
between the results for the replaced (test) and nonreplaced (control) lenses. The results were evaluated in conjunction with in-vitro measurements of process capability (manufacturing accuracy and reproducibility).
Results: The Focus and FreshLook Toric lenses showed significantly greater variability with the replaced lenses compared with the non-replaced lenses with the following variables: comfort, tightness on pushup, overall fit acceptance, visual acuity (high and low contras0 and subjective vision quality. In addition, the Focus Toric replaced lenses showed greater variability of orientation position and stability compared to nonreplaced lenses. The Acuvue Toric replaced lenses showed significantly greater variability in one variable: subjective vision quality. In a number of cases, a significantly greater variability was noted with the nonreplaced lenses when compared to the replaced lenses, which suggests a baseline for expected clinical consistency. Conclusions: This study has shown differences be-
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tween toric lenses in the repeatibility of clinical performance that can be explained in part by variations in manufacturing reproducibility.
Address for Correspondence Visioncare Research Ltd, 3 St George's Yard, Farnham, Surrey GU9 7LW
CONJUNCTIVAL SENSITIVITY IS ALTERED IN UNSUCCESSFUL CONTACT LENS WEARERS F Stapleton
Purpose: The r61e of the upper tarsal conjunctiva in ocular surface sensation is unknown, however the lid is likely to contribute to sensations of dryness and discomfort in ocular surface disease and in contact lens wear. The aim of this study was to measure the mechanical threshold of the tarsal conjunctiva using a modified Belmonte gas aesthesiometer and to compare this with sensitivity at other ocular sites. Methods: Six subjects who had discontinued contact lens wear due to discomfort and 12 normal non-contact lens wearing subjects participated. The right eyelid was everted and area 2 on the tarsal conjunctiva was stimulated using a warmed air pulse. A 2 AFC design using a method of constant stimuli was used and threshold for a 50% response rate was determined. Mechanical thresholds were similarly determined for the central and peripheral cornea and bulbar conjunctiva. The differences between subject groups and sites were determined using A_NOVA. Results: Mechanical thresholds for discontinued wearers were; tarsal conjunctiva 69+23 ml/min, bulbar
conjunctiva 8 7 + 2 9 m l / m i n , peripheral cornea 56 + 47 ml/min and central cornea 51+ 25 ml/min. In non-wearers these were; tarsal conjunctiva 121 + 56 ml/ rain, bulbar conjunctiva 127+33 ml/min, peripheral cornea 91 + 32 ml/min and central cornea 63 +26 ml/ rain. Thresholds were significantly different between groups and sites (P< 0.001). Subjects who had discontinued from lens wear had significantly lower tarsal and bulbar conjunctival thresholds (P< 0.05).
Conclusions: The sensitivity of the tarsal conjunctiva to mechanical stimuli is similar to the bulbar conjunctiva in non-contact lens wearers. Individuals who had discontinued from soft lens wear due to discomfort showed higher bulbar and tarsal conjunctival sensitivity compared to non-wearers. Prospective studies are needed to confirm whether conjunctival sensitivity can predict success in contact lens wear. Address for Correspondence CRCERT, University of New South Wales, Sydney NSW 2052, Australia
RESULTS OF LASIK WITH A 4TH GENERATION EXCIMER LASER: AUTONOMOUS LASIK RESULTS AND CUSTOMISED CORNEAL ABLATIONS M McDonald LASIK for myopia with astigmatism and hyperopia astigmatism using the LADARVision system will be reviewed. The Autonomous Technologies (ATC) LADARVision excimer laser system has an active tracker, which samples the eye position 4000 times per second. A small (0.9 mm) flying spot sculpts the cornea using sophisticated algorithms. The myopic patients received a 6 mm OZ if a spherical ablation was attempted; a 5.5 mm OZ with a 1 mm blend zone was utilised for myopic astigmatism patients. A 6 mm OZ was used for spherical hyperopia, with a 1.5 mm blend zone; hyperopic astigmatism patients received ablations with the same dimensions. Six US clinical sites collected data on 347 myopes and 360 hyperopes, with 270 myopes and 271 hyperopes reporting in at 6 months and 115 myopes and 46 hyperopes reporting in at 9 months. The mean age for the myopes was 42.8 9.3 years, and 53.2___9 years for the hyperopes. Half the patients were male and half were female. The myopic LASIK manifest refraction pre-operative treatment parameters included an average spherical equivalent of -4.51+2.17 D, with the sphere component averaging -4.03_+2.22 D and the cylinder (all eyes) averaging - 0.97 + 0.96 D, though the astigmats only alone averaged - 1.66 + 0.93 D. All myopic eyes (with and without astigmatism) available at 9 months had the following outcomes: 61% had a UCVA of 20/20 or better, 78% were 20/25 or better, and 97% were 20/40 or better. Eighty per cent were +0.5 dioptre, and 97% were + 1.00 dioptre of expected outcome. No eyes had a loss of greater than two lines of BCVA, though 0.9% had a loss of two lines of BCVA. No eyes had a BCVA of worse than 20/40. An increase of IOP of greater than 10 mmHg above baseline was noted in 0.67% of patients, related to steroid use; 0.3% had microkeratome-related miscreated flaps (one patien0; and 0.3% had induced astigmatism due to flap decentration (one patient). All eyes had a BCVA of 20/25 or better at the last recorded visit, and no eyes had an lOP of greater than 25 mmHg at any visit. Ninety-one per cent of patients no longer required distance correction, 68% stated that their quality of vision had improved, and 79% were satisfied with their results.
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The hyperopic LASIK patients had an average IOP of greater than 25 mmHg at any visit. All eyes had spherical equivalent of +2.25 _+1.50 D, with a spherical a BSCVA of 20/25 or better, except for two eyes with component averaging +2.91+1.49 D and a cylinder miscreated flaps which currently have a BSCVA of 20/ component (for all eyes) of - 1.33 _+1.50 D, though the 32. asfigmats alone averaged -2.13_-t-1.53 D. The stability Seventy-two per cent of patients felt that their quality of the cohort was established at 3 months, and verified of vision had improved; 73% were satisfied with their with the 6 month and 9 month data. At 9 months, 56% results, and 89% no longer required long distance vision. of the patients were 20/20 or better without correction, LASIK results on the first eyes treated for myopia and 72% saw 20/25 or better, and 95% saw 20/40 or better. hyperopia with or without astigmatism are very enSeventy-four per cent were -+0.50 D, and 91% were couraging with a single treatment. within _+1.00 D of intended correction. No eyes lost Updated results on the first 20 LASIK patients treated more than two lines of BSCVA, 4% lost two lines, and with the CustomCornea (wavefront-based) system also no eye had less than 20/40 BSCVA. Microkeratome- will be presented. related miscreated flaps and peripheral interface infiltrates both occurred in 0.8% of the patients, and Address for Correspondence 0.3% (one patient) had an increase in IOP in greater Refractive Surgery Center, EENT Institute, 2626 Napothan 10 mmHg above baseline, though no eye had an lean Avenue, New Orleans, LA 70115, USA
CONTACT LENS DEHYDRATION AND LENS AGEING P Morgan
Purpose: To investigate changes in hydrogel contact lens water content and lens comfort with wear. Methods: Six subjects wore each of four contact lens types (Acuvue [Vistakon], Gentle Touch [Wesley Jessen], Proclear [Biocompatibles] and Frequency 38 [CooperVision]) for 28 days. On the morning of each day of wear, a comfort score was recorded and water content was measured with a hand refractometer (Atago CL1). The same parameters were recorded at the end of each lens wearing day. Results: Over the 28 day period, absolute water content at insertion reduced for each lens type by 0.12%, 0.02%, 0.05% and 0.10% per day for Acuvue, Frequency 38, Genre Touch and Proclear respectively. At removal, there was a day-to-day water content reduction of 0.14% and 0.04% for the Acuvue and Gentle Touch lenses, no change for the Proclear
lens and a day-to-day increase of 0.05% for the Frequency 38 lens. Mean+SD daily dehydration values (absolute %) were 6.1_+3.0, 2.0+1.9, 3.9+2.3 and 1.7 + 2.2 respectively. No changes in lens comfort over time were demonstrated. The Acuvue lens was the most comfortable at lens insertion and the Acuvue and Proclear lenses were the most comfortable at lens removal.
Conclusions: All four contact lenses demonstrated a permanent and irreversible day-to-day reduction in water content with consequent adverse effects on lens oxygen transmissibility. We demonstrated differences between the lenses for daily lens dehydration and subjective comfort scores.
Address for Correspondence Department of Optometry & Neuroscience, UMIST, PO Box 88, Manchester M60 1QD
MUCIN BALL POST LENS DEBRIS IN HIGH DK SILICONE HYDROGEL WEARERS L Jones
Purpose: Experience with high Dk silicone hydrogel lenses has revealed post-lens debris which is characterised by the appearance of spherical, translucent particles referred to as 'mucin balls'. Although these entities are easily blinked away on lens removal and appear harmless, any association with discomfort, blurred vision or adverse reactions has not been investigated. The objective of this analysis was to determine whether any association between mucin ball observation and various ocular responses to contact tens wear exists. Methods: Ninety-two subjects wore lotrafilcon A lenses
on an extended wear basis for up to 30 nights and were followed for 6 months. Mucin balls were graded on a 0 to 4 scale (0.5 increments) at three visits. Subjective ratings and physiological response were recorded at all visits.
Results: Mucin balls were observed in 70% of subjects at one or more visits, 29% of subjects exhibited mucin balls at all three visits and there was no change in observation frequency over time. There was a 71% concordance between eyes. Mucin balls were graded at > 1 in 18% of eyes, > 2 in 4% of eyes and > 3 in 1% of eyes. Mucin ball appearance was not associated with any decrease in overall comfort vision or dryness and
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overall satisfaction ratings were high. The percentage of subjects 'never' using lubricating drops was higher in the subjects with mucin balls (P=0.0014). No association was found between biomicroscopic appearance, inflammatory responses and mucin ball observation. Conclusions: The presence of mucin balls does not appear to be detrimental to contact lens wear. Future
investigation into the relationship between mucin ball observation and the use of re-wetting drops is warranted.
Address for Correspondence CCLR, School of Optometry, University of Waterloo, Ontario N2L 3GI, Canada
A STUDY OF THE SPOILATION PROFILES OF HIGH Dk FLUOROSILICONE HYDROGEL LENSES V Franklin

The spoilation profiles of high Dk fluorosilicone hydrogels worn for 30 nights, either weekly replacement or continuously, were assessed using fluorescence s p e c t r o p h o t o f l u o r i m e t r y and ultra-violet spectroscopy. At least 35 patients were involved in the study and lenses were collected at the 6, 9 and 12 month point in the trial. Information was obtained on surface and lipid deposition on the front and back of the lens, as well as total protein uptake. The results obtained were compared to the results for a range of frequent replacement contact lenses, which had been used on a daily wear basis. The fluorosilicone hydrogel extended wear material had the lowest protein deposition of all the lenses tested, and the protein remained at the surface of the lens rather than being absorbed into the bulk of the lens matrix. The lipid deposition was well within the limits of the levels observed for the daily wear lenses, surface to bulk protein and lipid ratios were also determined by plasma emission and monitoring (PEEMS) and high performance liquid chromatography (HPLC). No differences were found between the spoilation profiles in the two wear modalities, weekly replacement for 30 nights, or 30 nights continuously. Although individual patients showed left to right eye variability, overall no differences in the accumulated results were obtained, as was also the case between the front and back surface deposition. The lipid profile was much more patient dependent that the protein deposition, but still driven by material/surface considerations.
Address for Correspondence Aston Biomaterials Research, Aston University, Aston Triangle, Birmingham B4 7E~
MULTIFOCAL AND BIFOCAL CONTACT LENS PERFORMANCE IN COMBINATION WITH A UNIOCULAR TORIC LENS K Fisher Astigmats are often considered marginal candidates for presbyopic correction with simultaneous vision contact lenses. Purpose: The goal was to evaluate visual performance and wearer acceptance when a bifocal or multifocal lens is paired with a uniocular single-vision toric lens. Methods: Twenty-two presbyopes with varying degrees of presbyopia (Add +0.50 to +2.50 D) and significant refractive cylinder (-0.75 to -2.25 D) in one or both eyes were each fitted with a uniocular toric lens in combination with bifocal and progressive multifocal lenses for the contralateral eye. Each combination of lenses was worn for 2 - 7 days, at which time fitting was refined and the lenses worn for another 3 - 7 days. Testing encompassed binocular distance and near contrast sensitivity and high/low ambient illumination acuities, as well as nearpoint stereoacuity, binocular visual range, and hand-eye co-ordination. Visual symptomatology, comfort, handling, ghosting, and subjective visual quality were also evaluated. Results: Performance deficits relative to spectacles were significantly greater when wearing simultaneous vision lenses on both eyes than when wearing one such lens along with a uniocular toric lens. When combined with a toric lens, the progressive multifocal outperformed the bifocal with respect to distance acuity, low illumination near acuity, contrast sensitivity, stereoacuity, and eye-hand co-ordination. The multifocal/toric combination was rated higher for overall visual quality, associated with fewer and less severe visual problems, and was preferred by the majority of the subjects including those previously wearing monofit single vision lenses. Conclusion: Pairing a progressive multifocal lens with a uniocular toric lens should be tried prior to other options when attempting to fit a presbyopic astigmat with soft contact lenses. Future Studies: Various multifocal and bifocal designs must be compared to develop a comprehensive strategy for successfully fitting this type of contact lens patient.
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Address for Correspondence
CIBA Vision Corporation, 11460 John's Creek Parkway, Duluth, GA 30097, USA
MANAGING CORNEAL INFILTRATES IN PATIENTS WITH HIGH Dk EXTENDED WEAR LENSES
R Chalmers
While the hypoxic changes previously associated with EW have been eliminated with new High Dk lenses, some patients have experienced transient ocular inflammation. This talk outlines the case history and management of three patients who developed corneal infiltrates of varying severity while wearing lotrafilcon A lenses.
CIBA Vison Corp, 11460 John's Creek Parkway, Duluth, GA 30097, USA
WAVEFRONT SENSING TECHNOLOGY - VISION CORRECTION FOR THE NEW MII.I.ENIUM
R Potvin
Adaptive optics, the technology designed to provide for atmospheric correction of telescopes, has itself been adapted - to the human eye. The resulting ability to measure higher order aberrations of the human eye holds incredible potential. Application of this technology to various forms of vision correction will be discussed.
Bausch & Lomb, 1400 N Goodman Street, PO Box 450, Rochester, NY 14603-0450, USA
CONTACT LENS DRY EYE . . . THE PROBLEM THAT WON'T GO AWAY
J Craig
Contact lens induced dry eye is by far and away the most common reason for contact lens drop-out in practice. This lecture will discuss both the environmental, as well as the clinical problem surrounding this perplexing phenomenon. It will conclude by putting forward a management strategy to reduce the incidence of contact lens drop-out from dry eye, in your practice.
Discipline of Ophthalmology, University of Auckland, Private bag 92019, Auckland 1001, New Zealand
THAT'S NOT WHAT I WAS TAUGHT AT UNIVERSITY!
J Meyler
Contact lens practice is one of the most rapidly changing fields within our profession and updating our knowledge is fundamental in allowing optimal patient care. This presentation will review changes to our management approach on a number of everyday clinical problems based on more recent contact lens research and remind us that prevention is often the best form of management.
Vistakon UK - Johnson & Johnson, The Braccans, London Road, Bracknell, Berks RG12 2AT
ADAPTATION AND RESISTANCE OF PSEUDOMONAS AERUGINOSA TO CONTACT LENS DISINFECTION
C Lakkis Purpose: Resistance of bacteria to contact lens disinfection solutions appears to play a r61e in increasing the exposure of the eye to micro-organisms during lens wear. We have reported variability among P. Aeruginosa strains in their susceptibility to two hydrogel contact lens chemical disinfectants and have found resistance to correlate with genes involved in cytotoxicity towards corneal to epithelial cells. When
cytotoxic P. Aeruginosa strains were exposed to a disinfectant preserved with POLYQUAD, in the contact lens case at room temperature, 4/6 strains grew to levels above the initial inoculum after 24 to 48 h. The aim of this study was to determine whether this growth is due to adaptation of the cytotoxic strains to the disinfectant.
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Methods: The cytotoxic P. Aeruginosa strain PAl03 was used to inoculate the POLYQUAD preserved disinfectant in the lens case environment, to give an initial inoculum of 107 CFU/ml. Cases were kept at room temperature (22C) for 7 days. The solution within the lens case, containing surviving PAl03 (pre-exposed PAl03), was then used to inoculate fresh disinfectant whilst the remaining solution was filter sterilised and challenged with pre-exposed PAl03 and a new inoculum of PAl03 (unexposed PAl03). Unexposed PAl03 as also used to inoculate flesh solution. Cases were stored at 22C and viable counts performed at 4, 18, 24, 48 and 168 (7 days) h post-inoculation.
days. When the growth of unexposed PAl03 was compared between the filtered and flesh disinfectant, inhibition of growth was observed in the filtered solution.
Results: An initial inoculum of approximately 106 CFU/ ml was achieved. When the growth of unexposed and pre-exposed PAl03 was compared in fresh disinfectant, Address for Correspondence the pre-exposed PAl03 showed statistically significantly University of California, Berkeley School of Optometry, higher levels of growth at all time points from 4 h to 7 #688 Minor Hall, Berkeley CA 94700-2020, USA
Conclusions: Inhibition of the growth of unexposed PAl03 in filtered compared to fresh solution suggests that the growth of cytotoxic strains in POLYQUAD preserved disinfectant is a result of adaptation to the disinfectant and/or the low nutrient environment of the contact lens case. This adaptation may influence virulence factors such as adherence (both to the contact lens and the corneal epithelium), epithelial cell invasion and cytotoxicity, contributing to the development of inflammatory and infectious complications.
SEVEN-DAY EXTENDED WEAR AND 30-DAY CONTINUOUS WEAR OF SOFT CONTACT LENSES WITH VERY HIGH OXYGEN TRANSMISSIBILITY. A STUDY OF 5 0 0 PATIENTS SE Nilsson Background and Method: New silicone hydrogel contact lenses with an oxygen transmissibility (Dk/0 3 - 5 times that of current soft lenses may reduce the risk of microbial keratitis. Cavanagh and his group showed that bacterial binding to exfoliated corneal epithelial cells after overnight wear of contact lenses was inversely related to tens Dk/t. However, the new high Dk/t soft lenses did not increase binding at all over no lens wear. In a 1-year study, a high Dk/t soft contact lens (Balafilcon A) was tested in 150 patients for 7-day extended wear and in 350 patients for 30-day continuous wear. Results: No sight threatening complications, e.g. bacterial keratitis, occurred. Limbal and bulbar injection decreased significantly. Positive slit lamp findings related to lens wear were seen in 24% of the eyes, primarily as slight corneal staining (11%), and to a much less extent also as sterile peripheral infiltrates, tarsal conjunctival abnormalities, CLARE and SEAL with no significant difference between the two groups. Most
infiltrates did not stain and healed upon a short period of discontinued lens wear. Thirteen per cent of the patients in the 7-day group and 8% in the 30-day group did not complete the study for reasons related to lens wear, e.g. because of discomfort or sterile peripheral infiltrates, with no significant difference between the two groups. The patients' subjective judgement of comfort, visual quality, freedom from dryness and handling varied from 89 to 95 on a scale from 0 to 100.
Conclusions: It seems that the new high Dk/t soft contact lenses may reduce serious complications such as microbial keratitis. Inflammatory reactions such as sterile peripheral infiltrates are still seen. The 30-day group did not show more complications than the 7-day group. Address for Correspondence Department of Ophthalmology, LinkSping University, HnkSping, SE-581 85, Sweden
BACTERIAL POPULATIONS PRESENT DURING EXTENDED WEAR OF CONTACT LENSES C Morris

Bacterial contamination of contact lenses during wear has been demonstrated in asymptomatic wearers 1 and may contribute to CL-related infection and inflammation. Microbial keratitis occurs more commonly in extended wear (EW) compared to daily wear (DW) use of CLs. 2-4 The aim of this study was to evaluate the bacterial contamination rate during EW over a much longer wear cycle (30 NEW), now possible with the introduction of highly oxygen permeable soft materials. For this purpose, FocusR NIGHT and DAYTM (a fluorosfloxane based polymer, 24% H20, Dk/t of 175 barrers/cm) was used. Two hundred and eighty-four lenses were aseptically collected at various time points from a DW, six NEW and 30 NEW patient group and placed in 2 ml PBS. After sonication, each lens was cultured, and a portion of the sonicated solution was plated out on a variety of media and grown
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under different conditions, all designed to maximise the chances of picking up organisms present on the lens. The remaining solution was stored at 5C and filtered if lenses exhibited no growth. The filter was then plated to establish lens sterility. Bacterial populations present on the lens at any given time point were not different, and were mostly normal skin flora. More importantly, the percentage of sterile lenses was the same during the wear cycle, and there was no significant increase in the number of organisms present on day 1 through to day 30.
The implications of these finding for 30 NEW will be discussed.
References:
I Gopinathan et al. J. Appl. Microbiol., 82, 1 - 7 (1997). Schein et al. N. Engl. J. Med., 321,773-778 (1989). a Stapleton et al. CLAO]., 19, 204-210 (1993). 4 Cheng et al. Lancet, 54, 179-183 (1999).
Address for Correspondence CIBA Vision Corp, 11460 John's Creek Parkway, Duluth, GA 30097, USA
THE IMPLICATIONS OF vCJD FOR CONTACT LENS PRACTICE G Macalister

The aim of this presentation is to provide the practitioner with an overview of the risks of transmission of variant Creutzfeldt-Jakob disease (vCJD) from person to person via contact lenses (and other devices which contact the eye). It will highlight the facts that have been established, focusing on those aspects of the scientific background that are fundamental to an informed view. The gaps in the scientific knowledge, and their implications, will be pointed out. Reference will also be made to studies that are currently in progress, the results of which may change our outlook. Prion biology: A brief outline of prion biology will be given. This will concentrate on the explanation of the most relevant points, for example the lack of effective decontamination methods, and the existence of different strains of prion, with distinct biological properties, which can alter when the disease crosses a species barrier. Transmission: There are three key questions. Firstly, will infectious prions be present in tears and at the ocular surface tissues of patients who are in the early pre-clinical stages of CJD? Secondly, is it possible to transfer these prions to another eye via contact lenses? Thirdly, could these prions then infect the brain of the second individual by passage from the ocular surface tissues? Scientists cannot yet provide exact answers to these questions, but indirect evidence, mainly from animal studies, points toward the likelihood that such transmission may be theoretically possible. If we acknowledge that there is some risk, however, small, of transmission via contact lenses, we are then left with the most important question. How likely are we to encounter a person infected with vCJD in our practice? It is now clear that the prion strain which causes BSE in cattle is identical to the one found in humans with vCJD. k follows that millions of people in the UK could have been exposed to the vCJD agent in the late 1980's before infected material was prevented from entering the food chain. Very few people are known to have contracted vCJD so far, but epidemiologists are unable to predict the future scale of the outbreak. Discussion: This review will discuss the ethical concerns that arise from the uncertain, but potentially very serious, risk of transmission of vCJD via contact lenses. Reference will be made to other interventions that could have the potential for cross-infection, and the reactions of other professional groups will be reported. In addition to the customary opportunity to pose questions, it is hoped that delegates will be able to use interactive handsets to vote on some of the issues raised.
Address for Correspondence Fingellan, Whines Lane, Cambridgeshire CB4 5PT
Contact Lensand AnteriorEye
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POSTER PRESENTATIONS
Jurassic sclerals, a thing of the past? J Lamb, BRyan, T Sabell and W Illahi Aim: The aim of this poster is to show in a step by step practical form how simple it can be to make an eye impression, produce a PMMA shell and subsequently adjust and fit it. Objective: The objectives are to remind practitioners that when they are dealing with a cornea which appears impossible to fit with a corneal contact lens (a contact lens being the only way of optically correcting it) an impression PMMA scleral lens may be the most successful and simplest option. It will also give practitioners the opportunity to see and touch PMMA scleral lenses, eye casts, materials and other practical tools of scleral lens fitting. Method and Materials: The poster shows a step by step practical guide to taking an eye impression, making a positive cast and an initial PMMA shell, grinding and edging it, and finally the near finished powered lens. Conclusion: We see how useful the PMMA scleral lens from impression can be and how relatively simple and cost effective it can be to produce them. Address for Correspondence Birmingham & Midlands Eye Centre, City Hospital NHS Trust, Dudley Road, Birmingham B18 7QU
scleral lenses. Some patients were found to be unsuccessful in the longer term, the main reasons being handling difficulties, solution intolerance or excessively toroidal sclera.
Address for Correspondence Birmingham & Midlands Eye Centre, City Hospital NHS Trust, Dudley Road, Birmingham B18 7QU
Gas permeable materials enable predictable scleral lens fitting processes K Pullum
The purpose of this presentation is to illustrate current scleral lens fitting techniques in the management of high refractive errors, abnormal ocular topography and ocular surface disorders. The theory and practice of scleral lens fitting are illustrated in various examples of typical eye conditions where scleral lenses are indicated. Fitting processes have undergone a transformation since the introduction of gas permeable materials. Fenestrated designs were necessary to allow some fresh oxygenated tear exchange with PMMA scleral lenses, but admitted bubbles to the pre-corneal fluid reservoir and lead to settling back on the globe. Both were significant problems, making scleral lens fitting a cumbersome and unpredictable exercise. Bubbles have traditionally been used to define the quality of fenestrated scleral lens fitting, but are inappropriate for assessment now that the great majority of eyes can be fitted using sealed designs with RGP materials. The depth of the pre-corneal fluid reservoir and the quality of corneal contact zones are the key features to evaluate as both have a significant bearing on both tolerance to lenses and visual performance.
Clinical evaluation of a design of gas permeable scleral contact lenses over a three year period W Illahi, B Ryan, T SabeU and J Lamb
The aim of this poster is to report a 3-year update of the outcome of all the corneas which were fitted with gas permeable scleral lenses in the Birmingham & Midland Eye Centre. Objectives: The objectives are to independently evaluate the success rate of RGP scleral lenses designed by Innovative Sclerals Ltd. on difficult eyes and to outline problems which may be encountered. Method: Forty-eight eyes were fitted with preformed rigid gas permeable scleral lenses between January 1996 and December 1999 at the Birmingham & Midland Eye Centre. All fittings were done according to the manufacturer's specification. Patients were followed-up and outcomes recorded. Conclusion: Gas permeable scleral lenses are a viable option for a large number of patients who are not suitable for any other type of lens including PMMA
Address for Correspondence 203 Ware Road, Hertford, Herts SG13 7EQ
Nomogram for fitting keratoconic eyes utilising computerised video-keratoseopy LG Sorbara and J Luong
Purpose: To determine a fitting nomogram relating the corneal curvature measurements of keratoconic eyes, to the back optic zone radius (BOZR) of the final lens design. Methods: Fifty-seven keratoconic eyes were fitted with a tricurve, multicurve or Rose-K rigid gas permeable (RGP) lens. Subjects were nominally grouped by the amount of corneal astigmatism (delta K): low (-2.05D+-0.91, n=17), moderate ( - 5 . 6 5 D _ + -1.21, n=24) and high ( - 1 0 . 9 7 D + - 3 . 1 3 , n=16). The lenses were fitted by trial lens fitting to achieve a traditional three-point, minimal apical touch fit. Once
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156 fitted, the relationships between the central topographical readings, amount of corneal astigmatism, steepest topographical reading at the apex of the cone and the final BOZRs were studied to establish a fitting nomogram. for corneal lenses, effected by changing a combination of the BOZR and the axial edge lift.
Address for Correspondence 203 Ware Road, Hertford, Herts SG13 7EQ Scleral lenses: a modern option for visual rehabilitation KW Pullum
Contact lenses are clinically indicated for irregular corneal topography, high refractive errors, for therapeutic purposes and in the management of ocular surface disorders. Sclerals lenses are considered relatively infrequently, but have some notable attributes. Unadapted short-term wear is usually possible as there is no lid/lens interaction edge sensation, they do not dislodge and powers over 30.00 D can be incorporated. The introduction of gas permeable materials has significantly improved tolerance and simplified fitting processes, thereby extending the applications of scleral lenses. The purpose of this presentation is to illustrate the current indications for scteral lenses and to assess outcome. Clinical information from the most recent follow-up consultation for a large group of patients who had been referred for an attempted scleral lens fitting or review of their current scleral lens management was evaluated. Assessment of 1024 patients, patients' case notes (1493 eyes) showed the major groups to be some type of: primary corneal ectasia (55%), corneal transplant (16%), aphakia (7%), and myopia (6%), various ocular surface disorders (11%) and miscellaneous others (5%). Assessment of the outcome showed 40% continued RGP scleral lenses and 10% remained with PMMA, 24% discontinued wear and 8% did not proceed beyond the initial fitting trial. Cases in progress amounted to 11% and 7% had been lost to follow-up at the time of writing. The indication for contact lens, contact lens history, demography, visual acuity and fellow eye status were analysed as outcome predictors, but there were few conclusive findings to show that any can be reliably used to eliminate the scleral lens option at the fitting stage. In conclusion, scleral lenses retain a unique functional r61e for visual and therapeutic purposes. A small place remains for PMMA, but RGP materials are providing a more satisfactory outcome with simpler fitting processes.
Results: The BOZRs were significantly different for each astigmatic category (P<0.05). All lenses were fitted steeper than the central fiat K. The formulae established were: low cyl amounts: BOZR=flat K(D) -0.609 (delta K); moderate cyl amounts: BOZR=fiat K(D) - 0 . 4 1 9 (delta K); high cyl amounts: BOZR=fiat K(D) -0.354 (delta K). The apical and steepest readings as measured by the topographer did not provide as predictable a relationship with the final BOZR, especially for the high cylindrical group (steepest K's of 68.58 D_+6.00, n--16). For the low and moderate astigmatic groups, the lenses were fitted between 6.25 and 7.57 D flatter than the steepest K. K the average of the central fiat and steepest apical K reading were used as the starting BOZR, the initial lens would be 3.0 to 7.0 D too steep. Conclusions: The use of corneal topographers in diagnosing early keratoconus has been well established and studied. Predicting the initial and/or final contact lens parameters by using this fitting nomogram will emphasise the importance of integrating corneal topography into contact lens practice.
Address for Correspondence School of Optometry, University of Waterloo, Waterloo, Ontario N2L 3G1, Canada
A keratoconus corneal lens fitting technique using linear axial profile increments KW Pullum and K Murphy
Keratometry is used as a guide to selection of the initial lens in keratoconus but the final optimum specification often bears little relationship to the corneal curvature in moderate or advanced stages of the condition. Further data may be gained from corneal topography mapping, but the predictive value remains questionable. This presentation describes how the central curvature and the aspheric peripheral configuration of the lens are integrated to give a single parameter, the axial profile. Address for Correspondence This is varied in equal incremental steps across the 203 Ware Road, Hertford, Herts SG13 7EQ range enabling a simplified, straightforward and highly predictable approach to keratoconus fitting. Examples of keratoconus fittings illustrate by use of clinical photo- Refractive changes with time in a keratoconic graphy how axial profile variations change the clinical patient with a rigid permeable contact lens in the appearance, how this variable relates to changes to the fight eye and penetrating keratoplasty in the left back optic zone radius and the predictability in terms of J Lamb and J Freeman achieving the optimum appearance of apical and peripheral corneal contact zones. An axial profile Aim: The aim of this abstract is to present a case increment of 0.1 mm gives a clinically significant result history demonstrating the refractive changes with time
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in a keratoconic patient wearing a rigid gas permeable (RGP) contact lens in the right eye and having had a penetrating keratoplasty in the left.
Objective: The objective is to outline the relative speed with which refractive changes can occur in a grafted and non-grafted keratoconic eye and present this is in a clear graphic form. Method and Materials: A 45-year-old Caucasian female presented in December 1997 with advancing and unstable keratoconus. At that time she was wearing rigid gas permeable (RGP) contact lenses. Initially both eyes were re-fitted with an alternate keratoconic design of contact lens in an attempt to improve her quality of vision. This resulted in some success with her right eye but was unsatisfactory with respect to visual acuity in the left eye. A penetrating keratoplasty procedure was subsequently carried out on the left eye and her visual acuity and refractive changes were monitored. These changes were recorded as spectacle prescription in sphero-cylindrical form using minus cyls and represented in this poster as a visual display relating to time. Best visual acuity was also recorded. Conclusions: Over a period of 18 months the refractive changes were seen to alter significantly especially in the grafted eye. The refractions demonstrate the significant changes that occur in the healing cornea using the ungrafted eye as a comparison. It is speculated that the use of a continuous suture in the keratoplasty may enhance the changeable nature of the refraction. Address for Correspondence Birmingham & Midlands Eye Centre, City Hospital NHS Trust, Dudley Road, Birmingham B18 7QU
Photography was carried out to demonstrate their fluorescein fit both with and without the influence of the lids. Best-corrected visual acuity was recorded. A subjective comment comparing their 'comfort' was also recorded from the patient.
Conclusion: The designs of all five pairs of keratoconic lenses were described and their fluorescein photographs were compared. Best VA and comfort were also compared and these along with the fluorescein fit were then related back to the original topography of the cornea and cone. Address for Correspondence Birmingham & Midlands Eye Centre, City Hospital NHS Trust, Dudley Road, Birmingham B18 7QU
Dk performance of lotrafilcon A following 30 night extended wear L Winterton

Contact lenses manufactured from a new class of high Dk materials have been launched in the UK and many other countries. The primary physiological benefit of these materials is based on their ability to allow adequate oxygen to reach the cornea during overnight wear. Some practitioners are dispensing these lenses with uncertainty that they maintain their high Dk performance throughout the approved 30 night extended wear period. The purpose of this prospective study was to document the oxygen transmissibility (Dk/ 0 of lotrafilcon A lenses from a normal practice environment that had been worn for 30 night extended
weal'.
One keratoconic patient, five keratoconic lens designs J Lamb, A Gardiner, M Hart and S Caddy Aim: The aim of this poster is to show a variety of different keratoconic designs of contact lens on one pair of keratoconic cornea. Objective: The objective is to demonstrate photographically using fluorescein under ultra violet light five pairs of 'best fit' rigid gas permeable contact lenses representing a variety of currently available keratoconic designs (on a pair of keratoconic corneas). Method and Materials: A 35-year-old Caucasian male, is fitted with five pairs of gas permeable contact lenses of differing keratoconic designs. Initially corneal topography is carried out on each eye to establish where the cone is positioned and how advanced it is. Both eyes were fitted according to the manufacturer's guidelines to the end point, considered to be their 'best fit'.
Methods: Twenty-eight lenses (28) that had been worn for at least 30 nights extended wear were collected. Worn lens powers ranged from -1.25 to -5.50 D. Worn lenses were stored in non-neutralised AOSept in individual vials and shipped to CIBA Vision Corporation for Dk and thickness measurements. Worn lenses were equilibrated in unpreserved saline and Dk was measured by the coulometric method. Thickness was measured using a Rehder thickness gauge as the average of 10 measurements for each lens. Measurements were also made on unworn (control) lenses at the same time. Results: The average Dk for both worn and unworn lenses was 140+2 barrers, which yields a Dk/t of 175 x 10 9 mlO~/(s m 2 mmHg). Conclusion: Lotrafilcon A lenses maintained high oxygen transmissibility with 30 night extended wear. Practitioners may be confident that the new lotrafilcon A lenses exceed the Dk/t threshold of 125 recommended by Harvitt & Bonanno. Additional investigations should examine the performance of other materials.
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Address for Correspondence CIBA Vision Corp, 11460 John's Creek Parkway, Duluth GA 30097, USA
The influence of front surface geometry on oxygen delivery for soft contact lenses T Hough, E Bauman and R Grant
Introduction: In 1984, Holden and Mertz established that in order to avoid oedema when wearing contact lenses it was necessary to have an oxygen transmissibility of 24 10 -9 (daily wear) or 87 10 9 (extended wear). To obtain the daily wear value, it was necessary to have 38% lenses with a thickness of 33 microns (0.033 mm) or 75% lenses with a thickness of 166 microns (0.166 ram). In practice, those values of thickness are only possible at the centre of the lens and commercially available lenses have thickness values which are greater than that for reasons of production and handling. Virtually all commercial spherical lenses have a 2-curve (lenficular) front surface geometry. With this construction, it is usual to have a relatively large front optic zone diameter, intended to improve handling characteristics by increasing mid-peripheral thickness. This means that the oxygen transmission away from the centre is in general very much less than the values identified as desirable by Holden & Mertz. Purpose: The purpose of the study was to identify the impact of multicurve front surface geometry on oxygen transmission for a range of water contents, material chemistry and lens powers. Methods: The axial thickness of five current high volume hydrogel lenses was measured at precisely controlled intervals across the complete lens profile for a representative range of powers, using: (a) the ISO64979; approved low force gauge; and (b) a novel optical method. The measured values, together with manufacturer's published data, were used to develop models of the lens thickness and to derive oxygen transmission across the lens. Results: The results show that the anterior design of high volume lenses has changed little in 15 years. The characteristic oxygen transmission profile obtained from published designs circa 1984 is essentially the same as most current lenses; the desirable values of transmission are only obtained within limited zones. The use of a 3-curve front surface geometry has a significant impact on the overall oxygen transmissibility of the lens. For a lens having a power of -5.00 D, the use of a tricurve front surface can improve the oxygen delivery by up to 40%. Discussion: Since 1984, although the Holden and Mertz work has remained definitive, there has been an increasing awareness of the need to deliver more
ContactLensand AnteriorEye
oxygen to the peripheral cornea. However, the impetus within industry has been to deliver very high volumes of hydrogel lenses at dramatically reduced unit costs. In the rush for volume, the design of soft lenses has been neglected; typical soft lens design has hardly changed in the past 15 years. Now, as production technology matures, there is an opportunity to offer genuine clinical advantage by introducing more sophisticated designs. This work illustrates the potential benefits for corneal health of improved soft lens design.
Address for Correspondence 4 Otter Way, Eaton Socon, Huntingdon, Cambs PE19 3LB
Five years of contact lens wear - investigating success T Harknett, T Bowden, H Shadbolt and L Amadi
This study is being conducted as part of a continuing project to evaluate the overall 'success' of patients wearing contact lenses over a period of 5 years; the intention is to build up an on-going assessment against the changing background of new lenses, new developments and patient expectations. The objectives are to determine: the percentage of patients continuing to wear contact lenses on a regular basis, patient compliance to aftercare schedules, wearing schedule and lens care instructions, any trends in the changes of lens type/design, wearing modality, and care regime, the incidence of problems and complications, factors causing patients to abandon contact lenses, if various extraneous events affect contact lens prescribing and wearing. Information will be gathered from a number of practices within the UK, with student investigators completing a questionnaire retrospectively from randomly selected patient records. The patients will be selected from those fitted during 1994. The outcome will be to identify and significant trends, to compare the results and conclusions with the previous study conducted in 1998/99, and any other similar investigations.
Address for Correspondence Centre for Applied Optics, City & Islington College, Bunhill Row, London ECIY 8LQ
Contact lens patient profile 2 0 0 0 T Bowden, T Harknett and H Shadbolt
Although we are all subjected to 'life style' questionnaires from time to time that include questions about contact lens wear there seems to be very little published data available to the profession. This study will seek facts and opinions from contact lens wearers about their lenses and lens performance in terms of comfort, convenience, quality of vision, and lens care products.
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The influence of other environmental factors will also be investigated. Patients will be selected at random by student investigators, and interviewed or asked to complete a questionnaire. These will be conducted when patients attend for aftercare, in a number of different practices within the UK. Comparisons will be made to previously published data and new data emerging from the City & Islington College 1999/2000 Contact Lens Success Study. Address for Correspondence 14 King Street, Gravesend, Kent DA12 2EE
3rd, 4th and 5th order aberrations are present in the human eye with pupil sizes up to 5.7 mm, suggesting the opportunity for enhanced visual correction over current techniques which only utilise sphero-cylindrical data. Address for Correspondence Bausch & Lomb, Inc., 1400 N Goodman Street, P O Box 450, Rochester, NY 14603-0450, USA
Attitudes towards visual correction A Patel, C Brown and P Morgan
Wavefront aberrations of the human eye - a large population sample IG Cox, RJ Potvin, MA Lagana, DR Williams and J Porter
Purpose: To determine the motives behind choosing a visual correction. Method: Four hundred and fifty questionnaires were distributed to randomly selected patients requiring a visual correction, via fifteen ophthalmic practitioners, nation-wide. Patients were asked to select the visual correction most applicable to them and to indicate the three most important reasons behind their choice. They were also asked the three most important reasons for not choosing the other methods of visual correction. Results: Two hundred and six questionnaires were returned. The age group of the participants ranged from 18 to over 65 years of age. Fifty-one per cent of those surveyed represented spectacle wearers, 45% represented contact lens wearers and 4% represented patients who had chosen laser surgery. Discussion: The survey demonstrated that selecting a visual correction is a multifactorial process. Convenience, eye health and comfort are the key issues influencing the selection of spectacles and contact lenses. Cosmetic appearance, cost, availability of information and eye health, however, are the principal factors when considering laser surgery.
Address for Correspondence Eurolens Research, Department of Optometry & Neuroscience, UMIST, P O Box 88, Manchester, Lancs M60 1QD
Purpose: To investigate the variation and correlations of the wave-aberration of the human eye across a large sample of non-pathological patients. Methods: A Hartmann-Shack wavefront sensor was used to measure the wavefront in a large population (n > 100). Subjects had a spherical refraction between +6.00 D and -12.00 D and refractive astigmatism of less than - 3 . 0 0 D, and ranged in age from 21 to 64 years. Three Hartmann-Shack images were collected in both eyes of each subject while fixating at infinity. The wavefront aberration was calculated as a Zernike polynomial expansion up to 5th order for 3 ram, 4.4 mm and 5.7 mm diameter pupils. Corneal curvature was measured using a Topcon auto-keratometer. Results: A large variation in wavefront aberration was found for 2nd through 5th order Zernike coefficients, the magnitude of variation decreasing as the order increased. Wavefront aberration increased for all Zernicke coefficients as pupil size increased from 3 mm to 5.7 mm. The population variation for each Zernike coefficient was centred around zero for all but primary spherical aberration which demonstrated a slightly under-corrected distribution peak. Primary coma showed the largest population variation after defocus and astigmatism. There was significant correlation between the wavefront aberration in fight and left eyes for Zernike 2nd through 4th orders, the correlation coefficients generally decreasing as the Zernike term increased. Spherical aberration showed the greatest correlation with age (r=-0.35), under-corrected spherical aberration increasing with age. Refractive error was not correlated with spherical aberration, whereas corneal curvature was significantly correlated with spherical aberration (r=-0.36), becoming more undercorrected with steeper corneal curvature. Conclusion: Wavefront aberration measurements of a large population sample demonstrated that significant
Ocular surface cooling with the Geggel PRK chiller P Morgan and E Svarverud
Purpose: Some clinicians advocate corneal cooling prior to PRK to reduce post-operative haze. This study was designed to quantify the degree of ocular surface cooling and the optimum coofing time with a new device. Method: Ocular surface cooling was performed on six subjects with a Geggel PRK Chiller (Rhein Medical Inc)
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whilst ocular surface temperature was measured in a non-invasive manner with a 6T62 Thermo Tracer (NEC San-ei Limited). The effects of active cooling for 1, 2 and 3 rain were determined in this controlled and randoraised experiment.
Results: As a control, the instillation of one drop of topical anaesthesia and eyelid retraction alone caused a mean + SD change in temperature (compared to baseline) of - 0 . 5 0 + 0 . 2 1 C , -0.77+0.34C and -1.01 _+0.36C after 1, 2 and 3 rain respectively. Active cooling with the chiller device in addition to anaesthesia and lid retraction caused a change in temperature of - 7 . 0 8 + 1.59C, -8.39+0.97C and - 7 . 1 9 + 1.08C for the same time intervals. The temperature changes for the three active cooling time intervals were not statistically different (ANOVA F=0.988, P=0.4061). Furthermore, the rates of temperature recovery after the chiller device was removed from the ocular surface were not statistically different for the three active cooling time intervals (ANOVA F=2.185, P=0.1631). Conclusion: Significant reduction in ocular temperature can be achieved with this cooling device. With the methodology used in this work, neither temperature reduction nor recovery rate were dependent on contact time. Of the three time intervals assessed, 1 rain with the chiller device appears to be the most appropriate cooling period. Address for Correspondence Eurolens Research, Department of Optometry & Neuroscience, UMIST, P O Box 88, Manchester, Lancs M60 1QD
lenses to 53.7% of patients, and cosmetic shells to 9.0% of patients. 13.4% of patients achieved visual acuity of 6/6 or better. However, a large proportion (38.8%) were recorded as no perception of light (NPL), contact lens fitting being solely for cosmetic reasons. Finally, of the 67 patients reviewed, 24 are still currently wearing their lenses, 12 have discontinued wear for various reasons, and 31 have failed to attend for aftercare appointments.
Conclusions: The majority of patients referred for contact lens fitting were males, with 18% of accidents occurring at work. The majority of cases were fitted with a contact lens for cosmetic reasons only, with no visual outcome. Continued success of contact lens wear was achieved in only 35.8% of all patients seen. Address for Correspondence Department of Optometry, Manchester Royal Eye Hospital, Oxford Road, Manchester M13 9WH
Incidence and geographical distribution of acanthamoeba keratitis in England C Radford and JKG Dart Purpose: A prospective study was undertaken to establish the incidence and geographical distribution of Acanthamoeba keratitis (AK) in England. Methods: AK cases presenting during the 18 month period to 31.3.99 were identified by the British Ophthalmic Surveillance Unit active reporting system. Reporting ophthalmologists were asked to complete a clinical data sheet. Patients were sent a questionnaire to evaluate the proportion of cases associated with established risk factors. Patients resident outside England were excluded. Results: Seventy-three patients, of whom at least 48 (92%) were contact lens (CL) wearers, met study criteria for proven or clinical AK. The annual incidence for the first 12 months was 1.30 per million adults, and 24.11 per million adult CL wearers. There was no significant difference between the incidence for the first 6 months of the study (1.10.97-31.3.98) and the same months in the second year (1.10.09-31.3.99). Geographical variation, however, was considerable, with significantly (P< 0.001) more cases in the South (1.93 per million) and East Anglia (4.13 per million) than in the North and Midlands (0.79 per million). Conclusions: Despite the recent introduction of new CL modalities and disinfection solutions, the incidence of AK in England appears to be static. Possible reasons for the marked geographical differences in incidence include inter-region variations in population structure (particularly with regard to the frequency of CL wear) and hardness of water supply.
The use of contact lenses following ocular trauma H Kirk and C Tromans Purpose: A retrospective study was performed to review the use of contact lenses following ocular trauma in the Contact Lens Clinic at Manchester Royal Eye Hospital. The aim was to determine types of lenses used, visual outcome and success rates. Materials and Methods: Seventy-two patients were identified from the database as having been fitted with a contact lens following some form of ocular trauma from 1994 to 1999. Case notes for 67 of these patients were available for review. Results: The ratio of males to females presenting for contact lens fitting was 4: 1, with each eye being affected almost equally (R eye: 47.8%; L eye: 52.2%). Penetrating injuries were the most common type of injury accounting for 65.7% of all recorded injuries. Aphakia was the most fl~equent outcome, occurring in 55.2% of patients, followed by corneal scarring (38.8%). RGP contact lenses were fitted to 37.3% of patients, soft
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Moorfields Eye Hospital, City Road, London EC1V 2PD
Does contact lens wearing influence personality?

P GheUer Common clinical observations seem to support the notion that the use of spectacles (Sp) or contact lenses (CL) can influence some psychological traits of patients. To evaluate this clinical observation, it was tested in a group of 53 subject (25 males, 28 females). Between them, 30 subjects were wearing spectacles (15 male, 15 females) and 23 (10 male, 13 females) were comfortably wearing CL for at least I year and for more than 12 h daily; conjunctival or corneal reactions were within normal limits. The age was between 20 and 75 years (average 46 years). The refractive errors were between -10.00 D and -36.00 D (average -17.50 D), with a corrected visual acuity ranging from 20' to 1.4' MAR (Sp group) or from 6.6' to 1' MAR (CL group). They were evaluated with Cattelis 16 Personality Factor Test type C (PFTC). The results obtained were compared with those obtained from a control group (28 subjects, range 22-70 years, average age 40 years). Bearing in mind that the small sample does not allow generalisation, the results obtained indicate that the use of CL, probably through a variation of the perceived environment, influence various personality factors.
Conclusions: Digital image technology is a rapidly advancing field. Digital photography offers a convenient, simple, rapid and accurate means of observing and recording anterior segment compfications and greatly assists practitioners in the management of patients within both primary care and research environments.

CCLR, School of Optometry, University of Waterloo, Waterloo, Ontario N2L 3G1, Canada
The oxygen transmissibility profile of siloxane hydrogel contact lenses

R Grant New siloxane hydrogel contact lenses have enabled considerable leaps in the oxygen transmission capabilities of soft contact lenses. However, the numbers cited for oxygen transmissibflity are calculated from the central thickness of a - 3 . 0 0 D lens, which gives the highest number. This does not take into consideration the transmissibility across the rest of the surface, which is dependent on the design of the lens. Silicone hydrogel lenses, and for comparison, a widely used ordinary hydrogel lens were sectioned and the thickness measured over the diameter of the lens using a high resolution microscopic measurement technique previously described. ~ The thickn e s s e s w e r e u s e d to p r o f i l e t h e o x y g e n transmissibility perpendicular to the posterior surface of the lenses across the whole lens surface, and this is presented graphically. The mean of this value, based on harmonic mean lens thickness 2 and the manufacturer's cited Dk, was 139.1, 74.8 and 22.2x 1 0 9 barrers/cm for the two lenses tested and ordinary soft lens control respectively. The maximum transmissibility at the thinnest part of the lens was 191.8, 101.5 and 32.710 9 barrers/cm respectively. Oxygen transmission with the new sfloxane hydrogel lens has been increased by a factor of approximately six times over the standard hydrogel lenses for both central and mean values, making it possible to satisfy even the most stringent estimates of the oxygen requirements for contact lenses during sleep. References:

Via Cherubini 8, 1-40125 Bologna, Italy
Recording of contact lens complications using digital image technology

D Jones, L Jones, K Dumbleton and N Pritchard Purpose: Clinical decision making concerning contact lens complications, particularly with respect to their change across time, can be greatly improved when supported by images of the ocular complication in question. With the advancement of modern technology, it is now possible to capture and store images in a variety of ways. One such method is by means of a digital camera mounted to a slit lamp. Methods: A high definition imaging system based on a Kodak DCS420 digital camera was used to obtain images of complications presenting to the authors within the Centre for Contact Lens Research. All conditions are commonly seen in clinical practice. Results: This poster will photo-document the cases observed. Each case will be succinctly described, a photograph presented and the method of management outlined.
1 Grant R. The influence of front surface geometry on oxygen delivery for soft contact lenses. Conference abstract. Contact Lens & Anterior Eye, 22, 145 (1999). Sammons W.A. Thin lens design and average thickness. J. Br. Contact Lens Assoc., 4, 90-97 (1981).

CIBA Vision Nordic AB, Datav~igen 24, S-436 32 Asldm, Sweden
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A comparison of on-eye performance and patient assessment of the Bausch & Lomb PureVision Lens and CIBA Night and Day Lens when worn on a 7-day EW cycle for one m o n t h DJ Siegel and J Spilkin Sixty subjects were enrolled in a 1-month extended wear evaluation comparing Bausch & Lomb PureVision and CIBA Focus Night & Day lenses. The PureVision lenses resulted in a statistically significant greater number of acceptable fits compared to the Night & Day lenses. The most common reason for unacceptable fits with the Night & Day lenses was edge fluting. None of the PureVision lenses resulted in unacceptable fits. At the Insertion Visit, the Night & Day lenses exhibited statistically, though not clinically, significant greater movement that the PureVision lenses. At the 1-day Visit, the PureVision lenses exhibited statistically better lens fitting characteristics and the Night & Day lenses exhibited significantly greater lens deposits. At the 1-month Visit, the Night & Day lenses exhibited significantly more mucin balls compared to PureVision. There were no statistically significant differences noted between the two lenses with respect to logMAR visual acuity, lens decentration, corneal staining, limbal injection or epithelial microcysts. No corneal infiltrates were observed with respect to either the PureVision or Night & Day lenses. Patient subjective assessments indicated that the PureVision lenses provided better comfort, greater overall satisfaction and marginally less dryness, especially at the initial study visits, compared to Night & Day. Silicone hydrogel material technology provides an opportunity for practitioners to re-visit extended wear. Differences between silicone hydrogel lenses, surface properties and lens design may account for performance differences measured in this study. Address for Correspondence Bausch & Lomb, PO Box 450, 1400 North Goodman Street, Rochester NY 14603-0450, USA
week of contralateral wear. Objective measures of Snellen VA, lens fit and subjective measures of overall comfort, overall vision, and overall handling were taken at dispensing and after I week of wear. Results: Snellen VA at the 1 week visit of 20/30 or better was achieved for all eyes. Overall fit at 1 week was acceptable for all lenses except in 1 eye wearing a 1-Day Acuvue in which fit was judged unacceptable. Subjective comfort, vision, and handling at dispensing averaged 8.6, 8.3, and 7.8, respectively, for Focus DAILIES and 7.0, 7.9, and 6.9, respectively, for 1-Day Acuvue. A statistically significant difference was found for comfort (P=0.0156, Wilcoxon sign rank test). Subjective comfort, vision, and handling at 1 week averaged 8.1, 8.8, and 8.0, respectively, for Focus DALLIES and 7.1, 8.2, and 7.1, respectively, for 1-Day Acuvue. No statistically significant differences were found between any subjective grades at 1 week (Wilcoxon sign rank test). Conclusions: Although Focus DAILIES and 1-Day Acuvue plus power lenses deliver similar measured VA and fit performance, patients may tend to be more satisfied with the comfort, vision, and handling of Focus DAILIES. Future investigations with larger numbers of patients may substantiate these results. Address for Correspondence CIBAVision Corporation, 11460 John's Creek Parkway, Duluth, GA 30097, USA
In-practice experience through 6 months with a lotrafilcon A high Dk soft contact lens B Long, T Grant and SR Robirds Product development, safety, and effectiveness data with high Dk lenses have been widely reported. Practical clinical experience is needed to demonstrate the performance and acceptance of this new generation of extended wear materials. Purpose: The purpose of this study was to gain experience with the lotrafilcon A (Focus NIGHT & DAY) lens in day-to-day practice. Method: Fifty-.six (56) practitioners in five countries (Mexico, Spain, Argentina, Brazil, Australia) dispensed lenses to 548 patients. Follow-up visits were at 1 week, 1 month, and 3 months with an optional 6 month visit. Clinical and patient subjective data were collected at each visit. Results: The patient sample consisted of 63% female, 37% males of average age 29.8_+10.0 years, 84% were experienced contact lens wearers, 16% were new wearers. At the 3 month visit practitioners recommended extended wear for 94% of their patients (87%
An objective and subjective clinical comparison of two daily disposable plus power lenses B Long, J Nick and M Reichner Plus powers of Focus DAILIES one-day contact lenses have been launched recently. Previous studies of minus power Focus DALLIES lenses found them to have better clinical performance and wearer preference than other daily disposable lenses. The purpose of this study was to evaluate the objective and subjective performance of Focus DAILIES plus powers in a 1 week dispensing study against 1-Day Acuvue. Method: Sixteen adapted contact lens wearers were dispensed Focus DAILIES plus and 1-Day Acuvue for a
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30 NEW, 3% 6 NEW, 4% mixed EW). At the 6 month visit, 94% of patients reported that they wore the lens for extended wear (79% 30 NEW, 8% 6 NEW, 7% mixed EW). Visual acuity was better than or equal to 20/25 for 95% of all eyes at all visits; lens fitting was judged as optimal or acceptable for 99% of all eyes at all visits. Average biomicroscopy was 0.1 ( 0 - 4 scale) with all signs averaging 0.2 or lower at 6 months. Minimal and acceptable deposits were reported. Patient comfort, subjective vision, and handling averaged better than 9.0 (0-10 scale) at 6 months. A success rate of 82% was noted at 6 months. No microbial keratitis was reported. Conclusions: Practitioners recommended and patients wore the lotrafilcon A lens for extended wear for 30 NEW. Patients rated comfort and overall satisfaction high and ocular health was maintained.
Address for Correspondence CIBAVision Corporation, 11460 John's Creek Parkway, Duluth, GA 30097, USA
conjunctival tissue anomalies. Hence the assessment of the conjunctiva with vital stains should be included in the investigation of any patient complaining of dry eye. Further because of the partial correlation between significant sodium fluorescein and lissamine green staining both vital stains should be used.
Address for Correspondence Contact Lens Research Consultants, 42 VauxhaU Bridge Road, Pimlico, London SWIV 2RX
Surface epithelial cell size m e a s u r e d in vivo using confocal microscopy is an underestimate of size measured with contact lens cytology F Stapleton, IJalbert, E Papas, S Kasses and B Holden
Purpose: The purpose of this study was to compare surface epithelial cell size measured using two in vivo techniques: confocal microscopy and contact lens cytology. Methods: Seven non-contact lens wearers were assessed. Using a slit scanning confocal microscope and automated image analysis, surface epithelial cell nuclei were identified. Average distance to closest neighbour was calculated as an estimate of epithelial cell size. Epithelial cells were harvested by contact lens cytology and were stained using acridine orange and ethidium bromide. Cells were visualised by fluorescent microscopy and length of longest cell diameter was determined. Results: The average distance to closest neighbour was significantly smaller than the corresponding average length of the longest cell diameter (P< 0.05). Measurements of nearest neighbour distance taken from confocal images did not correlate with contact lens cytology results (r=0.07; P > 0.05). A plot of the mean versus the difference between the two methods indicated that differences increased with cell size. Confocal microscopy tended to underestimate cell size.
Conjunctival characteristics of contact lens wearers and non wearers and their association with symptomatology K Girard-Claudon, M Guillon, C Maissa and P Cooper
Introduction: Recent evidence suggests that conjunctival anomalies significantly influence dry eye symptomatology. The purpose of the current investigation was to characterise conjunctival staining and test its influence on symptomatolog2 for both soft contact lens wearers (SCLW) and non-wearers (NonW). Methodology: Conjunctival staining was assessed on a five-point scale with sodium fluorescein and lissamine green independently in :four quadrants and the median and maximum values reported. Symptomatology was quantified with the McMonnies questionnaire.
Results: The investigation carried out on 102 SCLW and 79 NonW revealed low incidences of clinically significant Conclusions: Estimates of surface epithelial cell size staining (Grade 2 or higher) for both groups with, using confocal microscopy are smaller than the size of however, more staining for the SCLW group (P< 0.05). cells sampled using contact lens cytology. Reasons for In both groups staining was significantly greater for the this may include image analysis technique and differsymptomatic subjects (P< 0.05). The difference in the ences in the morphology of sloughed versus resident incidence of grade 2 staining or higher between cells. asymptomatic and symptomatic subjects was greater for lissamine green (SCLW 5.1% vs. 18.2%; NonW 5.4% vs. Address for Correspondence 25.0%) than for sodium fluorescein (SCLW 7.9% vs. 14.8%; CRC for Eye Research Technology, School of OptomeNonW 1.5% vs. 12.5%). Sodium fluorescein and lissamine try, UNSW, Sydney, NSW 2052, Australia green stainings were statistically correlated (SCLW r=0.753, P < 0.001; NonW r=0.693, P < 0.001). Clinically, however, a significant number of cases were found to Tear microsphere (TMS) with high Dk lenses produce significant staining with only one vital stain. D Sweeney, J Tan, L Keay, IJalbert and B Holden Conclusion: Ocular dryness symptomatology is associated with an increased incidence of significant Purpose: Tear microspheres (TMSs) also referred to as pre-corneal deposits, 'lipid plugs', or 'mucin bails', have
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been observed in low numbers with soft and RGP contact lens wear. We compared the incidence of TMSs between low Dk (group IV) and high Dk (group I) hydrogel lenses during extended wear. Method: One hundred and fifty-three subjects were randomly assigned either the low Dk 6N EW (n=77) or the high Dk 30N CW (n=76) lenses bilaterally. TMSs were observed using a biomicroscope (16 x ) as small (10 to 50 microns) spheres trapped between the lens and the cornea. They were seen to be adherent to the cornea until soon after lens removal leaving small, fluorescein filled indentations. The number of TMSs was counted at baseline, 1 week, 1, 3, 6, 9 and 12-month visits. Results: A significantly higher number of TMSs (P< 0.05) were found in the high Dk lens wear group (mean for all visits, 14 + 26) compared to low Dk (5 + 4) lenses at all visits except 12 month EW visit (P< 0.05). No relationship could be found between TMSs and any adverse events. Conclusions: High Dk lenses produced a higher incidence and number of TMSs than the low Dk lenses. We are investigating the hypothesis that they are lipid encapsulated mucin and proteinaceous material resulting from a 'shearing' interaction between the lens, tear film and ocular surface which especially occurs with high Dk lenses. This could be related to the higher lens modulus of elasticity or surface properties of the high Dk materials. TMSs do not apparently cause any clinical adverse effects. Address for Correspondence CCLRU, School of Optometry, UNSW, Sydney, NSW 2052, Australia
the PureVision lenses. Observations of lens surface deposition and posterior lens debris were slightly more frequent with the test lenses. Patient assessments of comfort, dryness and handling favoured PureVision, assessments of visual quality were similar for test and control lenses. The 123 patients that completed the 12month study completed a forced choice preference questionnaire at the exit visit. PureVision lenses were strongly favoured in all categories including a 9:1 overall preference. Silicone hydrogel technology is a significant step forward for the soft contact lens industry allowing the benefits of high oxygen permeability to be delivered in a low water content contact lens. Address for Correspondence Bausch & Lomb, Inc., 1400 N Goodman Street, P O Box 450, Rochester, NY 14603-0450, USA
I can see clearly n o w . . , correcting the low cylinder astigmat with toric lenses R Potvin and T Comstock With the advent of high quality disposable toric soft contact lenses, patients can now be fitted with astigmatic correction and have the same convenience offered by single vision spherical lenses. A recent international marketing survey of more than 3000 astigmats included responses from over 800 patients who were previously wearing spherical contact lenses. Of these, 90% of respondents subjectively reported more crisp, clear vision in toric lenses, while 10% preferred their previous spherical correction. To investigate these findings, a study was conducted in which low cylinder astigmats (contact lens cylinder < - 1 . 0 0 D) were enrolled in a 2-week crossover comparing spherical correction to toric correction. Best corrected visual acuity (high and low contrast, and low illumination at distance, high contrast at near) in spectacles and contact lenses was measured, along with comfort and subjective vision ratings. Visual performance was measured with a dynamic near computer task. Statistically-significant improvements in visual acuity and visual performance were measured, including a one-line improvement in logMAR high contrast distance visual acuity. Two-thirds of the subjects preferred the toric correction, all citing better vision as the main reason for their preference. Higher analog visual quality scores were given to tile toric lenses on insertion and after 1 week. There was no significant difference in lens comfort. These data suggest that a majority of low cylinder astigmats would enjoy improved visual quality with no decrease in lens comfort if fitted with disposable toric soft contact lenses. Address for Correspondence Bausch & Lomb, 1400 N Goodman Street, P O Box 450, Rochester, NY 14603-0450, USA
One-year prospective clinical trial of balafilcon A (PureVision) soft contact lenses when u s e d on a 30-day continuous wear schedule TL Comstock, T Crescuillo, D Dey and L Scheurich Advancements in soft contact lens material technology have resulted in the introduction of silicone-hydrogel soft contact lenses for 30-day continuous wear into the European market. Two hundred and twelve patients were entered into this multi-national clinical trial by eight investigators. All patients were fitted with PureVision lenses on one randomly selected eye and with Acuvue lenses on the contralateral eye. PureVision (test) lenses were worn on a 30-day continuous wear modality and were replaced monthly. Acuvue lenses were worn on a 7-day continuous wear modality and were replaced biweekly. Reports of epithelial oedema and neovascularization were virtually non-existent for both test and control lenses. All other slit lamp observations generally thought to be related to corneal hypoxia were less frequently reported in eyes wearing
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The corneal swelling and recovery response to contact lens-induced oedema in diabetic patients C O'Donnell and N Efron
Purpose:
videokeratoscopy performed on a 56 year old male, 3 years after an episode of AK in the left eye.
Methods: In-vivo slit-scanning real time confocal microscopy was performed (Tomey ConfoScan, Erlangen, Germany) using an Achroplan 40x/0.75 immersion objective on both eyes. Video frames containing all corneal layers were digitised and analysed both qualitatively and where possible quantitatively.
To see if there is any difference in corneal physiology between diabetic and non-diabetic patients.
Methods:
A single-masked controlled experiment was conducted to investigate the acute swelling and recovery response to corneal hypoxia in 23 diabetic patients (Type I n=20, Type II n=3; mean age 31.5-+ 10.6 years) and 23 non-diabetic control subjects (mean age 27.9-+ 10.1 years). The mean duration of diabetes was 14.0_+8.6 years. Six patients exhibited mild-moderate non-proliferative diabetic refinopathy, the remaining patients had no detectable eye disease. Measures of corneal thickness, endothelial cell density and corneal sensitivity were obtained. Corneal oedema was induced with a thick hydrogel contact lens (Dk/t=3.1) worn under closed-eye conditions for 2.5 h. Pachometry was repeated at regular intervals and the per cent recovery per hour (PRPH) calculated.
Results: No differences in corneal thickness (diabetic 543.8_+35.6 vs. non-diabetic 541.4+39.1 microns)
(t=-2.24, P=0.82), endothelial cell density (diabetic 3335 vs. non-diabetic 3497 cells/ram 2) (t=1.27, P=0.21) or corneal sensitivity (diabetic 4.85+1.1 vs. nondiabetic 5.0+1.1) (t=0.47, P=0.64) were observed between the groups. The per cent net-induced corneal oedema in the diabetic patients was less than that in the non-diabetic control subjects (diabetic 7.3+3.1 vs. non-diabetic 9.8-+2.4 per cent) (t=3.01, P=0.004). The rate of corneal de-swelling (PRPH) was faster in the non-diabetic subjects (diabetic 4.7_+ 1.6 vs. non-diabetic 5.6+1.5 per cent) (t=1.92, P=0.06); however, recovery to baseline corneal thickness occurred within 3 h in all subjects.
Conclusions: The experimental conditions are thought to mimic a worse-case scenario for contact lens wearers. The results do not identify any obvious problems arising in diabetic patients using thinner design hydrogel contact lenses on a daily wear basis.
The superficial and basal epithelial cells were easily imaged in both eyes. Anterior central stromal keratocyte cell density was recorded as 1104 cells/mm 2 in the right eye whereas no viable keratocyte nuclei could be imaged in the anterior stroma of the left eye. Instead a highly-reflective layer with scattered microdots and linear features was recorded. Posterior central stroma keratocyte cell density was similar in both eyes (RE 672 cells/mm ~ vs. LE 673 cells/mm2). Endothelial cell density did not differ significantly between the two eyes (RE 2581 cells/ram 2 vs. LE 2348 cells/ruraL Videokeratoscopy revealed 0.75 D of with-the-rule astigmatism RE and 7.50 D of irregular corneal astigmatism LE. A rigid gas permeable contact lens (Apex design 8.10:12.00+2.25 D) enabled the left eye to achieve visual acuity of 6/7.5.
Results: Conclusions: Slit-scanning confocal microscopy provided a useful insight into the cellular organisation of the cornea following A_K, with the posterior corneal layers appearing relatively normal. Although acanthamoeba cysts and trophozoites can often be imaged in the cornea during infection, these were not observed in this patient. Confocal microscopy allowed imaging of the posterior corneal layers despite the presence of corneal haze and therefore offers advantages over conventional biomicroscopy and specular microscopy.
A case study of advanced Fuch's endothelial dystrophy using the confocal microscope J Hollingsworth, N Efron and A B Tullo
Purpose: To use a confocal microscope to examine the
Confocal microscopy of the cornea after acanthamoeba keratitis C O'Donnell and N Efron
Purpose: Acanthamoeba keratitis (AK) is a rare but
various corneal layers of a patient with advanced Fuch's Endothelial Dystrophy (FED). A 79 year old male patient with advanced bilateral FED was examined. The right eye is decompensating and he is awaiting penetrating keratoplasty. An in-vivo slit-scanning real-time confocal microscope (Tomey ConfoScan P4, Erlangen, Germany) fitted with an Achroplan 40 /0.75NA immersion objective was
Methods:
potentially devastating corneal infection. Approximately 15% of patients with AK experience severe loss of vision. We report here the results of confocal microscopy and
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used to examine the central corneas of patient AS at 680 magnification. Video images of the basal cell layer, Bowmans layer, anterior stroma, posterior stroma, Descemet's membrane and the endothelium were captured and analysed; these were compared with those of an age- and sex-matched control.
tally in all three eyes. Dark bands were seen at the level of the posterior stroma in all three eyes.
Results: The basal epithelial cells can be seen much more distinctly in the RE of AS which is decompensating. Cell borders are thickened and more distinct. The basal epithelium of the LE of subject AS appears similar to that of the normal control. Bowman's layer, the anterior and posterior stroma, and Descemet's appear hazy in the eyes with FED. Dark bands were observed in the posterior stroma of both eyes of subject AS, but not in the control eyes. The endothelium appears abnormal in both eyes of subject AS, displaying an apparently convoluted surface topography. Confluent guttata are evident. Conclusion: Advanced FED is associated with changes to the cornea as viewed with the confocal microscope which may be related to the presence of extensive corneal oedema. Slit scanning confocal microscopy has revealed valuable new insights into the pathophysiology of FED.
Discussion: There appears to be a slight trend towards a reduced anterior KCD in the keratoconic eyes whilst the posterior KCD and ECD seem unaffected by keratoconus. Accurate image analysis was difficult in the most severe case of keratoconus because of poor image quality due to corneal scarring. The dark bands seen in the posterior stroma are consistent with slit lamp findings of Vogt's striae. Conclusions: Confocal microscopy is a potentially useful tool in monitoring changes in the keratoconic cornea.
Lymphangiectasis - a case report CA Woods
A case study of keratoconus using a confocal microscope J HoUingsworth, I Perez-Gomez and N Efron
This poster presents a pictorial case report on the condition spontaneous lymphangiectasis. This condition is benign and does not have any pathogenic origin. Ms A presented for a routine contact lens after care - she was asymptomatic regarding her contact lens wear and unaware of any ocular changes. During the routine slit lamp examination it was observed that the conjunctiva of the right eye had a vascular network filled with a transparent fluid that was absent of red blood cells lymphangiectasis. This condition self resolved after 2 days and was not a contra-indication for Ms A to continue with contact lens wear.
Address for Correspondence Victorian College of Optometry, Cns of Keppel and Cardigan Sts, Carlson 3053 Victoria, Australia
Purpose: To gain new insights into the pathophysiology of keratoconus. Methods: An in-vivo slit-scanning real-time confocal microscope (Tomey ConfoScan P4, Erlangen, Germany) fitted with an Achroplan 40 /0.75NA immersion objective was used to examine the central corneas of three keratoconic eyes of different patients at 680 magnification. Eyes 1, 2 and 3 were diagnosed as having keratoconus 12, 96 and 180 months ago, respectively. This was then compared with age matched controls. Results: The following features were measured in eyes 1, 2 and 3, respectively- anterior stromal keratocyte cell density (KCD): 806, 912 and [unable to measure due to stromal scarring] cells/ram2; posterior stromal KCD: 528, 696 and 698 cells/ram2; endothelial cell density (ECD): 3105, 2968 and 2905 cells/mm 2. The results obtained for the age matched control were: anterior stromal KCD 1064.33 cells/ram 2, posterior stromal KCD 618.67 cells/mm 2 and ECD 3079.16 cells/ram 2. Images of Bowman's layer showed nerves organised horizonContact Lens and Anterior Eye
Precision and accuracy of different grading scale systems for assessing the severity of contact lens complications N Efron, S Katsara and P Morgan
Purpose: Four comprehensive sets of grading scales ('systems') have been developed over the past decade for assessing the severity of contact lens-related ocular pathology. Two of these systems are photographic (CCLRU, 1996 and Andersen et al, 1996) and two are artist-rendered (Annunziato et al, 1992 and Efron, 1997). These grading scales illustrate various conditions in levels of severity from 0 (normal) to 4 (severe). The aim of this study was to determine if there are differences between the four systems with respect to grading precision (test-retest repeatability) and accuracy (between-scales grading scores).
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Methods: Only three complications are common to all four systems: corneal staining, conjunctival redness and papillary conjunctivitis. Thirteen subjects graded 30 images (to the nearest 0.1 increment) of each of these three complications using the four systems; this procedure was repeated 2 weeks later, yielding a data base comprising of 9360 grading estimates. Results: Significant between-subject and betweensystem differences in grading accuracy were revealed (ANOVA; P < 0.0001); however, there were no betweensystem differences in grading precision. The mean grading precision for all systems was approximately 0.7; that is, a difference or change in grading estimate of approximately 0.7 grading scale units is statistically significant. This compares with the essential design feature of all grading scales that a difference of 1.0 scale units is clinically significant. Conclusions: When communicating or comparing grading scores, clinicians should be aware that some individuals tend to grade higher or lower than others. Also, estimates of severity made with the different grading systems are not readily interchangeable, meaning that, for example, clinicians in group practice should all use the same system. Clinicians are encouraged to use grading scales as part of their routine contact lens practice so as to foster a disciplined and consistent approach to clinical decision making and record keeping. Address for Correspondence Eurolens Research, Department of Optometry & Neuroscience, UMIST, P O Box 88, Manchester, Lancs M60 1QD
apparent reduction in keratocyte cell density (lenswearing eye 21%; control eye 10%; P < 0.05). Folds were observed with the slit lamp biomicroscope, and long, straight, dark, orthogonal lines were observed with the confocal microscope, in the posterior stroma of the lens wearing eyes. Such features were not observed in the control eyes. The appearance of keratocytes appeared less distinct with greater levels of corneal oedema.
Conclusion: The apparent loss of keratocytes following overnight lens wear can be explained primarily in terms of corneal oedema causing (a) volumetric tissue expansion, and (b) a loss of optical clarity which hampers keratocyte detection. This data challenges previous suggestions that contact lens wear causes keratocyte cell death, and places the onus on researchers postulating such phenomena to account for the effects of oedema. Address for Correspondence Eurolens Research, Department of Optometry & Neuroscience, UMIST, P O Box 88, Manchester, Lancs M60 1QD
Grading scales for corneal oedema viewed with confocal microscope HA Mutalib and N Efron Purpose: To aid the interpretation of confocal microscopic images of structural changes to the cornea in response to contact lens wear, a set of reference images (grading scales) was constructed of the various corneal layers at known levels of oedema. Methods: Corneal oedema was induced by having 13 subjects sleep overnight wearing a disposable contact lens in one eye and no lens in the other eye. Images of all layers of all corneas were obtained at 680 magnification using an in-vivo slit-scanning real-time confocal microscope (Tomey ConfoScan P4, Erlangen, Germany) fitted with an Achroplan 40 x/0.75NA immersion objective. The thickness of all corneas was measured immediately following confocal microscopy using an ultrasonic pachometer (Model 850, AllerganHumphrey, USA). Results: A set of grading scales was constructed from the best available images at representative levels of oedema. Specifically, these images depict the basal epithelium, anterior stroma, posterior stroma and endothelium at each of five levels of oedema, ranging from 0% to 14%. Inspection of the confocal images reveals the following features: (a) borders of basal epithelial cells become more clear with increasing oedema, (b) ketatocytes in the anterior and posterior stroma appear to decrease in number and become less distinct with increasing oedema, (c) dark, straight
Confocal microscopy of the oedematous cornea following overnight lens wear N Efron, H Abdul Mutalib, K Hui Hiang and I Perez Gomez Purpose: To employ confocal microscopy to observe morphological changes in the oedematous human cornea with a view to explaining previous reports of apparent keratocyte cell death induced by contact lens wear. Method: Slit lamp biomicroscopy, slit-scanning confocal microscopy and ultrasonic pachometry were performed on both eyes of 13 subjects (3M, 10F, age 24 + 3 years) before and after 8 h overnight wear of a - 3.00 D Bausch & Lomb one day disposable lens (Dk/ t=15.1 10 -9 (cm/s) (ml02/ml mmHg) in one eye; the other non-lens-wearing eye acted as a control. Results: Following sleep, both corneas were swollen (lens-wearing eye 11.8+3.8%; control eye 2.1-+1.9%; P < 0.05) and the stroma of both corneas displayed an
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orthogonal lines appear in the oedematous posterior stroma, and (d) endothelial cell borders become less clear with increasing oedema.
Conclusion: This set of grading scales, comprising confocal images of various corneal layers at known levels of oedema, will provide a useful reference for researchers and clinicians employing this technique to study the ocular response to contact lens wear.
A case study of corneal guttata using a confocal microscope I Perez-Gomez, J HoUingsworth and N Efron
Purpose: To gain new insights into the pathophysiology of corneal guttata. Methods: An in-vivo slit-scanning real-time confocal microscope (Tomey ConfoScan P4, Erlangen, Germany) fitted with an Achroplan 4 0 x / 0 . 7 5 N A immersion objective was used to examine the central corneas of a patient with corneal guttata (BJ) and a normal age- and sex-matched control subject (JD) at x 680 magnification. BJ was diagnosed as having corneal guttata before cataract surgery 15 years ago. Following surgery, the cornea of the left eye began to decompensate, but resolved without treatment. The thickness of the central cornea of both eyes of BJ was measured using ultrasound pachometry (Model 850, Allergan-Humphrey, USA). Results: Posterior stromal keratocytes cell density (KCD) was higher in BJ (R 720, L 656 cells/ram 2) than in JD (R 608, L 576 cells/ruraL Vertical dark bands were seen in the LE of BJ. Endothelial cell density (ECD) was lower in BJ (R 2549, L 904 cells/ram 2) than in JD (R 2951, L 2934 cells/mm~). Guttata were more frequent and confluent in the LE of BJ. There was a similar amount of polymegathism in all four eyes. The central thickness of the corneas of BJ were R 538, L 528 microns. Conclusions: The prevalence of guttata and lower ECD in the LE of BJ could have resulted from corneal decompensation following surgery. The dark bands seen in the LE of BJ could correspond to the slit lamp appearance of stromal folds. Both corneas of BJ appeared to be of normal thickness despite the presence of guttata and a lower ECD. Confocal microscopy is capable of providing interesting new insights into the pathophysiology of corneal guttata.
Corneal keratocyte and endo cell density in a normal human population HA Mutalib, I Perez Gomez, J HoUingsworth and N Efron
Purpose: To document and quantify changes in corneal keratocyte cell density (KCD) and endothelial cell density (ECD) with age, so as to provide normative information against which pathophysiological alterations to these features can be gauged. Methods: Images were obtained from 100 normal corneas (50 subjects; age range 11-79 years) using an in-vivo slit-scanning real-time confocal microscope (Tomey ConfoScan P4, Erlangen, Germany) fitted with an Achroplan 40 /0.75NA immersion objective, giving 680 magnification. Images of keratocyte cells in the anterior and posterior stroma and endothelial cells were semi-antomatically analysed in an observer-masked, randomised manner. Inter-observer and intra-observer variability in cell analysis was assessed by having each of three observers undertake repeated analyses on selected images. Results: Strong inter-ocular correlations were revealed for both KCD and ECD (P<0.001). Anterior KCD correlated strongly with ECD (P<0.001). Significant negative correlations were found between anterior KCD, posterior KCD, and ECD vs. age (all P < 0.001). Inter-observer differences (P< 0.89) and intra-observer differences (P< 0.86) in estimates of cell density were insignificant. Conclusions: The observation of a reduction in ECD with age confirms the results of earlier studies. The apparent reduction in anterior and posterior KCD with age, and the correlation of KCD and ECD, are new findings which will necessitate a re-evaluation of models of corneal ageing. High between- and withinobserver repeatability in KCD and ECD analysis validates the measurement techniques employed in this study.
The clinical performance of the Quasar toric lens manufactured by means of a novel process E Atkin, P Morgan and T Hough
Purpose: In general, toric rigid contact lenses are manufactured using a crimping procedure during
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lathing. This method requires skilled technicians and limits the geometry of the lens surface to being spherical in the principal meridians. The purpose of this study was to investigate the short-term clinical performance of toric rigid lenses having aspheric (Quasar) geometry which were manufactured using the newly-available Variform attachment to the Taylor Hobson Optoform lathe; the use of this technology in this fashion was a novel process.
Hydration changes of Acuvue, Proclear and Resolution 55G lenses during 8 hours of
wear
N-M Quesnel, M-C Barrette, M-J Perreault, I Rouleau, M Thibodeau and C Giasson
One reason for discontinuation of soft contact lens wear is excessive lens dehydration, which can compromise the cornea and conjunctiva through reduced lens movement, tear debris entrapment and reduced corneal oxygenation. According to the manufacturer, the Proclear (Omafilcon A, Biocompatibles) and the Resolution 55G (Benz G, Laboratoires Opti-Centre) lens materials exhibits less dehydration than other materials of similar water content.
Methods: Twenty-one eyes from 15 subjects were fitted empirically in random order with (a) an aspheric-based toric lens manufactured by means of the novel process and (b) with the equivalent spherically-based toric lens manufactured using conventional methods. The following clinical parameters were measured using retrospective video analysis: vertical lens movement following a blink, horizontal and vertical centrafion, lens rotation following a blink, high and low contrast logMAR visual acuity. Subjective scores of comfort and vision were also recorded. Results: Vertical lens movement was similar for the two lens types (new lens +0.53 + 0.72 mm; conventional lens +0.61 + 0.73 ram; P=0.6206). Vertical lens centration was different for the two lenses (P=0.0087) with the new lens fitting slightly superiorly on average (+0.36 + 0.75 ram) and the conventional lens fitting slightly inferiorly (-0.15+0.89 mm). There was no difference in horizontal centration, with both lenses tending to sit slightly nasally (new lens - 0.07 + 0.52 ram; conventional lens 0.19+0.63 ram; P=0.3009). Rotation on blinking was similar for the two lenses (new lens +0.7_+ 8.6 degrees; conventional lens +0.5+9.1 degrees; P=0.6514). High contrast acuity was similar for the two lenses (new lens +0.02 + 0.15; conventional lens +0.04 + .013; P=0.4906), but low contrast acuity was better with the new lens (+0.17+0.14) than with the conventional lens (+0.23+0.16; P=0.0303). Subjectively, comfort was scored to be greater with the new lens (70.0_+ 17.3) compared with the conventional lens (55.0_+17.0; P=0.0004). Scores for vision were similar for the two lenses. Conclusions: The novel manufacturing p r o c e s s adopted for the lenses assessed in this work is likely to provide more reproducible lenses which can be manufactured more cost-effectively and efficiently than conventional methods. This study suggests that clinically, the new lenses perform similarly in terms of lens fitting characteristics and better than conventional lenses for comfort and low contrast visual acuity.
Purpose: This study was designed to compare the dehydration rate of the Proclear and the Resolution 55G lenses with another type of contact lens (Acuvue, EtaYilcon A, Vistakon) after 4, 6 and 8 continuous hours of lens wear. These lenses were chosen because they have similar nominal water content (58.1% for Acuvue, 58.9% for Proclear and 55% for Resolution 55G). Method: Fifteen hydrogel eligible contact lens patients randomly wore each lens studied in both eyes for the three periods of lens wear. Lenses were assigned randomly with both the investigator and patient masked. Lenses were soaked in a multipurpose contact lens solution (SOLO-Care, CIBAVision) for 24 h before insertion. The same solution was used throughout the experiment to clean and disinfect the lenses. Lens water content was measured @=3) using a hand-held Atago CL-1 soft contact lens refractometer before and after each period of wear. Results: The mean relative percentage dehydration for Proclear was similar to that of the Resolution 55G lenses after 4, 6 and 8 h of wear (1.2% for both lenses after 8 h). The Acuvue exhibited significantly more water loss compared to Proclear and Resolution after 4, 6 and 8 h of lens wear (5.7% compared to 1.2% after 8h). Conclusion: During a normal wearing period (8 h), Proclear and Resolution 55G lenses maintained a stable water content and dehydrate considerably less than Acuvue. Omafilcon A and Benz G materials could be beneficial for patients and particularly indicated for the ones complaining of dry eye symptoms.
Address for Correspondence School Optometry, University of Montreal, CP 6128, Succ. Centre-ville, Montreal, Quebec H3C 3J7, Canada
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Surface physio-chemistry and bacterial adhesion to contact lenses GM Bruinsma, HC van der Mei and HJ Busscher
A possible risk factor for contact lens-associated microbial kerafitis may be the adherence of bacteria to the lens surface. The physio-chemical properties of the bacterial cell surface as well as of the lens surface, like hydrophobicity and zeta potential (ZP), are both involved in adhesion. In this paper, cell surface hydrophobicity Coy water contact angles, WCA) and ZP of six bacterial strains isolated from infected eyes were determined. In addition, we have evaluated the adhesion of a clinical strain of P. aeruginosa to PureVision and Acuvue lenses in the presence and absence of an adsorbed tear film. Water contact angles on bacterial lawns ranged from very hydrophobic (P. aeruginosa #3, WCA 132 ) to very hydrophilic (S. liquefaciens MH, WCA 15). Zeta potential of the bacteria in 0.9% NaC1 ranged from - 1 6 mV for S. liquefaciens MH to - 2 mV for S. aureus 799, indicating that electrostatic interactions play a minor r61e in their adhesion. In the absence of a tear film, initial adherence rates of P. aeruginosa #3 was 14 times greater to Acuvue lenses (1142 cm 2s 1) when compared with PureVision lenses (80 cm -2 s 1). PureVision lenses with an adsorbed tear film continued to show a low level of adherence of P. aeruginosa #3 (74 cm -~ s 1) when compared with Acuvue lenses with an adsorbed tear film (268 cm 2s 1). This study demonstrates the low in vitro adherence of P. aeruginosa to PureVision lenses and the importance of physico-chemical surface properties in bacterial adhesion to contact lenses.
tear-film break-up time, dry eye symptoms, corneal epithelial staining and patency of the lacrimal system. A grading scale was used at the initial and all follow-up visits to quantify signs and symptoms. Key parameters included visual acuity, biomicroscopy, fluorescein and rose bengal staining, tear break-up time, plus visibility, and lacrimal patency. Patients were seen at a qualifying visit and at the following intervals thereafter: 1 day, 1 week, 2 weeks, 6 weeks, and 3 months.
Results: Significant decreases in symptoms (e.g., dryness, pain) and signs (e.g. conjunctival vascular injection, corneal epithelial staining) were observed following implantation, and these reductions were sustained through Day 90. Following implantation, mean scores on five-point comfort scales (0=none; 4=severe) decreased from baseline for dryness (3 vs 1), burning/stinging (2 vs 0.5) and itching (2 vs 1). Mean tear break-up time increased from 5.6 to over 10 s. Temporal and inferior epithelial staining decreased while scores for the superior quadrant remained unchanged. Conclusions: These results indicate that this punctal device is a promising new option for treatment of dry eye problems Address for Correspondence UAB School of Optometry, Birmingham, Alabama, USA
Comparative cleaning efficacy and safety of a new multi-purpose disinfecting solution JM Stein, L Napier, RP Stone, D Keith and FD Turner Introduction: The use of multi-purpose solutions (MPSs) for complete care of soft contact lenses continues to grow. There has been an increasing need for a MPS with superior cleaning ability compared to marketed MPSs. A new multi-purpose disinfecting solution (MPDS) with enhanced anti-microbial activity has been developed and recently marketed. Purpose: This study was conducted to evaluate the cleaning efficacy and safety of the new MPDS compared with a marketed MPS. Methods: This was a 30-day, randomised, multi-site, patient-observer-masked study. Two hundred and twelve healthy, experienced, daily-wear Acuvue ~ lens wearers were enrolled at nine sites in the U.S. Patients were randomly assigned to either Regimen 1 [OPTIFREE express~; (OFX) MPDS with Aldox'ce] or Regimen 2 (ReNu ~ Multi-Plus ~ MPS). Patients used the products according to the approved label for 30 days and were evaluated three times. Patients wore one pair of lenses on a daily-wear basis for the duration of the study. Regimen safety was evaluated using slit-lamp findings and adverse events. Cleaning efficacy was
Address for Correspondence University of Groningen, Dept of BioMedical Engineering and Bioadhesion, Bloemsingel 10, NL-9712 KZ Groningen, Netherlands
Clinical evaluation of a liquid occlusion delivery service L Semes, J Greiner, J Schachet and AB Epstein Introduction: Occlusion of the punctum is commonly used to treat dry eye problems. A new investigational device delivers a metered dose of liquid matrix into the canaliculus at which point the liquid rapidly solidifies. The device is designed to be more convenient for practitioners to insert compared to currently marketed punctal occlusion products. Purpose: To determine the safety and efficacy of a new punctal occlusion medical device. This report summarises the 3-month data of a 24-month on-going study. Methods: Patients (n=26) enrolled in this multi-site study met inclusion criteria which included reduced
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determined by measuring residual lens lysozyme using high performance liquid chromatography (HPLC). Results: Lenses cared for with Regimen 1 had significantly less residual lysozyme (545.7 g) than those cared for with Regimen 2 (984.8 g; P<0.0001). In addition, the lysozyme level associated with use of Regimen 1 was substantially less than previously measured using the same methodology following the use of a variety of other MPSs. Signs and symptoms with Regimen 1 were minor and consistent with those observed in two previous clinical studies. Conclusions: Results indicate that the new MPDS provides superior cleaning efficacy compared to a popular MPS. This enhanced cleaning characteristic is accomplished without compromising ocular health.
Results: The results show that MPDS is bactericidal, fungicidal and amoebicidal against an extensive variety of environmental contaminants of lens care accessories and ocular pathogens. It is effective in killing a broadspectrum of micro-organisms. The log reductions produced by MPDS exceeded the primary test criteria for disinfecting products and the populations of other clinical and environmental isolates were reduced as well. Conclusions: MPDS is an effective disinfecting system against a broad-spectrum of micro-organisms.
Address for Correspondence Alcon Research Ltd, 6201 S Freeway, Fort Worth TX 76134, USA Evaluation of a multi-purpose solution with superior biocidal efficacy against ocular pathogens MJ Miller, D Callahan, SE Norton and R Manchester
We have evaluated the biocidal efficacy of ReNu MultiPlus Multi-Purpose Solution with two other commercially available multi-purpose solutions (Complete Comfort Plus and Solo-Care) and one multi-purpose disinfecting solution (Opti-Free Express with Aldox), and a hydrogen peroxide system (AOSEPT). These products were tested according to the current ISO Stand-Alone Procedure for Disinfecting Products. ReNu MulfiPlus Solution demonstrated excellent efficacy against a broad range of ocular pathogens including bacteria and fungi, a higher mean log reduction of Staphylococcus aureus and Serratia marcescens than OptiFree Express and AOSEPT, and a higher mean log reduction of Candida albicans and Fusarium solani than Complete Comfort Plus, Solo-Care and AOSEPT. The results of this study indicate that ReNu MultiPlus Solution provides exceptional disinfecting power and the convenience of a one-bottle system.
Address for Correspondence Alcon Laboratories, Inc., R6-35, 6201 South Freeway, Fort Worth TX 76134, USA Evaluation of a multi-purpose disinfecting solution with broad-spectrum antimicrobial activity RA Rosenthal, CL McAnally, LS McNamee, RL Schlitzer and RP Stone
Introduction: Contamination of contact lenses, lens cases and lens care products is associated with microbial keratitis. Improper lens care and noncompliance may lead to the development of this microbial contamination. An effective disinfection system should demonstrate antimicrobial effectiveness not only against laboratory strains of micro-organisms but organisms actually recovered from lens cases, microbial keratitis and the environment. For this reason an effective disinfection system should demonstrate antimicrobial activity against a broad-spectrum of micro-organisms. Purpose: The purpose of this study was to evaluate the antimicrobial activity of Opti-Free Express Multi-Purpose Disinfecting Solution (MPDS) against microorganisms that have been recovered and reported as lens and lens case contaminants and agents associated with microbial keratitis. Methods: MPDS was challenged with many different microbial isolates from clinical and environmental sources. High numbers of Gram-positive and Gramnegative bacteria, yeast, mould and Acanthamoeba were introduced into the product and each isolate was evaluated three times in the MPDS product. Following exposure to the disinfecting solution, a sample was removed from the product and plated for survivors by suitable recovery methods. The plates were incubated and the number of survivors was enumerated.
Address for Correspondence Bausch & Lomb, Inc., 1400 N Goodman Street, P O Box 450, Rochester NY 14603-0450, USA Reduction of ocular pathogens using ReNu MultiPlus multi-purpose solution MJ Miller and R Manchester
Contact lens disinfection is defined as a chemical or physical process to reduce the number of viable microorganisms on a contact lens between periods of wear. This process normally subjects contact lenses to a regimen of cleaning, rinsing, and soaking in the manner recommended in product labelling and/or patient instructions. A series of studies were performed to examine the antimicrobial activity of ReNu MultiPlus Multi-Purpose Solution against a variety of microContact Lens and Anterior Eye
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Abstracts
organisms when used in regimen. ReNu MultiPlus Solution significantly reduced viable numbers of a broad range of ocular pathogens including bacteria, yeast and mould, Acanthamoeba trophozoites and cysts, and viruses. This study demonstrates that ReNu MultiPlus Solution provides exceptional antimicrobial activity when used in regimen. Address for Correspondence Bausch & Lomb, Inc., 1400 N Goodman Street, P O Box 450, Rochester NY 14603-0450, USA
Address for Correspondence CCLR, School of Optometry, University of Waterloo, Waterloo, Ontario N2L 3G1, Canada
Physical properties of multi-purpose contact lens solutions L Jones and J Lau
Purpose: This study was designed to investigate the physical properties of commercially available multipurpose (MPS) contact lens solutions. Methods: The osmolality and tonicity (Wescor 5500 vapour pressure osmometer), pH (Coming M-250 pH meter), viscosity (ViscoLab 3000 viscometer) and surface tension (Cahn DCA-322) of various contact lens solutions were measured at room temperature. The solutions examined were Opti-Free and Opti-Free Express (Alcon), Complete and Oxysept 1-Step (Allergan), ReNu MPS and ReNu MultiPlus (B&L) and AOSept and SoloCare (CIBA-Vision). CIBA Saline, CIBA SoftWear Saline and HPLC-grade water were used as controls. The peroxide systems were measured before and after neutralisation. All measurements were repeated on 3 occasions and the mean (+ SD) reported. Results: The tonicity and osmolality values indicated that most solutions were hypo-osmotic compared with tears, with typical values in the area of 0.85% saline (275 mOsmol/Kg). Significantly lower values were obtained with Opti-Free and Opti-Free Express, at 231 and 220 mOsmol/Kg respectively. Post neutralisation the osmolality increased for Oxysept and decreased for AOSept. The pH of most solutions was close to neutral (range 6.76 to 7.18), the exceptions being the peroxide systems prior to neutralisafion (AOSept at 5.95 and Oxysept at 3.51) and Opti-Free Express at 7.72. The average viscosity of most solutions fell within a narrow range of 0.92 to 1.15 mPa.s, the exception being Complete, with a markedly higher viscosity of 2.88 mPa.s. The surface tension (ST) values for solutions differed markedly. The AOSept, Opfi-Free and saline controls were similar in ST to water (around 72 raN/m) and other MPS exhibited ST around 40 InN~re. The exceptions were Opfi-Free Express, Complete and Oxysept, at 34.9, 36.7 and 46.9 m N / m respectively. Conclusions: This study details many physical properties not readily available from manufacturers and indicates that these properties vary significantly among solutions. These characteristics may partly explain the reason some patients exhibit such strong preferences for certain care systems.
Physical chemistry predicts dimensions of ocular discomfort of ophthalmic drops T Simpson, J Lau, L Jones, D Richter, K Dumbleton and D Fonn
Purpose: To determine the physical chemical attributes that correlate with the ocular sensation of ophthalmic eye-drops. Methods: Seventeen asymptomatic subjects inter-ocularly rated the similarity of six over the counter drops, using standard grading techniques. Five of the solutions were for the relief of the symptoms of dry eye and one was a hypertonic solution. Using MultiDimensional Scaling (MDS), the number of dimensions required to account for the dissimilarities and the positions of the stimuli (the drops) in this space was determined. The following physical chemical attributes were measured: Osmolality and tonicity (Wescor 5500 vapour pressure osmometer), pH (Corning M-250 pH meter), surface tension (Calm DCA-322 balance) and viscosity (ViscoLab viscometer). Correlation and regression analysis examined the linear associations and numerical relationships between the stimuli in the multidimensional space and their chemical attributes. Results: MDS uncovered two dimensions of ocular discomfort, one being 'stinging' and the other 'slippery'. The chemical attributes that significantly correlated with the stimuli in this space were; osmolality (r=0.99, P=0.003), tonicity (r:0.99, P=0.003) and viscosity (r=0.97, P=0.01). Normalised regression analysis showed that osmolality and tonicity regressions were in the stinging dimension and viscosity was in the slippery dimension. Conclusions: MDS of ophthalmic drops reveals two dimensions of ocular discomfort. The origins of the stinging dimension can more clearly be understood in terms of the chemo-nociceptors responsible, while slipperiness is a reflection of the stimulus viscosity. Perhaps, just as interestingly, pH and surface tension were not linearly associated with the stimuli in the two dimensions.
Contact Lensand AnteriorEye
Abstracts
173
Gas plasma sterilisation - is it a suitable process for optometry? DV Seal and A Finlay There has recently been concern about the spread of the BSE variant of CJD pfions as a result of re-using ophthalmic equipment that comes into contact with the corneal surface, in particular trial rigid gas permeable contact lenses. Current cleaning techniques are thought to be inadequate for equipment re-used on a person-toperson basis, identifying a need for a simple, rapid, costeffective method of on-site disinfection. Present disinfection regimes do not guarantee their effectiveness for many common pathogens nor of sterility. Common organisms of concern, other than prions, include S. aureus, found on the lid margin in 10% of people, other bacteria such as streptococci and Gram-negative rods, and common viruses such as Herpes simplex, adenovirus and EBV (Epstein-Barr virus). In addition, HIV (human immunodeficiency virus) and hepatitis viruses B&C can be found in the tears of normal eyes. Gas plasma sterilisafion (GPS) is a newly recognised process for the rapid disinfection of dry heat labile objects, ufilising ionised oxygen atoms that bind to nucleic acid. The equipment that is required for this process is currently only available from one manufacturer, at a minimum cost of 80 000 per unit. We are currently proceeding with experiments that use a simple costeffective version of GPS that would be suitable for rigid lenses and would guarantee sterility as required under existing British Standards. Initial tests have shown a bactericidal effect for S. aureus. GPS is known to be effective against viruses but has never been tested on prions. Address for Correspondence Department of Optometry & Vision Science, The City University, Northampton Square, London EC1V 0HB
the dominant bacterial pathogen for both groups. The overall incidence of microbial keratitis (MK) was 0.63 per 10 000 population and 3.4 per 10 000 CLW. Six cases of Acanthamoeba keratitis occurred, five in CLW (incidence 0.33 per 10 000 CLW). Overall, 74% of cases were not associated with CLW of whom 27% had a history of trauma. For CLW, statistical analysis identified overnight wear, smoking, lack of cleaning procedures, use of one-step peroxide disinfectant or storing lenses in tap water as significant risk factors.
Conclusions: Previous ocular disease and trauma were the main risk factors for MK in Hong Kong. By estimation of incidence, CLW appears as safe as that found in the US and UK but the infection rate could be reduced by avoiding overnight lens wear, better hygiene and less use of peroxide disinfectant. Acanthamoeba keratitis was found, but at a small risk, that was much less frequent than in the UBL
Address for Correspondence Department of Optometry & Vision Science, The City University, Northampton Square, London ECIV 0HB
A Novel Instrument to Quantify the Tension of Upper and Lower Eyelids. 2 0 0 0 BCLA Da Vinci Award K Ehrmann An instrument was developed for the objective measurement of passive lid tension of the upper and lower eyelid. Eyelid tension is defined as the first derivative of the force over elongation function. Lid tension is determined by gripping the eyelid at the eyelashes and displacing the lid while measuring the force exerted by the eyelid. Two motorised axes provide motion control of the clamp in anterior/posterior and nasal/ temporal direction. Each axis is fitted with a sensitive force transducer to record the force while first stretching and then relaxing the eyelid. Motion control, data collection and data analysis are computer controlled, with various user-selectable options for measurement speed, direction and end-of-measurement conditions. Calibration of the instrument reduced the maximum error of the recorded forces to + 10 mN. An adjustable bite bar is used to prevent head movement during the measurements. Repeatability for on-eye measurements was verified by multiple measurements on the same eye under identical conditions. The instrument is currently being used to characterise the lower and upper lid tension in different race and age groups. Other applications of the instrument may include measurements for reconstructive lid surgery and investigating correlation between lid tension and rotational recovery of toric contact lenses. Address for Correspondence 32 Cameron Avenue, Manly NSW 2095, Australia
Microbial keratitis in Hong Kong D Seal, D Lam and D Fan

Purpose: To establish the incidence, aetiology and risk factors for ulcerative keratitis (UK) in Hong Kong. Methods: A prospective cohort study was designed to examine all new cases of UK among residents in Kowloon and New Territories (East) over a period of 17 months with comprehensive microbiology. A nested case-control study was pursued for patients wearing contact lenses (CLW) to determine risk factors involving type of wear, case hygiene and disinfection. Results: Two hundred and twenty-three patients presented of whom 59 wore contact lenses. Corneal scrapes yielded positive cultures from 77 patients (35% overall, 56 ocular surface disease, 21 CLW). Ps. aeruginosa was
Abstracts
174
Visual performance and protein deposition in poly(HEMA) lenses made by three manufacturing methods C Maldonado-Codina and N Efron Purpose: To determine to what extent manufacturing method affects protein deposition in soft contact lenses and to determine if any differences in protein deposition affect visual function. Methods: Thirty-two subjects aged 27.5_+8.4 years were included in this subject-masked, randomised, prospective, cross-over study. All subjects wore three generic lenses in the same eye, each for a period of one month o n a daily wear basis. The three study lenses were all 38% water content poly(HEMA) lenses but each differed in the way that it was manufactured. The lenses were lathe-cut, spun-cast and cast-moulded. All were made from as similar a material as possible and fabricated in the same manufacturing plant. The BVP of all lenses worn by all subjects was -3.00 D. All subjects used the same multipurpose solution, which contained 0.0001% polyhexanide. High contrast (HCVA) as well as low contrast visual acuity (LCVA) was recorded after 30 rain, 6 h and 1 month of contact lens wear. Total protein deposition was quantified at I month using UV absorbance on a PYE Unicam SP8-100 UV/ VIS spectrophotometer (Cambridge, Ut0, exciting at 280 nm. Results: A two-way repeated measures ANOVA revealed no statistically significant differences in HCVA over time for each lens type nor a significant difference between lens types. The same was found for LCVA. A one-way repeated measures ANOVA showed a significant difference in protein deposition between lens types (F=6.3, P=0.0034). Post-hoc analysis showed that the spun-cast lens deposited significantly less protein than the lathe-cut (P=0.014) or cast-moulded lenses (P=O.O012). Conclusions: In this study spun-case HEMA lenses deposited less protein than lathe-cut or cast-moulded lenses polyCHEMA) lenses. The differences in the amount of protein, however, do not seem to affect visual function. Manufacturing method is an important consideration in the overall production of a contact lens.
ba keratitis. Contact lens wearers are most at risk from infection and account for over 90% of reported cases in the United Kingdom. Poor hygiene practices, notably the defaulting on recommended disinfection and cleaning procedures or the rinsing and storing of lenses in tap water are recognised risk factors. The cyst form of Acanthamoeba is highly resistant and can withstand extremes of temperature, desiccation and most contact lens disinfectants. Hydrogen peroxide based systems are effective against Acanthamoeba providing an adequate exposure time is used. Lenses must then be neutralised before use because the hydrogen peroxide has a cytotoxic effect on the eye. Neutralisation is achieved by the addition of a platinum catalyst or enzyme to break down the hydrogen peroxide during the disinfection process (one-step) or afterwards (two-step). The activity of such systems against the trophozoites and cysts of acanthamoeba keratitis isolates was investigated. Both one-step and two-step approaches were effective against trophozoites giving a 3-4 log reduction within 1 h. In contrast, the cysts were markedly more resistant with the one-step systems showing only a 1-1.5 log reduction after 6 h exposure. Two-step systems were most effective giving a 2-3 log reduction after 4 h or 4 log after 6 h. One-step systems are less active against Acanthamoeba cysts due to the rapid neutralisation of the hydrogen peroxide. Investigations are continuing to develop enhanced hydrogen peroxide systems against Acanthamoeba based on improved chemical formulations and slower neutralisation times.
Address for Correspondence Department of Microbiology & Immunology, Medical Sciences Building, University of Leicester, University Road, Leicester LE1 9HN
Dry eye symptomatology of contact lens wearers and non wearers P Cooper, M Guillon, C Maissa and K Girard-Claudon Introduction: The purpose of the investigation was to determine the frequency and nature of dry eye symptoms and to identify the questions that best predict dry symptomatology in a population of soft contact lens wearers (SCLW) and non wearers (NonW) attending an optometric practice for routine care. Method: The relevant McMonnies questionnaires were administered to 502 SCLW and 309 NonW to determine symptomatology. The data obtained for each population were compared by Kruskal-Wallis and the relative diagnostic value of the individual questions was determined by CHAID (Chi square Automated Interaction Detector) analysis. Results: The incidence of dry eye patients as significantly greater (P<0.001) for SCLW (43%) than for NonW (15%). For the NonW, dry skin and dryness of
Address for Correspondence Department of Optometry & Neuroscience, UMIST, PO Box 88, Manchester, Lancs M60 1QD
Activity of hydrogen peroxide disinfectants against

acantkamoeba
R Hughes and S Kilvington Acanthamoeba is a common environmental amoeba causing the potentially blinding infection of acanthamoeContact Lens and Anterior Eye
Abstracts
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the mouth or nose were significantly more frequent (P<0.001) for the symptomatic subjects pointing towards an association with systemic conditions as possible aetiology. For the SCLW problems with air conditioning, central heating and in car environment were significantly (P<=0.004) more frequent for the symptomatic subjects supporting the hypothesis of the evaporative aetiology of contact lens related dry eyes. For both groups the symptom of ocular dryness was the best detector of the overall symptomatology. The sensitivity of the question was 74% for NonW and 94% for SCLW, and the specificity 74% and 32% for NonW and SCLW respectively.
exhibited severe truncation in the results and videobased evaluations were on average 15 points higher than direct observations. A better correlation was achieved for grading limbai hyperaemia than bulbar hyperaemia for all techniques.
Conclusions: Off-line grading of previously recorded video observations is a viable recording method and achieves more consistent results than direct observation and recording. Observers clearly grade hyperaemia using different criteria. To reduce variations in grading performance a direct physical measure of hyperaemia, using a digital or photometric system, may be a more appropriate technique.
Conclusion: Dry eye symptomatology is a significant problem with current soft contact lenses, most fxe- Address for Correspondence quently due to excessive evaporation. The identification CCLR, School of Optometry, University of Waterloo, in routine practice of the presence of a dry eye problem Waterloo, Ontario N2L 3G1, Canada without administering a full dry eye questionnaire is best achieved by asking patients to report the incidence A comparative evaluation of IgA and Lysozyme of ocular dryness on a four point forced choice scale. deposition on Etafilcon & Lotrafilcon contact lens materials Address for Correspondence Contact Lens Research Consultants, 42 Vauxhall Bridge L Jones, M Senchyna, D Louie, C May and K Dumbleton Road, Pimlico, London SW1V 2RX Purpose: To compare and quantify the levels of lysozyme and IgA deposition on Etafilcon (Acuvue, FDA group IV) and Lotrafilcon (Focus Night & Day, Direct vs off-line grading of bulbar and limbal hyperaemia: a comparison of high D k vs low DK FDA group I) contact lens materials. extended wear lenses Methods: Lenses were sourced from participants folL Jones, K Dumbleton, T Simpson and D Fonn lowing their normal wearing period. Etafilcon lenses Purpose: To compare the grading of limbal and bulbar were worn for 14 days on a daily wear basis whilst being hyperaemia using video-taped images with real-time slit- cleaned and disinfected with a multipurpose care regimen. Lotrafilcon lenses were worn for 30 days on lamp observation. a continuous wear basis, with no removal or cleaning Methods: Twenty subjects participated in this masked taking place. Proteins were removed using an exhausstudy. Ten wore Acuvue lenses on a 7 day extended tive extraction process and then subjected to electrowear schedule and ten wore a high Dk silicone-hydrogel phoresis and Western blotting. Immunoreactivity was lens for up to 30 nights. The degree of limbal and bulbar visualised by incubation with ECL-plus chemilumineshyperaemia was graded using a 100-point severity scale cent substrate. The optical density of the resultant with verbal and photographic anchors, at four visits over bands was subsequently quantified from digitised a 9-month period. One observer graded the hyperaemia images. during the visit and video-taped the external ocular appearance, using a standardised illumination protocol. Results: IgA and lysozyme deposits were detected on The same observer and a second, equally experienced, both types of lenses, albeit in significantly different clinician later rated the degree of hyperaemia, using the concentrations. Mean IgA concentrations for Lotrafilcon and E t a f i l c o n w e r e 0 . 2 7 + 0 . 1 3 # g / l e n s and video-tape recordings and the same grading scale. 1.87 + 0.53 #g/lens, respectively (P< 0.01). Mean lysoResults: All three evaluations indicated that limbal and zyme concentrations were 0.24+0.08 #g/lens for Lobulbar hyperaemia were greater with the low Dk lenses trafilcon and 810 + 130 #g/lens for Etafilcon (P< 0.001). (P< 0.02) and that limbal and bulbar hyperaemia were positively correlated (r>0.63; P<0.001). During the Conclusions: These results dearly demonstrate that video-tape evaluations, the two observers were reason- IgA and lysozyme are deposited on both Etafilcon and ably well correlated (r=0.68 to 0.74), but one observer Lotrafilcon materials. Significantly greater quantities of consistently rated the hyperaemia approximately 10 both proteins were found on Etafilcon. These results points higher than the other. When comparing video- indicate that new high Dk silicone-hydrogel materials tape grading with direct slit-lamp observations, a poor exhibit significantly greater resistance to protein deposicorrelation was achieved (r=0.32 to 0.74) direct grading tion than conventional low Dk hydrogel materials.
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176
blotting. Lysozyme immunoreactivity was visualised by incubation with ECL-plus chemiluminescent substrate. The optical density of the resultant bands was subsequently quantified from digitised images.
Lysozyme deposition and removal from a high Dk silicone-hydrogel contact lens material: A comparison of 7 day vs 3 0 day wear D Louie, M Senchyna, L ]ones, C May, K Dumbleton
Purpose: To investigate the degree of lysozyme deposition and its ease of removal from a high Dk siliconehydrogel lens (Lotrafilcon A), when worn for 7 or 30 days on a continuous wear modality. Methods: Lotrafilcon lenses were collected from participants following a wearing period of either 7 or 30 consecutive days, with both lens types being collected for analysis after 30 days of lens wear. Lenses were cut into two equal pieces and one half subsequently exposed to a 10-s digital clean with a surfactant-based cleaner. Proteins were then removed from the two lenshalves using an exhaustive extraction process and subsequently exposed to electrophoresis and Western
Results: The mean lysozyme concentration deposited was 0.24 + 0.08 #g/lens. Analysis revealed no significant difference in lysozyme deposition between lenses worn for 7 versus 30 consecutive days (P=NS). Inter-subject variability was apparent. Surfactant cleaning resulted in a significant removal of the deposited lysozyme (P< 0.01), with a reduction of approximately 25% being measured. Conclusions: The Lotrafilcon lens material exhibits extremely low levels of lysozyme deposition, after both 7 and 30 days of continuous wear. No significant difference was found between the two wearing periods, although obvious inter-subject differences were observed.

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Contact Lens and Anterior Eye (2000) 23, 142-176

@ 2000 British ContactLensAssociation www.nature.com/clae

Abstracts of the 24th BCLAAnnual Clinical Conference Birmingham 2000

REFRACTIVE SURGERY FROM AN OPTOMETRIC PERSPECTIVE

VIDEOKERATOSCOPY IN CONTACT LENS PRACTICE

Contact Lens and Anterior Eye

RGP LENSES AND THEIR ROLE IN SLOVCING MYOPIC PROGRESSION A Canella

A NOVEL ASPHERIC SURFACE FOR CONTACT LENSES W Sammons

Contact Lens and Anterior Eye

CORNEAL ASPHERICITY AND RGP LENS WEAR S Klyce

MEASURING NON-SPHERICAL OPTICAL SURFACES C Woods

NEOVASCULARIZATION: THE SUPERFICIAL AND THE DEEP BA Weissman

DRY EYE AND CONTACT LF~NS WEAR L Carney

OBSERVING AND MEASURING OCULAR ERYTHEMA. WHAT DO WE MEAN BY REDNESS? E Papas

CLINICAL EVALUATION OF TORIC SOFT LENS REPRODUCIBILITY G Young

CONJUNCTIVAL SENSITIVITY IS ALTERED IN UNSUCCESSFUL CONTACT LENS WEARERS F Stapleton

CONTACT LENS DEHYDRATION AND LENS AGEING P Morgan

A STUDY OF THE SPOILATION PROFILES OF HIGH Dk FLUOROSILICONE HYDROGEL LENSES V Franklin

Address for Correspondence

MANAGING CORNEAL INFILTRATES IN PATIENTS WITH HIGH Dk EXTENDED WEAR LENSES

WAVEFRONT SENSING TECHNOLOGY - VISION CORRECTION FOR THE NEW MII.I.ENIUM

CONTACT LENS DRY EYE . . . THE PROBLEM THAT WON'T GO AWAY

THAT'S NOT WHAT I WAS TAUGHT AT UNIVERSITY!

ADAPTATION AND RESISTANCE OF PSEUDOMONAS AERUGINOSA TO CONTACT LENS DISINFECTION

BACTERIAL POPULATIONS PRESENT DURING EXTENDED WEAR OF CONTACT LENSES C Morris

The implications of these finding for 30 NEW will be discussed.

THE IMPLICATIONS OF vCJD FOR CONTACT LENS PRACTICE G Macalister

Address for Correspondence Fingellan, Whines Lane, Cambridgeshire CB4 5PT

Contact Lensand AnteriorEye

Dk performance of lotrafilcon A following 30 night extended wear L Winterton

Contact lens patient profile 2 0 0 0 T Bowden, T Harknett and H Shadbolt

Attitudes towards visual correction A Patel, C Brown and P Morgan

Address for Correspondence

Does contact lens wearing influence personality?

Address for Correspondence

The oxygen transmissibility profile of siloxane hydrogel contact lenses

Address for Correspondence

Recording of contact lens complications using digital image technology

Address for Correspondence

Lymphangiectasis - a case report CA Woods

Contact Lens and Anterior Eye

Contact Lens and Anterior Eye

Physical properties of multi-purpose contact lens solutions L Jones and J Lau

Microbial keratitis in Hong Kong D Seal, D Lam and D Fan

Activity of hydrogen peroxide disinfectants against

Contact Lens and Anterior Eye

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