Professional Documents
Culture Documents
1. Capillary
attraction
2. Centre
gravity
of
3. Tear meniscus
List the forces that influence the performance of a rigid contact lens
- Capillary attraction
- Gravity
- Tear meniscus
- Lid force and position
- Friction
Capillary attraction
- Force of attraction between the lens and the cornea varies with distance between them
the closer the surfaces the greater the attraction
- Flatter lenses decrease capillarity
- Steeper lenses do as well but because of suction effect at edge of a steep lens,
movement of the lens is reduced
- If possible to exactly align the lens on the cornea over the width of the lens, the lens
would not be tolerated by the eye as a result of too little movement and hence tear
exchange
Discuss the concept of gravity in the contact lens arena
Effects of gravity can most easily be seen by the use of concept of centre of gravity
For a contact lens the COG is near the back surface or even behind the lens
The further the COG moves behind the lens, the more support it has above the COG.
The position of COG is affected by
o Overall diameter
o Base curve
o Back vertex power
o Centre thickness
Related to the centre of gravity is the lens weight
Discuss the factors/ aims/ goals that need to be achieved when fitting rigid contact
lenses
Moderate edge width and clearance
Allows for tear exchange via the tear reservoir under peripheral curves of lenses
If too small no tear exchange
If too wide or lift too great discomfort, displacement and ejection
Central and mid-peripheral alignment
Allows for good centration and movement
Smooth movement
Movement ensures dispersal of metabolic and cellular waste
Allows for tear pumping effect that ensures exchange of tears beneath a lens along the
associated O2
Excess movement discomfort and visual disturbance
If lens is tight - no movement
Adequate centration
Decentration visual disturbance, discomfort and compromised cornea physiology
Comfort
Provide clear vision
Adequate wearing time
No ocular compromise
Normal head posture and ocular appearance
Protocol:
1. Routine visual exam
2. Discussion
3. CL preliminary exam:
- First lens to try
- Parameter changes and their effects
- Astigmatism
4. Tolerance trial and check
5. Dispensing
6. After care schedule
1. Routine exam
Usual examination
All patients considered binocular unless they only have one eye
Thorough visual exam including phorias, ranges, stereo
All patients have pathology until shown otherwise
Ophthalmoscopy
Case Hx
2. Discussion
Purpose
Informed
decision
Px motivation
Cost
3. Preliminary Exam:
Objective
1. Is px suitable for CL
2. Obtain baseline info
3. Advise px of options
Factors
to
1. Anatomical and physiological
2. Psychological
consider
3. Pathological
4. Personal and occupational need
5. Refractive
Preliminary
Ocular
dimensi
ons
Keratom
etry
Tear
layer
assessm
ent
Slit lamp
Normal structure
7. Iris
8. Lens
9. Expression of glands
Discuss the data that you would need to obtain from your preliminary exam of a
contact lens patient
1. Ocular dimentions
- HVID of the cornea
- Pupil diameter in light and dark
- Vertical palpebral fissure
- Lid position top and bottom
- Exophthalmos present or not
- Lid tension
- Check tarsal plate for papillae
- Blink quality: incomplete, twitch
2. Keratometry
- Make sure the mires are focused and accurately aligned
- Assess the quality of the mires
- Assess the TTT
3. Tear layer assessment
- Important to asses the quality of the tear layer
- 2 techniques
Invasive
Non-invasive
TBUT
TTT
Schirmer
Non-invasive TBUT
Phenol red thread testing
Tear prism height
Rose Bengal staining
Interference pattern
Expression of the glands
Debris in the tears
Assess the tear flow, volume, TBUT, osmolality and pH
4. Slitlamp
Lid margins and lashes
Bulbar and palpebral conjunctiva
Limbus
Anterior chamber angle
Tears
Cornea
Iris
Lens
Expression of the glands
5. Refractive state
6. Other considerations
High refractive status
High astigmatism
Progressive myopia
Keratoconus
Anisometropia
General health
Occupation
Keratometer method
Phone lab technician, give
findings, and have lens made
Method strongly discouraged
relevant
2
3
4
5
6
Other considerations:
High
>4
refractive
Compensate for vertex distance
status
Keep lenses as thin as possible lenticulate
Need for high DK/L materials
Progressive
Consider costs of frequent replacement of lenses as Rx changes
myopia
Disposable lenses? RGP?
High
astigmatism
keratoconus
Anisometropia
General
Diabetes
PRPH
health
Prone to infection
Healing takes longer
Decreased sensitivity
Allergies
Solutions
Hay fever
Seasonal problems
RA
Iritis
Insertion problems
Dry eyes
Scleritis
Pregnancy
Always
big
problem
Can change curvature of cornea
Decreased sensitivity
Increased thickness
Oedema
Medications
Discolouration
Decreased tear volume
Change in focus of eye
Occupation
Recreational and environmental factors
Sports
Hobbies
Dust
Fumes
Radiation
ahead
Observations:
1. Decentration
2. Stability
3. Movement after blink
4. Movement with lateral gaze
5. Lower lid influence
6. Upper lid influence
Optimal fit
Static:
1. Minimal
central
clearance
2. Light
mid-peripheral
contact zone
3. Optimal edge lift
4. Average
edge
clearance
Dynamic:
1. Lens must be centred
2. Stable
3. Superior lid coverage
(not always possible)
4. Movement should be
smooth vertical and 12mm
with
Static assessment
Patient looks straight ahead with
normal head posture
Lens in natural resting position
If necessary, use lids to centre lens on
cornea
Use Burton lamp and fluorescein
Observations:
1. Central zone (flat, steep, aligned)
2. Mid peripheral zone
3. Peripheral zone (width of edge lift)
4. Contact/clearance
5. Horizontal and vertical meridians
6. Axial edge lift vs clearance
7. Radial edge lift vs clearance
Types of fit
Tight fit
Static:
1. Excessive
apical
clearance
2. Heavy mid-peripheral
contact
3. Narrow edge
4. Decreased
edge
clearance
Dynamic:
1. Centred
2. Stable
3. Superior lid coverage
4. Little movement
Loose fit
Static:
1. Excessive cenral touch
2. Flat
mid-peripheral
contact zone
3. Excessive edge width
4. Excessive
edge
clearance
Dynamic:
1. Decentred
2. High/low riding
3. Unstable
4. Excess movement
2mm
>
4. Tolerance trial
Every new patient should undergo tolerance trial
Once lens has been determined that fits well and gives adequate vision, appointment
for TT should be scheduled
Procedure
1. Come in and insert lenses
2. 3h of wear
3. Return and check:
How does patient appear
How does patient feel
4. Over refraction
5. Check fit
6. Remove lenses and assess corneal status
7. Discuss findings with patient
8. Discuss success rates
9. Order lenses
Assessment
1. CCC
2. Staining
of cornea
3. Polymegathism/blebs
4. Striae
5. Folds
6. Haze
7. Limbal engorgement
8. Hyperemia
Ordering
1. Design
2. BC
3. Power
4. Material
5. Diameter
6. OZ
7. Thickness
8. Lenticular
Why
5. Dispensing:
Rules
1. No sleeping with lenses
2. Always right eye first
3. Clean hands
4. If you drop a lens, do not move your feet
5. Follow schedule and regimen
Cleaning
Daily cleaner
Soaking solution
Protein pills
Insertion
Schedule
1. Practice:
3h for 3d
4 for 3
5 for 3
2. See me
3. Add per day and see me in 2 weeks
4. See me in 1 month
5. See me in 2 months
6. See me in 6 months
6 for 3
7 for 3
6. After care
Major factor in continuing good CL performance, px satisfaction and corneal health
Involves regular, periodic, routine consultations to assess ocular response to CL and
condition of lenses
Good contact lens practitioner attributes:
1. Attempts to fit difficult cases
2. Concerned about cornea
3. Exemplary after care
1.
2.
3.
4.
5.
6.
7.
Tests:
Case Hx
Procedure review
VA and OR
Check fit
Check physiology
Lens inspection if necessary
Summary and advice
1. Base curve
Usually described as the fit of the lens
Design = major factor controlling lens-cornea relationship
Design influences centration and movement
2
main Spherical
Aspheric
--Monocurve-multicurve
--Conic sections/non-spherical
designs
--Usually tricurve does job well
--Curves approximate corneas actual
--Back
surfaces
are
mostly
a shape more exactly
continuous curve
--Fit flatter/more on alignment than
equivalent spherical lens
1. Better vision
1. Better alignment
2. Better centration
2. More difficult to make
3. Difficult to verify
4. More decentration
Clinical
Central Fl
Sensitive technique for comparing shape of cornea with
consideratio
that of BC
pattern
Only method we have to make fit decisions about BC
ns
Corneal
The way hard lenses are fit can influence corneal
curvature over time
curvature
3. Back surface
BOZR/BOZD
relationship
BOZR/BVP
relationship
BOZR/CA
relationship
Back
peripheral
radius
Tricurve lens
design
design
For every 0.5mm increase in BOZD, there must be 0.05mm increase in
BOZR to maintain the same Fl fitting pattern
BVP compensation for BOZR changes if BOZR is increased (flattened) by
0.05mm
Tear lens power will increase by -0.25D
For Corneal astigmatism > 1.50D
Decrease BOZR 0.05mm for each 0.50D increase in CA
Increasing BPR increases edge clearance
Fitting set with constant axial edge lift important
Curve
Central
2nd
Peripheral
Radius
BOZR
BOZR + 0.8
BOZR + 2.5
Diameter
BOZD (TD 1.4)
BOZD + 0.6
BOZD + 1.4
Configuratio
1. Comfort interaction between edge and lids
2. Durability too thin = increased chipping
n of edge
3. Tear meniscus
effects
8. Overall Diameter
Affects
COG (larger = COG backwards)
following
Stability larger diameters more stable
Comfort larger lenses more comfortable
Affects fitting Centration
Increase diameter, increase centration
in the following
Fit lens effectively steeper due to increase in sag
way:
Corneal
Affects physiology
cover
Lens
Larger lens = steeper = less movement
movement
Mid Larger diameter = steeper with more mid-periphery
bearing
peripheral
Decreased tear flow beneath lens results
bearing
Lid
Larger lens = more interaction with lids (esp top lid)
interaction
Better comfort
Can induce 3 and 9oclock staining due to increased
lift of lid away from cornea
9. Peripheral curves
Following
Width = 0.3-0.5mm
changes can
Radius = 2.5mm flatter than BC
be
Shape = spherical vs aspheric
introduced
Can
affect
Fl pattern at periphery of lens
the
Excessive edge clearance results in poor centration and poor comfort
following:
Wider-flatter PC means increased tear exchange
3 and 9 oclock staining may occur due to poor PC design
PC changes
Too much edge clearance > smaller peripheral curve
Fluorescein patterns
Procedure
Instil Fl into eye
Observe brightness of tear layer trapped under CL
Use Burton lamp to excite Fl which emits green light
Fl absorbs radiation maximally between 485 and 500nm
Re-emits greenish light at wavelengths between 525 and 530nm
Contrast improved by using yellow filter ifo objective lens on slit lamp
Fl patterns
Pictures one sees when evaluating fit of lens
Changes as lens moves on eye due to thickness changes in tear layer
Dynamic picture > photos and drawings are only a guide
False Fl patterns possible where pattern is totally unexpected
False
1. Unusual corneal topography
2. BC too steep > no Fl under lens dt tight fit
patterns
3. PC too deep > same as above
caused by:
4. Fl may dissipate quickly > impression of apical bearing
5. Fl sometimes collects on FS of lens > steep impression
Optimum Fl
1. Alignment or very slight apical clearance
2. Mid-peripheral alignment 1-2mm wide
pattern
3. Edge clearance 0.5mm wide
4. Obvious tear meniscus at edge of lens
Slide 8 Fluorescein patterns