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Co nt act Le ns Pract ice
To Suzanne, Zoe and Bruce
 Co nt act Le ns
Pract ice

T h i r d Ed i t i o n

EDITED BY
Nat han Efro n
AC, DSc (Manche ste r), PhD, BScO p tom (Me lb ourne ),
FACO , FAAO , FIACLE, FCCLSA
Profe ssor Eme ritus, School of O p tome try,
Q ue e nsland Unive rsity of Te chnolog y,
Brisb ane , Australia

EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO

iii
© 2018 Elsevier Ltd. All rights reserved.

First published 2002

Reprinted 2005
Second edition 2010
Reprinted 2013
T ird edition 2018

T e right o Nathan E ron to be identif ed as editor o this work has been asserted by him in accordance with the
Copyright, Designs and Patents Act 1988.

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T is book and the individual contributions contained in it are protected under copyright by the Publisher (other
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Notices

Knowledge and best practice in this f eld are constantly changing. As new research and experience broaden
our understanding, changes in research methods, pro essional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any in ormation, methods, compounds, or experiments described herein. In using such in ormation or
methods they should be mind ul o their own sa ety and the sa ety o others, including parties or whom they
have a pro essional responsibility.
With respect to any drug or pharmaceutical products identif ed, readers are advised to check the most
current in ormation provided (i) on procedures eatured or (ii) by the manu acturer o each product to be
administered, to veri y the recommended dose or ormula, the method and duration o administration, and
contraindications. It is the responsibility o practitioners, relying on their own experience and knowledge o
their patients, to make diagnoses, to determine dosages and the best treatment or each individual patient, and
to take all appropriate sa ety precautions.
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 CO NTENTS

Contrib uting Authors vii 13 Rig id Le ns O p tics 130

W NEIL CHARMAN
Pre ace to the Third Ed ition ix
14 Rig id Le ns Me asure me nt 136
Trib ute s x KLAUS EHRMANN

Acknowle d g e me nts xi 15 Rig id Le ns De sig n and Fitting 143

GRAEME YO UNG

PART 1 Int ro d uct io n 16 Rig id Toric Le ns De sig n and Fitting 156

RICHARD G LINDSAY

1 History 3 17 Rig id Le ns Care Syste ms 163

NATHAN EFRO N
PHILIP B MO RGAN

2 Ante rior Eye 10

JO HN G LAWRENSO N
PART 4 Le ns Re p lace me nt
3 Visual O p tics 28 Mo d alit ie s
W NEIL CHARMAN
18 Daily Disp osab le So t Le nse s 167
NATHAN EFRO N

PART 2 So ft Co nt act Le nse s

19 Re usab le So t Le nse s 175
4 So t Le ns Mate rials 45 JO E TANNER | NATHAN EFRO N

CARO LE MALDO NADO -CO DINA

20 Planne d Re p lace me nt Rig id Le nse s 187
5 So t Le ns Manu acture 61 CRAIG A WO O DS

NATHAN EFRO N

6 So t Le ns O p tics 68 PART 5 Sp e cial Le nse s and Fit t ing

W NEIL CHARMAN
Co nsid e rat io ns
7 So t Le ns Me asure me nt 73 21 Scle ral Le nse s 195
KLAUS EHRMANN
NATHAN EFRO N

8 So t Le ns De sig n and Fitting 86 22 Tinte d Le nse s 204

GRAEME YO UNG
NATHAN EFRO N | SUZANNE E EFRO N

9 So t Toric Le ns De sig n and Fitting 95 23 Pre sb yop ia 214

RICHARD G LINDSAY
JO HN MEYLER | DAVID RUSTO N

10 So t Le ns Care Syste ms 103 24 Exte nd e d We ar 231

PHILIP B MO RGAN
NO EL A BRENNAN | M-L CHANTAL CO LES

25 Sp ort 246
PART 3 Rig id Co nt act Le nse s NATHAN EFRO N

11 Rig id Le ns Mate rials 115 26 Ke ratoconus 251

NATHAN EFRO N LAURA E DO WNIE | RICHARD G LINDSAY

12 Rig id Le ns Manu acture 123 27 Hig h Ame trop ia 263

NATHAN EFRO N JO SEPH T BARR

v
vi CO NTENTS

28 Bab ie s and Child re n 268 41 Dig ital Imag ing 410

CINDY TRO MANS | HELEN WILSO N ADRIAN S BRUCE | MILTO N M HO M

29 The rap e utic Ap p lications 275 42 Comp liance 420

NATHAN EFRO N | SUZANNE E EFRO N NATHAN EFRO N

30 Post-re ractive Surg e ry 282 43 Practice Manag e me nt 427

SUZANNE E EFRO N NIZAR K HIRJI

31 Post-ke ratop lasty 287

BARRY A WEISSMAN
Ap p e nd ice s
32 O rthoke ratolog y 296 A Contact Le ns De sig n and Sp e cif cations 438
PAUL GIFFO RD

B Contact Le ns Tole rance s 440

33 Myop ia Control 306
PADMAJA SANKARIDURG | BRIEN A HO LDEN
C Ve rte x Distance Corre ction 441
34 Diab e te s 314
CLARE O ’DO NNELL
D Corne al Curvature – Corne al Powe r
Conve rsion 443

E Exte nd e d Ke ratome te r Rang e Conve rsion 445

PART 6 Pat ie nt Examinat io n and
Manag e me nt F So t Le ns Ave rag e Thickne ss 446
35 History Taking 323 G So t Le ns O xyg e n Pe r ormance 447
JAMES S W WO LFFSO HN

H Constant Ed g e Cle arance Rig id Le ns

36 Diag nostic Instrume nts 327 De sig ns 449
LYNDO N W JO NES | SRUTHI SRINIVASAN | ALISO N NG |
MARC SCHULZE
I So t Toric Le ns Misalig nme nt
37 Pre liminary Examination 346 De monstrator 450
ADRIAN S BRUCE
J Dry-e ye Q ue stionnaire 451
38 Patie nt Ed ucation 356
SARAH L MO RGAN K E ron Grad ing Scale s or Contact Le ns
Comp lications 453
39 A te rcare 364
LO RETTA B SZCZO TKA-FLYNN | NATHAN EFRO N L Scle ral Le ns Fit Scale s 456

40 Comp lications 385

NATHAN EFRO N Ind e x 459
 CO NTRIBUTING AUTHO RS

J o se p h T Barr, O D, MS, FAAO Suzanne E Efro n, BSc(Ho ns), MPhil,

Emeritus Pro essor, College o Optometry, T e Ohio State PGCe rt O cThe r
University, Columbus, Ohio, USA Locum Optometrist, Broadbeach, Queensland, Australia
27 High Ametropia 22 inted Lenses
29 T erapeutic Applications
No e l A Bre nnan, MScO p t o m, PhD, FAAO , 30 Post-re ractive Surgery
FCLSA
Clinical Research Fellow and Global Plat orm Lead, Myopia Klaus Ehrmann
Control, Johnson & Johnson Vision Care Inc., Jacksonville, Director – echnology, Brien Holden Vision Institute,
Florida, USA University o New South Wales, Sydney, Australia
24 Extended Wear 7 Sof Lens Measurement
14 Rigid Lens Measurement
Ad rian S Bruce , BScO p t o m, PhD, FAAO , FVCO
Lead Optometrist, Australian College o Optometry, Paul Giffo rd , PhD, MSc, BSc(Ho ns), MCO p t o m,
Melbourne, Victoria, Australia; Senior Fellow, Department FBCLA, FIACLE, FAAO
o Optometry and Vision Sciences, University o Melbourne, Private Practice, Brisbane, Queensland, and Adjunct Senior
Parkville, Victoria, Australia Lecturer, University o New South Wales, Sydney, Australia
37 Preliminary Examination 32 Orthokeratology
41 Digital Imaging
Nizar K Hirji, BSc, PhD, MBA, FCO p t o m,
M-L Chant al Co le s, BS, O D FAAO , FIMg t
Optometrist, Johnson & Johnson Vision Care Inc., Optometrist and Principal Consultant, Hirji Associates,
Jacksonville, Florida, USA Birmingham, UK; Visiting Pro essor o Optometry,
24 Extended Wear University o Manchester, Manchester, UK; Visiting
Pro essor o Optometry, City University, London, UK
W Ne il Charman, BSc, PhD, DSc, FO p t So cAm, 43 Practice Management
FCO p t o m(Ho n)
Emeritus Pro essor, T e University o Manchester, Manchester, UK Brie n A Ho ld e n, O AM, PhD, DSc(Ho n),
3 Visual Optics BAp p Sc, LO Sc (d e ce ase d )
6 Sof Lens Optics Founding Chie Executive O cer, Brien Holden Vision
13 Rigid Lens Optics Institute, University o New South Wales, Sydney, Australia
33 Myopia Control
Laura E Do w nie , PhD, BO p t o m, PGCe rt O cThe r,
FACO , FAAO , Dip Mus(Prac), AMusA Milt o n M Ho m, O D, FAAO FACAAI(Sc)
Lecturer and NHMRC ranslating Research Into Practice Private Practice, Azusa, Cali ornia, USA
( RIP) Fellow, Department o Optometry and Vision 41 Digital Imaging
Sciences, T e University o Melbourne, Parkville,
Victoria, Australia Lynd o n W J o ne s, PhD, FCO p t o m, Dip CLP,
26 Keratoconus Dip O rt h, FAAO , FIACLE, FBCLA
University Research Chair, Pro essor, School o Optometry
Nat han Efro n, AC, DSc, PhD, BScO p t o m, FACO , and Vision Science, and Director, Centre or Contact
FAAO , FIACLE, FCCLSA Lens Research, University o Waterloo, Waterloo, Ontario,
Pro essor Emeritus, School o Optometry, Queensland Canada
University o echnology, Brisbane, Queensland, Australia 36 Diagnostic Instruments
1 History
5 Sof Lens Manu acture J o hn G Law re nso n, BSc, PhD, MCO p t o m
11 Rigid Lens Materials Pro essor o Clinical Visual Science, City, University o
12 Rigid Lens Manu acture London, London, UK
18 Daily Disposable Sof Lenses 2 Anterior Eye
19 Reusable Sof Lenses
21 Scleral Lenses Richard G Lind say, BScO p t o m, MBA, FAAO ,
22 inted Lenses FCLSA, FVCO
25 Sport Private Practice, East Melbourne, Victoria, Australia
29 T erapeutic Applications 9 Sof oric Lens Design and Fitting
39 Af ercare 16 Rigid oric Lens Design and Fitting
40 Complications 26 Keratoconus
42 Compliance
vii
viii CO NTRIBUTING AUTHO RS

Caro le Mald o nad o -Co d ina, BSc(Ho ns), MSc, Lo re t t a B Szczo t ka-Flynn, O D, PhD, FAAO
PhD, MCO p t o m, FAAO , FBCLA Pro essor, Department o Ophthalmology and Visual Science,
Senior Lecturer in Optometry, T e University o Manchester, Case Western Reserve University; Director, Contact Lens
Manchester, UK Service, University Hospitals Case Medical Center,
4 Sof Lens Materials Cleveland, Ohio, USA
39 Af ercare
J o hn Me yle r, BSc(Ho ns), FCO p t o m, Dip CLP
Senior Director, Global Pro essional Af airs, Johnson & J o e Tanne r, BO p t o m
Johnson Vision Care Companies, Wokingham, Pro essional Services Manager, CooperVision Australia and
Berkshire, UK New Zealand
23 Presbyopia 19 Reusable Sof Lenses

Philip B Mo rg an, BSc(Ho ns), PhD, MCO p t o m, Cind y Tro mans, BSc(Ho ns), PhD, MCO p t o m,
FAAO , FBCLA Dip (Tp )IP, FEAO O
Pro essor o Optometry and Director, Eurolens Research, Consultant Optometrist, Manchester Royal Eye Hospital;
T e University o Manchester, Manchester, UK Honorary Clinical Lecturer, Department o Ophthalmology,
10 Sof Lens Care Systems T e University o Manchester, Manchester, UK
17 Rigid Lens Care Systems 28 Babies and Children

Sarah L Mo rg an, BSc(Ho ns), MPhil, MCO p t o m, Barry A We issman, O D, PhD, FAAO
FAAO , FBCLA Pro essor o Optometry, Southern Cali ornia College o
Staf Development Consultant, Manchester, UK; Optometry at Marshall B Ketchum University, Fullerton,
Vision Sciences Fellow in Optometry, T e University Cali ornia, USA; Emeritus Pro essor o Ophthalmology,
o Manchester, Manchester, UK Stein Eye Institute, David Gef en School o Medicine at
38 Patient Education UCLA, Los Angeles Cali ornia, USA
31 Post-keratoplasty
Aliso n Ng , PhD, MCO p t o m
Post Doctoral Fellow, Centre or Contact Lens Research, He le n Wilso n, BSc(Ho ns), MCO p t o m, Dip Tp (IP),
University o Waterloo, Waterloo, Ontario, Canada Dip O C, Dip Glauc
36 Diagnostic Instruments Principal Optometrist, Manchester Royal Eye Hospital,
Manchester, UK.
Clare O ’Do nne ll, BSc(Ho ns), MBA, PhD, 28 Babies and Children
MCO p t o m, FAAO , FBCLA
Head o Eye Sciences, Optegra Manchester Eye Hospital, J ame s S W Wo lffso hn, BSc(Ho ns), PGCe rt HE,
Didsbury; Reader, Aston University, Birmingham, UK PGDip Ad vClinO p t o m, MBA, PhD, FCO p t o m,
34 Diabetes FHEA, FSB, FAAO , FIACLE, FBCLA
Pro essor and Deputy Executive Dean, School o Li e and
David Rust o n, BSc, FCO p t o m, Dip CLP, FAAO , Health Sciences, Aston University, Birmingham, UK
FIACLE 35 History aking
Director, Global Pro essional Af airs, Johnson & Johnson
Vision Care Companies, Wokingham, Berkshire, UK Craig A Wo o d s, BSc(Ho ns), PhD, MCO p t o m,
23 Presbyopia Dip CLP, PGCe rt O cThe r, FAAO , FACO , FBCLA
Pro essor, Head o Clinical Partnerships, Deakin Optometry,
Pad maja Sankarid urg , BO p t o m, MIP, PhD School o Medicine, Deakin University, Geelong, Australia
Associate Pro essor, Program Leader – Myopia, Manager, 20 Planned Replacement Rigid Lenses
Intellectual Property, Brien Holden Vision Institute,
University o New South Wales, Sydney, Australia Grae me Yo ung , BSc, MPhil, PhD, FCO p t o m,
33 Myopia Control Dip CLP, FAAO
Director, Visioncare Research, Farnham, Surrey; Honorary
Marc Schulze , PhD, Dip lIng (AO ), FAAO Pro essor, School o Li e and Health Sciences, Aston
Clinical Scientist, Centre or Contact Lens Research, University, Birmingham, UK
University o Waterloo, Waterloo, Ontario, Canada 8 Sof Lens Design and Fitting
36 Diagnostic Instruments 15 Rigid Lens Design and Fitting

Srut hi Srinivasan, PhD, BS O p t o m, FAAO

Clinical Research Manager and Senior Clinical Scientist,
Centre or Contact Lens Research, University o Waterloo,
Waterloo, Ontario, Canada
36 Diagnostic Instruments
 PREFACE TO THE THIRD EDITIO N

T is book strives to achieve the ‘middle ground’ among contact considerable interest at present in view o the current myo-
lens textbooks. It is not intended to be a brie clinical manual o pia epidemic (especially in Asia), and the potential or tting
contact lens tting; nor is it intended to be a weighty tome with contact lenses that can arrest myopia progression to a cer-
extensive research coverage. Like its predecessors, this third tain degree. T e chapter on daily disposable lenses has been
edition o Contact Lens Practice seeks to be a comprehensive, updated and expanded, which is particularly important given
easily accessible book that provides in ormation o immediate that this modality now represents nearly one-third o contact
relevance to contact lens practitioners, underpinned by well- lenses prescribed worldwide.
ounded evidence and expert clinical insight by the authors I hope that students using this book nd it to be a valuable
o the various chapters, each o whom is an expert in the area guide to their studies and acquisition o knowledge in the sci-
covered. ence and art o contact lens tting, and I trust that this work
T is new edition is not just a cosmetic make-over. T ere will be a valuable companion to practitioners in their ef orts to
have been extensive revisions to most chapters, many o which satis y the needs o those patients tted with contact lenses.
have been written by authors who are new or this edition.
T ere is also a new chapter on myopia control – an area o Professor Nathan Efron AC

ix
TRIBUTES

Here we pay tribute to two contributors to Contact Lens Practice

who have passed away since the second edition o this book was
published.

Keith Edwards, who wrote the chapter on History Taking Brien Holden, who co-authored the chapter in this book on
in the rst two editions o this book, lost a long- ought battle Myopia Control, passed away suddenly in 2015. He was Chie
with cancer in 2014. Keith was an inspirational educator, cli- Executive O cer o the Brien Holden Vision Institute and Pro-
nician and researcher who had an impact internationally in essor at the School o Optometry and Vision Science at the
the eld o contact lenses and intraocular lenses. Following University o New South Wales, Australia. Pro essor Holden
his Optometry degree at City University, he worked in private was a global leader in eye care and vision research, and an inter-
practice and served as secretary o the London Re raction Hos- nationally renowned and awarded scientist and humanitarian.
pital and examinations advisor at the College o Optometrists. He was widely acknowledged as the most inf uential optome-
He was an inaugural director o Optometric Educators Ltd and trist o our generation. His career was spent inspiring scientists
later worked or Madden and Layman, which was acquired by and health-care pro essionals around the world with his dream
Bausch & Lomb in the late 1980s. He expanded his role rom o ‘vision or everyone, everywhere’. Pro essor Holden was the
UK Pro essional Services to Director o Global Clinical Devel- recipient o seven honorary doctorates rom universities around
opment or Surgical at Bausch & Lomb, which took him to the the world, and was awarded an Order o Australia Medal or his
US, where his nal job was as Vice-President o Clinical and work in eye health and vision science.
Regulatory A airs at LENSAR.

x
 ACKNO WLEDGEMENTS

I am grate ul to the contributing authors o this third edition o spending many long hours assisting me in assembling, editing,
Contact Lens Practice. All have worked diligently to update their organizing and proo reading the contributed material. She has
chapters, or write new chapters, to bring the latest clinically rel- done a wonder ul job. I really could not have completed this task
evant in ormation to the ore. without her assistance. I also thank Suzanne or co-authoring
I continue to enjoy the strong support o the long-standing Chapters 22 and 29 with me, and or revising and authoring
publisher o all o my books – Elsevier. In particular, I am grate- Chapter 30.
ul to Russell Gabbedy (Commissioning Editor) and Alexan- Let me also pay tribute to the photographers and illustra-
dra Mortimer (Development Editor) or their encouragement tors, many o whom were not contributing authors o this
and support during the planning and production o this book. book, or their extraordinary skills and insights in creating
T anks also to Samuel Crowe, or assisting e ciently with vari- such antastic imagery. I also thank them or giving me per-
ous aspects o production. mission to use this material in the book. I apologize i I have
Editing a book o this size and scope is a substantial undertak- made any errors in attribution; please let me know i I have
ing, and in this regard I wish to o er special thanks to my lovely erred in this regard, and I shall correct this at the f rst reprint-
wi e, Suzanne, who has served as a ‘virtual co-editor’ by way o ing opportunity.

xi
This pa ge inte ntiona lly le ft bla nk
 PART

1
Int ro d uct io n

PART O UTLINE
1 History 3
Nathan E ron
2 Ante rior Eye 10
John G Lawre nson
3 Visual O p tics 28
W Ne il Charman
This pa ge inte ntiona lly le ft bla nk
 1
Hist o ry
NATHAN EFRO N

Int ro d uct io n snugly into the orbital rim (Young, 1801) (Figs. 1.3 and 1.4).
A microscope eyepiece was tted into the base o the eyecup,
thus orming a similar system to that used by Descartes. Young’s
We canno t co nt inue t he se b rilliant succe sse s in t he invention was somewhat more practical in that it could be held
fut ure , unle ss we co nt inue t o le arn fro m t he p ast . in place with a headband and blinking was possible; however,
Calvin Coolid g e , inaug ural US p re sid e ntial ad d re ss, 1923 he did not intend this device to be used or the correction o
re ractive errors.
Coolidge was re erring to the successes o a nation, but his In a ootnote in his treatise on light in the 1845 edition o
sentiment could apply to any eld o endeavour, including con- the Encyclopedia Metropolitana, Sir John Herschel suggested
tact lens practice. As we continue to ride on the crest o a huge two possible methods o correcting ‘very bad cases o irregular
wave o exciting developments in the 21st century, we would not cornea’: (1) ‘applying to the cornea a spherical capsule o glass
wish to lose sight o the past. Hence the inclusion in this book o
this brie historical overview.
Outlined below in chronological order (allowing or some
historical overlaps) is the development o contact lenses, rom
the earliest theories to present-day technology. Each heading,
which represents a major achievement, is annotated with a year
that is considered to be especially signi cant to that develop-
ment. T ese dates are based on various sources o in ormation,
such as dates o patents, published papers and anecdotal reports.
It is recognized, there ore, that some o the dates cited are open
to debate, but they are nevertheless presented to provide a rea-
sonable chronological perspective. 

Early The o rie s (1508–1887)

Although contact lenses were not tted until the late 19th cen- Fig . 1.1 Id e a o Le onard o d a Vinci to alte r corne al p owe r.
tury, a number o scholars had earlier given thought to the
possibility o applying an optical device directly to the eye-
ball to correct vision. Virtually all o these suggestions were
impractical.
Many contact lens historians point to Leonardo da Vinci’s
Codex o the Eye, Manual D, written in 1508, as having intro-
duced the optical principle underlying the contact lens. Indeed,
da Vinci described a method o directly altering corneal power
– by immersing the eye in a bowl o water (Fig. 1.1). O course,
a contact lens corrects vision by altering corneal power. How-
ever, da Vinci was primarily interested in learning the mecha-
nisms o accommodation o the eye (Heitz and Enoch, 1987) Fig . 1.2 Fluid -f lle d tub e d e scrib e d b y Re né De scarte s.
and did not re er to a mechanism or device or correcting
vision.
In 1636, René Descartes described a glass uid- lled tube
that was to be placed in direct contact with the cornea (Fig. 1.2).
T e end o the tube was made o clear glass, the shape o which
would determine the optical correction. O course, such a device
is impractical as blinking is not possible; nevertheless, the prin-
ciple o directly neutralizing corneal power used by Descartes is
consistent with the principles underlying modern contact lens
design (Enoch, 1956).
As part o a series o experiments concerning the mecha-
nisms o accommodation, T omas Young, in 1801, constructed
a device that was essentially a uid- lled eyecup that tted Fig . 1.3 Eye cup d e sig n o Thomas Young .
3
4 PART 1 Int ro d uct io n

Fig . 1.4 Thomas Young .

Fig . 1.6 Ad ol Gaston Eug e ne Fick.

Fig . 1.5 ‘Animal je lly’ sand wiche d b e twe e n a ‘sp he rical cap sule o
g lass’ (contact le ns) and corne a, as p rop ose d b y Sir Jo hn He rsche l.

lled with animal jelly’ (Fig. 1.5), or (2) ‘taking a mould o the
cornea and impressing it on some transparent medium’ (Her-
schel, 1845). Although it seems that Herschel did not attempt to
conduct such trials, his latter suggestion was ultimately adopted
some 40 years later by a number o inventors, working indepen-
dently and unbeknown to each other, who were all apparently
unaware o the writings o Herschel. 

Glass Scle ral Le nse s (1888)

T ere was a great deal o activity in contact lens research in the late
1880s, which has led to debate as to who should be given credit Fig . 1.7 Eug è ne Kalt.
or being the rst to t a contact lens. Adol Gaston Eugene Fick
(Fig. 1.6), a German ophthalmologist working in Zurich, appears
to have been the rst to describe the process o abricating and a signi cant improvement in vision. A report o this work, pre-
tting contact lenses in 1888; speci cally, he described the tting sented to the Paris Academy o Medicine on 20 March, 1888
o a ocal scleral contact shells rst on rabbits, then on himsel and by Kalt’s senior medical colleague, Pro essor Photinos Panas,
nally on a small group o volunteer patients (E ron and Pearson, acknowledges and there ore e ectively con rms that the work
1988). In their textbook dated 1910, Müller and Müller, who were o Fick occurred earlier (Pearson, 1989).
manu acturers o ocular prostheses, described the tting in 1887 Credit or tting the rst powered contact lens must be given
o a partially transparent protective glass shell to a patient re erred to August Müller (Fig. 1.8) (no relation to Müller and Müller,
to them by Dr Edwin T eodor Sämisch (Müller and Müller, mentioned above), who conducted his work while he was a med-
1910). Pearson (2009) asserts that the tting was done by Albert ical student at Kiel University in Germany (Pearson and E ron,
C Müller-Uri. Fick’s work was published in the journal Archiv ür 1989). In his inaugural dissertation presented to the Faculty o
Augenheilkunde in March 1888, and must be accorded historical Medicine in 1889, Müller described the correction o his own
precedence over later anecdotal textbook accounts. high myopia with a powered scleral contact lens. Paradoxically,
French ophthalmologist Eugène Kalt (Fig. 1.7) tted two Müller subsequently lost interest in ophthalmology and went on
keratoconic patients with a ocal glass scleral shells and obtained to practise as an orthopaedic specialist.
 1 Hist o ry 5

T e Rohm and Haas company introduced transparent plas-

tic (polymethyl methacrylate: PMMA) into the USA in 1936,
and in the same year Feinbloom (1936) described a scleral lens
consisting o an opaque plastic haptic portion and a clear glass
centre. Soon a er, scleral lenses were abricated entirely rom
PMMA using lathing techniques. T e earliest report o the t-
ting o PMMA lenses appears to have been made by T ier in
1939. T ese lenses were said to be ‘about hal the weight o ordi-
nary glass, unbreakable and quicker to manu acture’. T ey did
not provoke any irritation, but the optical zone needed to be
repolished every 6 months (Pearson, 2015).
A key rationale or using PMMA or the manu acture o
contact lenses was that this material was considered to be bio-
logically inert in the eye. T is view was ormed by military
medical o cers who examined the eyes o pilots who su ered
eye injuries during World War II as a result o ragments rom
shattered cockpit windscreens (as would occur during aerial
dog ghts) becoming permanently embedded in the eye. T ese
eyes remained unreactive or years a er such accidents. Other
advantages o PMMA included its light weight, break resistance
and being easy to lathe and polish. 
Fig . 1.8 Aug ust Mülle r. (Courte sy of Richard Pe arson.)
Plast ic Co rne al Le nse s (1948)
T e lenses worn by Müller were made by an optical engineer, T e development o corneal lenses – or rigid lenses, as they are
Karl Otto Himmler (1841–1903), whose rm enjoyed, until the re erred to today – began as the result o an error in the labora-
outbreak o World War II, an international reputation or the tory o optical technician Kevin uohy. During the lathing o a
manu acture o microscopes and their accessories. Himmler PMMA scleral lens, its haptic and corneal portions separated.
must there ore be acknowledged as the rst manu acturer o uohy became curious as to whether the corneal portion could
optically ground contact lenses (Pearson, 2007). be worn, so he polished the edge, placed it in his own eye and
Little development occurred in the 50 years subsequent to ound that the lens could be tolerated (Bra , 1983). Further tri-
these early clinical trials. Improvements in methods o scleral als were conducted, leading to the development o the rigid con-
lens tting were described by clinicians such as Dallos, who tact lens (rigid lenses were previously re erred to as ‘hard’ lenses
emphasized the importance o designing the lens to acilitate i they were manu actured rom PMMA). uohy led a patent
tear ow beneath the lens (Dallos, 1936). Dallos also went on or his invention in February 1948.
to develop techniques or taking impressions o the human eye So began an era o popularization o the contact lens. T e
and grinding the lenses rom these impressions.  spherical uohy lens design su ered rom two main drawbacks:
considerable apical bearing, which caused central corneal abra-
sion and oedema, and excessive edge li , which made the lens
Plast ic Scle ral Le nse s (1936) easy to dislodge. It was soon realized that these problems could be
Carl Zeiss o Jena, Germany applied or a patent that proposed overcome by altering the peripheral curvature o the posterior lens
the manu acture o contact lenses rom ‘cellon, celluloid or an sur ace, heralding the development o multicurve and aspheric
organic substance with similar mechanical and optical prop- designs, which remain in widespread use today, albeit with supe-
erties’, which was eventually issued in 1923 (Pearson, 2015). rior gas-permeable materials (PMMA is now virtually obsolete). 
Cellon is cellulose acetate and celluloid is cellulose nitrate plas-
ticized with camphor; there ore, this is a re erence to a lens Silico ne Elast o me r Le nse s (1965)
made o a plastic material. T is was also the rst mention o
the manu acture o contact lenses by moulding. T e Zeiss pat- Silicone rubber orms a unique category amongst contact lens
ents envisaged that contact lenses made rom plastic materi- materials. It is a ‘so lens’ in terms o its physical behaviour and
als would be less expensive, have some exibility that would lenses are abricated rom this material in the orm o a so lens.
improve the t, be ‘unbreakable’ and o er ocular protection Unlike all other so lens materials, silicone elastomer does not
(Pearson, 2015). contain water and in this respect is analogous to a hard lens
It appears that in Germany there may have been some largely material. Silicone elastomer is highly permeable to oxygen and
unsuccess ul attempts to t plastic lenses rom around 1930. carbon dioxide and there ore provides minimal inter erence to
It was reported in that year that Zeiss contact lenses moulded corneal respiration; however, it is di cult to manu acture and
rom cellon and celluloid lacked the degree o polish achieved its sur ace is hydrophobic and must be treated to allow com ort-
with glass lenses and were unstable owing to the in uences o able wear. T e considerable di culties involved in enhancing
humidity and temperature. More serious ndings were that they sur ace wettability have limited the clinical application o this
put a ‘tourniquet’ on the conjunctiva in the region o the lim- lens, and ew advances have been made since it was originally
bus and caused extensive corneal erosion. T ese un avourable tted. T e precise date o silicone elastomer lenses becoming
results were possibly due to the act that they were made with a commercially available is unclear. T ere was some patent activ-
single back scleral radius o 12 mm (Pearson, 2015). ity in the mid 1960s to early 1970s, and Mandell (1988) claims
6 PART 1 Int ro d uct io n

to have personally observed ten patients who were wearing such eventually managed to persuade his peers to conduct urther
lenses in 1965, noting very poor clinical results.  trials at the Institute. He claims to have produced ‘the rst suit-
able contact lenses’ in late 1961 (Wichterle, 1978), which pre-
So ft Le nse s (1972) sumably approximates to the rst occasion when a so lens was
actually worn on a human eye. T e patent to develop so con-
Possibly the greatest understatement that can be ound in the tact lenses commercially was subsequently acquired by Bausch
literature pertaining to contact lens development is the nal & Lomb in the USA, who introduced so lenses into the world
sentence o a paper entitled ‘Hydrophilic gels or biological use’, market in 1972.
published in Nature on 9 January, 1960, by Wichterle and Lim Lenses manu actured rom HEMA were an immediate
(1960): ‘Promising results have also been obtained in experi- market success, primarily by virtue o their superior com ort
ments in other cases, or example, in manu acturing contact and enhanced biocompatibility. However, clinical experi-
lenses, arteries, etc.’ ence and laboratory studies indicated that the poor physi-
Initial attempts by Otto Wichterle (Fig. 1.9) to produce so ological response o the anterior eye during wear o the early
lenses abricated rom hydroxyethyl methacrylate (HEMA), and thick HEMA lenses could be enhanced by making so lenses
manu actured using cast moulding, met with limited success. more permeable to oxygen – speci cally by making them
Unable to attract support rom the Institute o Macromolecular thinner and o a higher water content. Much o the research
Research in Czechoslovakia (now the Czech Republic) where and development in contact lenses up to the present time
he worked, and indeed discouraged by his superiors, Wichterle has been concerned with the development o materials and
was orced to conduct urther secret experiments in his own lens designs that optimize biocompatibility, primarily by
home. Working with a children’s mechanical construction kit, enhancing corneal oxygenation and minimizing absorption
Wichterle developed the spin-casting technique (Fig. 1.10) and o proteins, lipids and other tear constituents (McMahon and
Zadnik, 2000). 

Rig id Gas-p e rme ab le Le nse s (1974)

In most respects, PMMA is considered to be an ideal contact
lens material; however, its single drawback is its impermeability
to gases that are exchanged at the corneal sur ace as part o aer-
obic metabolism. Speci cally, oxygen is prevented rom moving
rom the atmosphere into the cornea, and carbon dioxide ef ux
into the atmosphere is impeded. T is drawback has been the
major driving orce in the development o rigid lens materials
that are permeable to gases.
One o the rst rigid gas-permeable materials to be tried was
cellulose acetate butyrate, which a orded some oxygen perme-
ability but was subject to warpage. In 1974, Norman Gaylord
managed to incorporate silicone into the basic PMMA struc-
ture, heralding the introduction o a new amily o contact lens
polymers known as silicone acrylates (Gaylord, 1974). Subse-
Fig . 1.9 O tto Wichte rle . (Courte sy of De b b ie Swe e ne y.) quently, other ingredients such as styrene and uorine have
been incorporated into rigid materials in attempts to enhance
material biocompatibility urther. 

Disp o sab le Le nse s (1988)

In the early days o so lens development, patients would typi-
cally use the same pair o lenses until the lenses became too
uncom ortable to wear, caused severe eye reactions, or were
damaged or lost. It became apparent that lens deposition and
spoilation over time were major impediments to success ul
long-term lens wear. Although regular lens replacement was
an obvious solution to some o these problems, the high unit
cost o lenses proved to be a signi cant disincentive. In the early
1980s, orward-thinking practitioners – notably Klas Nilsson
o Gothenburg, Sweden – convinced patients o the bene ts o
replacing lenses on a regular basis (6-monthly in Nilsson’s case)
and began prescribing lenses in this way. A subsequent land-
mark scienti c publication co-authored by Nilsson – known as
the ‘Gothenburg study’ (Holden et al., 1985) – unequivocally
proved the bene ts o regular lens replacement. So was born the
Fig . 1.10 The p rototyp e sp in-casting machine b uilt at home b y Wich- concept o regular lens replacement, albeit relatively expensive
te rle using his son’s toy Me ccano construction se t. or the patient at the time.
 1 Hist o ry 7

I regular lens replacement were to become the norm, some- manu acturers had introduced silicone hydrogel lenses; this
thing had to be done about lens cost. A group o Danish cli- lens type is now available in toric and multi ocal designs and
nicians and engineers, led by ophthalmologist Michael Bay, a range o replacement modalities, including daily disposable
developed a moulding process so that low-cost, multiple indi- lenses. 
vidual lens packs could be produced (Mertz, 1997). T is prod-
uct – known as ‘Danalens’ – was released into the Scandinavian
market in 1984 and must be recognized as the rst truly dispos-
Myo p ia Co nt ro l Le nse s (2010)
able lens. However, the initial manu acturing process was crude In 2010, CooperVision released into some Asian markets a daily
and numerous problems with the lenses and packaging were disposable so lens that is designed to arrest the rate o progres-
reported (Benjamin et al., 1985; Bergmanson et al., 1987). sion o myopia. A variety o optical designs can be employed
T e pharmaceutical giant Johnson & Johnson, which had to achieve this so-called ‘anti-myopia’ e ect. T e CooperVision
not previously been involved in the contact lens business, MiSight lens has a ‘dual- ocus’ design that contains a large cen-
purchased the Danalens technology in 1984 and completely tral correction area surrounded by concentric zones o alternat-
overhauled the lens polymer ormulation, packaging system ing distant and near powers. T e near power is intended as a
and moulding technology (Mertz, 1997). T e result was the ‘treatment’ zone to prevent myopic progression (see Chapter 33
Acuvue lens, an inexpensive weekly-replacement extended- or a detailed account o myopia control lenses). 
wear lens, which was released in the USA in June 1988, and
worldwide shortly therea er. T e success o this lens elevated
Johnson & Johnson to a leadership position in the contact lens
Co nt act Le ns ‘Flat Pack’ (2011)
market. All other major contact lens companies ollowed suit, Japanese manu acturer Menicon introduced an ultra-thin orm
and today the majority o so lenses prescribed worldwide o packaging – known as the ‘ at pack’ – or their ‘Magic’ brand
(85%) are designed to be replaced monthly or more requently o daily disposable contact lenses. As well as being highly e -
(Morgan et al., 2015).  cient or storage and convenient or the user, this orm o pack-
aging reduces lens contamination because the lens back sur ace
is always presented to the patient upon opening the pack, which
Daily Disp o sab le Le nse s (1994) means that the person can pick up and insert the lens into the
T e ultimate requency with which lenses can be replaced eye without touching and contaminating the posterior lens sur-
is daily. A Scottish company, Award (which was acquired by ace, which comes into contact with the eye (Nomachi et al.,
Bausch & Lomb in 1996), developed a manu acturing technique 2013). T e contact lens is essentially sandwiched within a 1 mm
whereby the male hal o the mould that ormed the lens became thick aluminium oil sleeve that is resistant to evaporation, thus
the lens packaging. T is technique urther reduced the unit cost preserving the small amount o uid trapped within the pack
o a lens, making daily disposability a viable proposition. T e that moisturizes the lens.
‘Premier’ daily disposable lens was launched in the UK in 1994. Fig. 1.11 presents a historical timeline o key developments
Johnson & Johnson released the ‘1-Day Acuvue’ daily dispos- in the contact lens eld rom the time contact (scleral) lenses
able lens into western regions o the USA around the same time, were rst tted to human eyes in the late 1880s up to the
leading to an ongoing dispute as to which company (Award or present. 
Johnson & Johnson) was the rst to release a daily disposable
contact lens into the market (Meyler and Ruston, 2006). CIBA
Vision entered the daily disposable lens market in 1997 with a
The Fut ure
product called ‘Dailies’.  So lenses are likely to dominate the uture contact lens mar-
ket. Although rigid lenses are seldom tted today or purely
cosmetic reasons, there are many clinical indications or rigid
Silico ne Hyd ro g e l Le nse s (1998) lenses, such as keratoconus, distorted corneas, irregular and / or
T e allure o a so contact lens made rom a material with a high astigmatism, certain anterior eye pathologies and par-
phenomenally high oxygen per ormance never escaped the ticipation in extreme sports. Accordingly, specialized rigid
contact lens industry. T e development o such a lens would be lens ttings will continue to be an important aspect o contact
critical to solving hypoxic lens-related problems, which severely lens practice, albeit at relatively low levels. T e recent renewed
limit the clinical utility o contact lenses, especially or extended interest in scleral or mini-scleral lenses is unlikely to have a sig-
wear. Silicone elastomers were the obvious answer, but, or rea- ni cant impact on the overall proportion o lenses prescribed
sons outlined above, success ul lenses could never be produced owing to the specialist nature o tting such lenses.
rom this material. Polymer scientists in the contact lens indus- T e convenience and ocular health bene ts o daily dispos-
try had long recognized that many o the problems associated able lenses are likely to see this modality o lens wear continue
with silicone elastomers or contact lens abrication could theo- to increase in popularity. T is trend will be accelerated with
retically be overcome by creating a silicone–hydrogel hybrid. improvements in methods and e ciency o lens mass produc-
A er more than a decade o intensive research and devel- tion, which in turn will drive prices down and make these lenses
opment, two spherical-design silicone hydrogel lenses were more a ordable. O course, any increase in daily disposable
introduced into the market in 1998: Focus Night & Day (CIBA lens usage will be matched by a commensurate decrease in the
Vision) and Purevision (Bausch & Lomb). T e introduction o demand or, and use o , contact lens care solutions.
these lenses is considered by many to be the most signi cant Silicone hydrogels are set to continue as the main material
advance in contact lens material technology since the devel- type rom which lenses are abricated in view o their abil-
opment o HEMA by Wichterle in the 1960s. Within a decade ity to obviate hypoxic complications o lens wear; however,
o these products entering the market, all major contact lens the possibility o the arrival in the uture o an entirely new
8 PART 1 Int ro d uct io n

Fig . 1.11 Historical time line o contact le ns d e ve lop me nt. PMMA = p o lyme thyl me thacrylate ; HEMA = hyd roxye thyl me thacrylate .

category o lens material with even greater bene ts should not electronically or through some other means may acilitate
be discounted. enhanced presbyopic correction.
Contact lenses are likely to be used increasingly or the cor- Extended wear is the ultimate modality in terms o patient
rection o presbyopia; this trend may be uelled by the devel- convenience, but it is unlikely that this modality o lens wear
opment o superior multi ocal lens designs and the increasing will break through the ‘glass ceiling’ o a prescribing rate o
availability o such products as daily disposable lenses. Look- around 10% o lenses tted in the oreseeable uture, in view o
ing urther into the uture, contact lenses that switch power the ve times greater risk o microbial keratitis when sleeping in
 1 Hist o ry 9

all orms o contact lenses (Schein et al., 1989). Again, develop- and Lakkis, 2005; Lin et al., 2006), alternative anti-myopia designs
ment or invention o an entirely new category o lens material (Sankaridurg et al., 2011), anti-in ective and anti-in ammatory
with superior ocular biocompatibility or an ability to minimize lenses (Weisbarth et al., 2007; Zhu et al., 2008), drug delivery
microbial colonization would need to be developed be ore (Mohammadi et al., 2014), glucose monitoring and other orms
extended wear can capture an appreciably greater slice o the o metabolic sensing (Farandos et al., 2015), intraocular pressure
contact lens market. measurement (Chen et al., 2014), digital in ormation acquisition
As better toric lens designs become available, especially in and display (e.g. a contact lens version o Google Glass [Google
daily disposable modality, toric lenses tting is likely to increase Inc., Mountain View, CA]) and liquid crystal diode optical
steadily to represent approximately 45% o all so lenses pre- switching (Milton et al., 2014) – may open up whole new markets
scribed, which is the level at which all astigmatism ≥ 0.75 D is or contact lenses and move at least part o the industry in new
being corrected. We may see a resurgence in tinted lens tting and interesting directions. Contact lens practitioners may need to
as the newly developed coloured silicone hydrogel lenses gain in acquire new knowledge and tting skills so that they can embrace
popularity and similar products enter the market. any such innovative developments.
Finally, current developments in innovative contact lens appli-
cations – such as lens sur ace modi cations to include channels Acce ss t he co mp le t e re fe re nce s list o nline at
and patterns or improving post-lens tear exchange (Weidemann ht t p :/ / www.e xp e rt co nsult .co m.
REFERENCES
Benjamin, W. J., Bergmanson, J. P. G., & Estrada, P. J. Holden, B. A., Sweeney, D. F., Vannas, A., et al. Pearson, R. M. (2007). Karl Otto Himmler, manu-
(1985). Disposable ‘eight-packs’. Int. Eyecare, 1, (1985). E ects o long-term extended contact lens acturer o the rst contact lens. Cont. Lens Ante-
494–499. wear on the human cornea. Invest. Ophthalmol. rior Eye, 30, 11–16.
Bergmanson, J. P. G., Soderberg, P. G., & Estrada, P. Vis. Sci., 26, 1489–1501. Pearson, R. M. (2009). T e Sämisch case and the
(1987). A comparison between the measured Lin, M. C., Soliman, G. N., Lim, V. A., et al. (2006). Müllers o Wiesbaden. Optom. Vis. Sci., 86, 157–
and the desirable quality o hydrogel extended Scalloped channels enhance tear mixing under 164.
wear contact-lenses. Acta Ophthalmol., 65, hydrogel contact lenses. Optom. Vis. Sci., 83, Pearson, R. M. (2015). Comments on ‘Modern scler-
417–423. 874–878. al contact lenses: a review’ [van der Worp et al.
Bra , S. M. (1983). T e Max Schapero Lecture: con- Mandell, R. B. (1988). Historical development. (2014)]. Cont. Lens Anterior Eye, 38, 73–74.
tact lens horizons. Am. J. Optom. Physiol. Opt., 60, Chapter 1, Section 1, Basic Principles. In Pearson, R. M., & E ron, N. (1989). Hundredth anni-
851–858. R. B. Mandell (Ed.), Contact Lens Practice. (4th versary o August Müller’s inaugural dissertation
Chen, G. Z., Chan, I. S., Leung, L. K., et al. (2014). ed.). (p. 19). Spring eld, IL: Charles C. T omas. on contact lenses. Surv. Ophthalmol., 34, 133–141.
So wearable contact lens sensor or continuous McMahon, . ., & Zadnik, K. (2000). wenty- ve Sankaridurg, P., Holden, B. A., Smith, E., 3rd, et al.
intraocular pressure monitoring. Med. Eng. Phys., years o contact lenses – the impact on the cornea (2011). Decrease in rate o myopia progression
36, 1134–1139. and ophthalmic practice. Cornea, 19, 730–740. with a contact lens designed to reduce relative pe-
Dallos, J. (1936). Contact lenses, the ‘invisible spec- Mertz, G. W. (1997). Development o contact lenses. ripheral hyperopia: one-year results. Invest. Oph-
tacles’. Arch. Ophthalmol., 15, 617–623. Ch. 5, Section II, Contact Lenses. In H. Hamano, thalmol. Vis. Sci., 52, 9362–9367.
E ron, N., & Pearson, R. M. (1988). Centenary cel- & H. Kau man (Eds.), Corneal Physiology and Schein, O. D., Glynn, R. J., Poggio, E. C., et al. (1989).
ebration o Fick’s Eine Contactbrille. Arch. Oph- Disposable Contact Lenses (pp. 65–99). Boston: T e relative risk o ulcerative keratitis among us-
thalmol., 106, 1370–1377. Butterworth-Heinemann. ers o daily-wear and extended-wear so contact
Enoch, J. M. (1956). Descartes’ contact lens. Am. J. Meyler, J., & Ruston, D. (2006). T e world’s rst daily lenses. A case–control study. Microbial Keratitis
Optom. Arch. Am. Acad. Optom., 33, 77–85. disposables. Optician, 231(6053), 12. Study Group. N. Engl. J. Med., 321, 773–778.
Farandos, N. M., Yetisen, A. K., Monteiro, M. J., Milton, H. E., Morgan, P. B., Clamp, J. H., et al. Weidemann, K. E., & Lakkis, C. (2005). Clinical per-
et al. (2015). Contact lens sensors in ocular di- (2014). Electronic liquid crystal contact lenses ormance o microchannel contact lenses. Optom.
agnostics. Adv. Healthc. Mater., 4(6), 792–810. or the correction o presbyopia. Opt. Express, 22, Vis. Sci., 82, 498–504.
http://dx.doi.org/10.1002/adhm.201400504. 8035–8040. Weisbarth, R. E., Gabriel, M. M., George, M., et al.
Feinbloom, W. (1936). A plastic contact lens. Trans. Mohammadi, S., Jones, L., & Gorbet, M. (2014). (2007). Creating antimicrobial sur aces and mate-
Am. Acad. Optom., 10, 37–44. Extended latanoprost release rom com- rials or contact lenses and lens cases. Eye Contact
Gaylord, N. G. (1974). Oxygen permeable con- mercial contact lenses: in vitro studies us- Lens, 33, 426–429.
tact lens composition methods and article o ing corneal models. PLoS One, 9, e106653. Wichterle, O. (1978). T e beginning o the so
manu acture (to Polycon Lab Inc.). US Patent 3 http://dx.doi.org/10.1371/journal.pone.0106653. lens. Ch. 1, Section 1, Historical development. In
808 178. Morgan, P. B.Woods, C. A., ranoudis, I. G., (2015). M. Ruben (Ed.), Sof Contact Lenses. Clinical and
Heitz, R. F., & Enoch, J. M. (1987). Leonardo da Vin- International contact lens prescribing 2015. CL Applied Technology (pp. 3–5). Eastbourne: Baillière
ci: an assessment on his discourses on image or- Spectrum, 31(1), 28-33. indall.
mation in the eye. In A. Fiorentini, D. L. Guyton, Müller, F. A., & Müller, A. C. (1910). Das kunstliche Wichterle, O., & Lim, D. (1960). Hydrophilic gels or
& I. M. Siegel (Eds.), Advances in Diagnostic Visu- Auge. Wiesbaden: J. F. Bergmann, 68–75. biological use. Nature, 185(4706), 117–118.
al Optics (pp. 19–26). New York: Springer-Verlag. Nomachi, M., Sakanishi, K., Ichijima, H., et al. (2013). Young, . (1801). On the mechanisms o the eye.
Herschel, J. F. W. (1845). O the structure o the Evaluation o diminished microbial contamination Phil. Trans. R. Soc. Lon. [Biol. Sci.], 91, 23–88.
eye, and o vision. Vol. 4, Section XII, Light. In in handling o a novel daily disposable at pack Zhu, H., Kumar, A., Ozkan, J., et al. (2008). Fimbrolide-
E. Smedley, H. J. Rose, & the late H. J. Rose (Eds.), contact lens. Eye Contact Lens, 39, 234–238. coated antimicrobial lenses: their in vitro and in vivo
Encyclopedia Metropolitana (pp. 341–586). London: Pearson, R. M. (1989). Kalt, keratoconus and the e ects. Optom. Vis. Sci., 85, 292–300. Erratum in
B. Fellowes. contact lens. Optom. Vis. Sci., 66, 643–646. Optom. Vis. Sci., 85, 609.

9.e 1
 2
Ant e rio r Eye
JO HN G LAWRENSO N

Int ro d uct io n cornea is conventionally divided into our zones (central, para-
central, peripheral and limbal). T e central zone, which covers
A critical aspect o contact lens practice is monitoring the the entrance pupil o the eye, is spherical, approximately 4 mm
ocular response to lens wear, which ranges rom acceptable wide, and principally determines high-resolution image or-
physiological changes to adverse pathology. In order to do this, mation on the ovea. T e paracentral zone, which lies outside
practitioners must possess a thorough understanding o the the central zone, is atter and becomes optically important in
normal structure and unction o the anterior eye, which is the dim illumination when the pupil dilates. T e peripheral zone
subject o this chapter. In the course o reading other chapters is where the cornea is attest and most aspheric (Klyce et al.,
in this book, the reader may need to re er back to this chapter 1998). Due to a di erence in curvature between its posterior
on the unctional anatomy and physiology o the anterior eye and anterior sur aces, the cornea shows a regional variation
in order to develop a uller understanding o the phenomena in thickness. Centrally the thickness is approximately 0.54
being described.  mm (Doughty and Zaman, 2000), with a peripheral thickness
between 11% and 19% higher than in the centre (Khoramnia
The Co rne a et al., 2007). 

T e cornea ul ls two important unctions: together with the Microscop ic Anatomy

sclera it orms a tough brous outer coat that encloses the When the cornea is viewed in transverse section, ve distinct
ocular tissues and protects the internal components o the layers can be resolved: epithelium, Bowman’s layer, stroma, Des-
eye rom injury. Signi cantly, the cornea also provides two- cemet’s membrane and endothelium (Fig. 2.1).
thirds o the re ractive power o the eye. It is particularly well
suited to its role: the cornea is curved and transparent, and the Epithelium. T e epithelium represents approximately 10% o the
air–tear inter ace provides a re ractive sur ace o good optical thickness o the cornea (55 µm) (Feng and Simpson, 2008). It is a
quality. strati ed squamous non-keratinized epithelium, consisting o 5–6
layers o cells (Fig. 2.2), which undergo a constant process o cyclic
CO RNEAL ANATO MY
Gross Anatomy
T e cornea is elliptical when viewed rom in ront, with its long
axis in the horizontal meridian ( able 2.1). T is asymmetry is
produced by a greater degree o overlap o the peripheral cornea
by opaque limbal tissue in the vertical meridian. T e sur ace
area o the cornea is 1.1 cm 2, which represents about 7% o the
sur ace area o the globe (Maurice, 1984). opographically, the

TABLE Co rne al Dime nsio ns and Re lat e d

2.1 Me asure me nt s
Parame t e r Value
Are a 1.1 cm 2
Diame te r
Horizontal 11.8 mm
Ve rtical 10.6 mm
Rad ius of curvature
Ante rior ce ntral 7.8 mm
Poste rior ce ntral 6.5 mm
Thickne ss
Ce ntral 0.54 mm
Pe rip he ral 0.67 mm
Re fractive ind e x 1.376
Powe r 42 D Fig . 2.1 Transve rse se ction throug h the corne a. The stroma, which
re p re se nts 90% o the thickne ss o the corne a, is b ound e d b y the e p i-
(Data ad ap te d rom Bron e t al., 1997.) the lium (aste risk) and e nd othe lium (arrow).
10
 2 Ant e rio r Eye 11

shedding and replacement to maintain corneal integrity. T ree Basal cells consist o single-layer columnar cells with a verti-
distinct epithelial cell types are recognized: a single row o basal cally oriented oval nucleus. Ultrastructurally, they are similar in
cells, 2–3 rows o wing cells and 2–3 layers o super cial (squamous) appearance to wing cells. T e plasma membrane similarly shows
cells. In addition, several non-epithelial cells are present (e.g. pronounced in olding and the cytoplasm contains prominent
lymphocytes, macrophages and Langerhans cells). T e epithelium intermediate laments. A variety o cell junctions are present
orms a permeability barrier to water, ions and hydrophilic including: desmosomes, which mediate adhesion between cells;
molecules above a certain size, as well as orming an e ective hemidesmosomes, which are involved in the attachment o basal
barrier to the entry o pathogens. Further epithelial specialization cells to the underlying stroma; and gap junctions, which allow or
enhances adhesion between cells, to withstand shearing and intercellular metabolic coupling. Basal cells orm the germative
abrasive orces. Furthermore, throughout the thickness o the layer o the cornea, and mitotic cells are o en seen at this level. 
epithelium, adjacent cells are connected to one another by water
channels (aquaporins) that are engaged in transcellular water Basal Lamina and Bowman’s Layer. T e basal lamina
transport and gap junctions to allow the trans er o ions and small (basement membrane) is synthesized by basal cells. It varies
molecules between cells (Bron et al., 2015). in thickness between 0.5 and 1 µm, and under the electron
Super cial cells are structurally modi ed or their barrier microscope can be di erentiated into an anterior clear zone
unction and interaction with the tear lm. Scanning elec- (lamina lucida) and a posterior darker zone (lamina densa).
tron microscopy o sur ace cells shows extensive nger-like T e basal lamina is part o a complex adhesion system, which
and ridge-like projections (microvilli and microplicae), which mediates the attachment o the epithelium to the underlying
increase the epithelial sur ace area. Light, medium and dark stroma (Fig. 2.3). Hemidesmosomes link the cytoskeleton via a
cells can be distinguished depending on the number and pat- series o anchoring brils to anchoring plaques in the anterior
tern o sur ace projections (P ster, 1973). It has been sug- stroma. T e molecular components o this adhesion complex
gested that dark cells, which are relatively ree o these sur ace have been identi ed and include type VII collagen, integrins,
eatures, are close to being desquamated into the tear lm. By laminin and bullous pemphigoid antigen (Gipson et al., 1987).
contrast, the newly arrived light cells possess a more extensive Bowman’s layer (anterior limiting membrane) varies in thick-
array o sur ace projections. In high-power transmission elec- ness between 8 and 14 µm. With the light microscope it appears as
tron micrographs, microvilli and microplicae show an extensive an acellular homogeneous zone. Ultrastructurally, it is composed
lamentous covering known as the glycocalyx. T e glycocalyx o a randomly oriented array o ne collagen brils, which merge
is ormed rom membrane-bound mucin glycoproteins and is with the brils o the anterior stroma (Hogan et al., 1971). Fibrils
important or spreading and attachment o the precorneal tear are composed primarily o collagen types I, III and V. Collagen VII,
lm. In accordance with their barrier unction, a complex net- associated with anchoring brils, is also present. T ere is evidence
work o tight junctions links super cial cells that exclude water- that Bowman’s layer is ormed and maintained primarily by the epi-
soluble dyes such as uorescein (Bron et al., 2015). thelium, although its unction is unclear. T e absence o Bowman’s
Wing cells are so named because o their characteristic layer rom the cornea o most mammals, and the act that corneas
shape, with lateral extensions and a concave in erior sur ace to devoid o this layer over the central cornea ollowing photore rac-
accommodate the apices o the basal cells. T eir nuclei tend to tive keratectomy (PRK) apparently unction normally, suggest that
be spherical or elongated in the plane o the cornea. T e cell it is not critical to corneal integrity (Wilson and Hong, 2000). 
borders o the polygonal wing cells show prominent in oldings
that interdigitate with adjacent cells, and numerous desmo- Stroma. T e stroma is approximately 500 µm thick, and
somes. T is arrangement results in a strong intercellular adhe- accounts or 90% o the thickness o the cornea. It is composed
sion. T e cytoplasm contains prominent cytoskeletal elements predominantly o collagen brils (70% dry weight) embedded in
(predominantly actin and cytokeratin intermediate laments), a highly hydrated matrix o proteoglycans. A variety o collagen
and although the usual complement o organelles is present they
are ew in number.

Fig . 2.3 Sche matic re p re se ntation o the ad he sion syste m o the cor-
ne al e p ithe lium. Inte rme d iate lame nts in the cytoske le ton (CS) are
Fig . 2.2 Corne al e p ithe lium (d e tail). Thre e ce ll typ e s are p re se nt: linke d throug h he mid e smosome s (HD) via anchoring b rils (AF) to an-
b asal ce lls (aste risk), wing ce lls (arrowhe ad ) and sq uamous ce lls (arrow). choring p laq ue s (AP) in the ante rior stroma. BL= b asal lamina; D = d e s-
BL= Bowman’s laye r. mosome .
12 PART 1 Int ro d uct io n

Fig . 2.4 Se ction throug h the stroma. Ke ratocyte s (arrowe d ) are locat-
e d b e twe e n lame llae .
Fig . 2.6 Flat se ction throug h the stroma staine d with g old chlorid e .
Ke ratocyte s (arrowe d ) d isp lay a ste llate ap p e arance .

physiological measurements o collagen bre diameter and

spacing can be obtained or the hydrated cornea with the aid o
X-ray di raction. Using this technique, the mean bril diameter
in the human cornea is 31 nm, with an inter brillar spacing o
55 nm (Meek and Leonard, 1993). T is narrow bril diameter
and constant separation, which is a characteristic o corneal
collagen, are necessary prerequisites or transparency.
T e inter brillar space contains a matrix o proteoglycans
(approximately 10% o dry weight). T ese molecules are highly
sulphated, and along with bound chloride ions create a polyan-
ionic stromal inter brillar matrix that induces osmotic swelling.
As well as playing a major role in corneal hydration, collagen–
proteoglycan interactions are also thought to be important in
determining the size and spatial arrangement o stromal colla-
gen brils (Scott, 1991; Quantock and Young, 2008).
Collagen and proteoglycans are maintained by keratocytes.
T ese cells occupy 3–5% o stromal volume and lie between col-
lagen lamellae, attened in the plane o the cornea (Fig. 2.6).
Keratocyte density examined by con ocal microscopy and bio-
chemical methods (Møller-Pederson and Ehlers, 1995; Prydal
Fig . 2.5 Ele ctron microg rap h o stromal lame llae that cross e ach othe r et al., 1998) is non-uni orm. Density decreases rom super cial
ap p roximate ly at rig ht ang le s. Note the re g ular arrang e me nt o colla- to deep stroma (Hollingsworth et al., 2001) and increases rom
g e n b rils within lame llae . centre to periphery. Keratocytes display a large central nucleus
and long slender processes extend rom the cell body. Processes
types have been identi ed. ype I is the major bril- orming rom adjacent cells sometimes make tight junctions with each
collagen, with lesser amounts o types III and V. Non- bril- other. Cell organelles are not numerous but the usual comple-
orming collagens, including types VI and XII, are ound in the ment o organelles, including endoplasmic reticulum, Golgi
inter brillar matrix (Meek and Boote, 2009). A section taken apparatus and mitochondria, can be observed (Hogan et al.,
perpendicular to the corneal sur ace reveals that the collagen 1971).
brils are arranged in 200–250 layers (lamellae) running parallel Newer lamellar corneal transplantation techniques have
to the sur ace (Fig. 2.4). Lamellae are approximately 2 µm thick been developed that allow selective replacement o the diseased
and 9–260 µm wide, and extend rom limbus to limbus. Fibrils corneal layers. Deep anterior lamellar keratoplasty (DALK),
o adjacent lamellae make large angles with each other. In the which is increasingly being used to treat keratoconus and cor-
super cial stroma the angles are less than 90°, but brils become neal scarring, involves replacement o the a ected stroma while
orthogonal in the deeper stroma (Hogan et al., 1971; Meek and retaining the host’s healthy Descemet’s membrane and endo-
Boote, 2009). T is pre erred orthogonal orientation gradually thelium. Separation between the posterior stroma and Des-
changes in avour o circum erentially aligned collagen at the cemet’s / endothelium can be achieved by intrastromal injection
limbus. T is particular arrangement o collagen imparts a high o air, viscoelastic or saline. Dua and co-workers per ormed a
tensile strength or corneal protection, which is important given histological examination o donor corneas using air bubble sep-
its exposed position. Within lamellae, all collagen brils are aration and claimed to have identi ed a novel ‘pre-Descemet’s
parallel with uni orm size and separation (Fig. 2.5). Accurate posterior stromal layer’, which was widely publicized (Dua et al.,
 2 Ant e rio r Eye 13

Fig . 2.7 Hig h-p owe re d microg rap h o the p oste rior stroma. De s-
ce me t’s me mb rane (DM) is locate d b e twe e n the stroma (S) and the e n-
d othe lium (arro w).
Fig . 2.9 Tang e ntial (f at) se ction throug h the corne al e nd othe lium: a
sing le laye r o p olyg onal ce lls with irre g ular b ord e rs can b e ob se rve d .

replace damaged or e ete cells, there is a progressive reduction

in endothelial cell number with age. At birth the cornea
contains a total o approximately 500 000 cells, which represents
a mean density o 4500 cells / mm 2. During in ancy, cell loss
is particularly marked and a 26% reduction occurs in the rst
year o li e (Sherrard et al., 1987). T erea er the rate o loss
progressively declines into old age. Since gra ed corneas appear
to maintain transparency and unctional normality with an
endothelial cell density o less than 1000 cells / mm 2, it seems
that normal cell density represents a considerable ‘physiological
Fig . 2.8 Thre e -d ime nsional re p re se ntation o the p oste rior corne a reserve’ (Klyce and Beuerman, 1998). When viewed en ace, or
showing the e nd othe lium (e ), De sce me t’s me mb rane (d ) and stroma (s). example using a specular microscope, the endothelium appears
A stromal lame lla has b e e n re f e cte d to re ve al an intralame llar ke rato- as a mosaic o polygonal (typically hexagonal) cells (E ron et al.,
cyte (k). 2001). In response to pathology, trauma, age and prolonged
contact lens wear, the endothelial mosaic becomes less regular,
2013). However, the current consensus amongst corneal experts and shows a greater variation in cell size (polymegethism) and
is that this layer is not suf ciently unique to constitute a new shape (pleomorphism) as cells spread to ll gaps caused by
corneal layer (Jester et al., 2013).  cell loss. Under the electron microscope, the lateral borders o
the cells are markedly convoluted and adjacent cells are linked
Descemet’s Membrane. Descemet’s membrane is the basement by tight junctions (with less- requent gap junctions) (Hogan
membrane o the corneal endothelium. It lies between the et al., 1971). T e complement o organelles seen in endothelial
endothelium and the overlying stroma (Fig. 2.7). At birth it is cells re ects their high metabolic activity, with numerous
3–4 µm thick, and increases to a thickness o 10–12 µm in the mitochondria and a prominent rough endoplasmic reticulum. 
adult. In the periphery o aged corneas, Descemet’s membrane
displays periodic sections o thickening, which are known as
Hassall–Henle warts. T e anterior one-third o Descemet’s CO RNEAL INNERVATIO N
membrane represents that part produced in etal li e and, under
the electron microscope, is characterized by a periodic banded Source and Distrib ution of Corne al Ne rve s
pattern (Fig. 2.8). T e posterior two-thirds, which is ormed T e cornea is the most richly innervated sur ace tissue in
postnatally, has a more homogeneous granular appearance. the body. Corneal nerves are responsible or the detection o
Descemet’s membrane has a unique biochemical composition somatosensory stimuli and play an important role in initiating
in contrast with other basement membranes (Lawrenson the blink re ex, wound healing and tear secretion (see Sha-
et al., 1998). T e major basement membrane collagen type is heen et al., 2014, or a recent review). T e majority o corneal
type IV, whereas in Descemet’s membrane type VIII collagen nerves are sensory and derive rom the nasociliary branch o
predominates.  the trigeminal nerve (Ruskell and Lawrenson, 1994). T ere is
also evidence or the existence o a modest sympathetic inner-
Endothelium. T e endothelium is a monolayer o squamous vation rom the superior cervical ganglion (Mar urt and Ellis,
cells that lines the posterior sur ace o the cornea (Fig. 2.9) 1993). Branches rom the nasociliary nerve either pass directly
and plays a critical role in maintaining corneal transparency to the eye as long ciliary nerves or traverse the ciliary ganglion,
(Bonanno, 2012). As it has a limited capacity or mitosis to leaving it as short ciliary nerves that enter the eye close to the
14 PART 1 Int ro d uct io n

concluded that ree nerve endings were the exclusive receptors

or pain. Although the speci city theory has subsequently been
challenged, particularly with respect to its exclusivity, the ques-
tion as to whether pain is the only sensory modality perceived
by the cornea remains.
Modern experiments using care ully controlled corneal
stimulation, with a variety o mechanical, chemical and ther-
mal stimuli, have evoked only sensations o irritation or pain.
By contrast, electrophysiological studies o corneal a erent
neurones have identi ed neurones that respond to mechanical,
thermal and chemical stimulation. However, since the conscious
perception o these sensations has not been demonstrated, it
is likely that such speci city o modality is lost during central
nervous system processing. Electrophysiological recording also
allows or the mapping o receptive elds. T ese are o en large
and overlapping, which explains the inability o the cornea to
localize a stimulus accurately (Belmonte et al., 1997). T e sen-
sitivity o the cornea to mechanical stimulation is particularly
acute, and acts as a trigger or the protective blink and lacrimal
re exes. Cold receptors may be important in signalling evapo-
rative cooling, which is a major determinant o spontaneous eye
blink requency ( subota, 1998).
Fig . 2.10 Whole -mount g old chlorid e -staine d p re p aration o corne al Corneal a erent bres also exert important trophic in u-
ne rve s (arrows) locate d at b asal le ve l. ences. Damage to corneal sensory nerves by surgery, trauma or
in ection produces neuroparalytic keratitis – a condition that is
characterized by progressive epithelial cell loss and oedema. T e
optic nerve. Nerves destined or the cornea travel initially in mechanism o this trophic role is not ully understood, although
the suprachoroidal space, be ore crossing the sclera to advance the release o neuropeptides (e.g. substance P and calcitonin
radially towards the cornea. gene-related peptide) may be a actor. Sympathetic nerves also
Most o the 50–80 precorneal nerve trunks, which contain play a role in epithelial maintenance by regulating ion transport
a mixture o myelinated and unmyelinated bre bundles, enter processes, and cell proli eration and migration during wound
the cornea at mid-stromal level. Myelin is soon lost and the healing. 
unmyelinated nerve bre bundles divide repeatedly and move
anteriorly to orm a rich plexi orm network in the anterior one-
third o the stroma. Axons are particularly dense immediately CO RNEAL METABO LISM
beneath Bowman’s layer, orming an extensive subepithelial
plexus (Oliveira-Soto and E ron, 2001). From this plexus, axons Source of O xyg e n and Nutrie nts
pass vertically through Bowman’s layer, losing their Schwann In order to per orm its vital unctions, the cornea requires a
cell sheath in the process. Upon entering the epithelium, axons constant supply o oxygen and other essential metabolites (e.g.
turn through 90° and divide into a series o ne branches that glucose, vitamins and amino acids). However, its avascularity
course between basal cells (Fig. 2.10). Some branches pass into dictates that alternative routes must exist or the provision o its
the more super cial layers be ore terminating. T e density o metabolic needs. T ere are three possibilities: rom the perilim-
nerve terminals is greatest centrally, corresponding to approxi- bal vasculature, rom the tear lm or rom the aqueous humour.
mately 600 terminals / mm 2, which results in large overlapping In open-eye conditions the bulk o the oxygen required or the
receptive elds (Shaheen et al., 2014). cornea is obtained rom the atmosphere via di usion across
Corneal nerves display a complex neurochemistry. A variety the precorneal tear lm. Under steady-state conditions it can
o neurotransmitters and neuromodulators have been identi- be assumed that the tears are saturated with oxygen, and there-
ed, including acetylcholine, substance P, and calcitonin gene- ore at an oxygen tension corresponding to the atmosphere (155
related peptide. However, it is unclear how these particular mmHg at sea level). It has been estimated that the oxygen ten-
neurochemicals correlate with unction (Belmonte et al., 1997).  sion o the aqueous humour in the human eye lies between 30
and 40 mmHg (Klyce and Beuerman, 1998).
Functional Consid e rations Experiments using nitrogen- lled goggles or sealed scleral
Corneal nerves serve important sensory, re ex and trophic lenses have shown the corneal dependence on tear-side oxygen
unctions. Interest in the sensitivity o the cornea dates back to to avoid oedema and maintain normal unction. T e reason
the 19th century (Lawrenson, 1997), when the pioneering Ger- why the cornea swells during contact lens wear is explained in
man physiologist von Frey concluded that pain was the only Fig. 2.11. During eye closure the oxygen level in the tears is in
sensation perceived by the cornea. T is was consistent with his equilibrium with the palpebral vasculature (55 mmHg) (E ron
theory o the speci city o sensory receptors, which maintained and Carney, 1979).
that each sensory modality was subserved by a separate anatom- Signi cantly, corneal thickness increases by approximately
ically distinct nerve terminal. In his experiments on the cornea, 5% during sleep, and returns to baseline levels within 1 hour
von Frey could elicit only a sensation o pain and, as the cornea o eye opening. It has been suggested that overnight swell-
contained exclusively ree (unspecialized) nerve endings, he ing is related to tear lm tonicity rather than reduced oxygen
 2 Ant e rio r Eye 15

Fig . 2.11 (A) Cross-se ction o an e ye we aring a contact le ns, which Fig . 2.12 Me tab olic p athways p re se nt in the co rne a. HMP = he xose
imp e d e s ing re ss o oxyg e n into, and the e g re ss o carb on d ioxid e rom, monop hosp hate shunt; TCA cycle = tricarb oxylic acid (Kre b s) cycle ;
the corne a. (B) The contact le ns b locks oxyg e n sup p ly to the corne a (1), ATP = ad e nosine trip hosp hate ; NADPH = nicotinamid e ad e nine d inucle -
causing lactic acid to accumulate in the stroma (2). This d raws in wate r otid e p hosp hate (re d uce d orm).
(3), le ad ing to stromal oe d e ma (4). (Ad ap te d rom E ron, N. (1997). Con-
tact le nse s and corne al p hysiolog y. Biol. Sci. Re v., 9, 29–31.)
di use slowly across the endothelium into the anterior cham-
ber. However, during periods o hypoxia the proportion o glu-
availability (Klyce and Beuerman, 1998). T e oxygen ux into cose that is metabolized anaerobically increases. T e resulting
the cornea can be measured using polarographic oxygen sen- accumulation o lactate causes stromal oedema via an increased
sors. It is in the region o 6 µl / cm 2 / h or the cornea as a whole, osmotic load (Klyce, 1981) and localized tissue acidosis (Klyce
although the consumption rate or its composite layers is not and Beuerman, 1998).
equal. Consumption rates have been estimated as 40 : 39 : 21 or T e hexose monophosphate shunt (also known as the pen-
the epithelium, stroma and endothelium, respectively (Free- tose phosphate shunt) plays an important role in the corneal
man, 1972). epithelium (Berman, 1981), where it ul ls several important
Several lines o evidence indicate that the aqueous humour is unctions, including the generation o intermediates or biosyn-
the primary source o glucose and essential amino acids or the thetic reactions and the prevention o oxidative damage by ree
cornea (Maurice, 1984). T e glucose concentration o tears is radicals. 
low compared with that in the aqueous humour, and the inser-
tion o nutrient-impermeable implants into the stroma results CO RNEAL TRANSPARENCY
in degeneration o the tissue lying anterior to the implant.
Although exogenous glucose is primarily utilized, glycogen Under normal conditions the cornea is highly transparent,
stores are present in all corneal cells to provide glucose in con- transmitting more than 90% o incident light. Structurally, the
ditions o metabolic stress. cornea is a typical connective tissue consisting principally o a
T e role o the perilimbal vasculature in the provision o matrix o collagen and proteoglycans. Under normal circum-
oxygen and nutrients appears limited and it is likely that it is stances such an arrangement would avour light scatter with
signi cant only or the corneal periphery (Maurice, 1984).  consequent loss o transparency. T is raises two undamental
questions: how is transparency achieved, and how is it main-
O xid ative Me tab olism tained? o begin to answer these questions it is necessary to
T e cornea derives its energy principally rom the oxidative understand the spatial organization o the stromal matrix and
breakdown o carbohydrates (Riley, 1969). Glucose, which the importance o corneal hydration control.
is the primary substrate or the generation o adenosine tri-
phosphate (A P), is catabolized by three metabolic pathways: Stromal O rg anization
glycolysis, the tricarboxylic acid (Krebs) cycle and the hex- Maurice (1957) explained the transparency o the cornea on the
ose monophosphate shunt (Fig. 2.12). Anaerobic glycolysis basis o the small diameter and regular separation o the stro-
accounts or the majority (85%) o glucose metabolism. In mal collagen. He suggested that the collagen brils o the stroma
this pathway, glucose is rst oxidized to pyruvate and then were disposed in a regular crystalline lattice, and that light scat-
subsequently reduced to lactate, with a net yield o two mol- tered by the brils is eliminated by destructive inter erence in
ecules o A P per mole o glucose. T e CA cycle results in all directions other than the orward direction. T is situation
a greater energy yield (36 A P). T is pathway is most active will hold as long as the axes o the collagen brils are arranged
in the corneal endothelium, which has the greatest energy in a regular lattice with a separation less than the wavelength o
requirement. light. It has been suggested, however, that the brillar arrange-
Metabolic waste products can be potentially damaging i ment need not be in a per ect crystal lattice to maintain trans-
allowed to accumulate. Although carbon dioxide can readily parency (Maurice, 1984), although disruption o short-range
di use out o the cornea across its limiting layers, lactate is less order between brils will lead to increased scatter and a loss o
easily eliminated. Under normoxic conditions, lactate is able to transparency.
16 PART 1 Int ro d uct io n

T e actors involved in the maintenance o collagen bril size

and spatial order are not ully understood. It has been proposed
that collagen bril diameters may be controlled by the incorpo-
ration o minor collagens (e.g. type V) into the predominantly
type I brils (Meek and Leonard, 1993) and that their spatial
separation is a unction o proteoglycan–collagen interactions
(Scott, 1991). Proteoglycans are a amily o glycoproteins that
consist o a protein core to which are attached sugar chains
o repeating disaccharide units termed glycosaminoglycans
(GAGs). T ese molecules are increasingly being recognized
as important prerequisites or transparency (Quantock and
Young, 2008; Hassell and Birk, 2010). Proteoglycans were origi-
nally classi ed according to their glycosaminoglycan composi-
tion; however, current nomenclature groups them into amilies
based on homologous sequences o amino acids in their protein
core. Corneal stromal proteoglycans are members o the small
leucine-rich amily, which are small enough to t in the space
between collagen brils. T e most prevalent glycosaminoglycan
in the cornea is keratan sulphate, which is ound in three types Fig . 2.13 Sche matic re p re se ntation o the corne al e nd othe lial p ump .
o proteoglycan: lumican, keratocan and mimecan (Funder- CA = carb onic anhyd rase ; TJ = tig ht junctio n.
burgh et al., 1991; Funderburgh 2000). T e other type o corneal
proteoglycan is decorin, which contains a hybrid chondroitin dioxide by the enzyme carbonic anhydrase. Bicarbonate leaves
sulphate / dermatan sulphate side chain. Evidence rom several the cell via an apical bicarbonate ion channel. T e driving orce
sources has shown that lumican and decoran play important or the bicarbonate ux is generated by a sodium–potassium
roles in regulating collagen bril diameter and maintaining the A Pase that resides on the basolateral endothelial membrane.
spacing between brils once ormed, which are essential or T e energy associated with subsequent sodium re-entry (via
transparency.  Na+ / H + and Na+ / HCO3− transporters) is coupled to active
HCO3− ux (Hodson et al., 1991).
Hyd ration Control T e epithelium also contributes to corneal hydration con-
T e state o corneal hydration is another important determi- trol (Klyce and Beuerman, 1998). T e tight junctions between
nant o corneal transparency (Bonanno 2012). T e hydrophilic super cial epithelial cells orm an e ective permeability barrier
properties o the stroma are to a large part determined by pro- to ions and polar solutes. For example, the anionic molecule
teoglycans, which contribute to the xed negative charge o the sodium uorescein does not penetrate an intact epithelium.
stroma and produce a passive gel swelling pressure through However, damage to the super cial cells allows uorescein to
electrostatic repulsion (Hodson, 1997). Physiologically, corneal enter the epithelium, with resulting corneal staining. In addition
hydration is maintained at approximately 78%. I the cornea is to its barrier properties, the epithelium also possesses active ion
allowed to swell ±5% o this value, it begins to scatter signi cant transport systems or Na+ and Cl−. As these pumps contribute
quantities o light (Hodson, 1997). to the tonicity o the tear lm, it is likely that they are involved
Maintenance o physiological corneal hydration is to a large in the maintenance o stromal hydration. 
part dependent on the corneal endothelium, which possesses
both a barrier property and a metabolically driven pump. T e Re sp onse to O e d e ma
endothelial barrier to the ree passage o molecules rom the When corneas swell, light scattering increases, with an ensued
aqueous humour is ormed principally by ocal tight junctions transparency loss due to the disruption o the regular collagen
between adjacent endothelial cells. However, in contrast to matrix. T e collagen brils themselves swell very little and most
other barrier epithelia, these junctions are o low electrical resis- o the additional water goes into the inter brillar spaces. rans-
tance and allow the passage o ions and small molecules. T is mission electron micrographs o oedematous corneas show
leak is o set by the metabolically driven pumping o ions out o bril aggregation, with the result that large areas are devoid o
the stroma by the endothelium, which maintains a transcellular collagen brils (Stiemke et al., 1995). T ere is evidence that col-
potential di erence (aqueous side negative) to balance stromal lagen aggregation occurs as a result o loss o GAGs, which pre-
swelling pressure (Maurice, 1984). Disruption o this osmotic viously had maintained bre separation (Stiemke et al., 1995). 
gradient will result in stromal uid imbibition.
T e speci c endothelial ion transport mechanisms respon-
CO RNEAL EPITHELIAL WO UND HEALING
sible or the maintenance o physiological hydration are not
ully understood. A simpli ed model representing our cur- A smooth and intact corneal epithelium is necessary in order
rent level o knowledge is represented in Fig. 2.13. T ere is or the cornea to maintain clear vision. However, due to its
compelling evidence that a ux o bicarbonate ions is the pre- exposed position the cornea is potentially vulnerable to a vari-
dominant component o the endothelial ion transport system ety o external insults. It possesses several protective mecha-
(Hodson and Miller, 1976). Subsequent studies have identi ed nisms to avoid injury, but i tissue damage occurs it is capable
that Cl− transporters may also be important in maintaining the o an e ective wound-healing response (Gipson and Inatomi,
pump (Bonanno 2012). T e bicarbonate is generated either 1995; Nishida and anaka, 1996). Corneal epithelial repair is a
by a Na+ / HCO3− co-transporter located on the basolateral complex process involving an orchestrated interaction between
plasma membrane or via the intercellular conversion o carbon cells and extracellular matrix, which is coordinated by a variety
 2 Ant e rio r Eye 17

o growth actors. T e process can be divided into three phases:

(1) initial covering o the denuded area by cell migration, (2)
cell proli eration to replace lost cells and (3) epithelial di eren-
tiation to re- orm the normal strati ed epithelial architecture.
Following a ull-thickness epithelial de ect, bronectin, an
adhesive glycoprotein, is synthesized and covers the sur ace o
the bared stroma where it serves as a temporary matrix or cell
migration. T e adhesion between bronectin and the epithe-
lium is mediated by integrin–matrix interactions (integrins are a
amily o cell sur ace receptors that bind to certain extracellular
matrix proteins). Several growth actors have been implicated in
the control o the wound-healing response, including epidermal
growth actor, trans orming growth actor beta, platelet-derived Fig . 2.14 Sur ace anatomy o the e ye lid s. (Ad ap te d rom Bron, A. J.,
growth actor and broblast growth actor (Gipson and Ina- Trip athi, R. C. & Trip athi, B. (1997). Wol ’s Anatomy o the Eye and O rb it
tomi, 1995). Growth actors, which are produced by a variety o (8th e d .). Lond on: Chap man and Hall.)
sources (e.g. ocular sur ace epithelia and the lacrimal gland), are
able to regulate the process o epithelial migration, proli eration
and di erentiation. T ere is evidence that epithelial–stromal o the ssure is approximately 30–31 mm, with a vertical height
interactions play an important role in corneal wound healing o 10–11 mm. In the primary position, the upper lid, which is
(Wilson, 2000). Epithelial injury triggers keratocyte apoptosis the larger and more mobile o the two, typically covers approxi-
(programmed cell death) in the anterior stroma, via the release mately the upper third o the cornea, whilst the lower lid is level
o apoptosis-inducing cytokines rom epithelial cells. Kerato- with the in erior corneal limbus (Fig. 2.14). Important di er-
cyte apoptosis subsequently triggers a wound-healing cascade, ences in eyelid anatomy exist between Asian and Caucasian eyes
which in uences epithelial repair. (Saonanon, 2014). T e most obvious eature o the Asian eye is
Regeneration o the corneal epithelium is highly dependent the absent or very low lid old and uller upper eyelid.
on the integrity o the limbus (Lavker et al., 2004). Cumulative T e eyelid margins are about 2 mm thick rom ront to back.
evidence indicates that a proportion o limbal basal epithelial T e posterior quarter consists o conjunctival mucosa and the
cells possess the properties o stem cells, which are ultimately anterior three-quarters is skin. T e junction between the two is
responsible or corneal epithelial replacement. Stem cells have re erred to as the mucocutaneous junction. T ere has recently
several unique characteristics: they are poorly di erentiated, been a renewed interest in the marginal zone o the human eyelid,
long lived and have a high capacity or sel -renewal. When these with the identi cation o the role o the inner lid border, termed
cells divide, one o the daughter cells replenishes the stem cell the ‘lid-wiper’ owing to the analogy to a windscreen wiper, in
pool, whilst the other is destined to undergo urther cell divi- the distribution o the tear lm (Knop et al., 2011a, 2012). wo
sions be ore di erentiating. Such a cell is re erred to as a tran- or three rows o eyelashes (cilia) arise rom the anterior border
sient ampli ying cell. ransient ampli ying cells undergo several o the lid margins. T ese are longer and more numerous in the
rounds o cell division be ore ully di erentiating. T ese cells upper lid. T e lashes receive a rich sensory nerve supply, and
play an important role in epithelial wound healing, where their their sensitivity provides an e ective alerting mechanism.
proli erative capacity is increased by shortening cycle times and T e meibomian (tarsal) gland ori ces emerge just anterior
increasing the number o times that the transient ampli ying to the mucocutaneous junction (Fig. 2.15). About 30–40 glands
cells can divide be ore maturation.  open onto the upper margin, and slightly ewer (20–40) onto
the lower. On eversion o the lids the yellowish meibomian
The O cular Ad ne xa acini are visible as yellow clusters through the tarsal conjunc-
tiva (Bron et al., 1991; Knop et al., 2011b). Meibomian glands
T e ocular adnexa are those structures that support and pro- can be more clearly visualized using in rared meibography, and
tect the eye, and include the eyelids, conjunctiva and lacrimal instruments that use this method are now commercially avail-
system. T ey play an important role in the ormation o the pre- able (Srinivasan et al., 2012) (Fig. 2.16). At the medial angle,
ocular tear lm and collectively de end the eye against antigenic the eyelid margins enclose a triangular space – the lacus lacri-
challenge. malis – which contains the plica semilunaris and the caruncle.
Lacrimal papillae are small elevations located 5–6 mm rom the
EYELIDS medial canthal angle, which contains a small aperture (punc-
tum) that is the opening to the lacrimal drainage system. 
T e eyelids are two mobile olds o skin that per orm several
important unctions: they act as occluders that shield the eyes Muscle s of the Eye lid s
rom excessive light, and through their re ex closure they a ord Movements o the eyelids are governed by the coordinated
protection against injury. T e lids also orm a precorneal tear action o several muscles.
lm o uni orm thickness during the upturn phase o each
blink. T e action o blinking is also important or tear drainage. Orbicularis Oculi. T e orbicularis oculi is the sphincter muscle
o the eyelids, and can anatomically be divided into two main
Gross Anatomy divisions: the palpebral and the orbital (Fig. 2.17). Fibres o the
T e eyelids are joined at their extremities, termed ‘the canthi’, palpebral division arise rom the medial palpebral ligament
and when the eye is open, an elliptical space, the palpebral s- and arc across the eyelids in a series o hal -ellipses, meeting at
sure, is ormed between the lid margins. In the adult, the length the lateral canthus to orm a lateral raphe. T e lateral palpebral
18 PART 1 Int ro d uct io n

Fig . 2.17 Sche matic re p re se ntation o the d ivisions o the orb icularis
oculi and the rontalis. a = p re tarsal; b = p re se p tal; c = orb ital; d = ronta-
lis. (Ad ap te d rom Bron, A. J., Trip athi, R. C. & Trip athi, B. (1997). Wol ’s
Anatomy o the Eye and O rb it (8th e d .). Lond on: Chap man and Hall.)

ligament also acts as an anchor point. T e palpebral division

can be urther subdivided into marginal, pretarsal and preseptal
parts. T e marginal part (pars ciliaris), which is also known as
Riolans muscle, is responsible or maintaining the apposition
Fig . 2.15 (A) Sche matic re p re se ntation o the e ye lid marg in. mcj = mu- o the lid to the cornea during lid closure. A third part o the
cocutane ous junction. (B) Gross ap p e arance o the e ye lid marg in. muscle (pars lacrimalis) is closely associated with the lacrimal
O p e ning s o the me ib omian g land s are cle arly visib le (arrow). (Ad ap te d
rom Bron, A. J., Trip athi, R. C. & Trip athi, B. (1997). Wol ’s Anatomy o
out ow pathway. T e pars lacrimalis (also known as Horner’s
the Eye and O rb it (8th e d .). Lond on: Chap man and Hall.) muscle) encloses the canaliculi and provides attachments to the
lacrimal sac and its associated ascia.
T e orbital part o the orbicularis oculi lies outside the palpe-
bral division and extends or some distance beyond the orbital
margins. Muscle bres arise predominantly rom bone at the
medial orbital rim and appear to sweep around the lids without
interruption as a series o complete ellipses. However, studies
have shown that the muscle bres o the orbital and palpebral
division o the orbicularis are relatively short (0.4–2.1 mm) and
overlapping (Lander et al., 1996). T e regional divisions o the
orbicularis also show a unctional distinction. T e action o the
palpebral part o the muscle is to produce the re ex or voluntary
closure o the lids during blinking. Contraction o the orbital
division produces the orcible closure o the lids that occurs in
sneezing or in response to a pain ul stimulus. 

Levator Palpebrae Superioris. T e levator palpebrae superioris

is primarily responsible or elevating the upper lid during
blinking and or maintaining an open palpebral aperture. T e
levator palpebrae arises rom the lesser wing o the sphenoid,
above and anterior to the optic canal, and runs orward along
the roo o the orbit above the superior rectus be ore terminating
anteriorly in a an-shaped tendon (aponeurosis). Some bres
are attached to the anterior sur ace o the tarsal plate, whilst the
remainder pass between ascicles o the orbicularis (Fig. 2.18).
T e superior palpebral sulcus orms at the upper border o the
attachment to the orbicularis. 

Superior and Inferior Tarsal Muscles (of Müller). T ese

smooth muscles arise rom the lower border o the levator in the
upper lid and the in erior rectus in the lower lid, and insert into
the orbital margins o the tarsal plates. T e role o the superior
Fig . 2.16 Normal me ib omian g land s o the up p e r tarsus (top ) and low- tarsal muscle is to assist the levator in maintaining the width
e r tarsus (b ottom) o a 38-ye ar-old woman, imag e d using no n-invasive o the palpebral aperture. A mild degree o ptosis results rom
in rare d me ib og rap hy. (Imag e courte sy o Re iko Arita.) damage to its sympathetic nerve supply (Horner’s syndrome). 
 2 Ant e rio r Eye 19

Fig . 2.18 Diag ram showing the re lations o the le vator p alp e b rae
sup e rioris. a = le vator ap one urosis; tm = sup e rior tarsal muscle (o Mül-
le r); t = tarsal p late ; s = orb ital se p tum. (Ad ap te d rom Gray, H., Bannis-
te r, L. H., Be rry, M. M. & Williams, P. L. (1995) Gray’s Anatomy: The Ana-
tomical Basis o Me d icine and Surg e ry (38th e d .). Ed inb urg h: Churchill
Living stone .)

Control of Eye lid Move me nts

Movements o the eyelids occur through the coordinated action
o several muscles – the levator palpebrae, tarsal muscles, the
orbicularis oculi and the rontalis. T e elevation o the upper lid
and the control o its vertical position are mediated principally
by the levator. In vertical gaze, lid position and eye movements
are closely linked. During elevation the state o contraction o
Fig . 2.19 Sag ittal se ction throug h the up p e r lid . TP = tarsal p late ;
the levator is varied to maximize visibility. In extreme upgaze, O O c = orb icularis oculi; R = Riolan’s muscle ; EF = e ye lash ollicle s;
lid retraction is augmented by the action o the rontalis, which PC = p alp e b ral conjunctiva; ES = e ye lid sur ace .
elevates the eyebrows. In downgaze, coordinated lid move-
ments similarly occur through levator relaxation. In periodic
and re ex blinks, the levator is spontaneously inhibited prior to T ey are anchored to the orbital margins by the medial and lat-
orbicularis contraction in lid closure. Similarly, in lid opening eral palpebral ligaments. Each tarsus is approximately 25 mm
the orbicularis relaxes, ollowed by contraction o the levator. long and 1–2 mm thick. T e upper tarsus is semioval with a
Spontaneous eye-blink activity is in uenced by both central and height o 11 mm at its midpoint, whereas the in erior tarsus is
peripheral actors ( subota, 1998). narrower (4 mm in height). T e posterior sur ace o the eyelid
Compared with the upper lid, the lower lid is relatively is lined by the palpebral conjunctiva, which is rmly adherent
immobile and has no counterpart to the levator palpebrae. T e to the underlying tarsal plate. 
depression o the lower lid that occurs in downgaze is due to the
attachment o the sheaths o the in erior oblique and in erior Gland s of the Eye lid s
rectus muscles to the tarsal plate via a brous extension.  Meibomian Glands. T e tarsal plates contain the acini and ducts
o the meibomian (tarsal) glands. Ducts are vertically oriented with
Microscop ic Anatomy respect to the lid margins, with multiple secretory acini that open
T e histological appearance o the upper and lower lids is similar, laterally onto each duct. T e glands occupy nearly the ull length
and in sagittal section the ollowing six tissue layers can be resolved: and width o each tarsus, and are ewer and shorter in the lower
skin, subcutaneous connective tissue, muscle layer, submuscular lid. Histologically, the acini are lined by a layer o undi erentiated
connective tissue, tarsal plate and palpebral conjunctiva (Fig. 2.19). basal cells that divide, and cells are displaced rom the basement
T e eyelid skin is thin and very elastic. It is continuous with membrane. As they progress towards the duct they gradually
the palpebral conjunctiva at the lid margin, and keratinization enlarge and develop lipid droplets in their cytoplasm (Fig. 2.20).
is maintained up to this mucocutaneous junction. T e subcu- Ultimately, cell membranes rupture and cellular debris, together
taneous connective tissue is composed o a loose areolar tissue with the lipid product, is discharged into the duct.
and contains hair ollicles and associated glands. T e muscle T e stimulus or meibomian gland secretion is unclear.
layer consists o striated muscle bres o the orbicularis oculi, Although a modest autonomic innervation o the meibomian
which are arranged in bundles ( ascicles) separated by con- glands has been demonstrated, there is still some doubt regard-
nective tissue. T e orbicularis extends throughout the lid. T e ing a neuromodulation o glandular secretion; it is likely that the
marginal part o the muscle (Riolan’s muscle) is separated rom principal control o the glands is hormonal, and both androgens
the pretarsal portion by connective tissue that contains the eye- and oestrogens have been shown to regulate meibomian secre-
lash ollicles. T e loose submuscular connective tissue layer lies tion (Sullivan et al., 2000; Knop et al., 2011b). A long ductal
between the orbicularis and the tarsal plate and contains the system carries the secretion to the lid margin, and the compres-
major nerves and vessels o the lid. sive action o the palpebral division o the orbicularis oculi on
T e tarsal plates (tarsi) are composed o dense brous con- the meibomian ducts acilitates the ow o lipid and its eventual
nective tissue and provide support and determine lid shape. delivery onto the lid margins. 
20 PART 1 Int ro d uct io n

Fig . 2.22 Sche matic re p re se ntation o a mid -sag ittal se ction throug h
the e ye lid and conjunctival sac showing the d i e re nt conjunctival re -
Fig . 2.20 Histolog ical se ction showing me ib omian g land acini. Se cre - g ions. M = marg inal; T = tarsal; O = orb ital; B = b ulb ar; L= limb al; F = or-
tory ce lls d e g e ne rate (aste risk) as the y ap p roach the d uct (D). nical.

Fig . 2.23 Static d ime nsions o the conjunctival sac in millime tre s.
M = me d ial canthus. (Ad ap te d ro m Ehle rs, N. (1965). O n the size o the
co njunctival sac. Acta O p hthalmol., 43, 205–210.)
Fig . 2.21 Histolog ical se ction throug h the ciliary zone o the e ye lid .
Gland s o Ze is (Z) d ischarg e the ir conte nts into an e ye lash ollicle (EF), palpebral conjunctiva. Veins o the eyelids empty into veins o
which contains the re mnants o an e ye lash. M = g land o Moll. the orehead and temple, and some empty into the ophthalmic
vein. Lymphatics drain to the preauricular and submandibular
Glands of Zeis and Moll. Ciliary glands o Zeis and Moll are lymph nodes. 
ound in association with eyelash ollicles ( akahashi et al.,
2013) (Fig. 2.21). Zeis glands are unilobular sebaceous glands
that open directly into the ollicle. T e unction o their oily THE CO NJ UNCTIVA
secretion is to lubricate the lashes to prevent them rom drying
out and becoming brittle. Glands o Moll are modi ed sweat Gross Anatomy
glands (apocrine) consisting o an unbranched spiral tubule. T e conjunctiva is a thin transparent mucous membrane that
T e exact unction o these glands is unclear, although their extends rom the eyelid margins anteriorly, providing a lining to
secretion is rich in IgA, which suggest a role in the immune the lids, be ore turning sharply upon itsel to orm the ornices,
de ence o the ocular sur ace (Stoeckelhuber et al., 2003).  rom where it is re ected onto the globe, covering the sclera up
to its junction with the cornea. It thus orms a sac that opens
Blood and Ne rve Sup p ly anteriorly through the palpebral ssure. T e conjunctiva is con-
Nerves of the Eyelids. T e levator palpebrae and orbicularis ventionally divided into the ollowing regions: marginal, tarsal,
oculi muscles are innervated by the oculomotor and acial orbital (these three collectively orm the palpebral conjunctiva),
nerves, respectively. T e sensory supply o the upper lid bulbar and limbal (Fig. 2.22).
derives rom branches o the ophthalmic nerve (supraorbital, T e static dimensions o the conjunctival sac in the primary
supratrochlear and lacrimal). T e supply to the lower lid comes position are illustrated in Fig. 2.23 (Ehlers, 1965). T e marginal
rom branches o the maxillary nerve (zygomatic, in raorbital).  zone extends rom a line immediately posterior to the openings
o the tarsal glands and passes around the eyelid margin, rom
Blood and Lymphatic Supply to the Eyelids. T e arterial where it continues on the inner sur ace o the lid as ar as the
supply derives rom branches o the ophthalmic, lacrimal subtarsal old (a shallow groove that marks the marginal edge
and in raorbital arteries, which contribute to two palpebral o the tarsal plate). T e tarsal conjunctiva is highly vascular
arcades in the upper lid and one in the lower. Branches rom and is rmly attached to the underlying brous connective tis-
these arcades supply the skin, orbicularis, tarsal glands and sue. From the convex border o the tarsal plate, the orbital zone
 2 Ant e rio r Eye 21

Fig . 2.24 Hig h-p owe r slit-lamp vie w o the conjunctival p alisad e s o
Vog t (aste risks) at the lowe r limb us.

extends as ar as the ornices. Over this region the conjunctiva is

more loosely attached to underlying tissues, and so readily olds.
Fig . 2.25 Histolog ical se ction throug h the b ulb ar conjunctiva. E = e p i-
Elevations o the conjunctival sur ace in the orm o papillae the lium; S = stro ma. Gob le t ce lls can b e se e n in the e p ithe lium (arrows).
and lymphoid ollicles are commonly observed in this region. The stroma can b e re solve d into an ad e noid laye r (arrowhe ad ) and a
T e transparency o the bulbar conjunctiva readily permits d e e p b rous laye r (aste risk).
the visualization o conjunctival and episcleral blood vessels.
Here, the conjunctiva is reely movable owing to its loose attach-
ment to enon’s capsule (the ascial sheath o the globe). As the
bulbar conjunctiva approaches the cornea, its sur ace becomes
smoother and its attachment to the sclera increases. T e limbal
conjunctiva extends approximately 1–1.5 mm around the cornea.
Its junction with the cornea is ill de ned, particularly in the ver-
tical meridian, owing to a variable degree o conjunctival / scleral
overlap. T e limbus has a rich blood supply, and in the majority
o individuals a radial array o connective tissue elevations – the
palisades o Vogt – can be seen adjacent to the corneal margin
(Fig. 2.24). T e palisades are most prominent in the vertical
meridian, and their visibility is enhanced in pigmented eyes.  Fig . 2.26 Histolog ical se ction throug h the p alisad e re g ion. Conne c-
tive tissue rid g e s can b e se e n p roje cting into the ove rlying e p ithe lium
Microscop ic Anatomy (arrows).
In histological section, two distinct layers can be resolved: an
epithelium containing a variable number o goblet cells, and a unique array o connective tissue ridges (the palisades o Vogt),
vascular stroma that consists o a super cial lymphoid layer and which project into the overlying epithelium (Fig. 2.26). Clinical
a deep brous layer (Fig. 2.25). T e appearance o the conjunc- and experimental evidence suggests that the palisades are the
tiva shows a marked regional variability. repositories o stem cells and there ore act as the regenerative
organ o the corneal epithelium (Dua and Azuara-Blanco,
Epithelium. In the marginal zone, the epithelium is strati ed 2000). T e conjunctival epithelium additionally contains several
and squamous with relatively ew goblet cells, although this has non-native cell types, including dendritic cells, melanocytes and
recently been disputed ollowing the description o intracellular lymphocytes. 
crypts lined with goblet cells lying deep within the epithelium in
the region o the so-called ‘lid wiper’ region (Knop et al., 2012). Goblet and Other Secretory Cells. Goblet cells provide the
It has been suggested that a subpopulation o epithelial cells that mucous component o the tear lm. T ey arise in the basal
lie close to the mucocutaneous junction may be acting as stem cell layers and migrate to the sur ace, there becoming ully
cells or the palpebral conjunctiva (Wirtscha er et al., 1999). di erentiated. Mature goblet cells are larger than the surrounding
Approaching the tarsus, the epithelium thins to 2–3 layers o epithelial cells and contain a peripherally placed nucleus. T e
cuboidal cells with scattered goblet cells. T e epithelium o the cytoplasm is packed with membrane-bound secretory granules
orbital zone is slightly thicker (2–4 cells) with more numerous that discharge rom the apical sur ace in an apocrine manner.
goblet cells. T e number o goblet cells declines over the bulbar T e number o goblet cells shows a marked regional variation
conjunctiva and at the limbus the epithelium is again strati ed in density (Kessing, 1968) (Fig. 2.27), and these cells are
squamous, and goblet cells are absent. T e limbus contains a occasionally seen lining intraepithelial crypts (o Henle).
22 PART 1 Int ro d uct io n

Fig . 2.27 Diag ram showing the re g ional variation in g ob le t ce ll d e nsi-

ty. Gob le t ce ll d e nsity is g re ate st ove r the caruncle , p lica se milunaris and
in e rior nasal p alp e b ral conjunctiva. (Ad ap te d rom Bron, A. J., Trip athi,
R. C. & Trip athi, B. (1997). Wol ’s Anatomy o the Eye and O rb it (8th e d .).
Lond on: Chap man and Hall. Re p rod uce d ro m Bron, 1997.)
Fig . 2.28 Histolog ical se ction throug h a lymp hoid ollicle (F). Note the
mod i cation o the ove rlying e p ithe lium (aste risk).
T e apices o many sur ace epithelial cells o the conjunc-
tiva contain numerous carbohydrate-containing secretory
vesicles, which are seen to migrate to the cell sur ace where
they use with the plasma membrane (Dilly, 1985). It is likely
that this represents a mechanism or recycling the cell sur-
ace glycocalyx rather than a secondary source o secretory
mucin. 

Conjunctival Stroma. T e conjunctival stroma (substantia

propria) is variable in thickness. It can be resolved into
two distinct layers: a super cial adenoid layer and a deeper
brous layer (see Fig. 2.25). T e adenoid layer contains
numerous lymphocytes with local accumulations in the orm
o lymphoid ollicles (Fig. 2.28). Follicles represent aggregates
o predominantly B cells, which orm part o the so-called
conjunctiva-associated lymphoid tissue (Knop and Knop, Fig . 2.29 Hig h-p owe r slit-lamp p hotog rap h showing the limb al vascu-
2005). T e adenoid layer also contains a large number o mast lar arcad e s. (Courte sy o Eric Pap as.)
cells, which play a major role in ocular allergy (McGill et al.,
1998). T e deep brous layer is generally thicker than the
adenoid layer and contains the majority o conjunctival blood Blood Vessels and Lymphatics. T e arterial supply derives
vessels and nerves.  rom two sources: palpebral branches o the nasal and lacrimal
arteries, and anterior ciliary arteries.
Inne rvation and Blood Sup p ly Palpebral vessels serve two vascular arcades within the eye-
Nerves. he conjunctiva receives nerves rom sensory, lid. T e in erior (marginal) arcade sends branches through the
sympathetic and parasympathetic sources. Sensory nerves, tarsal plate to the eyelid margin and tarsal conjunctiva. T e
which are trigeminal in origin, reach the conjunctiva via superior (palpebral) arcade supplies the tarsal, orbital, ornix
branches o the ophthalmic nerve. he principal unction and bulbar conjunctiva. T e limbal zone, in contrast, is served
o these ibres is to equip the conjunctiva with the ability by anterior ciliary arteries. T e anterior ciliary arteries travel
to detect a variety o sensations – or example, touch, pain, along the tendons o the rectus muscles and give o branches
warmth and cold. Sensory nerve terminals include both at episcleral level prior to dipping down into the sclera to link
ree (unspecialized) nerve endings and the more complex with the major iridic circle. Episcleral branches pass orward
corpuscular endings (classically re erred to as Krause end and loop back a ew millimetres short o the cornea to become
bulbs) (Lawrenson and Ruskell, 1991). Conjunctival blood conjunctival vessels. Forward extensions o these vessels orm
vessels receive a dual autonomic innervation. Parasympathetic the limbal arcades (limbal loops), which are a complex net-
ibres issuing rom the pterygopalatine ganglion and work o ne capillaries (Fig. 2.29). Conjunctival veins are more
sympathetic ibres rom the superior cervical ganglion numerous than arteries. T ey can be readily di erentiated rom
are responsible or vasodilation and vasoconstriction, arteries owing to their larger calibre, darker colour and more
respectively.  tortuous path. 
 2 Ant e rio r Eye 23

Fig . 2.31 Low-p owe r lig ht microg rap h o the lacrimal g land . Acini are
arrowe d . Ad ip ose conne ctive tissue (aste risks) e xte nd s across the g land .

Fig . 2.30 Late ral vie w o the orb it showing the position o the lacrimal
g land. The levator ap oneurosis (LA) p artially divid e s the g land into an
orb ital (OD) and palpe bral (PD) d ivision. (Adapted rom Kron eld, P. C.,
McHug h, S. L. & Polyak, S. L. (1943). The Human Eye in Anatomical
Transp are ncie s. Roche ste r, NY: Bausch & Lomb .)

Functional Consid e rations

T e conjunctiva contributes the mucin component o the pre-
ocular tear lm and plays an important role in the de ence o
the ocular sur ace against microbial in ection. Mucins are a
amily o high-molecular-weight glycoproteins that include
membrane-bound and secretory varieties (Cor eld et al., 1997;
Gipson and Inatomi, 1997; Hodges and Dartt, 2013). Goblet
cells are the primary source o secretory mucin, whilst sur-
ace epithelial cells o both the conjunctiva and cornea possess
mucin-like molecules within their glycocalyx. T e conjunctiva Fig . 2.32 Ele ctron microg rap h o p art o a lacrimal acinus showing
also orms part o a common mucosal de ence system, which lig ht and d ark se cre tory ce lls.
is an important component o the de ence o the human body
against microorganisms (McClellan, 1997; Knop and Knop, a lower palpebral lobe, which can o en be visualized through
2005). T e conjunctiva possesses the immunological capacity the conjunctiva upon lid eversion (Bron, 1986). T e gland is
or antigen processing, and cell-mediated and humoral immu- pinkish in colour, with a lobulated sur ace. Between 6 and 12
nity. Humoral immunity is provided by speci c antibodies (par- ducts leave the gland through the palpebral lobe and discharge
ticularly immunoglobulin A [IgA]) produced by trans ormed B into the conjunctival sac at the upper lateral ornix. 
cells (plasma cells) in the stroma. lymphocytes orm the basis
o cell-mediated immunity.  Microscopic Anatomy. T e lacrimal gland is tubuloacinar in
orm (Fig. 2.31). Its secretory units (acini) contain secretory
cells surrounded by myoepithelial cells (Ruskell, 1975). Acinar
LACRIMAL SYSTEM
secretory cells show extensive olding o their plasma membrane
T e lacrimal apparatus provides or the production and main- and apical microvilli. Adjacent cells are linked by tight junctions
tenance o the preocular tear lm. T e normal unction o this that restrict di usion between cells. T e most prominent eature
system is essential or the integrity o the ocular sur ace and the o these cells is the presence o abundant secretory granules.
provision o a smooth re ractive sur ace. T e lacrimal apparatus wo principal secretory cell subtypes have been identi ed on
comprises a secretory system that includes the main and acces- the basis o their granule content (Fig. 2.32). T e majority o
sory lacrimal glands, and a drainage system that consists o the cells contain dark granules (dark cells), with a smaller number
paired puncta and canaliculi, the lacrimal sac and the nasolac- o cells containing light granules (light cells). T e unctional
rimal duct. signi cance o this heterogeneity is uncertain at present. Ducts
consist o a single layer o cuboidal cells that lack secretory
Lacrimal Gland granules. Myoepithelial cells are dendritic cells that are closely
Gross Anatomy. T e main lacrimal gland is the key provider associated with the perimeter o acini and ducts. It is likely that
o the aqueous component o the tears. T e gland is located in a these contractile cells play a role in the expulsion o tears rom the
shallow depression o the rontal bone behind the superolateral gland. T e interstices o the gland contain numerous blood vessels
orbital rim (Fig. 2.30). It is partially split by the aponeurosis and nerves. A large population o immune cells (particularly IgA-
o the levator palpebrae into an upper larger orbital lobe and secreting plasma cells) are also ound between acini. 
24 PART 1 Int ro d uct io n

Fig . 2.33 Diag ram showing the role o the g astrointe stinal tract g e n-
e rating sp e ci c immunog lo b ulin A (Ig A) in the lacrimal g land . Antig e ns
which challe ng e the ocular sur ace ultimate ly d rain to the g astrointe s-
tinal (GI) tract whe re the y stimulate B ce lls in Pe ye r’s p atche s (g ut-as- Fig . 2.34 Illustration o the lacrimal d rainag e syste m. C = canaliculi;
sociate d lymp hoid tissue ). Se nsitize d B ce lls the n p ass to the lacrimal LS = lacrimal sac; P = p unctum; NLD = nasolacrimal d uct. (Ad ap te d rom
g land via the circulation. SC = se cre tory comp one nt. (Ad ap te d rom Al- Kron e ld , P. C., McHug h, S. L. & Polyak, S. L. (1943). The Human Eye in
lansmith, M. R. (1992). The Eye and Immunolog y. Maryland He ig hts, MO : Anatomical Transp are ncie s. Roche ste r, NY: Bausch & Lomb .)
Mosb y. Cop yrig ht Else vie r 2002.)

It has been demonstrated that the lacrimal gland also

Blood and Nerve Supply. T e arterial supply to the lacrimal secretes into the tears growth actors that are important or the
gland is provided by the lacrimal artery, which enters the posterior maintenance o the ocular sur ace and epithelial wound healing
border o the gland. Venous drainage occurs via the lacrimal (P ug elder, 1998). Prominent amongst these growth actors are
vein. A rich autonomic innervation includes secretomotor epidermal growth actor and trans orming growth actor beta. 
(parasympathetic) bres that issue rom the pterygopalatine
ganglion and sympathetic (vasomotor) bres rom the carotid Lacrimal Drainag e Syste m
plexus. T e lacrimal nerve traverses the gland to provide a sensory ears collect at the medial canthal angle, where they drain into
innervation to the conjunctiva and lateral aspect o the eyelid.  the puncta o the upper and lower lids. Each punctum is a small
oval opening approximately 0.3 mm in diameter that is located
Accessory Lacrimal Glands. Numerous small accessory at the summit o an elevated papilla. From each punctum the
lacrimal glands, which include the eponymous glands o canaliculus passes rst vertically or about 2 mm and then turns
Wol ring and Krause, are ound within the conjunctival stroma. sharply to run medially or about 8 mm (Fig. 2.34). At the angle,
T ey have a particular predilection or the upper ornix and a slight dilation, the ampulla, can be seen. T e canaliculi con-
above the tarsal plate, and, on the basis o proportion o total verge towards the lacrimal sac, usually orming a common can-
lacrimal tissue, it has been estimated that they contribute aliculus be ore entry. T e lacrimal sac occupies a ossa ormed
5–10% o aqueous tear volume. Structurally, they have a similar by the maxillary and lacrimal bones. It measures 1.5–2.5 mm in
appearance to the lacrimal gland proper. However, true acini are diameter and approximately 12–15 mm in vertical length. From
absent and glands consist o elongated tubules that connect with the lacrimal sac tears drain into the nasolacrimal duct, which
ducts opening onto the conjunctival sur ace (Sei ert et al., 1993).  extends or about 15 mm, passing through a bony canal in the
maxillary bone, to an opening in the nose beneath the in erior
Functional Considerations. In addition to its role as the principal nasal turbinate. A old o mucosa is o en observed at the ter-
provider o the aqueous phase o the tear lm, the lacrimal gland mination o the duct: this has been termed ‘the valve o Hasner’,
is also a major component o the ocular sensory immune system, although there is no strong evidence that it unctions as a valve.
which acts as the rst line o de ence against microbial in ection T e process o tear drainage is an active process mediated
(Sullivan and Sato, 1994). T e secretory immune system is by the contraction o the orbicularis during blinking (Doane,
mediated through secretory IgA. T e lacrimal gland is the main 1981). ears enter the canaliculi principally by capillary action.
source o tear IgA and the gland contains a large number o IgA- During the early part o the blink the puncta are occluded as
producing plasma cells. T e mechanism by which an antigenic the orbicularis urther contracts. T e canaliculi and lacrimal
challenge o the ocular sur ace induces a lacrimal antibody sac are also compressed, orcing uid into the nose. An alterna-
response is not ully understood. However, as the administration tive hypothesis has been proposed whereby orbicularis contrac-
o an antigen by a gastrointestinal route raises speci c IgA levels tion dilates the sac, creating a negative pressure, which draws
in tears, one suggested mechanism is that ocular antigens – a er in the tears rom the canaliculi (Jones, 1961). An investigation
drainage through the nasolacrimal duct – stimulate B cells in by Paulsen et al. (2000) described a vascular plexus embedded
gut Peyer’s patches. T ese sensitized B cells then populate the in the wall o the lacrimal sac and duct that may in uence tear
lacrimal gland where they trans orm into plasma cells (Fig. 2.33). out ow. It is postulated that opening and closing o the lumen o
 2 Ant e rio r Eye 25

TABLE Physical Pro p e rt ie s o f t he Pre o cular Te ar

2.2 Film
Parame t e r Value
O smolarity 302 (± 6.3) mO sm/l
pH 7.45
Thickne ss 3 µl
Volume 7.0 (± 0.2) µl
Rate of p rod uction
Unstimulate d 1–2 µl / min
Stimulate d >100 µl / min
Re fractive ind e x 1.336

the lacrimal passages can be achieved by regulating blood ow

within this plexus. 

The Pre o cular Te ar Film

FUNCTIO N AND PRO PERTIES O F THE
PREO CULAR TEAR FILM
T e tear lm is a complex uid that covers the exposed parts o the
ocular sur ace ramed by the eyelid margins. T e physical charac-
teristics o this uid are summarized in able 2.2. Classically, the
tear lm has been regarded as a trilaminar structure with a super-
cial lipid layer secreted by the meibomian glands, which overlies
an aqueous phase derived rom the main and accessory lacrimal
glands, and an inner mucinous layer consisting o membrane-
spanning mucins o the ocular sur ace epithelium and secretory
mucins produced mainly by conjunctival goblet cells. T e tear
lm per orms several important unctions, which can be broadly
classi ed as optical, metabolic support, protective and lubrication.
By smoothing out irregularities o the corneal epithelium, the
tear lm creates an even sur ace o good optical quality that is re-
ormed with each blink. T e air–tear inter ace orms the principal
re ractive sur ace o the optical system o the eye and provides two-
thirds (43 D) o its total re ractive power. As the cornea is avascular Fig . 2.35 Schematic rep rese ntation o the orbital g lands, which contrib -
ute the various components o the preocular tear lm. (Adapted rom Dartt,
it is dependent on the tear lm or its oxygen provision. When the D. A. (1992). Physiology o tear production. In M. A. Lemp & R. Marquardt
eye is open the tear lm is in a state o equilibrium with the oxygen (ed s) The Dry Eye: A Comprehensive Guide. Berlin: Springer-Verlag.)
in the atmosphere, and gaseous exchange takes place across the
tear inter ace. T e constant turnover o the tear lm also provides
a mechanism or the removal o metabolic waste products. (i.e. in response to strong physical or emotional stimulation) is
ears play a major role in the de ence o the eye against mediated by the main lacrimal gland. However, Jordan and Baum
microbial colonization. T e washing action o the tear uid (1980) questioned the concept o basic and re ex secretion, and
reduces the likelihood o microbial adhesion to the ocular sur- suggested that it is more accurate to think o tear output as a con-
ace. Moreover, the tears contain a host o protective antimicro- tinuum, whereby the rate o production is proportional to the
bial proteins. T e tear lm acts as a lubricant, smoothing the degree o sensory or emotive stimulation (Dartt, 2009). T is con-
passage o the lids over the corneal sur ace and preventing the cept would also mean that a unctional distinction between main
transmission o damaging shearing orces. o acilitate this, tear and accessory lacrimal glands, in terms o basal and re ex tear
uid displays non-Newtonian behaviour with respect to shear production, is unnecessary. Rather, it is more likely that tear ow
( i any, 1991). Newtonian uids maintain a constant viscosity is the combination o contributions rom both glands, although
with increasing shear rates. By contrast, tear uid has a rela- the output rom the accessory glands alone is suf cient to main-
tively high viscosity between blinks to aid stability, and with tain a stable tear layer (Maitchouk et al., 2000). 
increasing shear rates during the blink process the viscosity alls
dramatically, thereby easing the movement o the lids over the SO URCES AND CO MPO SITIO N
ocular sur ace.
ears are composed o a complex secretion that combines the
Te ar Prod uction products o several glands (Fig. 2.35). Although the precise com-
Jones (1966) rst used the terms ‘basic (basal)’ and ‘re ex’ to position o tear uid varies with collection method, ow rate and
describe tear ow. He proposed that the accessory lacrimal glands time o day, it can be considered as a watery secretion containing
were the basic (minimal ow) secretors, and that re ex secretion electrolytes and proteins, with lesser amounts o lipid and mucin.
26 PART 1 Int ro d uct io n

is a constitutively secreted lacrimal protein whose rate o secre-

TABLE Bio che mical Co mp o sit io n o f t he Pre o cular tion is independent o ow rate. During sleep, the levels o IgA
2.3 Te ar Film increase as secretory IgA production continues and as acinar
Co mp o ne nt Co nce nt rat io n secretion declines (Sack et al., 1992). IgA plays an important
role in the de ence o the ocular sur ace against microbial in ec-
ELECTRO LYTES* tion by preventing bacterial and viral adhesion, and inactivating
Na + 135 mEq / l
Cl− 131 mEq / l
bacterial toxins. Other immunoglobulins (e.g. IgG and IgM) are
K+ 36 mEq / l present in tears at much lower levels.
HCO 3 − 26 mEq / l Lysozyme, lacto errin and lipocalin, in contrast, originate
Ca 2+ 0.46 mEq / l rom acinar cells and their rate o secretion roughly matches
Mg 2+ 0.36 mEq / l ow rate. Lysozyme is a well-known bacteriolytic protein that
MAJ O R PRO TEINS* has the ability to lyse the cell wall o several Gram-positive bac-
Lysozyme 2.07 g / l teria. Lacto errin serves an important bacteriostatic unction by
Se cre tory Ig A 3.69 g / l binding iron and making it unavailable or bacterial metabo-
Lactofe rrin 1.65 g / l lism. It also acts as a ree radical scavenger, thereby reducing
Lip ocalin 1.55 g / l
Alb umin 0.04 g / l ree-radical-mediated cell damage ( i any, 1997). Lipocalins
Ig G 0.004 g / l are a amily o lipid-binding proteins with an af nity or a broad
LIPIDS† array o lipids, including atty acids, phospholipids and choles-
Wax e ste rs 41% terol. It has been suggested that tear lipocalins act as scavengers
Chole ste ryl e ste rs 27.3% or a wide range o meibomian lipids, which could spill onto
Polar lip id s 14.8% the corneal sur ace and perturb its wettability (Glasgow et al.,
Hyd rocarb ons 7.5% 2000). Furthermore, lipocalin may promote lipid solubility at
Die ste rs 7.7% the aqueous–lipid inter ace to acilitate the ormation o a thin
Triacylg lyce rid e s 3.7%
Fatty acid s 2.0% layer o lipid on the sur ace o the tear lm. 
Fre e ste rols 1.6%
Mucins
MUCIN ‡
MUC1 nd
Mucins are a amily o high-molecular-weight glycoproteins, o
MUC5AC nd which sugars contribute up to 85% o their dry weight. Structur-
MUC4 nd ally, they consist o a polypeptide backbone to which chains o
MUC16 nd sugar molecules attach via O-linkages to the amino acids serine
(Data ad ap te d rom Ti any, 1997.) and threonine. Mucins are a heterogeneous group o molecules
Source s: that can be subdivided into secretory and integrated-membrane
*Main and acce ssory lacrimal g land s. varieties (Cor eld et al., 1997; Hodges and Dartt, 2013). So ar,
†Me ib omian g land s.
‡Ep ithe lial ce lls / g ob le t ce lls.
modern molecular biology techniques have identi ed up to
nd = not d e te rmine d .
20 mucin (MUC) genes, although only our o these (MUC1,
MUC5AC, MUC4 and MUC16) are expressed on the human
ocular sur ace (Gipson and Inatomi, 1997; McKenzie et al., 2000;
Ele ctrolyte s P ug elder et al., 2000; Mantelli and Argüesco, 2008). T e epithelia
Human tears contain approximately the same range o electro- o the cornea and conjunctiva express the transmembrane mucins
lytes as ound in plasma ( i any, 1997). able 2.3 gives typi- MUC1, and to a lesser extent MUC4 and MUC16, which attach
cal values or the ionic composition o human tears. However, to apical microvilli where they orm a hydrophilic base to acilitate
as the electrolyte content o tears varies with ow rate, there is the spreading o the goblet-cell-derived mucin MUC5AC. Mucins
signi cant variation in measured values. During the process play a major role in stabilizing and spreading the tear lm and
o secretion by the lacrimal gland, there is a process o active provide protection against desiccation and microbial invasion
electrolyte transport that is coupled to the passive movement o (Gipson and Inatomi, 1997; Hodges and Dartt, 2013). 
water by an osmotic process. Acinar-derived uid is essentially
an isotonic ultra ltrate o plasma. Its composition is altered as Lip id s
it passes along the ductal system, where urther chloride and T e source o lipids in the tear lm is the meibomian glands
potassium ions are secreted. A variety o ion transport proteins embedded within the tarsal plates o each lid. T e blinking pro-
have been identi ed in acinar cells, including sodium–potas- cess is an important mechanism in the expulsion o the secre-
sium A Pase and potassium and chloride channels.  tion rom the glands ( i any, 1995). Meibomian lipid (also
known as meibum) is delivered directly as a clear oil onto the lid
Prote ins margins and is spread over the tear lm rom the inner edge o
ear proteins are thought to originate rom three main sources: the lid margins with each blink. T e thickness o the lipid layer
the lacrimal gland, ocular sur ace epithelia and conjuncti- is variable (mean thickness 42 nm, range 15–157 nm; King-
val blood vessels. T e major lacrimal proteins include secre- Smith et al., 2000, 2010), and depending on thickness gives rise
tory IgA, lysozyme, lacto errin and lipocalin ( ormerly known to characteristic inter erence patterns when viewed in specular
as tear-speci c prealbumin) (see able 2.3). IgA, which is re ection (Fig. 2.36) (Guillon, 1998). Meibomian secretion con-
the major immunoglobulin in tears, is secreted as a dimer by sists o a complex mixture o lipids ( able 2.3), including wax
plasma cells in the interstices between lacrimal acini. It then and cholesteryl esters (which together constitute approximately
binds to a receptor on the basolateral aspect o acinar cells, and 70% o meibum), atty acids and atty alcohols ( i any, 1995;
is transcytosed across the cell and secreted into tear uid. IgA Butovich, 2013). T e primary unctions o this secretion are to
 2 Ant e rio r Eye 27

Fig . 2.37 Diag ram showing the comp osition o the p re ocular te ar
Fig . 2.36 Lip id laye r o the p re ocular te ar lm vie we d in sp e cular re - lm. Inse ts sho w d e tails o the g lycocalyx and lip id –aq ue ous inte r ace .
f e ction. A ‘wave ’ ap p e arance can b e se e n, which re p re se nts the most (Ad ap te d rom Corf e ld , A. P., Carring ton, S. D., Hicks, S. J. e t al. (1997).
commonly ob se rve d lip id p atte rn in the p op ulation. O cular mucins: p urif cation, me tab olism and unctions. Prog . Re tin. Eye
Re s., 16, 627–656.)

provide a hydrophobic barrier at the lid margin to prevent over- is thought to consist o a mixture o soluble and gel- orming
spill o tears, and to cover the sur ace o the tear lm to retard mucins (Hodges and Dartt, 2013). 
evaporation (Craig and omlinson, 1997). 
Co nclusio n
MO DELS O F TEAR FILM STRUCTURE
It is clear rom the above account that our understanding o the
T e classical trilaminar model o tear lm structure in terms o structure and unction o the anterior eye is ar rom complete,
a super cial lipid layer, a middle aqueous layer and deep mucin which places certain limits on our understanding o clinical,
layer, rst proposed by Wol and subsequently modi ed by contact-lens-related phenomena. It is essential, there ore, that
Holly and Lemp (1977), has received broad acceptance. How- uture research continues to ocus on undamental aspects o
ever, the results o recent studies have led to a re-evaluation o ocular anatomy and physiology, as well as on the more applied
the nature o the aqueous and mucinous layers. Several pieces o clinical applications that are described in the remainder o this
evidence have suggested that the mucin contribution to the tear book.
lm is much greater than was previously thought (Prydal et al.,
1992), and an alternative tear lm model, which possesses a Acce ss t he co mp le t e re fe re nce s list o nline at
substantial mucinous phase, has been proposed (Fig. 2.37). T e ht t p :/ / www.e xp e rt co nsult .co m.
nature o the mucinous phase has not been ully established, but
REFERENCES
Allansmith, M. R. (1992). T e Eye and Immunol- Funderburgh, J. L. (2000). Keratan sulphate: struc- King-Smith, P. E., Hinel, E. A., & Nichols, J. J.
ogy. St Louis, MO: Mosby. ture, biosynthesis and unction. Glycobiology, 10, (2010). Application o a novel inter erometric
Belmonte, C., Garcia-Hirsch eld, J., & Gallar, J. 951–958. method to investigate the relation between lipid
(1997). Neurobiology o ocular pain. Prog. Retin. Funderburgh, J. L., Funderburgh, M. L., Mann, M. layer thickness and tear lm thinning. Invest.
Eye Res., 16, 117–156. M., et al. (1991). Physical and biological proper- Ophthalmol. Vis. Sci., 51, 2418–2423.
Berman, E. R. (1981). Biochemistry o the Eye. New ties o keratan sulphate proteoglycan. Biochem. Klyce, S. D. (1981). Stromal lactate accumulation
York: Plenum Press. Soc. rans., 19, 871–876. can account or corneal oedema osmotically ol-
Bonanno, J. A. (2012). Molecular mechanisms un- Gipson, I. K., & Inatomi, . (1995). Extracellular lowing epithelial hypoxia in the rabbit. J. Physi-
derlying the corneal endothelial pump. Exp. Eye matrix and growth actors in corneal wound ol., 321, 49–64.
Res., 95, 2–7. healing. Curr. Opin. Ophthalmol., 6, 3–10. Klyce, S. D., & Beuerman, R. W. (1998). Structure
Bron, A. J. (1986). Lacrimal streams: the demon- Gipson, I. K., & Inatomi, . (1997). Mucin genes and unction o the cornea. In H. E. Kau man, B.
stration o human lacrimal uid secretion and expressed by the ocular sur ace epithelium. Prog. A. Barron, & M. B. McDonald (Eds.), T e Cor-
the lacrimal ductules. Br. J. Ophthalmol., 70, Retin. Eye Res., 16, 81–98. nea (2nd ed.) (pp. 3–50). Boston: Butterworth-
241–245. Gipson, I. K., Spurr-Michaud, S. J., & isdale, A. Heinemann.
Bron, A. J., Benjamin, L., & Snibson, G. R. (1991). S. (1987). Anchoring brils orm a complex net- Klyce, S. D., Maeda, N., & Byrd, . J. (1998). Cor-
Meibomian gland disease. Classi cation and work in human and rabbit cornea. Invest. Oph- neal topography. In H. E. Kau man, B. A. Bar-
grading o lid changes. Eye, 5, 395–411. thalmol. Vis. Sci., 28, 212–220. ron, & M. B. McDonald (Eds.), T e Cornea (2nd
Bron, A. J., ripathi, R. C., & ripathi, B. (1997). Glasgow, B. J., Marshall, G., Gasymov, O. K., et al. ed.) (pp. 1055–1075). Boston: Butterworth-
Wolf ’s Anatomy o the Eye and Orbit (8th ed.). (2000). ear lipocalins: potential scavengers or Heinemann.
London: Chapman and Hall. the corneal sur ace. Invest. Ophthalmol. Vis. Sci., Knop, E., & Knop, N. (2005). T e role o eye-
Bron, A. J., Argüeso, P., Irkec, M., et al. (2015). 40, 3100–3107. associated lymphoid tissue in corneal immune
Clinical staining o the ocular sur ace: mecha- Gray, H., Bannister, L. H., Berry, M. M., et al. protection. J. Anat., 206, 271–285.
nisms and interpretations. Prog. Retin. Eye Res., (1995). Gray’s Anatomy: T e Anatomical Basis Knop, E., Knop, N., Zhivov, A., et al. (2011a). T e
44, 36–61. o Medicine and Surgery (38th ed.). New York: lid wiper and muco-cutaneous junction anatomy
Butovich, I. A. (2013). ear lm lipids. Exp. Eye Churchill Livingstone. o the human eyelid margins: an in vivo con o-
Res., 117, 4–27. Guillon, J. P. (1998). Non-invasive earscope Plus cal and histological study. J. Anat., 218, 449–461.
Cor eld, A. P., Carrington, S. D., Hicks, S. J., et al. routine or contact lens tting. Cont. Lens Ante- Knop, E., Knop, N., Millar, ., et al. (2011b). T e
(1997). Ocular mucins: puri cation, metabolism rior Eye, 21, S31–S40. international workshop on meibomian gland
and unctions. Prog. Retin. Eye Res., 16, 627–656. Hassell, J. R., & Birk, D. E. (2010). T e molecular basis dys unction: report o the subcommittee on
Craig, J. P., & omlinson, A. (1997). Importance o o corneal transparency. Exp. Eye Res, 91, 326–335. anatomy, physiology, and pathophysiology o the
the lipid layer in human tear lm stability and Hodges, R. R., & Dartt, D. A. (2013). ear lm mu- meibomian gland. Invest. Ophthalmol. Vis. Sci.,
evaporation. Optom. Vis. Sci., 74, 8–13. cins: ront line de enders o the ocular sur ace; 52, 1938–1978.
Dartt, D. A. (1992). Physiology o tear produc- comparison with airway and gastrointestinal Knop, N., Korb, D. R., Blackie, C. A., et al. (2012).
tion (Ch. 10, pp. 65–99). In M. A. Lemp, & R. tract mucins. Exp. Eye Res., 117, 62–78. T e lid wiper contains goblet cells and goblet cell
Marquardt (Eds.), T e Dry Eye: a Comprehensive Hodson, S. A. (1997). Corneal stromal swelling. crypts or ocular sur ace lubrication during the
Guide. Berlin: Springer-Verlag. Prog. Retin. Eye Res., 16, 99–116. blink. Cornea, 31, 668–679.
Dartt, D. A. (2009). Neural regulation o lacrimal Hodson, S. A., & Miller, F. (1976). T e bicarbonate ion Kron eld, P. C., McHugh, S. L., & Polyak, S. L.
gland secretory processes: relevance in dry eye pump in the endothelium which regulates the hy- (1943). T e Human Eye in Anatomical ranspar-
disease. Prog. Retin. Eye Res., 28, 155–177. dration o the rabbit cornea. J. Physiol., 263, 563–577. encies. Rochester: Bausch & Lomb.
Dilly, P. N. (1985). On the nature and the role o the Hodson, S. A., Guggenheim, J., Kaila, D., et al. Lander, ., Wirtscha er, J. D., & McLoon, L. K.
sub-sur ace vesicles in the outer epithelial cells o (1991). Anion pumps in ocular tissues. Biochem. (1996). Orbicularis oculi muscle bres are rela-
the conjunctiva. Br. J. Ophthalmol., 69, 477–481. Soc. rans., 19, 849–852. tively short and heterogeneous in length. Invest.
Doane, M. G. (1981). Blinking and the mechanics Hogan, M. J., Alvarado, J. A., & Weddell, J. E. Ophthalmol. Vis. Sci., 37, 1732–1739.
o the lacrimal drainage system. Ophthalmology, (1971). Histology o the Human Eye. Philadel- Lavker, R. M., seng, S. C., & Sun, . . (2004). Cor-
88, 844–851. phia: Saunders. neal epithelial stem cells at the limbus: looking at
Doughty, M. J., & Zaman, M. L. (2000). Human Hollingsworth, J., Perez-Gomez, I., Mutalib, H. A., some old problems rom a new angle. Exp. Eye.
corneal thickness and its impact on intraocular et al. (2001). A population study o the normal Res., 78(3), 433–446.
pressure measures: a review and meta-analysis cornea using an in vivo, slit-scanning con ocal Lawrenson, J. G. (1997). Corneal sensitivity in
approach. Surv. Ophthalmol., 44, 367–408. microscope. Optom. Vis. Sci., 78, 706–711. health and disease. Ophthalmol. Physiol. Opt.,
Dua, H. S., & Azuara-Blanco, A. (2000). Limbal Holly, F. J., & Lemp, M. A. (1977). ear physiology 17, S17–S22.
stem cells o the corneal epithelium. Surv. Oph- and dry eye. Surv. Ophthalmol., 22, 69–87. Lawrenson, J. G., & Ruskell, G. L. (1991). T e struc-
thalmol., 44, 415–425. Jester, J. V., Murphy, C. J., Winkler, M., et al. (2013). ture o corpuscular nerve endings in the limbal
Dua, H. S., Faraj, L. A., Said, D. G., et al. (2013). Lessons in corneal structure and mechanics to conjunctiva o the human eye. J. Anat., 177,
Human corneal anatomy rede ned: a novel pre- guide the corneal surgeon. Ophthalmology, 120, 75–84.
Descemet’s layer (Dua’s layer). Ophthalmology, 1715–1717. Lawrenson, J. G., Reid, A. R., & Allt, G. (1998).
120, 1778–1785. Jones, L. . (1961). An anatomical approach to Corneal glycoconjugates: an ultrastructural
E ron, N. (1997). Contact lenses and corneal physi- problems o the eyelids and lacrimal apparatus. lectin-gold study. Histochem. J., 30, 51–60.
ology. Biol. Sci. Rev., 9, 29–31. Arch. Ophthalmol., 66, 111–124. Maitchouk, D. Y., Beuerman, R. W., Ohta, ., et al.
E ron, N., & Carney, L. G. (1979). Oxygen levels be- Jones, L. . (1966). T e lacrimal tear system and its (2000). ear production a er unilateral removal
neath the closed eyelid. Invest. Ophthalmol. Vis. treatment. Am. J. Ophthalmol., 62, 47–60. o the main lacrimal gland in squirrel monkeys.
Sci., 18, 93–95. Jordan, A., & Baum, J. (1980). Basic tear ow: does Arch. Ophthalmol., 118, 246–252.
E ron, N., Perez-Gomez, I., Mutalib, H. A., et al. it exist? Ophthalmology, 87, 920–930. Mantelli, F., & Argüesco, P. (2008). Functions o oc-
(2001). Con ocal microscopy o the normal hu- Kessing, S. V. (1968). Mucus gland system o the ular sur ace mucins in health and disease. Curr.
man cornea. Cont. Lens Anterior Eye, 24, 16–24 conjunctiva: a quantitative normal anatomical Opin. Allergy Clin. Immunol., 8, 477–483.
Erratum in: Cont. Lens Anterior Eye, 24, 83–85. study. Acta Ophthalmol, 95(Suppl.), 1–333. Mar urt, C. F., & Ellis, L. C. (1993). Immunohisto-
Ehlers, N. (1965). On the size o the conjunctival Khoramnia, R., Rabsilber, . M., & Au arth, G. U. chemical localisation o tyrosine hydroxylase in
sac. Acta Ophthalmol., 43, 205–210. (2007). Central and peripheral pachymetry mea- corneal nerves. J. Comp. Neurol., 336, 527–531.
Feng, Y., & Simpson, . L. (2008). Corneal, limbal, surements according to age using the Pentacam Maurice, D. M. (1957). T e structure and transpar-
and conjunctival epithelial thickness rom opti- rotating Scheimp ug camera. J. Cataract Re ract ency o the cornea. J. Physiol., 136, 263–286.
cal coherence tomography. Optom. Vis. Sci., 85, Surg., 33, 830–836. Maurice, D. M. (1984). T e cornea and sclera. In
880–883. King-Smith, P. E., Fink, B. A., Fogt, N., et al. (2000). H. Davson (Ed.), T e Eye. (3rd ed.) (Vol. 1B) (pp.
Freeman, R. D. (1972). Oxygen consumption by T e thickness o the preocular tear lm: evidence 1–158). Orlando: Academic Press.
the component layers o the cornea. J. Physiol., rom re ection spectra. Invest. Ophthalmol. Vis. McClellan, K. A. (1997). Mucosal de ence o the
225, 15–32. Sci., 41, 3348–3359. outer eye. Surv. Ophthalmol., 42, 233–346.
27.e 1
27.e 2 REFERENCES

McGill, J. I., Holgate, S. ., Church, M. K., et al. Prydal, J. J., Franc, F., Dilly, P. N., et al. (1998). Kerato- Stiemke, M. M., Watsky, M. A., Kangas, . A., et al.
(1998). Allergic eye disease mechanisms. Br. J. cyte density and size in conscious humans by digital (1995). T e establishment and maintenance o
Ophthalmol., 82, 1203–1214. image analysis o con ocal images. Eye, 12, 337–342. corneal transparency. Prog. Retin. Eye Res., 14,
McKenzie, R. W., Jumblatt, J. E., & Jumblatt, M. M. Quantock, A. J., & Young, R. D. (2008). Development 109–140.
(2000). Quanti cation o MUC2 and MUC5AC o the corneal stroma, and the collagen–proteo- Stoeckelhuber, M., Stoeckelhuber, B. M., & Welsch,
transcripts in the human conjunctiva. Invest. glycan associations that help de ne its structure U. (2003). Human glands o Moll: histochemi-
Ophthalmol. Vis. Sci., 41, 703–708. and unction. Dev. Dyn., 237, 2607–2621. cal and ultrastructural characterization o the
Meek, K. M., & Boote, C. (2009). T e use o X-ray Riley, M. V. (1969). Glucose and oxygen utiliza- glands o Moll in the human eyelid. J. Invest.
scattering techniques to quanti y the orientation tion by the rabbit cornea. Exp. Eye Res., 8, Dermatol., 121, 28–36.
and distribution o collagen in the corneal stro- 193–200. Sullivan, D. A., & Sato, E. H. (1994). Immunology
ma. Prog. Retin. Eye Res., 28, 369–392. Ruskell, G. L. (1975). Nerve terminals and epithe- o the lacrimal gland. In D. M. Albert, & F. A.
Meek, K. M., & Leonard, D. W. (1993). Ultrastruc- lial cell variety in the human lacrimal gland. Cell Jakobiec (Eds.), Principles and Practice o Oph-
ture o the corneal stroma: a comparative study. iss. Res., 158, 121–136. thalmology (pp. 479–486). Philadelphia: W.B.
Biophys. J., 64, 273–280. Ruskell, G. L., & Lawrenson, J. G. (1994). In- Saunders.
Møller-Pederson, ., & Ehlers, N. (1995). A three- nervation o the anterior segment. In M. Sullivan, D. A., Sullivan, B. D., Ullman, M. D., et al.
dimensional study o the human corneal kerato- Guillon, & M. Ruben (Eds.), Contact Lens (2000). Androgen in uence on the meibomian
cyte density. Curr. Eye Res., 14, 459–464. Practice (pp. 225–237). London: Chapman gland. Invest. Ophthalmol. Vis. Sci., 41, 3732–3742.
Nishida, ., & anaka, . (1996). Extracellular ma- and Hall. akahashi, Y., Watanabe, A., Matsuda, H., et al.
trix and growth actors in corneal wound heal- Sack, R. A., an, K. O., & an, A. (1992). Diurnal (2013). Anatomy o secretory glands in the eye-
ing. Curr. Opin. Ophthalmol., 7, 2–11. tear cycle: evidence or a nocturnal in amma- lid and conjunctiva: a photographic review. Oph-
Oliveira-Soto, L., & E ron, N. (2001). Morphology tory constitutive tear uid. Invest. Ophthalmol. thal. Plast. Reconstr. Surg., 29(3), 215–219.
o corneal nerves using con ocal microscopy. Vis. Sci., 33, 626–640. i any, J. M. (1991). T e viscosity o human tears.
Cornea, 20, 374–384. Saonanon, P. (2014). Update on Asian eyelid anat- Int. Ophthalmol. Clin., 15, 371–376.
Paulsen, F. P., T ale, A. B., Hallmann, U. J., et al. omy and clinical relevance. Curr. Opin. Ophthal- i any, J. M. (1995). Physiological unctions o the
(2000). T e cavernous body o the human e - mol., 25, 436–442. meibomian glands. Prog. Retin. Eye Res., 14, 47–74.
erent tear ducts: unction in tear out ow Scott, J. E. (1991). Proteoglycan: collagen interac- i any, J. M. (1997). ears and conjunctiva. In
mechanism. Invest. Ophthalmol. Vis. Sci., 41, tions and corneal ultrastructure. Biochem. Soc. J. J. Harding (Ed.), Biochemistry o the Eye
965–970. rans., 19, 877–881. (pp. 1–15). London: Chapman and Hall.
P ster, R. R. (1973). T e normal sur ace o the cor- Sei ert, P., Spitznas, M., Koch, F., et al. (1993). T e subota, K. (1998). ear dynamics and dry eye.
neal epithelium: a scanning electron microscopic architecture o human accessory lacrimal glands. Prog. Retin. Eye. Res., 17, 565–596.
study. Invest. Ophthalmol. Vis. Sci., 12, 654–668. Ger. J. Ophthalmol., 2, 444–454. Wilson, S. E. (2000). Role o apoptosis in wound
P ug elder, S. C. (1998). ear uid in uence on the Shaheen, B. S., Bakir, M., & Jain, S. (2014). Corneal healing in the cornea. Cornea, 19, S7–S12.
ocular sur ace. Adv. Exp. Med. Biol., 438, 611–617. nerves in health and disease. Surv. Ophthalmol., Wilson, S. E., & Hong, J. W. (2000). Bowman’s layer
P ug elder, S. C., Liu, Z., Monroy, D., et al. 59, 263–285. structure and unction. Critical or dispensable
(2000). Detection o sialomucin complex Sherrard, E., Novakovic, P., & Speedwell, L. (1987). to corneal unction? A hypothesis. Cornea, 19,
(MUC4) in human ocular sur ace epithelium Age related changes o the corneal endothelium 417–420.
and tear uid. Invest. Ophthalmol. Vis. Sci., 41, and stroma as seen in vivo with the specular mi- Wirtscha er, J. D., Ketcham, J. M., Weinstock, R. J.,
1316–1326. croscope. Eye, 1, 197–203. et al. (1999). Mucocutaneous junction as a ma-
Prydal, J. J., Artal, P., Woon, H., et al. (1992). Study Srinivasan, S., Menzies, K., Sorbara, L., et al. (2012). jor source o replacement palpebral conjunctival
o human preocular tear lm thickness and In rared imaging o meibomian gland structure epithelial cells. Invest. Ophthalmol. Vis. Sci., 40,
structure using inter erometry. Invest. Ophthal- using a novel keratograph. Optom. Vis. Sci., 89, 3138–3146.
mol. Vis. Sci., 33, 2006–2011. 788–794.
 3
Visual O p t ics
W NEIL CHARMAN

Int ro d uct io n T e distribution across the population o parameters such

as sur ace radii, component spacing and re ractive indices has
T e human eye is a remarkable optical instrument (Navarro, been studied by a variety o authors (McBrien and Barnes, 1984;
2009; Artal, 2014). Its per ormance has been honed by mil- Charman, 2010). Re ractive indices o the media vary little
lennia o evolution to meet admirably the needs o the neural between eyes, apart rom the non-uni orm re ractive index dis-
system that it serves. At its best, ew human-engineered photo- tribution within the lens, which changes with age as the lens
graphic lens systems can match its semi eld o more than 90°, grows throughout li e (Pierscionek et al., 1988; Pierscionek,
its range o -numbers rom about / 11 to better than / 3, and 1995; Jones et al., 2005; Kasthurirangan et al., 2008). Each
its near di raction-limited axial per ormance when stopped dimensional parameter appears to be approximately normally
down under photopic light levels. Moreover, the ocus o the distributed amongst di erent individuals (Stenstrom, 1946;
eye o the young adult can be adjusted with reasonable accuracy Sorsby et al., 1957). T e values o the di erent parameters in
or distances between about 0.1 m and in nity. Nevertheless, all the individual eye are, however, correlated so that the resultant
eyes su er rom a variety o regular and irregular aberrations, distribution o re ractive error is strongly peaked near emme-
while a substantial subset displays clinically signi cant spheri- tropia, rather than being normal (Fig. 3.2).
cal and astigmatic re ractive errors. In addition, the ability to T is correlation is thought to be due to a combination o
change the power o the crystalline lens to view near objects is genetic and environmental actors; visual experience helping to
an asset that declines with age, to disappear entirely by the mid ‘emmetropize’ the eyes actively ( roilo, 1992; Saunders, 1995;
50s, when presbyopia is reached. Wildsoet, 1997; Weale, 2003; Mutti, 2010; Flitcro 2014). T e
T e invention o spectacles in the 13th century, and their sub- apparently greater incidence o myopia in recent times has been
sequent relatively slow re nement, ollowed by the more rapid attributed to the greater prevalence o near tasks and other
development o contact lenses in the 20th century, has done changes in environment and li estyle (Rosen eld and Gilmar-
much to provide solutions to the problems o both re ractive tin, 1998; Pan et al., 2011). 
error and presbyopia: improvements in the design o both types
o lens continue to be made. Re ractive surgical techniques,
MO DEL EYES AND AMETRO PIA
including both laser-based methods that modi y the corneal
contour and intraocular lenses, are beginning to compete with Many authors have produced paraxial models o the emmetropic
spectacle and contact lens corrections, although unanswered eye, based on typical measured values o the ocular parameters
questions still remain concerning the long-term e cacy and (T ibos and Bradley, 1999; Atchison and Smith, 2000; Rabbetts,
sa ety o some o the procedures used. In this chapter the basic 2007; Atchison, 2009). T ese simpli y the optical complexities
optics o the eye and its components will rst be reviewed. T is o the real eye while having approximately the same basic imag-
will be ollowed by a discussion o the modi cations that the ing characteristics. Some examples are given in able 3.1; uller
correction o re ractive error – particularly by contact lenses – details o these and other more elaborate eye models (e.g. Gon-
produces in actors such as spectacle magni cation, accommo- charov and Dainty, 2007) are given in the cited re erences.
dation and convergence (Douthwaite, 2005).  Using the parameters o the model eyes it is straight orward to
calculate the positions o the cardinal points, which, in thick-lens
theory, can be used to summarize paraxial imagery (Fig. 3.3).
The Basic O p t ics o f t he Eye and
Ame t ro p ia
GENERAL O PTICAL CHARACTERISTICS
T e amiliar, and deceptively simple, optical layout o the eye is
shown in Fig. 3.1.
About three-quarters o the optical power comes rom the
anterior cornea, with the crystalline lens providing supple-
mentary power that, in the pre-presbyope, can be varied to
ocus sharply on objects at di erent distances. T e actual opti-
cal design is, however, subtle, in that all the optical sur aces
are aspheric, while the lens, and probably also the cornea,
displays a complex gradient o re ractive index. T ere is little
doubt that such re nements play an important role in control-
ling aberration. Fig . 3.1 Sche matic horizontal se ction o the human e ye .
28
 3 Visual O p t ics 29

It is, however, important to stress that these eye models are only For a distant object (zero object vergence) the image vergence
representative. In practice, an eye o shorter or longer axial length n′ / l′ equals Fe. For emmetropia we require that the image o the dis-
may still be emmetropic. T is behaviour and the various possible tant object lies on the retina, i.e. l′ = k′, implying that Fe = n′ / k′ = K′,
origins o re ractive error are easy to understand in terms o these where K′ = n′ / k′ is the dioptric length o the eye. T ere are, then, in
basic models. Consider, or simplicity, the generic reduced eye principle an in nite number o matching pairs o values o Fe and
shown in Fig. 3.4, with a single re ractive sur ace o radius r, re rac- K′ that lead to emmetropia, so that eyes that are relatively larger or
tive index n′ and axial length k′. T e power o the eye, Fe, is given by: smaller than the ‘standard’ models may still be emmetropic.
Fe = (n' − 1) /r In the case o ametropia Fe and K′ are no longer equal. I the
power o the eye is too high (Fe > K′) we get myopia; i too low
(Fe < K′) we get hypermetropia. T e ocular re raction K is given by:
K= K' − Fe
T us, or example, myopia (K negative) can occur i K′ is too
low, corresponding to an axial length k′ that is relatively too
great (axial ametropia), or i Fe is relatively too large (re ractive
ametropia). A high Fe may arise as a result o either too small a
corneal radius r or because n′ is too large (note, however, that
changes in n′ a ect both Fe and K′). Although more sophisti-
cated eye models are characterized by more parameters, the
possible origins o ametropia are essentially the same.
Astigmatism can arise either because one or more o the
optical sur aces is toroidal or because o tilts o sur aces with
respect to the axis, particularly o the lens.
How accurate do our models and associated calculations
have to be? Although in the laboratory it may theoretically be
possible to measure all the parameters o an individual eye, in
general all that will be known in the consulting room is that the
eye is ametropic. T us, in clinical contact lens practice, precise
calculation o the optical e ects in the uncorrected or corrected
eye is rarely possible; it is more important that the general mag-
nitude o the e ects be borne in mind and that the approximate
changes brought about by correction be ully understood. 

ACCO MMO DATIO N AND THE PRECISIO N O F

O CULAR FO CUS

Fig . 3.2 Distrib ution o some ocular p arame te rs and o re ractive e r- T e decline with age in the subjective amplitude o accommo-
ror. (A) Rad ius o curvature o the ante rior corne a. (B) Ante rior chamb e r dation (i.e. the reciprocal o the distance, measured in metres,
(A.C.) d e p th. (C) Le ns p o we r. (D) Axial le ng th. (E) Sp he rical e q uivale nt re - o the nearest point at which vision remains subjectively clear to
ractive e rror. In (A)–(D) the d ashe d curve re p re se nts the corre sp ond ing the distance-corrected patient) is illustrated in Fig. 3.5A.
normal d istrib ution. Note that, whe re as ind ivid ual p arame te rs are d is- Few everyday tasks require accommodation in excess o about
trib ute d ap p roximate ly normally, re ractive e rrors are strong ly p e ake d
ne ar e mme trop ia. (Afte r Ste nstrom, S. (1946). Unte rsuchung e n ub e r d e r 4 D, so that it is normally only as individuals approach 40 years
Variation und Kovaration d e r op tische Ele me nte d e s me nschliche n Au- o age that marked problems with near vision start to appear. It
g e s. Acta O p hthalmol., 15(Sup p l. 26). [Translate d b y Woo lf, D.]) is, however, important to recognize that, even or objects lying

TABLE
3.1 Parame t e rs o f So me Paraxial Mo d e ls o f t he Human Eye
Sche mat ic Eye (mm) Simp lifie d Sche mat ic Eye (mm) Re d uce d Eye (mm)
Surface rad ii (mm) Ante rior corne a 7.80 7.80 5.55
Poste rior corne a 6.50 — —
Ante rior le ns 10.20 10.00 —
Poste rior le ns −6.00 −6.00 —
Distance s from Ante rior Corne a Poste rior corne a 0.55 — —
(mm) Ante rior le ns 3.60 3.60 —
Poste rior le ns 7.60 7.20 —
Re tina 24.20 23.90 22.22
Re fract ive Ind ice s Corne a 1.3771 — —
Aq ue ous humour 1.3374 1.333 1.333
Le ns 1.4200 1.416 —
Vitre ous humour 1.3360 1.333 —

(Data from Charman, W. N. (1991) O p tics of the human e ye . In W. N. Charman (e d .) Vision and Visual Dys unction. Vol. 1: Visual O p tics and Instru-
me ntation (p p . 1–26). Lond on: Macmillan.)
30 PART 1 Int ro d uct io n

Fig . 3.3 Examp le s o p araxial mod e ls o the human e ye . In e ach case F

and F ′ re p re se nt the f rst and se cond ocal p oints, re sp e ctive ly, P and P ′
the f rst and se cond p rincip al p oints, and N and N ′ the f rst and se cond
nod al p oints. (A) Unaccommod ate d sche matic e ye with our re racting
sur ace s. (B) Simp lif e d , unaccommod ate d e ye with thre e re racting sur-
ace s. (C) Re d uce d e ye with a sing le re racting sur ace . (Ad ap te d from
Charman, W. N. (1991). O p tics of the human e ye . In W. N. Charman (e d .)
Vision and Visual Dys unctio n. Vol. 1: Visual O p tics and Instrume ntation
(p p . 1–26). Lond on: Macmillan.)

Fig . 3.5 (A) The d e cline in monocular sub je ctive amp litud e o ac-
co mmod ation, re e re nce d to the sp e ctacle p lane , with ag e . (B) Typ ical
ste ad y-state accommod ation re sp onse / stimulus curve , showing lag s
o accommod ation or ne ar stimuli. (Data in (A) from Duane , A. (1922).
Stud ie s in monocular and b inocular accommod ation with the ir clinical
imp licatio ns. Am. J. O p hthalmol., 5, 865–877.)

Fig . 3.4 A g e ne ric re d uce d e ye mod e l, with p arame te rs as ind icate d . r

is the rad ius o curvature o the re racting sur ace , k′ the axial le ng th and We have already seen (see Fig. 3.2A) that the radius o curvature
n ′ the re ractive ind e x. The e ye shown is hyp e rme trop ic. over the central region, as measured by conventional keratometers,
shows considerable individual variation, and it has been recog-
within the available range o accommodation, accommoda- nized or more than a century that many corneas display marked
tion is rarely precise. ‘Lags’ o accommodation usually occur astigmatism. Corneal astigmatism is not, o course, necessarily
in near vision and ‘leads’ or distance vision (Fig. 3.5B). As the equal to the total ocular astigmatism, as additional astigmatism
accommodation system is driven via the retinal cones, these lags (residual astigmatism) may be contributed by the crystalline lens.
increase i the environmental illumination is reduced to meso- Earlier work on corneal topography using modi cations o
pic levels and the accommodation system is e ectively inopera- traditional keratometers concentrated on approximating the
tive at scotopic light levels, when the system reverts to its slightly orm o the corneal sur ace by a conicoid, in which each meridian
myopic (around −1 D) tonic level (Ciu reda, 1991, 1998).  is a conic section. In this approach the anterior corneal sur ace
can be described by the ollowing equation (Bennett, 1966, 1988):
Co rne al To p o g rap hy x2 + y2 + pz2 = 2r 0 z
It has already been stated that the optical sur aces o the eye are where the coordinate system has its origin at the corneal apex, z
not necessarily spherical. T e topography o the anterior cornea is the axial coordinate, r0 is the radius o curvature at the cornea
is o particular interest since, as the dominant re ractive sur- apex and the shape actor p is a constant parameter character-
ace, its orm has a major inf uence on overall re ractive error izing the orm o the conic section or the individual eye. Values
and ocular aberration. In contact lens work, it is o enormous o p < 0 represent hyperboloids, p = 0 paraboloids, 0 < p < 1 f atten-
importance to the tting geometry. ing (prolate) ellipsoids, p = 1 spheres and p > 1 steepening (oblate)
 3 Visual O p t ics 31

Fig . 3.6 (A) Histog ram showing the d istrib ution o the shap e actor, p , in 176 e ye s. (B) Typ ical re sult rom a top og rap hic instrume nt, showing the local
variation in nominal sp he rical p owe r across our astig matic corne as. (Ad ap te d from Kie ly, P. M., Smith, G. & Carne y, L. G. (1982). The me an shap e of
the human corne a. O p tica Acta, 29, 1027–1040.)

ellipsoids. T e same equation is sometimes written in terms o the

Q- actor or the eccentricity e o the conic section, where:
p = 1 + Q = 1 − e2
Kiely et al. (1982) ound mean r0 and p values o 7.72 ± 0.27
mm and 0.74 ± 0.18, respectively, these values being supported
by the results o Guillon et al. (1986), that is, 7.85 ± 0.25 mm
and 0.85 ± 0.15; broadly similar p values are ound in di erent
racial groups: 0.70 ± 0.12 in Chinese eyes (Zhang et al., 2011) and
0.74 ± 0.19 in A ro-Americans (Fuller and Alperin, 2013). T us
the typical general orm o the cornea is that o a f attening ellip-
Fig . 3.7 Formation o the re tinal b lur circle or a myop ic e ye . D is the
soid, with the curvature reducing in the periphery (Fig. 3.6A). p up il d iame te r and d is the b lur circle d iame te r.
Recent years have seen the introduction o a range o topo-
graphic instruments, marrying optical with electronic and com-
puter technology, that can routinely give a much uller picture
o the corneal contour (see Chapters 36, 41). T ese videokerato- Pup il Diame t e r and Re t inal Blur
graphic and scanning-slit results show that the conicoidal model is Circle s
only a rst approximation to corneal shape and that individual eyes
show a wide range o individual asymmetries. In particular, the rate As will be discussed below, although the retinal image is always
o corneal f attening is o en di erent in di erent meridians (Fig. blurred by both aberration and di raction, in ametropia and
3.6B), while the corneal cap o steepest curvature may be displaced presbyopia it is o en de ocus blur that is the major source o
with respect to the visual axis, on average lying about 0.8 mm below degradation. De ocus will occur whenever the object point lies
(Mandell et al., 1995). More elaborate models have been devised to outside the range o object distances embraced by the ar and
describe these asymmetries in corneal shape (Navarro et al., 2006) near points o the individual. As noted earlier, even within this
Currently the most popular orm o output or the topo- range, small errors o ocus will normally occur owing to the
graphic data is probably a colour-coded map o the cornea, steady-state errors that are characteristic o the accommoda-
showing regions o di erent axial (sagittal) power (see Chapter tion system. Using a reduced eye model and simple geometric
36). T is may be slightly misleading, since each local area o the optical approximations (Smith, 1982, 1996; Atchison and Smith,
cornea is toroidal rather than spherical. For this reason both sag- 2000; Rabbetts, 2007) – which are normally valid or all errors
ittal and tangential power maps are o en used (Mount ord et al., o ocus over about 1 D – such blur depends on the dioptric
2004). It is possible that other orms o representation, such error o ocus and the pupil diameter. From Fig. 3.7 it can be
as those that plot local departures in height rom a best- tting seen that, or any object point and assuming that the eye pupil is
sphere, will ultimately prove more use ul, particularly in relation circular, spherical de ocus produces a ‘blur circle’ on the retina.
to the tting o rigid contact lenses (Salmon and Horner, 1995; Using similar triangles, it is easy to show that the diameter
Horner et al., 1998). T e contribution o the cornea to the over- (d, in mm) o this blur circle is:
all ocular wave aberration can be deduced rom the videokerato- d = ΔFD/K'
gram (Hemenger et al., 1995; Guirao and Artal, 2000). Scanning
slit instruments, such as the Orbscan and Pentacam, allow the where ΔF is the dioptric error o ocus with respect to the object
orm o the posterior sur ace o the cornea to be deduced, as well point, D is the pupil diameter in millimetres and K′ is the diop-
as that o the anterior sur ace (see Chapters 36, 41).  tric length o the eye. I astigmatism is present, the blur patch
32 PART 1 Int ro d uct io n

is an ellipse, with major and minor axes corresponding to the With errors o ocus smaller than about 1 D, di raction,
ocus errors in the two principal meridians. aberration and the neural capabilities o the visual system are
We can express the blur circle diameter in angular terms as: more important than de ocus blur and the MAR exceeds that
α = ΔFD 10 − 3 rads = 3.44ΔFD min arc Eq. 3.1 predicted by Eq. 3.2.
T e natural pupil diameter is chief y dependent on the ambi-
T us, or a 3 mm diameter pupil, the blur circle diameter ent light level. Fig. 3.8 shows typical results or this relationship
increases by roughly 10 min arc per dioptre o de ocus. Chan in young adults.
et al. (1985) measured blur circle diameters experimentally and Pupil diameters at any light level tend to decrease with age
ound that results or pupil diameters between 2 and 6 mm and (senile miosis: Winn et al., 1994) and with accommodation, as
de ocus between 1 and 12 D were quite accurately predicted by well as varying with a variety o emotional and other actors
Eq. 3.1. (Loewen eld, 1998). Some typical values or older eyes under
T e impact o blur on visual acuity depends somewhat on di erent lighting conditions are given in able 3.2.
the acuity target chosen and the criteria and observation condi- Clearly, reducing the pupil size results in smaller amounts
tions used. We would expect the minimum angle o resolution o blur in the retinal image or any given level o de ocus,
(MAR) to be somewhat smaller than the blur circle diameter. and thus the depth o ocus is increased. For example, an
Smith (1996) suggests that, or errors o ocus above about 1 D, uncorrected low myope may experience minimal levels o
letter targets, a 50% recognition rate, and normal chart lumi- distance blur under good photopic levels o illumination
nances o about 150 cd / m 2 (giving pupil diameters o about 4 but may notice considerable blur when driving at night,
mm): when the pupil is large. Pupil diameter strongly in luences
MAR = 0.65ΔFD min arc Eq. 3.2 the design and per ormance o bi ocal and other types
o contact lens or the presbyope (Koch et al., 1991; see
Chapter 23). 

Effe ct s o f Diffract io n and Ab e rrat io n

As noted above, these are chie ly important when the eye is
close to its optimal ocus. he point image or a spherical
error o ocus then no longer approximates to a blur circle
(or a point in the absence o de ocus) but has more complex
orm.

DIFFRACTIO N
I the optical per ormance o the eye were limited only by di -
raction, the in- ocus retinal image o a point object would be an
Airy di raction pattern. T e angular radius o the rst dark ring
in this pattern would be:
θmin = 1.22λ/D radians = 4194λ/D min arc
where the wavelength λ and the pupil diameter D are
expressed in the same units. It is usually assumed that it
Fig . 3.8 De p e nd e nce o p up il d iame te r on f e ld luminance in young
ad ults. (Ad ap te d from Farre ll, R. J. & Booth, J. M. (1984). De sig n Hand - will be possible to resolve the images o two identical point
b ook or Imag e ry Inte rp re tation Eq uip me nt (Se c. 3.2, p . 8). Se attle , WA: objects i their angular separation equals this value (the Ray-
Boe ing Ae rosp ace Co.) leigh limit). 

TABLE Me ans, St and ard De viat io ns and (Bracke t e d ) Rang e s o f Pup il Diame t e r in Vario us Visual Tasks and
3.2 Illuminance s fo r Pre sb yo p ic Pat ie nt s o f Diffe re nt Ag e s
Pup il Diame t e r Pup il Diame t e r
Co nd it io n Ag e s 40–49 (mm) Ag e s 50–59 (mm)
Nig ht d riving 5.2 ± 0.8 4.6 ± 0.8
(3.8–6.2) (3.1–5.8)
Re ad ing (low illumination, 215 lux) 3.5 ± 0.6 3.0 ± 0.5
(2.l6–4.6) (2.3–4.4)
Re ad ing (hig h illumination, 860 lux) 2.9 ± 0.5 2.6 ± 0.3
(2.2–3.9) (2.1–3.6)
O utd oors (ind ire ct sunlig ht, 3400 lux) 2.7 ± 0.5 2.5 ± 0.4
(1.9–3.4) (1.9–3.4)
O utd oors (d ire ct sunlig ht, 11 000 lux) 2.3 ± 3.4 2.2 ± 0.3
(1.8–3.1) (1.8–2.9)

(Data from Koch D. D., Samue lson S. W., Haft E. A. & Me rin L. M. (1991). Pup illary size and re sp onsive ne ss. Imp lications for sele ction of a b ifocal
intrao cular le ns. O p hthalmolog y, 98, 1030–1035.)
 3 Visual O p t ics 33

Examples o some typical axial results or normal eyes cor-

MO NO CHRO MATIC ABERRATIO NS
rected or any spherocylindrical re ractive error are shown in
Aberration obviously acts to introduce additional blur into both Fig. 3.11. T e wave ront error is usually expressed in microns
in- ocus and out-o - ocus images. Monochromatic aberration (micrometres).
can arise rom a variety o causes. T e eye would be expected Departures rom the re erence sphere (in this case o in nite
to display the classical Seidel aberrations (spherical aberra- radius) o more than a quarter o a wavelength (i.e. around 0.14
tion, coma, oblique astigmatism, eld curvature and distortion) µm or the green region o the spectrum) would be expected
inherent in any system o spherical centred sur aces but, due to to degrade image quality. What is striking is the wide variation
the various asphericities, tilts, decentrations and irregularities between the aberrations shown by di erent eyes. T e aberration
that may occur in its optical sur aces (see Fig. 3.6B), its aberra- in the central 2–3 mm o the pupil is usually modest, but much
tional behaviour is much more complex than that which would larger amounts may be ound in the periphery o dilated pupils.
be expected on the basis o simple schematic eye models o the On the basis o wave ront aberration results, it is possible to
type illustrated in Fig. 3.3 and able 3.1. calculate monochromatic point and line spread unctions and
Early authors attempted to analyse ocular aberration in terms also the ocular modulation and phase trans er unctions or any
o the individual Seidel aberrations. However, these attempts pupil diameter (Hopkins, 1962).
were o limited value because o the lack o rotational symme- Note that the wave ront maps shown in Fig. 3.11 were
try in the system. Monochromatic aberration is now most com- obtained on axis with the eyes under cycloplegia. In each case,
monly expressed in terms o the wave ront aberration (Atchison, ocular aberrations get worse nearer to the peripheral pupil, as
2004; Charman, 2005). T e behaviour o a ‘per ect’ optical sys- with most optical systems. In practice, the aberrations on the
tem, according to geometrical optics, can be visualized either as visual axis o each individual eye vary slightly with time owing
involving rays radiating rom an object point to be converged to
a unique image point, or as spherical wave ronts diverging rom
the object point to converge at the image point, so that the object
point is the centre o curvature o the object wave ronts and the
image point is that o the image wave ronts (Fig. 3.9A).
T e rays and wave ronts are everywhere perpendicular to
one another. I we have aberration, the image rays ail to inter-
sect at a single image point. Similarly, the wave ronts, which are
still everywhere perpendicular to the rays, are no longer spheri-
cal (Fig. 3.9B). It is usual to express the wave ront aberration at
any point in the pupil as the distance between the ideal spherical
wave ront, centred on the gaussian image point, and the actual
wave ront, where both are selected to coincide at the centre o
the exit pupil (Fig. 3.9C).
Recent years have seen an explosion o interest in ocular
aberrations, largely uelled by the realization that the earlier
excimer-laser re ractive surgical techniques o en resulted in
poor vision because these procedures introduced unacceptably
high levels o aberration. As a result, a variety o commercial
aberrometers have become available or measuring the wave-
ront aberration o the eye (Krueger et al., 2004; Atchison,
2005). One o the more elegant designs involves the use o a
Hartmann–Shack wave ront sensor (Liang et al., 1994, 1997;
Liang and Williams, 1997). A regular array o identical micro-
lenses allows the slope o the wave ront across a lattice o points
in the pupil to be determined. T e principle can be understood
with re erence to Fig. 3.10.
Suppose we have a point source on the retina o a per ect
emmetropic eye. T e light leaving the eye can be envisaged
either as a bundle o parallel rays or as a series o plane wave-
ronts (Fig. 3.10A). We now place our array o microlenses in
the path o the emerging light. Evidently each lens will converge
the parallel rays to its second ocal point, so that in the common
ocal plane we shall see an absolutely regular array o image
points. I now the eye su ers rom aberration, the emergent rays Fig . 3.9 (A) With a p e r e ct le ns, rays rom the ob je ct (O ) conve rg e to
a sing le imag e p oint. Alte rnative ly we can visualize d ive rg e nt sp he rical
are no longer parallel and the associated wave ronts are no lon- wave ronts (shown as d ashe d line s) rom the ob je ct p oint co nve rg ing
ger f at (Fig. 3.10B). T us the rays no longer come to a ocus on as sp he rical wave ronts to the imag e p oint. (B) I the le ns su e rs rom
the axes o the lenses; the lateral displacement rom the ocal ab e rration, the imag ing rays ail to conve rg e to a sing le p oint and the
point o each lens is directly proportional to the local inclina- corre sp ond ing wave ronts are not sp he rical. (C) The wave ront ab e rra-
tion, W ′, is sp e cif e d as the d istance b e twe e n the id e al wave ront, or re -
tion o the ray or the slope o the wave ront. It is, then, easy to e re nce sp he re , ce ntre d on the g aussian imag e p oint, O ′, and the actual
calculate the orm o the emergent wave ronts and the wave- wave ront in the e xit p up il. It is usually ad juste d to b e ze ro at the ce ntre
ront aberration rom the distorted pattern o image points. o this p up il.
34 PART 1 Int ro d uct io n

(A–C) the signal-to-noise o the Hartmann–Shack point images

is poor in some cases; this may lead to errors in the estimates o
the corresponding local slope and orm o the wave ront.
Although the basic wave ront map gives a use ul impression
o the orm and extent o the wave ront errors, it is help ul to be
able to quanti y this in some way. Various methods are available,
but those that are the most popular at the present time are the
total root mean square (RMS) wave ront error and the values o
the Zernike coe cients or the wave ront error.
T e basic method or obtaining RMS wave ront error or any
diameter o pupil is easily understood. We divide the pupil into
equal small areas, and sum the squared values o the wave ront
error or each small area. T is sum is then divided by the num-
ber o areas and the square root o this result gives the RMS
wave ront error. It can be shown that, i the RMS aberration is
less than a 14th o a wavelength (i.e. about 0.04 µm), there is
negligible loss in retinal image quality in comparison with an
eye whose per ormance is limited only by di raction. Obviously
or any eye the RMS error will vary with pupil diameter: in gen-
eral, as the wave ront aberration tends to increase in the outer
zones o the dilated pupil, the RMS aberration increases with
pupil diameter.
Applegate et al. (2007) investigated axial RMS wave ront
errors as a unction o pupil diameter and age in a large sample
o normal eyes that were corrected or spherical and cylindrical
re ractive error. able 3.3 gives the means and standard devia-
tions o their data or subjects aged 30–39 years.
It is interesting to note that the typical axial RMS wave ront
Fig . 3.10 Principle o the Hartmann–Shack techniq ue . (A) E ects with a
pe r ect e mmetropic eye, where the imag es are ormed on the axis o each error or a 3 mm pupil (see able 3.3) is close to the limit at
microle ns and hence are regularly sp aced . (B) E ects with an ab errated which the image di ers negligibly rom that rom an aberration-
eye, where the image array is irre g ular as the imag es are no long er ormed ree system (about 0.04 µm). T e luminance at which this pupil
on the axe s o the le nse s (se e te xt). f′ is the ocal le ngth o the microle nse s. diameter is ound, a ew hundred cd / m 2, corresponds to that
ound on cloudy days in the UK. T us, in most eyes, wave ront
aberration can play only a minor role in vision under daylight
conditions.
o give some clinical insight into the image degradation
caused by these levels o RMS wave ront aberration, we can
roughly evaluate the blurring e ect o the RMS aberration by
equating it with those o an ‘equivalent de ocus’ – that is, the
spherical error in ocus that produces the same magnitude o
RMS aberration or the same pupil size. T e equivalent de ocus
is given by:
Equivalent defocus (D) = 4.31/2 [RMS error] /R2
where the RMS aberration is measured in microns and the pupil
diameter, R, in millimetres. able 3.3 includes values or the
equivalent de ocus at each pupil diameter; except at the largest
Fig . 3.11 (A–C) Wave ront se nsor imag e s on the visual axis or thre e
pupil diameter, the equivalent de ocus is always less than 0.25
e ye s with a p up il d iame te r o 7.3 mm. An ab e rration- re e e ye wo uld D. Although the assumption that equal RMS error produces
g ive a re g ular he xag onal lattice o p oints. (D–F) Corre sp ond ing d e rive d equal degradation o vision is not completely justi ed (Apple-
wave ront ab e rration. Contours are at 0.15 µm inte rvals or sub je ct O P gate et al., 2003), it is evident that, in normal eyes, the impact o
and at 0.3 µm inte rvals or sub je cts JL and ML. The p e ak-to-valle y wave - optical blur due to monochromatic aberration is modest under
ront e rror or a 7.3 mm p up il is ab out 7, 4 and 5 µm or JL, O P and ML,
re sp e ctive ly. Note that or an ab e rration- re e e ye the re would b e a com- most photopic conditions. For comparison, the reliability o
p le te ab se nce o contours. (Re p rod uce d with p e rmission from Liang , clinical re ractive techniques is only around ±0.3 D (O’Leary,
J. & Williams, D. R. (1997). Ab e rrations and re tinal imag e q uality of the 1988; Bullimore et al., 1998).
human e ye . J. O p t. So c. Am. A, 14, 2873–2883.) T e second common way o speci ying aberrations is in
terms o Zernike coe cients (Atchison, 2004; Charman, 2005).
to actors such as accommodation f uctuations and tear-layer T e idea here is that, as very di erent orms o wave ront can
changes a er a blink (Ho er et al., 2001; Cheng et al., 2004; have the same total RMS error yet still produce somewhat di -
Montés-Micó et al., 2004). T ere will also be variation in the erent e ects on vision, it is better to break the complex wave-
measured wave ront errors owing to the limited reliability o ront patterns o the type shown in Fig. 3.11 into a set o simpler
any aberrometer. It can be seen, or example, that in Fig. 3.11 ‘building blocks’. Each ‘block’, mathematically described by a
 3 Visual O p t ics 35

TABLE Variat io n in t he Me an Axial Hig he r-o rd e r Mo no chro mat ic RMS Wave fro nt Erro r and it s St and ard De viat io n in
3.3 t he Eye s o f Sub je ct s Ag e d 30–39 Ye ars*
Pup il Diame t e r (mm) Typ ical Luminance Le ve l (cd / m 2 ) RMS Wave fro nt Erro r (µm) Eq uivale nt De fo cus (D)
3 400 0.052 ± 0.022 0.16
4 70 0.102 ± 0.041 0.18
5 7 0.174 ± 0.062 0.19
6 0.1 0.289 ± 0.091 0.22
7 0.0005 0.513 ± 0.138 0.29

*Also g ive n is the typ ical amb ie nt luminance le ve l at which the natural p up il d iame te rs occur (take n rom Fig . 3.8) and the e q uivale nt d e ocus (se e
te xt).
(Data from Ap p le g ate , R. A., Donne lly, W. J., Marsack, J. D. e t al. (2007). Thre e -d ime nsional re lationship b e twe e n hig he r-ord e r root-me an-sq uare
wave front e rro r, p up il d iame te r, and ag ing . J. O p t. Soc. Am. A, 24, 578–587.)

Zernike polynomial, corresponds to a speci c type o wave ront aberration’. T e third order includes vertical and horizontal pri-
de ormation: some o these are closely related to the traditional mary coma and the ourth order primary spherical aberration.
Seidel aberrations. T e set o polynomials, named a er their What levels o Zernike aberrations are ound on the visual
originator Fritz Zernike (1888–1966), has the advantage that axis in normal eyes? It must be remembered that, like the total
the individual polynomials are mathematically independent o RMS aberration, the values will tend to increase with pupil
one another. T e overall complex wave ront can then be speci- diameter, but a variety o studies involving large numbers o
ed in terms o the size o the contributions made by each o subjects give very similar results (Salmon and van de Pol, 2006).
these constituent wave ront de ormations: the size o the contri- T e study by Applegate et al. (2007) generated mean values or
bution that each makes is given by the value o the coe cient o the magnitudes o di erent types o third- and ourth-order
the corresponding polynomial. In the recommended ormula- Zernike aberration or di erent pupil sizes and age (coe cients
tion in current use, each coe cient gives the RMS wave ront or still higher-order Zernike modes are usually much smaller).
error (in microns) contributed by the particular Zernike mode able 3.4 gives their values or 30–39-year-old eyes. Note that,
(Atchison, 2004; Charman, 2005): the overall RMS wave ront where appropriate, the coe cients or similar, but di erently
error is given by the square root o the sum o the squares o oriented, Zernike polynomials have been combined.
the individual coe cients. T e relative sizes o the di erent It is evident that, at the smaller 3 mm pupil size, third-order
Zernike coe cients thus give detailed in ormation on the rela- coma and tre oil aberrations tend to dominate over ourth-order
tive importance o the di erent aberrational de ects o any par- aberrations, including spherical aberration, although spherical
ticular eye. aberration becomes comparable to coma or the larger 6 mm
T e Zernike polynomials can be expressed in terms o polar pupil.
coordinates (ρ, θ) in the pupil, where ρ = R / Rmax is the relative A somewhat di erent picture emerges i we average the
radial coordinate, Rmax being the maximum pupil radius, and θ signed coe cients, rather than considering the RMS values.
is the azimuthal angle, de ned in the same way as in the opto- Fig. 3.13 gives some typical data, in this case or a large sample
metric notation, except that it can rise to 360°. Each polynomial, (109) o normal eyes with a pupil diameter o 5.7 mm (Porter
or wave ront building block, is de ned by the highest power (n) et al., 2001). What is striking is that almost all the modes have a
to which ρ is raised (the radial order) and the multiple (m) or mean close to zero, although individual eyes may have substan-
the angle θ (the angular requency): m = −2, or example, means tial aberration, as shown by the relatively large standard devia-
that θ appears as sin2θ, while m = +3 means that it appears as tions. A notable exception is the j = 12, Z04 spherical aberration
cos3θ. T e polynomials and coe cients are, then, conveniently mode, where the mean is positive and di ers signi cantly rom
described as Zm m
n and Cn respectively. Fig. 3.12 shows the rst zero. T us, the picture that emerges is that most eyes have a cen-
ew levels o the ‘Zernike tree’ ormed by the di erent polyno- tral tendency to be ree o all higher-order aberration, except
mials, the levels corresponding to successively greater powers or spherical aberration, which shows a signi cant bias towards
o n. slight positive (undercorrected) values. T e Zernike coe cients
T e top two rows o the tree (n = 0 and n = 1) are o no sig- o normal individual eyes vary randomly about these mean val-
ni cance or image quality: piston (n = 0) just corresponds to a ues in a way that presumably depends upon the idiosyncratic
longitudinal shi o the wave ront and tilts (n = 1) to small pris- sur ace tilts, decentrations and other asymmetries o the indi-
matic shi s in the image point. T e second-order terms (n = 2) vidual eye. T e aberrations o eyes where pathology, such as
all depend upon the square o the radius in the pupil. T is is, keratoconus, is present may, however, be much larger.
o course, a amiliar eature o the sag ormula and in act Z02 Away rom the visual axis, the major contribution to retinal
represents spherical de ocus and the other terms astigmatism image blur in the axially corrected eye is usually oblique astig-
in crossed-cylinder orm, with the principal meridians either at matism (Atchison, 2012a). T e magnitude o the dioptric di er-
45 / 135 ( Z−− 22 ) or 90 / 180 ( Z− 22 ). T us, collectively, the second- ence between the sagittal and tangential oci is similar in most
order terms correspond to our amiliar spherocylindrical de o- eyes. Atchison and Smith (2000) suggest that this di erence
cus and can be compensated or by an appropriate contact lens between the two power errors can be described by:
or other type o correction. T e higher-order (third and greater)
A (θ) = 2.66 × 10 − 3 θ2 − 2.09 × 10 − 7 θ4
polynomials represent the residual aberrations, which, in the
past, it has not normally been possible to correct. Clinically where θ degrees is the eld angle with respect to the visual axis
these higher-order aberrations have o en been described rather and the oblique astigmatism, A(θ), is in dioptres. Although the
loosely by terms such as ‘irregular astigmatism’ and ‘spherical amount o astigmatism shows little variation, the relationship
36 PART 1 Int ro d uct io n

Fig . 3.12 The f rst f ve le ve ls o the Ze rnike ‘p yramid ’ or ‘tre e ’ showing the contour map s corre sp ond ing to the f rst 15 Ze rnike p olynomia ls (up to
the ourth ord e r). The contour scale is arb itrary and , in the ind ivid ual e ye , will vary with the coe f cie nt o e ach p olynomial. Rows re p re se nt succe ssive
ord e rs, n (i.e . the maximal p owe r to which the normalize d p up il rad ius is raise d ) and columns d i e re nt azimuthal re q ue ncie s, m. Also shown (in b rack-
e ts) are the ind e x numb e rs, j, o the p olynomials and some o the name s use d to d e scrib e the m: p olynomials (11) and (13) are o te n calle d se cond ary
astig matism. H / V astig matism = horizontal / ve rtical astig matism.

TABLE Me an Ab so lut e Le ve ls RMS Wave fro nt Erro rs (WFE) o f Diffe re nt Typ e s o f Hig he r-o rd e r Ze rnike Ab e rrat io n,
3.4 and t he ir St and ard De viat io ns, fo r 30–39-ye ar-o ld Sub je ct s and Tw o Pup il Diame t e rs
RMS WFE (µm) fo r 3 mm RMS WFE (µm) fo r 6 mm
Ab e rrat io n Co mb inat io n o f Co e fficie nt s Pup il Diame t e r Pup il Diame t e r
Tre foil (j = 6 and 9) 0.027 ± 0.017 0.139 ± 0.089
Coma (j = 7 and 8) 0.031 ± 0.022 0.136 ± 0.087
Te trafoil (j = 10 and 14) 0.010 ± 0.004 0.056 ± 0.030
Se cond ary astig matism (j = 11 0.015 ± 0.008 0.055 ± 0.027
and 13)
Sp he rical ab e rration 0.014 ± 0.010 0.130 ± 0.090
Total hig he r-ord e r RMS (j = 12) 0.052 ± 0.022 0.289 ± 0.091

(Data from Ap p le g ate , R. A., Donne lly, W. J., Marsack, J. D., e t al. (2007) Thre e -d ime nsional re lationship b e twe e n hig he r-ord e r root-me an-sq uare
wave front e rror, p up il d iame te r, and ag ing . J. O p t. Soc. Am. A, 24, 578–587.)
 3 Visual O p t ics 37

Fig . 3.13 Typ ical d ata or the me ans o the sig ne d value s o the Ze rnike
coe f cie nts o e ye s at a p up il d iame te r o 5.7 mm: among the hig he r-
o rd e r coe f cie nts only j = 12 ( ), sp he rical ab e rration, has a value that
d i e rs sig nif cantly rom ze ro. ANSI = Ame rican National Stand ard s In-
stitute . (Ad ap te d from Porte r J., Guirao, A., Cox, I. G. & Williams, D. R. Fig . 3.14 The long itud inal chromatic ab e rration o the e ye as ound
(2001). The human e ye ’s monochromatic ab e rrations in a larg e p op ula- b y d i e re nt inve stig ators. (Ad ap te d from Charman, W. N. (1991). O p tics
tion. J. O p t. Soc. Am. A, 18, 1793–1803.) o f the human e ye . In W. N. Charman (e d .) Vision and Visual Dys unction.
Vol. 1: Visual O p tics and Instrume ntation (p p . 1–26). Lond on: Macmillan.)

between the two image sur aces and the retina varies across
eyes and re ractive groups. It has been speculated that those
eyes where the mean sphere shows relative hyperopia in the
periphery may be more susceptible to the development o myo-
pia (Charman and Radhakrishnan, 2010; Smith, 2011; Flitcro ,
2012). For this reason there is ongoing interest in exploring the
extent to which modi ying the pattern o peripheral re raction,
in particular by reducing relative peripheral hyperopia, by the
wearing o suitably designed spectacles or contact lenses (Shen
et al., 2010; Sankaridurg et al., 2011; Aller and Wildsoet, 2013),
or by orthokeratology (Cho et al., 2005; Walline et al., 2009; Si
et al., 2015), may reduce myopia progression in children. Results
to date appear to be promising. 

CHRO MATIC ABERRATIO N

As the re ractive indices o all the ocular media vary with wave-
length, the eye su ers rom both longitudinal and transverse
chromatic aberration. At the ovea, the ormer is more impor-
tant – the amount o aberration approximating to that which
would occur i the eye media were all water. Unlike the mono-
chromatic aberrations, longitudinal chromatic aberration varies
very little between individuals and equals about 2.5 D across the
visible spectrum (Fig. 3.14).
As the visual axis is usually displaced rom the nominal Fig . 3.15 White -lig ht op tical line sp re ad unctions or e ye s with d i -
optical axis o the eye by about 5°, some individually varying, e re nt p up il d iame te rs (mm) at op timal ocus. The solid line curve s g ive
transverse chromatic aberration is ound at the ovea, typically the e xp e rime ntal me asure me nts, and the d ashe d curve s the the ore tical
amounting to about 0.8 min arc (Rynders et al., 1995); this ur- re sult or a d i raction-limite d syste m. (Ad ap te d from Camp b e ll, F. W. &
Gub isch, R. W. (1966). O p tical q uality of the e ye . J. Physiol. (Lond on),
ther degrades oveal image quality.  186, 558–578.)

O VERALL O PTICAL PERFO RMANCE O F THE EYE

the per ormance de cit due to aberration steadily increases as
IN WHITE LIGHT
the pupil diameter increases. It should, however, be borne in
Both monochromatic and chromatic aberration will degrade mind that under natural conditions large pupils are ound only
the in- ocus retinal image in comparison with that which would when eld luminances are low and neural per ormance is poor.
be expected or an aberration- ree eye with the same pupil size. T us di raction-limited optical per ormance with large pupils
Fig. 3.15 illustrates this or the case o the image o a ne line – would be o little value as the neural retina could not utilize the
that is, the line spread unction. available in ormation. Although monochromatic aberrations at
T e experimental results are compared with the calculated constant pupil diameter tend to increase in later li e, under nat-
pro les or the aberration- ree case (Campbell and Gubisch, ural conditions the pupil diameter is smaller, so that the quality
1966). With small pupils, aberration has only minor e ects, but o the retinal image changes very little (Applegate et al., 2007). 
38 PART 1 Int ro d uct io n

O CULAR DEPTH O F FO CUS or liquid crystal phase plates (Liang et al., 1997; Vargas-Martin
et al., 1998). Although all these corrections are, at present, ea-
I the retinal image is gradually de ocused, its quality will deteri- sible only in the laboratory, they do show that marked improve-
orate owing to de ocus blur. Nevertheless, there is a nite range ments in spatial vision can be achieved over the uncorrected
o ocus over which this blur causes no appreciable deteriora- eye, particularly i both monochromatic and chromatic aber-
tion in visual per ormance. T e precise value o the total depth rations are corrected; i only monochromatic aberrations are
o ocus depends on how it is assessed (e.g. Atchison, 2012b), corrected, per ormance in white light improves only modestly
but Fig. 3.16 gives some representative photopic values rom (Yoon and Williams, 2001).
di erent studies. It can be seen that, or typical photopic pupils Will it prove possible to correct axial ocular aberrations in
o about 4 mm diameter, visual per ormance will remain rela- everyday li e? In theory, having measured the wave aberrations
tively una ected provided that the spherical error o ocus does o the individual eye, the orm o the cornea could be appro-
not exceed about ±0.25 D.  priately shaped, or example by a computer-controlled scan-
ning spot excimer laser, to compensate or the aberrations.
CO RRECTIO N O F HIGHER-O RDER O CULAR T is has been the inspiration behind the development o many
ABERRATIO N commercial aberrometers that, when coupled to suitably con-
trolled excimer lasers, are used in wave ront-guided re ractive
Conventional corrections are designed to compensate or the surgery (Krueger et al., 2004). In practice, rather than eliminat-
spherocylindrical errors o the eye. As noted earlier, in wave- ing monochromatic aberrations, this approach has so ar only
ront terms these correspond to second-order wave ront aber- been able to ensure that postsurgery aberrations are comparable
rations. Would it be possible to improve visual per ormance with normal levels, partly because o our limited knowledge o
urther by also correcting the higher-order aberrations o the regression e ects associated with corneal healing.
eye, as we can now easily measure these under clinical condi- Alternatively a tight- tting, customized, contact lens with
tions? Until recently, the irregular and individual nature o minimal transverse and rotational movement might be engi-
the monochromatic wave ront aberrations o the eye made it neered to play the same role (Klein and Barsky, 1995; Klein,
impossible to correct them ully, although some reduction in 1998; Schweigerling and Snyder, 1998). T e lenses would lack
the average spherical aberration could be achieved with appro- rotational symmetry and would be customized so that their
priately aspheric contact lenses (see Chapters 6 and 13). local optical thickness varied in such a way as to compensate
Longitudinal chromatic aberration can be corrected by a or the wave ront aberration o the individual eye. o improve
suitable achromatizing doublet lens, but the improvement in optical per ormance in eyes with normal levels o aberration,
retinal image quality in white light is small and occurs mainly at any lens decentration should be less than about 0.5 mm and
intermediate spatial requencies (Campbell and Gubisch, 1967); any rotation less than 10° (Bara et al., 2000; Guirao et al., 2001).
no improvement in conventional high-contrast, white-light However, such approaches would reduce only the monochro-
visual acuity is normally detectable (Hartridge, 1947). matic aberrations, which, in any case, change with the level
More recently, however, real progress has been made in cor- o accommodation (Ivano , 1956; Lopez-Gil et al., 1998) and
recting monochromatic aberration using either adaptive optics other actors (Charman and Chateau, 2003). T e blur e ects
due to chromatic aberrations would remain uncorrected. More-
over, the worst monochromatic aberration occurs in the periph-
ery o the dilated pupil, and pupil dilation occurs only when
light levels are low and visual per ormance is largely limited by
neural, rather than optical, actors. For these reasons, custom-
ized correction o aberration seems likely to be pro table only
in the case o individuals whose monochromatic aberration is
particularly high, as in keratoconus (Jinabhai et al., 2012). T is
problem is discussed urther in Chapters 6 and 13. 

Effe ct ivit y, Sp e ct acle Mag nificat io n,

Acco mmo d at io n and Co nve rg e nce
Effe ct s w it h Co nt act Le ns and
Sp e ct acle Co rre ct io ns
Many patients may wish to change rom a spectacle to a con-
tact lens correction, and vice versa. Although the corrections
may be equally e ective in producing in- ocus retinal images in
both eyes, they do have a number o slightly di erent secondary
e ects, most o which are associated with the act that, whereas
contact lenses are placed directly on the cornea, spectacle lenses
Fig . 3.16 Examp le s o e xp e rime ntal me asure me nts o p hotop ic, total are placed at a signi cant distance, typically 10–20 mm, in ront
monocular d e p th o ocus / f e ld as a unction o p up il d iame te r (op ti- o this sur ace. Corrections achieved by corneal ablation using
mal ocus lie s mid way throug h the total d e p th o ocus). (Ad ap te d from
Charman, W. N. (1991). O p tics of the human e ye . In W. N. Charman (e d .)
excimer lasers, such as photore ractive keratectomy (PRK), laser
Vision and Visual Dys unction. Vol. 1: Visual O p tics and Instrume ntation in situ keratomileusis (LASIK) or other corneal surgical proce-
(p p . 1–26). Lond on: Macmillan.) dures, such as radial keratotomy or intrastromal rings, produce
 3 Visual O p t ics 39

broadly similar e ects to contact lenses, although their e ective when the magnitude o the ocular re raction exceeds about ±4
optical zones are usually smaller. D. Appendix C provides a tabulation o ocular re raction values
based on spectacle lens re ractions or various vertex distances. 
EFFECTIVITY
SPECTACLE MAGNIFICATIO N
T e role o the distance correction is to produce an intermediate
image at the ar point o the particular eye. Due to the non-zero Spectacle magni cation, as its name implies, describes the ratio
vertex distance o any spectacle correction, this ar point will lie o the image size in the corrected ametropic eye to that in the
at slightly di erent distances rom the two types o correcting uncorrected eye. It is particularly signi cant in cases o aniso-
lens. T us the spectacle and contact lens powers required to cor- metropia, where a er correction the di erential magni cation
rect a particular eye will di er. o the two retinal images may give rise to symptoms o aniseiko-
From Fig. 3.17A we can see that, using a reduced eye model, nia, and with cylindrical errors, where the di erent magni ca-
i the vertex distance is a (taken as positive) and the ocular tions in the two principal meridians caused by the correction
re raction is K, giving a ar point distance rom the cornea may lead the patient to complain o distorted images.
k = 1 / K, the second ocal point o the correcting lens lies at a T e retinal images o any object in the eyes o an uncorrected
distance a + k. ametrope have a scale that is governed by the chie rays passing
T us the power o the correcting lens (Fc) is: rom the extremities o the object through the centres o the
Fc = 1/ (a + k) = 1 (a + 1/K) = K/ (1 + aK) entrance and exit pupils o the eye. Each image point will, o
course, be blurred (Fig. 3.18A). Although placing a contact lens
For a contact lens, a will be zero so that the required value o on the cornea does not a ect the course o the chie ray, and
Fc equals the ocular re raction in this simple model. T is does not hence does not alter the size o the retinal image, this is not the
apply with a spectacle lens. T e result is that a hypermetrope will case with a spectacle lens. A positive correction increases the
require a higher-powered contact lens than a spectacle lens, the angle that the chie ray makes with respect to the axis, whereas
reverse occurring or a myope. T e di erence between the two a negative correction reduces it.
correcting powers is plotted as a unction o the spectacle cor- Fig. 3.18B illustrates this e ect or a positive, thin lens cor-
rection or a vertex distance o 14 mm in Fig. 3.17B, rom which rection and a reduced eye with both entrance and exit pupils at
it can be seen that the di erence between the required powers the cornea. We de ne the spectacle magni cation, SM, as the
o correction becomes signi cant (i.e. greater than 0.25 D) only retinal image height in the corrected eye, h′, divided by that in
the uncorrected eye, h0′. From the diagram it can be seen that, i
all angles are assumed to be small:
SM = h'/h0 ' = w'k'/w0 'k' = w'/w0 ' = (w/n') / (w0 /n') = w/w0

Fig . 3.18 (A) Ray g e ome try in the case o an uncorre cte d hyp e rme t-
Fig . 3.17 (A) Ge ome try re lating the ar p oint o an ame trop ic e ye (hy- rop e . (B) E e ct o a corre cting sp e ctacle le ns. Note that the ang le that
p e rme trop ic in the case shown) and the corre cting le ns. (B) Di e re nce the incid e nt chie ray make s with the axis is incre ase d rom w0 with-
b e twe e n the re q uire d p owe rs o contact le ns and sp e ctacle corre ctions, out corre ction to w with corre ction. Corre sp ond ing ly, the ang le o the
as a unction o the sp e ctacle corre ction, assuming that the ve rte x d is- chie ray with the axis a te r re raction is incre ase d rom w0′ to w′ a te r
tance o the sp e ctacle le ns is 14 mm. co rre ction.
40 PART 1 Int ro d uct io n

In addition to spectacle magni cation as de ned above, rela-

tive spectacle magni cation (RSM) is sometimes discussed. T is
is the ratio o the retinal image size in the corrected ametropic
eye to that in a speci ed emmetropic schematic eye. T eoreti-
cally it has the advantage o putting retinal image size on an
absolute basis. However, in most clinical work it is the changes
described by spectacle magni cation that are o interest and
RSM is o limited practical use.
As noted earlier, when anisometropes are corrected by
spectacle lenses, marked di erences in spectacle magni ca-
tion may occur between the two eyes, which may result in
symptoms o aniseikonia. It is obvious that these are much
reduced in the case o contact lenses, which there ore mini-
mize the possibility o aniseikonic symptoms (Winn et al.,
1986). A closely related e ect occurs when the anisometrope
looks in di erent directions with the head in a xed position.
When ordinary spectacles are worn and the visual axes do not
pass through the optical centres, prismatic e ects are intro-
duced, o magnitude given by Prentice’s rule P = cFc, where P
Fig . 3.19 Typ ical value s or sp e ctacle mag nif cation ob taine d with
sp e ctacle le ns and contact le ns corre ctions. The ratio o the two sp e c- is the induced prism power in prism dioptres, c the decentra-
tacle mag nif cations is also shown. E e ctivity has b e e n allowe d or, so tion in centimetres and Fc the lens power in dioptres. I the
that p oints on any ve rtical line re e r to the same ame trop ia. (Ad ap te d corrections are the same or both eyes, these prismatic e ects
from We sthe ime r, G. (1962). The visual world of the ne w contact le ns cause no problems or the spectacle wearer. In anisometropia,
we are r. J. Am. O p tom. Assoc., 34, 135–138.)
however, the prismatic e ects will be di erent or each eye. For
example, in reading, the visual axes o a young anisometrope
As the role o the correcting lens is to orm an image o height would normally intercept the lenses o the distance correc-
h1′ at the ar point, we thus have (Fig. 3.18B): tion at some distance below the optical centres. Assuming this
SM = [h1 '/ (fc' − a)] / [h1 '/fc'] = 1/ [1 − aFc] distance to be 8 mm and the corrections to be right eye (RE)
−3.00 D, le eye (LE) −6.00 D, the prismatic e ects would
In this simple model, the spectacle magni cation will be be RE 2.4Δ and LE 4.8Δ, respectively, both base-down. T e
unity or contact lenses (vertex distance a = 0), less than unity di erence in vertical prism power exceeds normal usional
or negative, myopic spectacle corrections and greater than 1 abilities, so that, to avoid the problem, the spectacle-corrected
or positive corrections. Somewhat perversely, spectacle cor- anisometrope would have to execute head turns during read-
rection is o en expressed as the percentage by which it di ers ing rather than simply depress the visual axes. T is problem is
rom unity, so that a spectacle magni cation o 1.05× would be absent with well-centred contact lenses. 
described as ‘5% magni cation’.
In practice we cannot strictly treat corrections as thin ACCO MMO DATIO N DEMAND
lenses and the entrance and exit pupils do not lie at the cor-
nea. For practical purposes the pupils may be taken as being Just as the position o the correcting lens a ects the correct-
situated about 3 mm behind the cornea. Using a thick-lens ing power required and the spectacle magni cation, so too
extension o the arguments already used, it can then be does it inf uence the accommodation required to view a near
shown that: object. T e accommodation necessary with any particular cor-
SM = [(1 − bF ′v) (1 − (t/n) F1 )]
−1
≈ (1 + bF ′v) (1 + (t/n) F1 ) rection can easily be calculated or any given object distance,
lens position and correcting power by determining the di er-
where b is the vertex distance measured rom the back sur ace ence between the vergence o the light striking the cornea when
lens to the entrance pupil, and t, n, F1 and F′ v are the lens thick- viewing a near object and that or a distant object. However, an
ness, re ractive index, anterior sur ace power and back vertex adequate approximation or most purposes is that the accom-
power, respectively. It can be seen that the magni cation is a modation demand (A, in dioptres) is given by:
unction o both lens design and vertex distance. Fig. 3.19 shows
A ≈ −L(1 + 2aK)
typical values o spectacle magni cation or both contact lens
and spectacle corrections. where L is the object vergence (negative or real objects), a
Note particularly that spectacle magni cation is always close is the vertex distance and K is the ocular re raction. In this
to unity or contact lenses, so that there are likely to be ew approximation, a is zero or a contact lens, so that we can see
magni cation-related complaints rom patients when moving that or a myope (negative K) the accommodation demand is
directly rom no correction to a contact lens correction or rom higher with contact lenses than with spectacle lenses, whereas
one contact lens correction to another. Casual contact lens wear- the reverse is true or hypermetropes. I we consider an object
ers who normally wear spectacle corrections may theoretically at 33 cm (L = −3 D) and a spectacle vertex distance a = 14 mm,
notice spatial distortion, although or myopes this is counter- we nd that the di erence in demand with the two types o
balanced by the bene t o relatively larger retinal images, which correction becomes signi cant (>0.25 D) when the magni-
may improve acuity. Spectacle magni cation e ects a er cor- tude o the re ractive error, K, is larger than about 3 D. T us,
neal re ractive surgery are similar to those with contact lenses higher myopes approaching presbyopia might slightly delay
(Applegate and Howland, 1993). the need or a reading addition by wearing spectacles, whereas
 3 Visual O p t ics 41

CO NVERGENCE DEMAND
Contact lenses move with the eyes, hence convergence demands
when viewing near objects are identical to those applying in the
uncorrected state. In contrast, myopes with a negative spectacle
correction or distance observe near objects through base-in
prisms, as they are no longer looking through the optical centres
o their lenses (Fig. 3.21).
T e base-in prismatic e ects reduce the convergence
requirement, compared with the naked eye or contact lens
situation. Spectacle-corrected hypermetropes, however, experi-
ence a base-out e ect at near, which increases the convergence
demand. Allowing or a typical interpupillary distance o 65
mm and the centre o rotation o each eye being about 12 mm
behind the cornea, application o Prentice’s rule shows that, or
an object distance o 33 cm, the convergence demand or each
eye is reduced by about 0.25Fc prism dioptres or a negative
spectacle correction and similarly increased or a positive cor-
Fig . 3.20 Ocular accommodation required when a patient with the spec-
tacle ametropia given on the abscissa views targets at either 0.50 or 0.33
rection. In most cases, then, the change in convergence demand
m (vergence, L= −2 or −3 D) when corrected with either spectacles (a = 14 is small compared with the usion reserves. Since both accom-
mm) or contact lenses. (Adapted from Westheimer, G. (1962). The visual modation and convergence demands are higher or myopes
world of the new contact lens wearer. J. Am. Optom. Assoc., 34, 135–138.) with contact lenses, and lower or hypermetropes, the accom-
modation–convergence links are minimally disturbed. 

O t he r O p t ical Effe ct s
T ere are certain additional phenomena related to prismatic
e ects o ophthalmic lenses that are not encountered by contact
lens wearers. T ese phenomena, which are experienced by spec-
tacle lens wearers, relate to the e ective eld o view in static
gaze, the extent o eye movements required to maintain xation
and the appearance o the eyes as viewed by another person (or
when looking in a mirror).

FIELDS O F VIEW AND FIXATIO N

With spectacle lenses, the prismatic e ects associated with the
lens peripheries result, when the eyes are stationary, in an annu-
lar zone o the visual eld being invisible (a ring scotoma) with a
positive correction, and being seen diplopically with a negative
correction. Analogously, when the eye is rotated to view objects
away rom the axis o the correction, a larger eye movement, in
comparison with the uncorrected eye, is required with a nega-
tive spectacle lens and a smaller one with a positive correction.
T is can be seen in Fig. 3.22.
I C is the centre o rotation o the eye, the e ective eld o
view as seen through the spectacle lens is governed by the posi-
tion o its image, C′, as ormed by the correcting lens.
T ese xation e ects are absent with contact lens corrections,
as the lenses ollow the movements o the eyes rom xation to
xation. T e periphery o the static eld o view may, however,
be slightly a ected i the contact lens or its optical zone is small,
and in the case o rigid lenses f are or glare may occur owing
to discontinuities at the edge o the lens or optic zone a ecting
ray pencils rom the periphery o the eld. A er laser re ractive
Fig . 3.21 Prismatic e e cts o d istance sp e ctacle corre ctions d uring surgery, the optic zone diameter may be smaller than the dilated
ne ar vision. pupil, leading to complaints o haloes at night. 

hypermetropes would nd near vision easier with a contact APPARENT SIZE O F THE EYES
lens correction.
Fig. 3.20 shows results rom a slightly more re ned model or A cosmetic disadvantage o spectacle lenses is that they alter the
the accommodation demand at two object distances.  apparent size o the eyes o the wearer as seen by other people:
42 PART 1 Int ro d uct io n

Because l is small (<0.02 m) this can be approximated by:

M = 1 − Fcl
T us i l is −20 mm and Fc is −10 D, the eyes nominally appear
to be only 80% o their true size. In act, or the viewer the
apparent size will vary depending upon the viewing direction,
as conditions will not necessarily be paraxial. T ese magni ca-
tion e ects can be reduced by minimizing the vertex distance
with high-powered spectacle corrections.
Clearly, with contact lenses this cosmetic disadvantage is
absent. 

Co nclusio n
Fig . 3.22 Fie ld s o vie w as se e n throug h sp e ctacle le ns corre ctions.
The ce ntre o rotation o the e ye is at C, and its imag e as se e n throug h
It has been shown that, although various types o correction
the sp e ctacle le ns is at C′. B is the ap p are nt macular f e ld o vie w and A all produce sharp retinal images in the ametropic eye, the
the actual f e ld . sizes o the associated retinal images will di er, as will the
demands on accommodation and convergence. A particular
the eyes appear larger with positive spectacle corrections and advantage o contact lenses is that they produce little change
smaller with negative ones. Using a thin lens approximation, in the retinal image size in comparison with the uncorrected
where the power o the correcting lens is Fc and the eye is at a eye.
distance l rom the lens, it is easy to show that the paraxial mag-
ni cation, M, o the anterior eye is given by: Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
M = 1/ (1 + Fcl)
REFERENCES
Aller, ., & Wildsoet, C. (2013). Optical control o Charman, W. N., & Radhakrishnan, H. (2010). conventional RGP lens and simulated, custom-
myopia has come o age: or has it? Optom. Vis. Peripheral re raction and the development o re- ized contact lens corrections: a comparison. Oph-
Sci., 90, e135–e137. ractive error: a review. Ophthal. Physiol. Opt., 30, thal. Physiol. Opt., 32, 200–212.
Applegate, R. A., & Howland, H. C. (1993). Mag- 321–328. Jones, C. E., Atchison, D. A., Meder, R., et al. (2005).
ni cation and visual acuity in re ractive surgery. Cheng, H., Barnett, J. K., Vilupuru, A. S., et al. (2004). Re ractive index distribution and optical proper-
Arch. Ophthalmol., 111, 1335–1342. A population study on changes in wave aberration ties o the isolated human lens measured using
Applegate, R. A., Ballentine, C., Gross, H., et al. with accommodation. J. Vis., 4(4), 272–280. magnetic resonance imaging. Vision Res., 45,
(2003). Visual acuity as a unction o Zernike Cho, P., Cheung, S. W., & Edwards, M. (2005). T e 2352–2366.
mode and level o root mean square error. Optom. longitudinal orthokeratology research in children Kasthurirangan, S., Markwell, E. L., Atchison, D. A.,
Vis. Sci., 80, 97–105. (LORIC) in Hong Kong: a pilot study on re rac- et al. (2008). In vivo study o changes in re ractive
Applegate, R. A., Donnelly, W. J., Marsack, J. D., et al. tive changes and myopic control. Curr. Eye Res., index distribution in the human crystalline lens
(2007). T ree-dimensional relationship between 30, 71–80. with age and accommodation. Invest. Ophthalmol.
higher-order root-mean-square wave ront error, Ciu reda, K. J. (1991). Accommodation and its Vis. Sci., 49, 2531–2540.
pupil diameter, and aging. J. Opt. Soc. Am. A, 24, anomalies. In W. N. Charman (Ed.), Vision and Kiely, P. M., Smith, G., & Carney, L. G. (1982). T e
578–587. Visual Dys unction, Vol. 1: Visual Optics and In- mean shape o the human cornea. Optica Acta, 29,
Artal, P. (2014). Optics o the eye and its impact on strumentation (pp. 231–279). London: Macmillan. 1027–1040.
vision: a tutorial. Adv. Optics Photonics, 6, 340–367. Ciu reda, K. J. (1998). Accommodation, the pupil Klein, S. A. (1998). Optimal corneal ablation or
Atchison, D. A. (2004). Recent advances in represen- and presbyopia. In W. J. Benjamin (Ed.), Borish’s eyes with arbitrary Hartmann–Shack aberrations.
tation o monochromatic aberrations o human Clinical Re raction (pp. 77–120). Philadelphia: J. Opt. Soc. Am. A, 15, 2580–2588.
eyes. Clin. Exp. Optom., 87, 138–148. Saunders. Klein, S. A., & Barsky, B. A. (1995). Method or gen-
Atchison, D. A. (2005). Recent advances in the Douthwaite, W. A. (2005). Contact Lens Optics and erating the anterior sur ace o an aberration- ree
measurement o monochromatic aberrations in Lens Design (3rd ed.). Ox ord: Butterworth- contact lens or an arbitrary posterior sur ace.
human eyes. Clin. Exp. Optom., 88, 5–26. Heinemann. Optom. Vis. Sci., 72, 816–820.
Atchison, D. A. (2009). Age-related paraxial sche- Duane, A. (1922). Studies in monocular and binocu- Koch, D. D., Samuelson, S. W., Ha , E. A., et al.
matic emmetropic eyes. Ophthal. Physiol. Opt., lar accommodation with their clinical implica- (1991). Pupillary size and responsiveness. Impli-
29, 58–64. tions. Am. J. Ophthalmol., 5, 865–877. cations or selection o a bi ocal intraocular lens.
Atchison, D. A. (2012a). T e Glenn A. Fry Award Farrell, R. J., & Booth, J. M. (1984). Design Hand- Ophthalmology, 98, 1030–1035.
Lecture 2011: Peripheral optics o the human eye. book or Imagery Interpretation Equipment (Sec. Krueger, R. R., Applegate, R. A., & MacRae, S. M.
Optom. Vis. Sci., 89, E954–E966. 3.2, p. 8). Seattle: Boeing Aerospace Co. (Eds.). (2004). Wave ront Customized Visual Cor-
Atchison, D. A. (2012b). Depth o ocus o the hu- Flitcro , D. I. (2012). T e complex interactions rection: the Quest or Supervision II. T oro are:
man eye. In I. G. Pallikaris, S. Plainis, & W. N. o retinal, optical and environmental actors Slack.
Charman (Eds.), Presbyopia: Origins, Ef ects, and in myopia aetiology. Prog. Retin. Eye Res., 31, Liang, J., & Williams, D. R. (1997). Aberrations and
reatment (pp. 21–28). T oro are: Slack. 622–660. retinal image quality o the human eye. J. Opt. Soc.
Atchison, D. A., & Smith, G. (2000). Optics o the Flitcro , D. I. (2014). Emmetropisation and the Am. A, 14, 2873–2883.
Human Eye. Ox ord: Butterworth-Heinemann. aetiology o re ractive errors. Eye (London), 28, Liang, J., Grimm, B., Goelz, S., et al. (1994). Objective
Bara, S., Mancebo, ., & Moreno-Barriuso, E. (2000). 169–179. measurement o wave aberrations o the human
Positioning tolerances or phase plates compen- Fuller, D. G., & Alperin, D. (2013). Variations in eye with the use o a Hartmann–Shack wave ront
sating aberrations o the human eye. Appl. Opt., corneal aspphericity (Q-value) between A rican- sensor. J. Opt. Soc. Am. A, 11, 1949–1957.
39, 3413–3420. Americans and whites. Optom. Vis. Sci., 90, Liang, J., Williams, D. R., & Miller, D. . (1997).
Bennett, A. G. (1966). Aspheric contact lens sur- 667–673. Supernormal vision and high-resolution retinal
aces. Parts I, II and III. Ophthal. Optician, 8(20), Goncharov, A. V., & Dainty, C. (2007). Wide- eld imaging through adaptive optics. J. Opt. Soc. Am.
1037–1040; 8(23), 1297–1311; 9(5), 222–230. schematic eye models with gradient-index lens. A, 14, 2884–2892.
Bennett, A. G. (1988). Aspherical and continuous J. Opt. Soc. Am. A, 24, 2157–2174. Loewen eld, I. E. (1998). T e Pupil. Boston: Butter-
curve contact lenses. Parts I to IV. Optometry Guillon, M., Lydon, D. P. M., & Wilson, C. (1986). worth-Heinemann.
oday, 28, 11–14; 140–142; 238–242; 433–444. Corneal topography: a clinical model. Ophthal. Lopez-Gil, N., Iglesias, I., & Artal, P. (1998). Retinal
Bullimore, M. A., Fusaro, R. E., & Adams, C. W. Physiol. Opt., 6, 47–56. image quality in the human eye as a unction o
(1998). T e repeatability o automated and clini- Guirao, A., & Artal, P. (2000). Corneal wave aberration the accommodation. Vision Res., 38, 2897–2907.
cal re raction. Optom. Vis. Sci., 75, 617–722. rom videokeratography: accuracy and limitations Mandell, R. B., Chiang, C. S., & Klein, S. A. (1995).
Campbell, F. W., & Gubisch, R. W. (1966). Opti- o the procedure. J. Opt. Soc. Am. A, 17, 955–965. Location o the major corneal re erence points.
cal quality o the eye. J. Physiol. (London), 186, Guirao, A., Williams, D. R., & Cox, I. G. (2001). Optom. Vis. Sci., 72, 776–784.
558–578. E ect o rotation and translation on the expected McBrien, N. A., & Barnes, D. A. (1984). A review
Campbell, F. W., & Gubisch, R. W. (1967). T e e - bene t o an ideal method to correct the eye’s and evaluation o re ractive error development.
ect o chromatic aberration on visual acuity. higher-order aberrations. J. Opt. Soc. Am. A, 18, Ophthal. Physiol. Opt., 4, 201–213.
J. Physiol. (London), 192, 345–358. 1003–1015. Montés-Micó, R., Alio, J. L., Munoz, G., et al. (2004).
Chan, C., Smith, G., & Jacobs, R. J. (1985). Simulat- Hartridge, H. (1947). T e visual perception o ne Postblink changes in total and corneal aberration
ing re ractive errors: source and observer meth- detail. Phil. rans. Roy. Soc. B, 232, 519–671. a er a blink. Ophthalmology, 111, 758–767.
ods. Am. J. Optom. Physiol. Opt., 62, 207–216. Hemenger, R. P., omlinson, A., & Oliver, K. (1995). Mount ord, J., Ruston, D., & Dave, . (2004).
Charman, W. N. (1991). Optics o the human eye. Corneal optics rom videokeratographs. Ophthal. Corneal topography and its measurement. In
In W. N. Charman (Ed.), Vision and Visual Dys- Physiol. Opt., 15, 63–68. J. Mount ord, D. Ruston, & . Dave (Eds.), Or-
unction. Vol. 1: Visual Optics and Instrumentation Ho er, H., Artal, P., Singer, B., et al. (2001). Dynam- thokeratology: Principles and Practice (pp. 17–47).
(pp. 1–26). London: Macmillan. ics o the eye’s wave aberration. J. Opt. Soc. Am. A, Ox ord: Butterworth Heinemann.
Charman, W. N. (2005). Wave ront technology: past, 18, 497–506. Mutti, D. O. (2010). Hereditary and environmental
present and uture. Cont. Lens Anterior Eye, 28, Hopkins, H. H. (1962). T e application o requency contributions to emmetropization and myopia.
75–92. response techniques in optics. Proc. Phys. Soc., 79, Optom. Vis. Sci., 87, 255–259.
Charman, W. N. (2010). Optics o the eye. In M. 889–919. Navarro, R. (2009). T e optical design o the human
Bass, M. J. M. Enoch, & V. Lakshminarayanan Horner, D. G., Salmon, . O., & Soni, P. S. (1998). eye: a critical review. J. Optom., 2, 3–18.
(Eds.), Handbook o Optics, Vol. III Vision and Corneal topography. In W. J. Benjamin (Ed.), Bor- Navarro, R., Gonzalez, L., & Hernandez, J. L. (2006).
Visual Optics (3rd ed.). (pp. 1.1–1.65). New York: ish’s Clinical Re raction (pp. 524–558). Philadel- Optics o the average normal cornea rom general
McGraw Hill. phia: Saunders. and canonical representations o its sur ace to-
Charman, W. N., & Chateau, N. (2003). T e prospects Ivano , A. (1956). About the spherical aberration o pography. J. Opt. Soc. Am. A, 23, 219–232.
or super-acuity: limits to visual per ormance a er the eye. J. Opt. Soc. Am. A, 46, 901–903. O’Leary, D. J. (1988). Subjective re raction. In
correction o monochromatic aberrations. Ophthal. Jinabhai, A., Charman, W. N., O’Donnell, C., et al. K. Edwards, & R. Llewellyn (Eds.), Optometry
Physiol. Opt., 23, 479–493. (2012). Optical quality or keratoconic eyes with (pp. 111–139). London: Butterworth.

42.e 1
42.e 2 Re fe re nce s

Pan, C.-W., Ramamurthy, D., & Saw, S. M. (2011). Saunders, K. J. (1995). Early re ractive development In P. Mouroulis (Ed.), Visual Instrumentation
Worldwide prevalence and risk actors or myo- in humans. Surv. Ophthalmol., 40, 207–216. (pp. 101–159). New York: McGraw Hill.
pia. Ophthal. Physiol. Opt., 32, 3–15. Schweigerling, J., & Snyder, R. W. (1998). Custom roilo, D. (1992). Neonatal eye growth and emme-
Pierscionek, B. K. (1995). Variations in re ractive in- photore ractive keratectomy ablations or the cor- tropisation – a literature review. Eye, 6, 154–160.
dex and absorbance o 670 nm light with age and rection o spherical and cylindrical re ractive er- Vargas-Martin, F., Prieto, P. M., & Artal, P. (1998).
cataract ormation in the human lens. Exp. Eye ror and higher-order aberration. J. Opt. Soc. Am. Correction o the aberrations in the human eye
Res., 60, 407–414. A, 15, 2572–2579. with a liquid-crystal spatial light modulator:
Pierscionek, B. K., Chang, D. Y. C., Ennis, J. P., et al. Shen, J., Clark, C. A., Soni, P. S., et al. (2010). limits to per ormance. J. Opt. Soc. Am. A, 15,
(1988). Non-destructive method o construct- Peripheral re raction with and without contact 2552–2562.
ing three-dimensional gradient-index models lens correction. Optom. Vis. Sci., 87, 642–655. Walline, J. J., Jones, L. A., & Sinnott, L. . (2009).
or crystalline lenses: 1. T eory and experiment. Si, J.-K., ang, K., Bi, H.-S., et al. (2015). Ortho- Corneal reshaping and myopia progression. Br. J.
Am. J. Optom. Physiol. Opt., 65, 481–491. keratology or myopia control: a meta-analysis. Ophthalmol., 93, 1181–1185.
Porter, J., Guirao, A., Cox, I. G., et al. (2001). T e hu- Optom. Vis. Sci., 92(3), 252–257. http://dx.doi. Weale, R. A. (2003). Epidemiology o re ractive
man eye’s monochromatic aberrations in a large org/10.1097/OPX.0000000000000505. errors and presbyopia. Surv. Ophthalmol., 48,
population. J. Opt. Soc. Am. A, 18, 1793–1803. Smith, E. L. (2011). Prentice Award Lecture 2010: A 515–543.
Rabbetts, R. B. (2007). Bennett & Rabbetts’ Clinical case or peripheral optical treatment strategies or Westheimer, G. (1962). T e visual world o the new
Visual Optics (4th ed.). Ox ord: Elsevier. myopia. Optom. Vis. Sci., 88, 1029–1044. contact lens wearer. J. Am. Optom. Assoc., 34,
Rosen eld, M., & Gilmartin, B. (1998). Myopia and Smith, G. (1982). Ocular de ocus, spurious resolu- 135–138.
Nearwork. Ox ord: Butterworth-Heinemann. tion and contrast reversal. Ophthal. Physiol. Opt., Wildsoet, C. F. (1997). Active emmetropization –
Rynders, M., Lidkea, B., Chisholm, W., et al. (1995). 2, 5–23. evidence or its existence and rami cations
Statistical distribution o oveal transverse chro- Smith, G. (1996). Visual acuity and re ractive error. or clinical practice. Ophthal. Physiol. Opt., 17,
matic aberration, pupil centration, and angle psi Is there a mathematical relationship? Optom. o- 279–290.
in a population o young adult eyes. J. Opt. Soc. day, 36(17), 22–27. Winn, B., Ackerley, R. G., Brown, C. A., et al. (1986).
Am. A, 12, 2348–2357. Sorsby, A., Benjamin, B., Davey, J. B., et al. (1957). T e superiority o contact lenses in the correc-
Salmon, . O., & Horner, S. D. G. (1995). Compari- Emmetropia and its Aberrations. Medical Re- tion o all anisometropia. Cont. Lens Anterior Eye,
son o elevation, curvature and power descriptors search Council Special Reports Series, No. 293. 9(Suppl.), 95–100.
or corneal topographic mapping. Optom. Vis. London: HMSO. Winn, B., Whitaker, D., Elliott, D. B., et al. (1994).
Sci., 72, 800–808. Stenstrom, S. (1946). Untersuchungen uber der Factors a ecting light-adapted pupil size in nor-
Salmon, . O., & van de Pol, C. (2006). Normal- Variation und Kovaration der optische Elemente mal human subjects. Invest. Ophthamol. Vis. Sci.,
eye Zernike coe cients and root-mean-square des menschlichen Auges. Acta Ophthalmol, 35, 1132–1137.
wave ront errors. J. Cataract Re ract. Surg., 32, 15(Suppl. 26) [ ranslated by Wool , D. (1948) as: Yoon, G.-Y., & Williams, D. R. (2001). Visual per or-
2064–2074. Investigation o the variation and covariation o mance a er correcting the monochromatic and
Sankaridurg, P., Holden, B., Smith, E., et al. (2011). the optical elements o human eyes. Am. J. Op- chromatic aberrations o the eye. J. Opt. Soc. Am.
Decrease in rate o myopia progression with a tom. Arch. Am. Acad. Optom., 25, 218–232; 286– A, 19, 266–275.
contact lens designed to reduce relative peripher- 299; 340–350; 388–397; 438–449; 496–504.]. Zhang, Z., Wang, J., Niu, W., et al. (2011). Corneal
al hyperopia: one-year results. Invest. Ophthalmol. T ibos, L. N., & Bradley, A. (1999). Modelling the asphericity and its related actors in 1052 Chinese
Vis. Sci., 52, 9362–9367. re ractive and neurosensor systems o the eye. subjects. Optom. Vis. Sci., 88, 1232–1239.
 PART

2
So ft Co nt act Le nse s

PART O UTLINE
4 Soft Le ns Mate rials 45
Carole Mald onad o-Cod ina
5 Soft Le ns Manufacture 61
Nathan E ron
6 Soft Le ns O p tics 68
W Ne il Charman
7 Soft Le ns Me asure me nt 73
Klaus Ehrmann
8 Soft Le ns De sig n and Fitting 86
Grae me Young
9 Soft Toric Le ns De sig n and Fitting 95
Richard G Lind say
10 Soft Le ns Care Syste ms 103
Philip B Morg an
This pa ge inte ntiona lly le ft bla nk
 4
So ft Le ns Mat e rials
CARO LE MALDO NADO -CO DINA

United States Adopted Name (USAN) o a particular lens mate-

Int ro d uct io n rial (e.g. eta lcon A or lotra lcon A), but any urther under-
So contact lenses have had a massive impact on the global standing o the material is o en lacking. T is chapter aims to
contact lens market since they became widely available in the give meaning and background to these USAN names in order
early 1970s. Since their introduction, the number o so contact to help the reader understand and di erentiate between di er-
lenses being prescribed around the world has steadily increased ent so lens materials. 
and it is mainly the sale o so contact lenses that is responsible
or an industry that is estimated to be worth around US$ 8 bil- Po lyme rs
lion annually (Nichols, 2015). A recent survey has indicated that
so lenses currently make up about 87% o all contact lens re ts All contact lens materials may be classi ed as polymers. T e
worldwide (Morgan et al., 2016). word ‘polymer’ is derived rom ancient Greek, meaning ‘many
T e saturation o the contact lens market with so lenses has parts’. Polymers are solid materials (as opposed to gases or liq-
occurred primarily or two reasons. First, so lenses provide uids) that are made up o high-molecular-weight chains (i.e.
wearers with what they see as the two most important require- long chains), which in turn are made up rom small repeating
ments or success ul contact lens wear – good vision and good units. T ese repeating units are called monomers. Polymers
com ort. T e major obstacle as ar as rigid lenses are concerned are macromolecules (giant molecules) made rom thousands
is generally accepted as being their lack o com ort and, in o atoms. T e term ‘polymer’ is there ore an umbrella term or
particular, their initial discom ort (Polse et al., 1999). Second, materials that include plastics (e.g. polymethyl methacrylate
advances in manu acturing technology have directed the indus- [PMMA], used in the manu acture o ‘hard’ rigid lenses), bres
try towards so lenses and, still urther, towards the concept o (e.g. nylon), elastomers (i.e. rubbers such as silicone rubber)
disposability. and the materials being discussed in this chapter – hydrogels.
Contact lens materials (both so and rigid) are good exam- T e term ‘hydrogel’ is o en used interchangeably with the
ples o biomaterials. A biomaterial may be de ned as a natural term ‘so ’ when re erring to contact lenses. So lenses are so
or synthetic material that is suitable or introduction into living named because they are made rom water-swollen, cross-linked,
tissue, especially as part o a medical device. T e term encom- hydrophilic polymers that are exible and compliant. T e term
passes a vast array o technologies, including tissue engineering, ‘hydrophilic’ is used to describe the act that the networks rom
arti cial organs, bioceramics, medical devices and implantable which these materials are made are ‘water-loving’.
drug delivery systems. Contact lenses are classed as a medical T e widespread use o polymers in many areas o our every-
device in most countries. day lives has become a common and accepted phenomenon –
Very ew o us are likely to get through li e without having so much so that they have been re erred to as the ‘steel o the
some kind o biomaterial introduced into our bodies. T e most 21st century’. Polymers possess many properties that make
common examples in use today include dental llings, contact them suitable or a wide range o applications, some o which
lenses, intraocular lenses, heart valves and stents. T is list in are unique. T ese properties are in part due to the length o the
itsel highlights just how diverse biomaterials must be in order molecules rom which they are made. Additionally, polymers
to satis y their very speci c end application – or example, a also derive their unique characteristics rom the ability o cer-
contact lens material has very di erent properties to a material tain atoms to join together to orm stable covalent bonds.
used or dental llings. Many polymers are composed o hydrocarbons (i.e. carbon
I a biomaterial is to be success ul in its application, it ol- [C] and hydrogen [H] alone) such as polyethylene and poly-
lows that it must also be biocompatible. Biocompatibility re ers styrene. However, even though the basic make-up o many
to the ability o a material to per orm with an appropriate host polymers is carbon and hydrogen, other elements can also be
response in a speci c application. An ‘appropriate host response’ involved. Oxygen (O), nitrogen (N), chlorine (Cl), uorine
would include not having toxic or injurious e ects on biologi- (F) and silicon (Si) are other elements commonly ound in the
cal systems. Biomaterials manu actured or use as contact lenses molecular make-up o polymers. Many polymers have carbon
must not only satis y all these requirements or sa e use within backbones (these are considered organic polymers), but some
the eye, but additionally they must also have very speci c char- can also have silicon or phosphorous backbones (these are con-
acteristics such as being transparent (and remain so on-eye), be sidered inorganic polymers).
com ortable and be relatively cheap to manu acture. T e kinds o atoms making up a polymer as well as their
T is chapter reviews the building blocks, properties and geometric arrangement give each polymer its chemical distinc-
characteristics o the materials that are used to manu acture tiveness, and thus, its particular use and unction. Polymers
so contact lenses and provides some o the history o develop- themselves may be completely natural (e.g. cellulose), partly
ment o these materials. Most clinicians are amiliar with the natural (e.g. cellulose acetate) or completely synthetic (e.g.
45
46 PART 2 So ft Co nt act Le nse s

PMMA). Most o the polymers used in the manu acture o so T e rst is an alternating copolymer, which is shown in Fig. 4.4.
contact lenses all into this last category, i.e. they are man-made. In this scenario, each monomer pre ers to interact with the el-
low monomer rather than itsel .
At the opposite extreme is the ordered or block copolymer,
THE STRUCTURE O F PO LYMERS
where there is an overwhelming tendency or a unit to be suc-
A polymer chain can be described by speci ying the kind o ceeded by another o the same kind. Here, long sequences o
repeating units present and their spatial arrangement. In this one type o unit alternate with long sequences o the other kind
way, several broad categories o polymer can be described. (Fig. 4.5).
A homopolymer is one in which only one type o monomer T e third major classi cation is the random copolymer.
is used, i.e. the units are chemically and stereochemically iden- Here, di erent units are randomly distributed along the chain
tical, with the exception o the end units. I the chain units are (Fig. 4.6).
arranged in a linear sequence the polymer is re erred to as a Departing rom the restrictions o a linear array, branched
linear homopolymer. T is is shown schematically in Fig. 4.1. copolymers, known as ‘gra polymers’, can also be prepared.
Departures rom this simple array lead to structures o increas- T e backbone o the molecule is composed o one type o unit,
ing geometric complexity. A non-linear or branched structure is and the long side chains, or gra s, are made up o another. More
shown in Fig. 4.2. sophisticated types o gra polymers have backbones made up
T e chemical di erences between linear and branched o di erent repeating units and several distinctly chemically
polymers may be quite small, yet, because o the structural di erent side groups. T is type o polymer is represented sche-
di erences, the two molecules can have quite markedly di er- matically in Fig. 4.7.
ent properties. A good example o these di erences is ound One nal important classi cation is that o polymers into
between low-density polyethylene (branched) and high-density either amorphous or crystalline polymers (i.e. their macro-
polyethylene (linear). Low-density polyethylene is commonly molecular order) (Fig. 4.8). Crystalline polymers have a geo-
used as a packaging lm (e.g. cling lm and or carrier bags), metrically regular structure and are generally sti , resistant to
whereas high-density polyethylene is used or making pipes and chemicals and tough. T ey have limited use as materials or
durable plastic bottles because o its higher impact strength. contact lenses owing mainly to their poor optical qualities (i.e.
Non-linear and network structures can also be prepared they tend to be translucent or opaque). A good example o a
rom a collection o linear chains by covalently linking together semicrystalline polymer is polypropylene, which is o en used
chain units selected rom di erent molecules. Such a system is to make the casts in the cast-moulded manu acturing process
said to be cross-linked. T is is shown schematically in Fig. 4.3. o contact lenses.
Here, X represents the chemical species (the cross-linker) that Amorphous polymers, on the other hand, do not have a
covalently links together the A units rom di erent molecular regular structure. T e polymer chains intermingle and are in
chains. When a suf cient number o units are intermolecularly
cross-linked, an in nite network is ormed. A cross-linker is
an important ingredient in a so contact lens monomer mix,
which will be discussed later.
A copolymer is one in which more than one type o mono-
mer is used. T e properties o a copolymer depend not only on
the chemical nature and amounts o the co-units, but also very
markedly on how the units are distributed along the chain. For
linear copolymers, three ‘ideal’ arrangements can be described.

Fig . 4.3 Cross-linke d syste m.

Fig . 4.1 Line ar homop olyme r.

Fig . 4.4 Alte rnating cop olyme r.

Fig . 4.2 Branche d homop olyme r. Fig . 4.5 Block cop olyme r.
 4 So ft Le ns Mat e rials 47

random positions (imagine a pile o spaghetti on a plate), which monomer mix. A solvent is used when lenses are manu actured by
o en allows these polymers to be transparent. Depending on ‘wet casting’, where the solvent is gradually replaced with saline. I
their chain mobility, amorphous polymers can be classi ed as a solvent is not used, the manu acturing process is o en re erred
either ‘plastic’ or ‘glassy’ ( ighe, 1997).  to as a ‘dry casting’ (i.e. the contact lens is cast as a xerogel).
Chain Polyme rization
PO LYMERIZATIO N
T e monomers used in chain polymerization are unsaturated
T e chemical reaction that monomers undergo in order to orm and are sometimes re erred to as vinyl monomers. Essentially
long-chained polymers is known as polymerization. Broadly this means that the monomer has one or more carbon-to-
speaking, monomers can be chemically joined together in two carbon double bonds. During the polymerization process the
ways: by step growth (condensation) or chain growth (addition) monomer concentration decreases steadily with time, resulting
processes. Condensation polymers are produced by the reaction in a reaction mixture that contains monomer, high-molar-mass
o monomeric units with each other, resulting in the elimination polymer and a low concentration o growing chains. Chain
o a small molecule (e.g. water). However, hydrogels are gener- polymerization is characterized by three distinct stages: initia-
ally ormed through chain growth (addition) polymerization. tion, propagation and termination.
Be ore entering into the intricacies o polymerization it is
important to establish that, in order to make a contact lens mate- Initiation. A hydrogel monomer mixture usually contains
rial, the ollowing three basic ‘ingredients’ are required in the an initiator. T is is a chemical whose role is to start o the
monomer ‘mix’: (1) the monomer(s), (2) a cross-linking agent polymerization process. Initiators readily ragment into ree
and (3) an initiator. In some cases a solvent is also added to the radicals (a highly chemically reactive atom, molecule or molecular
ragment with a ree or unpaired electron) when activated by heat
or some other orm o radiation (e.g. ultraviolet light).
T e type o initiator used will depend on the manu actur-
ing method. For example, a thermal initiator would usually be
required in the manu acture o buttons or rods that will eventu-
ally orm lathed lenses and a photo initiator would usually be
required or spun-cast and cast-moulded lenses.
Fig . 4.6 Rand om cop olyme r.
T e ragmentation o the initiator is schematically repre-
sented by the ollowing equation, where I represents the initia-
tor molecule and I• represents a ree radical.
I− I 2I
T e ree radicals ormed are then able to combine with the
monomer (M), resulting in a ree radical o the monomer (this
is why the polymerization o hydrogels is sometimes re erred to
as ree radical polymerization):
I• + M →IM•  

Propagation. T e monomer radical, which is a transient

compound, is now able to combine with another monomer unit,
resulting in another new compound:
IM• + M →IMM•
Fig . 4.7 Gra t cop olyme r.
By the continuation o this process, the polymer chain is propa-
gated. T e resultant chain may consist o thousands o mono-
mer units:
IMn • + M →IM• (n + 1) 

Termination. Polymerization does not usually continue until

all o the monomer has been used up because the ree radicals
involved are so reactive that they inevitably nd a variety o ways
o losing their reactivity. Polymerization can be terminated in
two main ways. T e rst method is recombination. T is occurs
when two growing molecules containing ree radicals meet,
share their unpaired electrons and so orm a stable covalent
Fig . 4.8 Sche matic re p re se ntation o macromole cular ord e r showing bond, thereby extinguishing their reactivity. T e second
an amorp hous p olyme r (le t) and a crystalline p olyme r (rig ht). (Re - method o termination is known as disproportionation. T is
d rawn rom Kastl, P. R., Re ojo, M. F. & Dab e zie s, O . H. (1984) Re vie w
o p olyme rization or the contact le ns f tte r. In O . H. Dab e zie s (Ed .) The occurs when two radicals interact via hydrogen abstraction,
CLAO Guid e to Basic Scie nce and Clinical Scie nce . O rland o: Grune & leading to the ormation o two reaction products, one o which
Stratton Inc.) is saturated and one o which is unsaturated.
48 PART 2 So ft Co nt act Le nse s

T e conditions under which polymerization take place

MECHANICAL PRO PERTIES
become important when one considers that so contact lenses
are currently made using three main methods o manu acture: T e mechanical properties o hydrogel contact lenses are unda-
lathing, spin casting and cast moulding; however, cast mould- mentally important because they are directly related to actors
ing is by ar the most commonly used method. Lenses made such as the com ort, visual per ormance, tting characteristics,
by these di erent methods o manu acture will undergo very physiological impact, durability and handleability o the lenses.
di erent polymerization conditions that are likely to have an In the hydrated state most hydrogels are so and exible.
e ect on the resultant material. How a material is processed is When they are allowed to dehydrate they become hard and
likely to a ect almost every aspect o a lens, rom its clinical per- brittle. Lower-water-content polymers tend to become more
ormance to its physical and chemical properties (Maldonado- hard and brittle than higher-water-content materials. Hydrogels
Codina and E ron, 2004).  take up water because they are hydrophilic; that is, hydrogels
swell in water (as well as many other liquids), which causes
Pro p e rt ie s o Hyd ro g e l Mat e rials them to become so with elastic properties (the water acts as
a plasticizer).
T e ocular environment places signi cant demands on the per- Unlike per ectly elastic materials, which de orm under stress
ormance o hydrogels as biomaterials. T ese materials must: but return to their original size and shape when the stress is
• maintain a stable, continuous tear lm released, hydrogels are viscoelastic. T is means that they de orm
• be permeable to oxygen in order to maintain normal cor- time-dependently when a stress is applied to them and recover
neal metabolism time-dependently when the stress is removed. T eoretically,
• be permeable to ions in order to maintain on-eye move- this can result in permanent de ormation o the material.
ment One o the main dif culties in characterizing the mechanical
• be com ortable properties o a contact lens is that there is no single property
• provide clear, stable vision measurement that will accurately re ect its ‘in-use’ situation.
• be durable or the li etime o the lens. raditional material mechanical testing involves applying a
T ese essential properties are expanded upon below. de orming orce (the ‘stress’) to a sample and observing the way
that the sample responds (the ‘strain’).
O PTICAL TRANSPARENCY Stress can be compression, tensile or shear. Compression is a
stress that acts to shorten an object. ension is a stress that acts
A hydrogel to be used as a contact lens material needs to be to lengthen an object. Shear is a stress that acts parallel to a sur-
transparent in order to achieve maximal visual per ormance. ace. Strain is de ned as the amount o de ormation an object
T e light transmittance o polymers includes the descrip- undergoes compared with its original size and shape. When a
tion o materials as being transparent, translucent or opaque. tensile stress is applied to a material, the stress gradually builds
ransparent polymers are those that you can see through, up until the specimen breaks ( ractures).
translucent polymers are those that you cannot see through A generalized stress–strain curve is shown in Fig. 4.9 and
but allow light to pass through, and opaque polymers are provides several mechanical characteristics o the material
those that you can neither see through nor allow light to pass under test. T e strength o a material is de ned as the orce
through. Usually the optical clarity o contact lens materials per cross-sectional unit area required to cause ailure when the
is expressed as the percentage o transmission o the visible
electromagnetic spectrum. Hydrogels that are use ul as con-
tact lens materials transmit over 90% o light in the visible
part o the spectrum.
When a hydrogel loses its transparency it is likely to be due to
microphase separation o water. T is is due to regions o di er-
ing re ractive index being ormed within the gel. Hydrogels that
show this type o behaviour (typically synthesized by making
copolymers with large blocks or segments o hydrophobic and
hydrophilic monomers rather than randomly dispersing them)
do have advantages in terms o enhanced strength and perme-
ability per ormance.
I the phase separation is limited (e.g. the phase size is
shorter than the wavelength o light), transparent materi-
als can still be obtained. Some hydrogels are known to lose
their transparency when heated and this is an important con-
sideration as there is an increase in temperature rom lens
packaging to eye and, additionally, some patients still ther-
mally disin ect their lenses, although this practice is seldom
employed today.
rying to combine hydrophilic hydrogel monomers and
hydrophobic silicone-based monomers into transparent hydro- Fig . 4.9 Typ ical te nsile stre ss–strain curve or a the ore tical mate rial.
Point A on the g rap h re p re se nts the e long ation at b re ak, p oint B re p -
gels has been a major technical dif culty in the development o re se nts the ultimate stre ng th and p oint C re p re se nts the yie ld p oint o
success ul silicone hydrogel materials. ighe (2004) likens this the mate rial. A typ ical so t le ns hyd rog e l d oe s not d e monstrate a yie ld ;
technical challenge to trying to mix oil with water.  inste ad , it would b re ak at p oint C on the g rap h.
 4 So ft Le ns Mat e rials 49

sample is subjected to a particular type o stress. Some materi- Several actors can a ect the mechanical properties o a
als will go through a yield point, which is de ned as the stress hydrogel material and these can be broadly divided into: (1)
at which a material begins to de orm plastically. Contact lens material composition actors and (2) polymer-processing ac-
hydrogels typically do not demonstrate a yield point. Young’s tors. Examples o material composition actors include changing
modulus (E), or the elastic modulus, is determined by the initial the comonomers used in the hydrogel preparation. I the hydro-
slope o the stress–strain curve and is, there ore, a constant (i.e. gel is not a homopolymer, then increasing the relative amount
it is the stress divided by the strain). Young’s modulus and the o physically stronger component(s) will lead to an increase in
thickness o the material (t) are related together in determining the nal mechanical strength o the material. T is may have the
the sti ness o a lens. Just as Dk / t indicates the relative trans- e ect o altering the mechanical strength by increasing the sti -
missibility o di erent lenses, so the sti ness actor multiplied ness o the backbone polymer, or example by replacing acry-
by the thickness (E × t) indicates the relative resistance to de or- lates with methacrylates, or it may alter the hydrophilicity o the
mation o the lens. polymer by replacing hydroxyethyl methacrylate (HEMA) with
It is important to note that several di erent moduli can be methacrylic acid (MAA). In general, as the equilibrium water
measured, but Young’s modulus is the one that is most com- content (EWC) o a hydrogel increases, its modulus decreases.
monly re erred to in association with contact lenses. T e elon- Another important material composition actor is that the
gation at break o the material, also re erred to as the strain, is mechanical properties o a hydrogel are dependent on the cross-
the raction o its original length that a material stretches when link density in the system. Cross-links act as anchors or physi-
placed under a load. It is a measure o how much the material cal links and prevent the polymer chains rom slipping past
can de orm be ore breakage. Strain is dimensionless (i.e. it has each other. In general, the strength o a hydrogel increases with
no units attached to it). increasing cross-link density, particularly when in the swollen
A point o potential con usion in the literature is the lack o state, where physical entanglements are low.
standardization o the units used or measuring stress. Stress is Cross-link density can be increased by the addition o larger
de ned as orce per unit area. T e Système Internationale (SI) amounts o cross-linking agent. Although increasing the cross-
unit o stress is N / m 2 (newtons per square metre). One newton link density within a hydrogel network is bene cial in relation
is the orce required to give a mass o 1 kg an acceleration o to its mechanical properties, it must also be considered that
1 m s−2. A newton spread out over a square metre is a pretty changes to other properties o the polymer will occur. T e swell-
eeble orce, so MN / m 2 (mega newtons per square metre or 106 ing capacity o the hydrogel is likely to be reduced with increas-
N / m 2) is a more use ul unit. ing cross-link density, and hence, its oxygen permeability will
T e pascal is also seen in the literature with re erence to also be reduced, which is undesirable in a contact lens material.
stress. T e pascal is actually the SI unit o pressure. T e units A balance o all the properties o a polymer is critical to its end
o pressure are de ned in the same way as those or stress: application.
orce / unit area. One pascal is the pressure generated by a Polymer-processing actors that can a ect the mechanical
orce o 1 N acting on an area o 1 m 2 (1 Pa = 1 N / m 2). Mega properties o a hydrogel essentially re er to the act that hydrogel
newtons / m 2 and mega pascals, there ore, have numerically materials are highly sensitive to the processing and abrication
equal values. conditions to which they are subjected. Lenses made by di er-
In US customary units, stress is expressed in pounds- orce ent methods o manu acture will undergo very di erent mate-
per square inch (psi). T e conversion actor is as ollows: rial processing, particularly polymerization. T ese di erent
1 MPa = 145.0377 psi material-processing steps may have an e ect on the mechani-
cal properties o the resultant lens. For example, lathed lenses
T e strength o a hydrogel gives some indication o the are ormed rom solid buttons o dehydrated material and these
behaviour o the material during handling, whilst the modulus buttons are usually bulk-polymerized over relatively long peri-
indicates the extent to which the eyelid will de orm it and has ods compared with a cast-moulded lens. T ermal initiators are
an impact on the tting characteristics o the lens in addition to o en used in button production, which have low activation
its com ort. Rigid lens materials have a relatively high modulus energies, allowing water baths or ovens to be set to relatively low
(in the region o 103 MPa), whereas so lens materials have a temperatures. T is type o polymerization is likely to lead to a
much lower value when in the hydrated state (in the region o polymer structure consisting o longer chains (higher molecular
0.2–1.5 MPa). weights) and there ore more chains.
Since the introduction o silicone hydrogels in the late 1990s In the cast-moulding process a small amount o monomer is
there has been renewed interest in the concept o ‘modulus’ as placed between two casts to orm the lens directly. T e polym-
an important so lens physical property. T ese lenses (particu- erization process is typically very ast, which is one o the rea-
larly the early ‘sti er’ rst-generation silicone hydrogel lenses) sons why this is the method o choice or bulk (disposable) lens
generally have a higher tensile modulus than do hydrogels. T e manu acture. Rapid polymerization times are likely to produce
higher moduli o these materials have certain clinical implica- shorter chains, more chain ends and less ef cient cross-links. 
tions, which are discussed in more detail in the silicone hydro-
gel materials section o this chapter. SURFACE PRO PERTIES
T e generally poor mechanical strength (including tear
strength) o so lenses is arguably the main reason why they T e sur ace characteristics o a hydrogel lens will directly a ect
have relatively short li etimes. T is problem has been somewhat its interactions with the tear lm and consequently its biocom-
overcome by the introduction o disposable lenses, which essen- patibility in the ocular environment. ‘Wettability’ is used to
tially means that the majority o so lenses no longer need to describe the tendency or a liquid to spread on to a solid sur-
last more than a day, 2 weeks or a month, depending on their ace, and in vivo wettability in a contact lens context implies
intended replacement schedule. the ability o the tear lm to spread and maintain itsel over a
50 PART 2 So ft Co nt act Le nse s

contact lens sur ace. In vivo wettability is a key measure o clini- Fig. 4.11 shows the contact angles o two contact lenses.
cal per ormance because the success o any contact lens is con- Note that the contact angle o lens B is considerably larger than
sidered to be related to its ability to support a stable tear layer that o lens A. However, it is important to bear in mind that the
in the eye. General clinical consensus is that ailure to meet this wettability o a given sur ace depends on a number o actors,
requirement is likely to result in a lens that is uncom ortable, including the sur ace tension o the test liquid and, as such, it is
has reduced visual per ormance and orms deposits rapidly. T e a property o a liquid–solid combination rather than o the solid
quality o the pre-lens tear lm will also have an e ect on the sur ace alone.
riction between the eyelid and the lens sur ace. T is in turn T e most commonly used techniques applied to contact
is thought to be important in the aetiology o physiological lenses include sessile drop and captive bubble methods. In the
responses such as contact-lens-related papillary conjunctivitis sessile drop technique a drop o liquid (usually water) is applied
(CLPC) and lid wiper epitheliopathy (LWE). T e issue o wetta- to a dry or drying hydrogel lens sur ace in air (see Fig. 4.11). In
bility has received considerable attention since the introduction the captive bubble technique, the hydrogel lens is submerged in
o silicone hydrogel materials at the turn o the century, in view liquid (usually water, saline or arti cial tears) and a bubble o
o the potentially poor wettability o lenses manu actured rom air is applied to the lens sur ace. T e contact angles obtained or
this material. a lens–liquid combination are highly methodologically depen-
In vivo wettability is generally assessed with a range o rela- dent (Maldonado-Codina and Morgan, 2007) and any report-
tively crude clinical tests that have been used or several decades. ing o contact angles should include the experimental details
T ese include tear lm break-up time (with or without the pres- such as the method itsel , the probe liquid and prior treatment
ence o uorescein), inter erometry and various techniques o the material under test.
based around specular re ection. Un ortunately, these methods T e sessile drop and the captive bubble techniques give dis-
requently ail to di erentiate adequately between lens sur ace crepant results or a given sample because a di erent type o
types, even when relatively di erent lens sur aces are evaluated. contact angle is measured in each technique: an advancing-type
On the other hand, laboratory measures o wettability are contact angle is measured in the sessile drop technique and a
well established and are o en better at di erentiating lens sur-
aces. Wettability in relation to contact lenses has traditionally
been assessed in vitro using contact angle analysis. When a drop
o liquid is placed on a solid sur ace, an angle is ormed at the
solid–liquid–air inter ace (Fig. 4.10). T is angle is re erred to as
the contact angle.
Contact angles can be equilibrium, advancing or receding.
T e advancing contact angle is the angle ormed when a liq-
uid is advanced over an unwetted sur ace. T e receding contact
angle is the angle ormed when a liquid is withdrawn over a
previously wetted sur ace. T ere is usually a di erence between
the advancing and receding contact angles (the advancing angle
is usually the larger one) or hydrogel materials and this di -
erence is re erred to as the ‘hysteresis’. Essentially, the smaller
the contact angle, the better the liquid spreads over the solid
sur ace and the more wettable is the solid sur ace. It is, however,
important to bear in mind that the relationship between these
laboratory measurements and the clinical per ormance o the
lenses is not ully understood.

Fig . 4.10 Sche matic re p re se ntation o the se ssile d rop te chniq ue Fig . 4.11 Se ssile d rop contact ang le imag e s o a contact le ns with
showing the contact ang le (θ) me asure d whe n a d rop is p lace d on a a g ood we tting sur ace (A) and a p oor we tting sur ace (B). Note the
solid sur ace . larg e r contact ang le or le ns with the p oor we tting sur ace .
 4 So ft Le ns Mat e rials 51

receding-type contact angle is measured in the captive bubble T e sur ace EWC o a contact lens can be measured using a
technique. Additionally, both o these techniques can be used so contact lens re ractometer (E ron and Brennan, 1987). T is
to assess the hysteresis o a given material; that is, advancing is a hand-held instrument that can be readily used in the clinical
and receding angles respectively can be obtained using the ses- setting. It utilizes the inverse relationship between the re ractive
sile drop technique alone or the captive bubble technique alone index and EWC o hydrogel materials. T e measured re rac-
(Read et al., 2011). tive index o a contact lens is converted to percentage water in
T e receding contact angle obtained in vitro is especially sucrose using the Brix scale. T is approach does, however, have
relevant when considering the per ormance o a contact lens limitations in that it assumes that dehydrated hydrogels all have
in vivo. T e advancing angle corresponds more to the establish- the same re ractive index (i.e. that o dry sucrose). However, this
ment o the tear lm, which is assisted mechanically by the eye- assumption is not strictly true and the di erence in re ractive
lid. Conversely, the receding angle is thought to be important in index o a particular hydrogel material and sucrose will lead
the stability o the tear lm between blinks. to the di erence between Brix measures and manu acturer-
Another aspect o the lens sur ace that has important clini- reported water contents.
cal implications is its rictional characteristics. Friction is de ned Dif culties are also encountered with this instrument when
as the resistance that a solid sur ace encounters when it moves attempting to measure the EWC o silicone hydrogel lenses.
over another. In doing so, these solid sur aces can undergo ‘wear T ese lenses have a lower re ractive index compared with hydro-
and tear’ which can be reduced i there is suf cient lubrication gels and their EWC is overestimated with the so contact lens
between the sur aces. In the eye, the tear lm acts as such a lubri- re ractometer. Additionally, since it is sur ace EWC that is being
cant between the eyelid margin conjunctiva and the ocular sur- measured with this instrument, it is unknown what e ect the
ace. T e area o the eyelid margin conjunctiva that ‘rubs’ over the sur ace coatings on some o these lenses have on the nal result.
ocular sur ace has been termed the ‘lid wiper’ (Korb et al., 2002). British and International Organization or Standardization
When a contact lens is in situ, the ‘lid wiper’ ‘rubs’ over the (ISO) standards speci y both thermogravimetric and re ractive
lens sur ace many thousands o times during a wearing day and index methods as valid techniques or measuring the EWC o
it is thought that this interaction is highly important in govern- a hydrogel lens (BSI, 2006a). T e thermogravimetric method
ing the com ort o a lens – particularly its end-o -day com ort involves measuring the weight o a lens in the hydrated state and
(Coles and Brennan, 2012). T e rictional characteristics o a then remeasuring the lens in the completely dehydrated state.
lens sur ace are a unction o not only the lens material chem- T e disadvantages o this method are that it is time consuming
istry but also o how that sur ace interacts with the ocular envi- and destroys the lens. 
ronment. Dehydration, spoilation, poor tear lm characteristics
and irregularities o the ocular sur ace can all lead to increased
O XYGEN PERMEABILITY
riction between the lens and the eyelid margin during wear.
T ese rictional properties are an important consideration in Since the cornea receives most o its oxygen rom the atmo-
the overall design o a contact lens. sphere, the oxygen transmissibility pro le o a contact lens is
Coef cient o riction (CoF) laboratory measurements have one o its most important properties. Oxygen permeability is a
now become commonplace or contact lens materials. T e CoF property o the material itsel and is described as the Dk, where
is the ratio o the orce needed to initiate or sustain sliding to the D is the di usivity o the material and k is the solubility o the
normal orce holding the two sur aces together and in the labo- material. T e di usivity is a measure o how quickly oxygen can
ratory some kind o lubricant would be required. As with many move through a material, whilst the solubility is a measure o
other laboratory set-ups, it is very dif cult to simulate on-eye how much oxygen the material can hold. Oxygen permeability
conditions and this is primarily why di erent CoF results have o a hydrogel will vary with temperature.
been obtained by di erent research groups carrying out these Oxygen permeability is governed by the EWC in hydro-
experiments (Ross et al., 2005; Roba et al., 2011).  gels. T is relationship is based on the ability o oxygen to pass
through the water rather than through the material itsel . T e
WATER CO NTENT relationship between the EWC and oxygen permeability has
been ound to be (Morgan and E ron, 1998):
T e EWC o a hydrogel lens is de ned as: Dk = 1.67e0.0397EWC
weight of water in polymer where e is the natural logarithm (Fig. 4.12).
EWC = × 100
total weight of hydrated polymer In order to calculate the amount o oxygen that will move
rom the anterior to the posterior sur ace o a lens, the oxygen
T e EWC o a hydrogel may vary depending on the environ- permeability (Dk) is divided by the thickness o the lens (t). T e
mental conditions. For example, pH, tonicity and temperature units o Dk have been traditionally known as Fatt units (a er
may alter the EWC o a hydrogel. Increased temperature is an Pro essor Irving Fatt, who carried out much o the early work
important consideration because there is a signi cant increase on oxygen permeability o contact lens materials) or Barrer,
in temperature when a contact lens is taken rom its packag- whereby:
ing solution (normally at room temperature) and placed on the − 11
( 2 )
eye. Most contact lens hydrogels will undergo a small change in Dk (Barrer) = 10 cm × mlO2 / (s × ml × mmHg)
EWC when placed in solutions o di erent pH and osmolality, Dk/t (Barrer/cm) = 10− 9 (cm × mlO2 ) / (s × ml × mmHg)
but these changes will be most pronounced in ionic materials.
T e oxygen and ion permeability o a contact lens material However, the SI unit or pressure is the pascal (Pa). Because
are intimately associated with its EWC. T is is discussed in the unit mmHg is now becoming obsolete internationally,
more detail in the ollowing sections. it is being advocated that the closest accepted metric unit o
52 PART 2 So ft Co nt act Le nse s

Fig . 4.12 Re lationship b e twe e n Dk and e q uilib rium wate r conte nt or conve ntional hyd rog e l and silicone hyd rog e l le nse s.

pressure – 100 Pa, or hectopascal (hPa) – should replace mmHg alling within 1.46–1.48 at 20% water content and 1.37–1.38 at
(BSI, 2006b). T e new units are re erred to as ‘Dk units’ in this 75% water content – that is, the re ractive index decreases with
latest British and international standard. When hPa is used, Dk increasing water content. Because o this relationship, it is pos-
and Dk / t values are quoted as below: sible to calculate the re ractive index o a hydrogel i its EWC is
− 11
( 2 ) known (and vice versa), which is the basis or the use o the so
Dk in 'Dk units' = 10 cm × mlO2 / (s × ml × hPa) contact lens re ractometer, as discussed above. T is relationship
(Dk/t) in 'Dk/t units' = 10− 9 (cm × mlO2 ) / (s × ml × hPa) is well established or hydrogel lenses but not or silicone hydro-
gel lenses.
T e dif culty here is that converting rom the traditional Barrer It is unlikely that a relationship between the re ractive index
or Fatt units to ISO units involves multiplying Dk or Dk / t by the and the water content will hold or all silicone hydrogel lenses
constant 0.75006. T us, or example, a lens quoted with a tradi- on the market as many are based on completely di erent mate-
tional Dk / t o 40 units will have a revised ISO Dk / t o 30 units. rial chemistries. British and ISO standards recommend the use
It is understandable that such a ‘downsizing’ will be resisted by o an Abbé re ractometer to measure the re ractive index o a
contact lens manu acturers, because higher numeric Dk / t are hydrogel contact lens (BSI, 2006a). However, other more auto-
perceived clinically as being ‘superior’.  mated instruments have been used or the assessment o hydro-
gel lens re ractive index (Nichols and Berntsen, 2003; Lira et al.,
2008). 
FLUID AND IO N PERMEABILITY
T e development o silicone hydrogel materials has highlighted SWELL FACTO R AND DIMENSIO NAL STABILITY
the importance o the so-called hydraulic permeability or water
transport o a contact lens material. Essentially, a minimum T e dimensional stability o a hydrogel lens re ers to its ability
level o hydraulic (as well as ionic) permeability is necessary in to maintain its original dimensions under various conditions.
order to maintain adequate lens movement. T is is important in It is dependent on any actor that will change the water content
allowing the post-lens tear lm to re- orm between blinks, thus or swelling behaviour o the hydrogel. Factors that in uence the
reducing the likelihood o these quite elastic lenses rom bind- swell actor include temperature, pH and tonicity. T e swelling
ing to the cornea. Water is able to move through a hydrogel in behaviour is particularly important during the manu acture o
quite a di erent way to sodium ions; that is, it is more dif cult contact lenses in the dry state (e.g. when a so contact lens is
or sodium ions to travel through the gel as in order to do so lathed). During the lathing process a smaller, steeper lens o
they must be accompanied by a shell o water ( ighe, 2004). In greater power is made so that, when it is hydrated, it swells to
the eye, the sodium ion permeability o contact lens materials the required dimensions and power required. It is vital, there-
is particularly important as it is a major constituent o the tear ore, that the swell actors o the material are accurately known.
lm. Sodium ion transport is impeded in gels with water con- T e swell actor is described by the ollowing relationship:
tent below 20%.  Swell factor (SF) = wet dimension/dry dimension
Initially it was thought that a hydrogel material swelled isotropi-
REFRACTIVE INDEX
cally – that is, the same in all directions. With time it was ound,
Ideally hydrogels abricated or contact lens materials should however, that the consistently anomalous swelling behaviour
have a re ractive index similar to that o the cornea (i.e. near o hydrogels could be explained only by speci ying two swell
to 1.37). T e variation o re ractive index with EWC in hydro- actors. T ese swell actors are those in the diameter and axial
gels is almost linear, with most hydrogel re ractive indices (thickness) directions. From these, the value o the radial swell
 4 So ft Le ns Mat e rials 53

actor o a contact lens can be calculated using the ollowing

equation:
2
SFrad = (SFdia ) /SFax
where SFrad is the radial swell actor, SFdia is the diametral swell
actor and SFax is the axial swell actor. 

So t Le ns Mat e rials
So lens materials can be conveniently divided into two main
groups: (1) hydrogel materials (now sometimes re erred to as
low-Dk materials) and (2) silicone hydrogel materials (high-Dk
materials).

HYDRO GEL MATERIALS

Hydrogel lenses were developed as a result o the extraordinary
pioneering e orts o Pro essor Otto Wichterle and Dr Draho-
slav Lim o the Institute o Macromolecular Chemistry o the
Czechoslovak Academy o Sciences in Prague in the mid 1950s.
Wichterle and Lim were working on the synthesis o a new
material that they hoped could be used or implantation into the
human body. T at material was poly(hydroxyethyl methacry-
late) or pHEMA (Wichterle and Lim, 1960). T ey soon realized
that the material had potential applications in the manu acture
o contact lenses, but were prevented rom researching such a
project by the directors o the institute, who perceived this work
as being a petty distraction rom undamental studies in chem-
istry. Wichterle was eventually orced to carry out his contact
lens experiments at home and, despite such dif cult circum-
stances, he success ully managed to produce the rst spun-cast
lens (made rom his son’s toy construction set) in 1961 (Wich-
terle and Lim, 1961). T e enormity o his breakthrough or the
contact lens industry cannot be understated.
pHEMA is made by polymerizing 2-hydroxyethyl meth-
acrylate monomer with a cross-linker such as ethylene glycol
dimethacrylate (EGDMA) (Fig. 4.13). Most o the hydrophilic
behaviour o HEMA is due to the presence o the hydroxyl group Fig . 4.13 Some o the monome rs use d in hyd rog e l le ns mate ri-
(OH) at the end o the monomer. At this location in the resul- als. HEMA = hyd roxye thyl me thacrylate ; NVP = N-vinyl p yrrolid one ;
tant polymer hydrogen bonding with water molecules occurs, MMA = me thyl me thacrylate ; MAA = me thacrylic acid ; EGDMA = e thyl-
causing them to be drawn into the polymer matrix. T e result is e ne g lycol d ime thacrylate ; GMA = g lyce ryl me thacrylate ; DMA = N,N-
d ime thyl acrylamid e .
that contact lenses made rom pHEMA contain approximately
40% water in the ully hydrated state.
Lenses abricated rom pHEMA were rst distributed in In hydrogel materials, oxygen is transported through the
western Europe in 1962, but sales were disappointing. In 1965, water channels in the lens, and not the polymer itsel . Con-
the National Patent Development Corporation bought the tact lens manu acturers, there ore, had two possible avenues
licence or the American rights to the technology rom the to ollow to increase the oxygen transmissibility o lenses:
Czechs. T is was subsequently sold on to Bausch & Lomb, develop ‘hyperthin’ lenses, or develop materials with higher
which at that time manu actured ophthalmic equipment and water content. Producing lenses that were thinner was a rela-
spectacle lenses. Bausch & Lomb signi cantly re ned Wich- tively straight orward matter or lens designers and several
terle’s spin-casting process and nally obtained approval rom such lenses were launched, such as the Hydrocurve thin lens
the US Food and Drug Administration (FDA) or its pHEMA (So Lenses) in 1977 and subsequently the O3 series (Bausch &
lenses in 1971. T is time, the lenses became very popular very Lomb). T ese lenses were in the region o 0.035–0.06 mm thick,
quickly – both practitioners and patients enjoyed the bene ts o which was less than hal the thickness o the original Bausch &
increased com ort, reduced adaptation time and easier tting Lomb pHEMA lenses.
procedures compared with rigid corneal lenses, which were the Developing materials with a higher EWC led to the success-
main alternative. With time, more companies developed their ul development o HEMA copolymers. One o the rst suc-
own pHEMA lenses; however, it soon became clear that these cess ul copolymerizations was with N-vinyl pyrrolidone (NVP)
lenses were not problem ree. Most o these problems stemmed (see Fig. 4.13). T e amide (N—C=O) moiety is very polar and
rom the act that the lenses caused hypoxia, but other compli- two molecules o water can become hydrogen-bonded to it.
cations relating to solution toxicity and lens spoliation were also NVP-based copolymers lose the slippery eel o pHEMA and
common. consequently can eel quite rubbery. T ese copolymers also
54 PART 2 So ft Co nt act Le nse s

tend to have relatively high evaporation rates o water, which Glyceryl methacrylate (GMA) is more hydrophilic than
may be seen as a problem or lens stability and com ort. T is HEMA owing to the act that the monomer contains two
occurs because the amide group does not bind water as strongly hydroxyl groups (see Fig. 4.13). T is monomer has been used
as a hydroxyl group. In addition, these polymers are also signi - in contact lens materials in two main ways. T e rst method
cantly more temperature sensitive than pHEMA-based materi- has used GMA in combination with MMA to produce mate-
als; that is, their parameters tend to change with increasing or rials that have water contents in the range o 30–42%. T ese
decreasing temperature. T is is important when tting a lens as materials are thought to be sti er and stronger than pHEMA
its parameters may change on-eye. hydrogels, but their oxygen permeabilities are not ideal or in-
NVP-based lenses have also been associated with increased eye use.
corneal staining (solution-induced corneal staining or ‘SICS’) T e second method has been to use GMA in combination
and decreased com ort when used in conjunction with solutions with HEMA to produce a high-water non-ionic contact lens
containing higher levels o polyhexanide (Jones et al., 1997, materials (up to approximately 70% has been possible). T ese
2002). T is does not mean that polyhexanide-based solutions contact lenses are said to be ‘biomimetic’ – that is, they are
cannot be used with NVP-containing lenses, but rather that the claimed to improve biocompatibility by imitating the hydro-
interaction should be borne in mind and, i any signi cant cor- philic properties o mucin. Manu acturers also suggest that
neal-staining or discom ort symptoms arise these can usually these lenses show a low rate o dehydration and a rapid rate o
be treated simply by changing the solution to one containing a rehydration (i.e. they have good ‘water balance ratios’). In addi-
lower level o polyhexanide or one ree rom polyhexanide. tion, the materials are thought to be relatively deposit-resistant
Most contact lens practitioners are amiliar with methyl meth- and seem to be insensitive to pH changes in the range o pH
acrylate (MMA) as the material rom which ‘hard lenses’ are made 6–10. An example o such a lens is the hioxi lcon A mate-
(i.e. PMMA) (see Fig. 4.13). When MMA and NVP are copoly- rial used in the Clear 1 Day lenses manu actured by Clearlab.
merized, a completely new material is obtained with very di erent Another example o a so-called biomimetic lens is the Proclear
characteristics to the HEMA / NVP (also known as HEMA / VP) lens (Coopervision), which contains phosphoryl choline (PC)
copolymers. Depending on their composition, contact lenses and HEMA. PC is said to mimic the natural chemistry o cell
made rom MMA / VP copolymers can contain 60–85% water. membranes.
MMA is very hydrophobic, but is use ul in so lens hydrogels In the early 1970s an English optometrist, John de Carle,
as it gives the resultant polymers increased mechanical strength. proposed that i the EWC o hydrogel lenses could be suf -
Another hydrophilic monomer that has been very success- ciently increased then these lenses could be worn success ully
ully used in contact lens hydrogels is MAA (see Fig. 4.13). on an overnight or extended-wear basis. He developed the rst
When added to a so lens polymer ormulation, it results in a extended wear lens to be distributed in the UK, known as Per-
so lens with ionized groups (negatively charged) within the malens (de Carle, 1975). T e lens material had an EWC o 71%
polymer matrix, allowing the lens to absorb more water. T e and was made rom a HEMA / VP / MAA copolymer. In 1981
higher the amount o MAA, the higher is the EWC o the result- the lens was given FDA approval or ‘extended wear’ o up to
ing polymer. Amounts o MAA in the region o 1.5–2.5% will 30 days along with another lens, the Hydrocurve II (Wesley
increase the water content o a HEMA material into the mid- Jessen).
water-content range o 50–60%, thereby allowing oxygen per- Slowly, other lenses were given approval or extended wear
meability to increase signi cantly. Another advantage o these during the 1980s, but along with the increase in demand or
ionic lenses is that, although they attract large quantities o pro- these lenses came an increase in complications. In 1989 stud-
tein (particularly positively charged lysozyme) (Suwala et al., ies were published showing that the risk o microbial keratitis
2007), a large proportion o these proteins are in their natural, was 5–15 times greater or extended wear than or daily wear
non-denatured orm (Subbaraman et al., 2006; Suwala et al., (Poggio et al., 1989; Schein et al., 1989). As a result, the FDA
2007; Subbaraman and Jones, 2010), which is thought to be recommended that extended wear be limited to six consecutive
bene cial in terms o contact-lens-related complications such nights and, with that, the enthusiasm or extended wear died
as contact lens papillary conjunctivitis and, very importantly, in down to some extent until the emergence o silicone hydrogel
terms o their antimicrobial action (Brennan and Coles, 2008). lenses in the late 1990s.
Un ortunately, using MAA to increase the water content o a able 4.1 lists some o the most common hydrogel lenses on
polymer also has its disadvantages. T ese include: the market and groups them into their appropriate FDA classi -
• A lens that is extremely sensitive to changes in tonic- cation (see Appendix 4.1, below, or details on the classi cation
ity (McCarey and Wilson, 1982): the Na+ ions present in o hydrogels).
saline solution have the e ect o ‘shielding’ the carboxyl- Most o the work that has been carried out on ‘improving’
ate anions. In hypotonic solutions (e.g. pure water), since hydrogel lenses has been channeled towards developing them
these shielding ions are present to a ar lesser degree, more into disposable lenses and especially into daily disposable
chain repulsion will occur, which increases the swelling o lenses. In order to achieve this, manu acturers have invested in
the network and consequently the EWC o the material. In more sophisticated automated manu acturing technologies to
hypertonic solutions, the reverse situation occurs and the meet demand and make their production economically viable.
material network shrinks, causing its EWC to decrease. T is has been no easy task and it should be emphasized just how
• A pH-sensitive lens (McKenney, 1990): i the pH o the so- important these hydrogel materials still are to the contact lens
lution in which the lens is immersed is decreased (i.e. the industry today.
hydrogen ion concentration is increased), the carboxylate Additionally, ‘enhanced’ daily disposable lenses have been
anions are more shielded and the network becomes less introduced onto the market, such as 1-Day Acuvue Moist (John-
expanded. T is will cause a decrease in the lens EWC. son & Johnson), Dailies AquaCom ort Plus (Alcon) and So Lens
• Dimensional instability when the lens is heat disin ected. daily disposable (Bausch & Lomb). T ese lenses utilize techniques
 4 So ft Le ns Mat e rials 55

TABLE
4.1 Se le ct e d Hyd ro g e l Le nse s
Name Manufact ure r / Sup p lie r Princip al Co mp o ne nt s EWC (%) USAN No me nclat ure
FDA GRO UP 1 (< 50% EWC < 0.2% IO NIC CO NTENT)
Biome d ics 38 Coop e rvision HEMA 38 Polymacon
Durawave UltraVision CLPL HEMA, GMA 49 Hioxi lcon B
Me nicon So t Me nicon HEMA, VA, PMA 30 Ma lcon A
O p tima Toric Bausch & Lomb HEMA / VP 45 He lcon B
Sauf on 38 Sauf on HEMA 38 Polymacon
So Le ns 38 Bausch & Lomb HEMA 38 Polymacon
FDA GRO UP II ( >50% EWC < 0.2% IO NIC CO NTENT)
Biotrue O ne d ay Bausch & Lomb HEMA, VP 78 Ne so lcon A
Dailie s Aq uaCom ort Plus Alcon PVA 69 Ne lcon A
Focus Dailie s All Day Com ort Alcon PVA 69 Ne lcon A
O mnif e x Coop e rvision MMA, VP 70 Lid o lcon-A
Procle ar Coop e rvision HEMA, PC 62 O ma lcon B
Sauf on-55 Sauf on HEMA, VP 55 N/A
So Le ns d aily d isp osab le Bausch & Lomb HEMA, VP 59 Hila lcon B
UltraWave UltraVision CLPL HEMA, GMA 57 Hioxi lcon A
FDA GRO UP III ( < 50% EWC <0.2% IO NIC CO NTENT)
Accuso t* O p hthalmos HEMA, PVP, MAA 47 Droxi lcon-A
Com ort Fle x* Cap ital Contact Le ns HEMA, BMA, MAA 43 De lta lcon-A
So t Mate II* CIBA Vision HEMA, DAA, MAA 45 Bu lcon-A
FDA GRO UP IV (>50% EWC >0.2% IO NIC CO NTENT)
Acuvue 2 Johnson & Johnson HEMA, MAA 58 Eta lcon A
1-Day Acuvue Moist Johnson & Johnson HEMA, MAA 58 Eta lcon A
Biome d ics 55UV Coop e rVision HEMA, MAA 55 O cu lcon D
Fre shlook ColorBle nd s Alcon HEMA, MAA 55 Phe m lcon A
Fre q ue ncy 55 Coop e rVision HEMA, MAA 55 Me tha lcon A
Pe rmale ns* CIBA Vision HEMA, VP, MAA 71 Pe r lcon-A

*No long e r availab le .

FDA = Food and Drug Ad ministration; EWC = e q uilib rium wate r conte nt; HEMA = 2-hyd roxye thyl me thacrylate ; VP = N-vinyl p yrrolid one ;
MMA = me thyl me thacrylate ; PC = p hosp horylcholine ; GMA = g lyce ryl me thacrylate ; MAA = me thacrylic acid ; VA = vinyl ace tate ; PMA = p olyme thyl
acrylate ; PVA = p olyvinyl alcohol; PVP = p olyvinyl p yrrolid one (i.e . g ra t cop olyme r); BMA = b utyl (p rob ab ly isob utyl) me thacrylate ; DAA = d iac-
e tone , acrylamid e ; USAN = Unite d State s ad op te d name .

o macromolecular entrapment and / or release o hydrophilic into the lens matrix and is not released rom the lens during
sur ace-active polymers at the lens sur ace in order to improve wear. T e PVP is adsorbed on to the pre ormed lens sur ace a er
end-o -day com ort by stabilizing the pre-lens tear lm. manu acture rom solution. T e lens packaging states that the
T e Dailies AquaCom ort Plus lens is manu actured rom lenses are supplied in ‘bu ered saline with povidone’. Povidone
nel lcon A, which consists o a cross-linked unctionalized poly- is another name or PVP. PVP is quite polar and it is likely to be
vinyl alcohol (PVA) macromer with the addition o non- unc- relatively strongly attracted to the eta lcon material, potentially
tionalized PVA (Winterton et al., 2007). T is un unctionalized providing a mechanism or its retention on the lens sur ace. T e
PVA macromer is ree to elute rom the lens into the tear lm persistence o the PVP at the lens sur ace during wear has been
with each blink. T is PVA is thought to emerge rom the lens veri ed by Ross et al. (2007), who have also described the PVP
matrix as ‘strands’ at the lens sur ace, and it is this e ect together as being in a predominantly ‘looped structure’ across the lens
with the e ect o soluble PVA in the tear lm that is re erred to sur ace. T e PVP is thought to reduce the coef cient o riction
as the ‘sur ace modi cation’ o these lenses. T e released PVA o the lens sur ace
may improve lens com ort by decreasing the sur ace tension o T e So Lens daily disposable lens is modi ed by the adsorp-
the tears, or by mimicking mucin, ound naturally in the tear tion o etronic 1107 – a hydrophilic sur ace-active polymer
lm (Mahomed et al., 2004). T e blister packaging also contains composed o ethylene oxide / propylene oxide block copolymer
hydroxypropyl methylcellulose (HPMC), which is a lubricat- – onto the lens sur ace. T e etronic at the sur ace lowers the
ing agent used to improve com ort on lens applications, as well coef cient o riction o the lens, but it has been shown to be pro-
as polyethylene glycol (PEG), which is a hydrophilic wetting gressively lost rom the sur ace during wear (Ross et al., 2007). It
agent with a high af nity or PVA used or enhancing com ort is likely, there ore, that the etronic is held by weak orces at the
throughout the day. lens sur ace, which would explain the lowest in-eye persistence
PVA and polyvinyl pyrrolidone (PVP) are common soluble o three ‘enhanced’ lenses investigated by Ross et al. in 2007. 
polymeric components in com ort drops and arti cial tears
and have a viscous consistency at elevated concentrations and SILICO NE HYDRO GEL MATERIALS
molecular weights, giving them good sur ace spreading char-
acteristics. T e 1-Day Acuvue Moist lens is manu actured rom When Holden and Mertz (1984) de ned the critical oxygen
the eta lcon A polymer (HEMA / MAA) together with the levels in order to avoid corneal oedema or daily and extended
incorporation o small concentrations o low-molecular-weight wear they concluded that 24.1 Barrer / cm was the oxygen trans-
PVP into the ionic material network. Here the PVP is ‘locked’ missibility required or daily wear and 87 Barrer / cm was that
56 PART 2 So ft Co nt act Le nse s

required or overnight wear. T ese values were re-evaluated by and needs to be sur ace treated. Sur ace treatments o silicone
Harvitt and Bonanno (1999), who ound that the minimum elastomer lenses have not been particularly success ul in the
oxygen transmissibility required to avoid anoxia throughout past because Si—O chains have a tendency to rotate very eas-
the entire cornea was 35 Barrer / cm or the open eye and 125 ily and any hydrophilic parts o a newly treated sur ace tend to
Barrer / cm or the closed eye. disappear inside the polymer.
Fig. 4.12 shows the relationship between the EWC and the Dk Silicon, however, has been very success ully incorporated
o hydrogels and silicone hydrogels. From the graph, it is obvi- into rigid lens materials and it was this development that proved
ous that there is an upper limit to how much oxygen permeabil- to be a key milestone in the subsequent development o silicone
ity can be attained simply by increasing the EWC o hydrogel hydrogel materials. T e work o Norman Gaylord at Polycon
materials. A hydrogel with a theoretical EWC o 90% and a cen- Laboratories drove the development o the rst siloxane-based
tral thickness o 0.1 mm would have an oxygen transmissibility rigid lens material that merged the properties o MMA with
in the region o 60 Barrer / cm, which still alls ar short o that the increased oxygen per ormance o silicone rubber (Gaylord,
required to avoid additional overnight corneal oedema. Such a 1974, 1978). T e resultant siloxymethacrylate monomer was
lens would need to be in the region o 0.06 mm thick, which is tris(trimethylsiloxy)-methacryloxy-propylsilane (see Fig. 4.14)
unrealistic rom both a manu acturing and a clinical point o and is more commonly re erred to as RIS.
view (Holden et al., 1986). T e patent literature shows that combining silicone with
I reducing the thickness o lenses made rom hydrogels was hydrogel monomers has been a goal or polymer scientists
not an option or achieving success in extended wear, then poly- since the late 1970s. T e biggest obstacle to this approach, how-
mer scientists had to come up with an altogether new kind o ever, is that silicone is hydrophobic and poorly miscible with
material. T at material was silicone. T e element silicon (Si) is hydrophilic monomers, resulting in opaque, phase-separated
the most abundant element on earth a er oxygen (e.g. in the materials. In order to solve this problem, two main approaches
orm o silicates or oxides such as sand and clay). Silicones are have been utilized ( ighe, 2004). T e rst approach involves
organic compounds o silicon and oxygen. the insertion o polar groups into the section o the RIS mol-
Incorporating silicone into contact lens materials was not ecule, arrowed in Fig. 4.14, in order to aid its miscibility with
a new concept when scientists began trying to produce sili- hydrophilic monomers ( anaka et al., 1979; Künzler and Ozark,
cone hydrogels. Indeed, the rst material to be used in contact 1994).
lenses was silicone dioxide (glass). Additionally, silicone rub- T e second approach is that o utilizing macromers. Mac-
ber (polydimethyl siloxane, PDMS) (Fig. 4.14) has been used romers are large monomers ormed by preassembly o struc-
with limited success as a contact lens material in the orm o tural units that are designed to bestow particular properties
silicone elastomer lenses. T ese lenses have not become popular on the nal polymer ( ighe, 2004). T is is illustrated in Fig.
mainly because o lens-tightening and sur ace wettability prob- 4.15 with an example rom an Alcon patent (Nicolson et al.,
lems (PDMS is extremely hydrophobic) (Josephson and Ca ery, 1996) that contains poly( uoroethylene oxide) segments and
1987). PDMS has an oxygen permeability in the region o 600 oxygen-permeable polysiloxane units. Fig. 4.12 demonstrates
Barrer but is unwettable by tears, deposits high degrees o lipid the relationship between Dk and EWC or silicone-containing

Fig . 4.14 Silicone -b ase d mate rials. PDMS = p olyd ime thyl siloxane ; TRIS = tris(trime thylsiloxy)-me thacryloxy-p rop ylsilane ; TPVC = carb amate -
sub stitute d TRIS.
 4 So ft Le ns Mat e rials 57

hydrogels based on RIS, highlighting the bene ts o increased T e design o a lens, and in particular the edges, may also
oxygen per ormance. have an impact on ocular compatibility. It has been suggested
T e rst two silicone hydrogels were launched in the late that the design o the lens edge in conjunction with the mechan-
1990s – the PureVision lens (Bausch & Lomb) and the Air Optix ical properties o silicone hydrogel lenses may be responsible
Night and Day lens (Alcon) and are now commonly re erred to or increased conjunctival staining and conjunctival epithelial
as ‘ rst-generation’ silicone hydrogels. Both were licensed or 30 aps observed with these lenses (Lo strom and Kruse, 2005).
days o continuous wear ( able 4.2). T e exact compositions o A kni e-point edge or chisel-shaped edge may cause more con-
these materials are proprietary, but the USAN-registered com- junctival staining and ap ormation than a round edge by
ponents o the bala lcon A material show that it is based on ‘carving’ into the conjunctival tissue (Back, 2007). It has been
a carbamate-substituted RIS-based material known as PVC proposed that certain edge designs incorporating localized
(see Fig. 4.14). T e PVC is then copolymerized with NVP to increases in posterior edge li , reduced peripheral thickness or
orm the bala lcon material. peripheral channels may reduce the pressure on the conjunctiva
T e Air Optix Night and Day lens (lotra lcon A) ( able 4.2) (Back, 2007). However, more recent work has suggested that
is ‘biphasic’. ighe (2004) describes the lens as being a uoro- lenses that produce more circumlimbal staining are not associ-
ether macromer copolymerized with RIS and N,N-dimethyl ated with reduced levels o com ort (Maissa et al., 2012).
acrylamide (DMA) in the presence o a diluent. Its biphasic In an attempt to improve on the problems encountered
(two-channel) structure means that oxygen and water perme- with these rst-generation lenses, manu acturers have engaged
ability channels are not reliant on each other. T e silicone-con- in a programme o research aimed at manu acturing silicone
taining phase allows passage o oxygen whilst the water phase hydrogel lenses with improved mechanical and sur ace charac-
primarily allows the lens to move. teristics. T is has resulted in the gradual emergence o ‘second-
Without urther treatment both o these rst-generation generation’ and ‘third-generation’ silicone hydrogel lenses such
silicone hydrogel lenses would be unsuitable or wear owing to as Acuvue Oasys, 1-Day Acuvue ruEye, Avaira, Clariti, Dailies
the act that the resultant material sur aces are very hydropho- otal 1 and MyDay lenses (see able 4.2).
bic. In order to overcome this problem, both lenses are sur ace T e main advantage o these newer silicone hydrogels
treated using gas plasma techniques. High-energy gases or compared with the early silicone hydrogels is that they have
gas mixtures (the plasma) are used to modi y the lens sur ace increased water contents, reduced moduli and do not need to
properties without changing the bulk properties. T e result be sur ace treated. T e mechanical and sur ace properties o the
or the bala lcon lens is that sur ace wettability is gained via newest lenses are now similar to that o hydrogels (see able
plasma oxidation, which produces glassy silicate islands on the 4.2). Recent clinical work indicates that there may be a lower
lens sur ace. incidence o CLPC with these lenses (Maldonado-Codina et al.,
T e lotra lcon lens is coated with a dense 25 nm thick coat- 2004).
ing. Both resultant sur aces have low molecular mobility, which Some o the lenses in able 4.2 are based on materials con-
minimizes the migration o hydrophobic silicone groups to the taining RIS-like components. Acuvue Advance and Acu-
sur ace. However, despite these sur ace modi cations, wetta- vue Oasys are based on anaka’s original patent ( ollowing its
bility problems with these lenses were reported. It is generally expiration a er 25 years) using a modi ed RIS molecule, a
accepted that silicone hydrogel lenses have in erior wettability silicone macromer and hydrophilic monomers such as HEMA
compared with hydrogels, which occurs as a result o the hydro- and DMA. Alcohol is used as a solvent to aid the miscibility o
phobic interaction o silicone with the tear lm. these ingredients and is then extracted ollowing polymeriza-
Another important di erence between these rst-genera- tion. High-molecular-weight PVP is the internal wetting agent
tion silicone hydrogel materials and hydrogels is that they have (the Hydraclear) used in these lenses, which is entangled and
signi cantly greater elastic moduli (i.e. they are ‘sti er’). Such there ore ‘entrapped’ within the lens matrix and which allows
mechanical characteristics mean that the lenses are easy to han- them to be manu actured without requiring a sur ace treatment
dle, but have also been implicated in the aetiology o a num- (Maiden et al., 2002; McCabe et al., 2004). T e PVP essentially
ber o clinical complications (Dumbleton, 2003). T ese include works by shielding the silicone rom the tear lm at the lens
higher incidences o super cial epithelial arcuate lesions, mucin inter ace.
balls and CLPC (in particular, localized CLPC compared with T e Bio nity (com lcon A) and Avaira lenses (en lconA)
generalized CLPC), especially with continuous wear o these are not based on RIS chemistry. T ey are comprised solely
lenses (Skotnitsky et al., 2002). T e sti ness o the material o silicon-containing macromers and require no sur ace treat-
may contribute to the mechanical irritation o the lens rubbing ment or wetting agent. T e patents surrounding the materials
against the conjunctiva o the upper eyelid producing a local- re er to a mono unctional macromer (which contains only one
ized response. double bond taking part in the polymerization process) being

Fig . 4.15 Typ ical siloxy-containing macrome r (macromonome r) structure .

 58
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 4 So ft Le ns Mat e rials 59

Fig . 4.16 Exte nt o silicone hyd rog e l contact le ns f tting as a p e rce ntag e o all so t le nse s p re scrib e d in se ve n nations b e twe e n 2000 and 2015.

combined with another rubber-like siloxy macromer, result- they are manu actured. T ick pHEMA lenses that were replaced
ing in a material with much longer chains (higher molecular every ew years are now a thing o the past.
weight) compared with the other silicone hydrogels (Iwata et al., Whilst extended-wear hypoxia-related problems with hydro-
2005, 2006). T e patents also discuss other hydrophilic mono- gels have been resolved with the introduction o silicone hydrogel
mers, which are presumably the key to why these materials do materials, a number o mechanical and sur ace material-related
not need to be sur ace treated. complications still remain, despite the introduction o second-
T e introduction o second- and third-generation lenses has and third-generation polymers. For daily wear, there has been
seen a signi cant rise in the number o silicone hydrogel lenses somewhat o a renaissance towards tting hydrogel materials in
being prescribed on a daily-wear basis in addition to the intro- recent years. T is has come about because o the lack o evidence
duction o daily disposable silicone hydrogel lenses (Morgan or increased com ort with silicone hydrogels, the lack o evi-
et al., 2016) (Fig. 4.16).  dence to show that signi cant pathology results owing to oxygen
levels reaching the anterior eye during daily wear and the con-
Classi icat io n o So t Le ns Mat e rials rmation that the incidence o microbial keratitis is no di er-
ent between the two lens material groups. Future development
T ere are two main classi cation systems or so contact lens o so contact lens materials is likely to concentrate on trying
materials. T ese classi cation systems are expanded upon in to resolve the issues o in ammation and in ection, improving
Appendix 4.1, below.  lens com ort (particularly towards the end o the day), enhanc-
ing post-lens tear exchange and improving sur ace wettability.
Co nclusio n ACKNO WLEDGEMENTS
A basic understanding o the materials rom which contact T e author wishes to thank Andy Broad, revor Glasbey, David Rus-
lenses are made as well as their behaviour is vitally important to ton, Guy Whittaker and Inma Perez-Gomez or use ul comments and
any contact lens practitioner as it is likely to orm an important discussions.
aspect o patient management. So contact lenses have come a
long way since the pioneering e orts o Pro essor Otto Wich- Acce ss t he co mp le t e re fe re nce s list o nline at
terle in the late 1950s in terms o material, design and the way ht t p :/ / www.e xp e rt co nsult .co m.
60 PART 2 So ft Co nt act Le nse s

APPENDIX
CLASSIFICATIO N O F SO FT LENS MATERIALS
4.1

Fo o d and Drug Ad minist rat io n (FDA) TABLE FDA Classif cat io n Syst e m o r So t Le ns
Classi icat io n Syst e m 4A.1 Mat e rials
T e FDA classi cation system or so lens materials is shown Gro up Mat e rial
in able 4A.1. T e classi cation system groups lens materials I Low-wate r-conte nt (<50%), non-ionic p olyme rs
based on their water content and physical charge. For many II Hig h-wate r-conte nt (>50%), non-ionic p olyme rs
years the classi cation system consisted o our hydrogel III Low-wate r-conte nt (<50%), ionic p olyme rs
groups. However, since silicone hydrogels were introduced, IV Hig h-wate r-conte nt (>50%), ionic p olyme rs
this classi cation system has not been ideal because these V Silicone hyd rog e l mate rials
lenses are undamentally di erent in their material chemis-
try. As a result, a h group or silicone hydrogels has been TABLE
introduced.  4A.2 BS EN ISO Hyd ro g e l Su f x Gro up s
Gro up Suffix Mat e rial
The ISO Classi icat io n Syst e m I Low-wate r-conte nt, non-ionic: mate rials that
BS EN ISO 18369-1 / DAM1: 2009 sets out the new international contain le ss than 50% wate r and contain
1% or le ss (e xp re sse d as mole raction) o
standard method or the classi cation o a contact lens material monome rs that are ionic at p H 7.2
given as a six-part code as ollows: II Medium- and high-water-content, non-ionic:
(pre x) (stem) (series suf x) (group suf x) (Dk range) (sur- materials that contain 50% water or more, and
ace modi cation code) contain 1% or less (expressed as mole rac-
tion) o monomers that are ionic at pH 7.2
For so lens materials, the classi cation denotes whether the III Low-wate r-conte nt, ionic: mate rials that con-
material is ionic and the range in which the water content o the tain le ss than 50% wate r and contain g re ate r
material lies. T e presence or absence o sur ace modi cations than 1% (e xp re sse d as mole raction) o
is also indicated. monome rs that are ionic at p H 7.2
T e pre x is a term assigned to a material to designate a spe- IV Medium- and high-water-content, ionic: ma-
terials that contain 50% water or more, and
ci c chemical ormulation. Use o this pre x, which is adminis- contain greater than 1% (expressed as mole
tered by the United States Adopted Names (USAN) Council, is raction) o monomers that are ionic at pH 7.2
optional or all countries other than the USA. V Enhance d oxyg e n p e rme ab le mate rials (e .g .
wo types o stem are used. T e lcon stem is af xed to the silicone hyd rog e l)
pre x and is applied or materials that contain ≥10% water by
mass (hydrogel materials). Focon is applied to materials con-
taining ≤10% water by mass (i.e. non-hydrogel materials). TABLE
BS EN ISO Hyd ro g e l Dk Gro up s
T e series suf x is also administered by the USAN council, 4A.3
and is used in cases in which the original ratio o the mono- Gro up Dk Rang e (ISO Dk Unit s)
mers o an existing contact lens polymeric material is changed
0 <1
to make a new material. In this case, the capital letter A is added 1 1–15
a er the stem designation. Subsequent changes in monomer 2 16–30
ratio are designated by the next letter o the alphabet. T ese let- 3 31–60
ters are used to di erentiate copolymers o unchanged mono- 4 61–100
mer units, but with di erent ratios. It can be omitted i there is 5 101–150
6 151–200
only one ormulation. 7, e tc. Incre asing in incre me nts o 50 Dk
T e group suf x, represented by a Roman numeral, indicates
the range o water content and ionic character o the material
( able 4A.2).
able 4A.3 shows how the oxygen permeability o the materi- Examp le
als is classi ed. In order to demonstrate the BS EN ISO classi cation system,
T e modi cation code, designated by a letter m, denotes the 1-Day Acuvue Moist lens would be classi ed as ollows:
whether the lens has a sur ace modi cation that renders the Pre x: eta
sur ace characteristics di erent to the bulk material. Such Stem: lcon
treatments include plasma treatment, acid / base hydrolysis Series suf x: A
and incorporation o a material that migrates to the sur ace. Group suf x: IV
Certain types o tinted lens may also be considered sur ace Dk range: 2
modi ed. In the case o an unmodi ed sur ace, this suf x is Modi cation code: none
omitted.  T e lens can, there ore, be classi ed as (eta lcon A) (IV) (2).
REFERENCES
Back, A. (2007). Contact lenses and methods or re- Korb, D. R., Greiner, J. V., Herman, J. P. et al. Lid- Poggio, E. C., Glynn, R. J., Schein, O. D., et al. (1989).
ducing conjunctival pressure in contact lens wear- wiper epitheliopathy and dry-eye symptoms in T e incidence o ulcerative keratitis among users
ers. CooperVision Inc. US patent 2007035693. contact lens wearers. CLAO J., 28, 211–216. o daily-wear and extended-wear so contact
Brennan, N. A., & Coles, M. C. (2008). Letter to the Künzler, J., & Ozark, R. (1994). Fluorosilicone hy- lenses. N. Engl. J. Med., 321, 779–783.
editor: risk o corneal in ammatory events with drogels. US patent no. 5321108. Polse, K., Graham, A., Fusaro, R., et al. (1999).
silicone hydrogel and low dk hydrogel extended Lira, M., Santos, L., Azeredo, J., et al. (2008). T e e - Predicting RGP daily wear success. CLAO J., 25,
contact lens wear: a meta-analysis. Optom. Vis. ect o lens wear on re ractive index o hydrogel 152–158.
Sci., 85, 364. and silicone-hydrogel contact lenses: a compara- Read, M. L., Morgan, P. B., Kelly, J. M., et al. (2011).
BSI. (2006a). BS EN ISO 18369-4:2006. Ophthalmic tive study. Cont. Lens Anterior Eye, 31, 89–94. Dynamic contact angle analysis o silicone hydro-
Optics – Contact Lenses. Part 4. Physicochemical Lo strom, ., & Kruse, A. (2005). A conjunctival gel contact lenses. J. Biomater. Appl., 26, 85–99.
properties o contact lens materials. London: Brit- response to silicone hydrogel lens wear. CL Spec- Roba, M., Duncan, E. G., Hill, G. A., et al. (2011).
ish Standards Institution. trum, 20(9), 42–44. Friction measurements o contact lenses in
BSI. (2006b). BS EN ISO 18369-1:2006. Ophthalmic Mahomed, A., Ross, G., & ighe, B. (2004). Contact their operating environment. ribol. Lett., 44,
Optics – Contact Lenses. Part 1. Vocabulary, clas- lenses and com ort enhancers: in vivo and in vitro 378–397.
si cation system and recommendations or labelling release o soluble PVA. Birmingham, UK: Poster Ross, G., Nasso, M., Franklin, V., et al. (2005). Sili-
speci cations. London: British Standards Institution. presented at the BCLA International Con erence cone hydrogels; trends in products and properties.
Coles, C. M. L., & Brennan, N. A. (2012). Coef cient and Exhibition, 21–23 May, 2004. Brighton, UK.: Poster presentation at the BCLA
o riction and so contact lens com ort. Optom. Maiden, A. C., Vanderlaan, D. G., urner, D. C., International Con erence and Exhibition, 3–5
Vis. Sci., 88, e-abstract 125603. et al. (2002). Hydrogel with internal wetting June, 2005.
de Carle, J. . (1975). Hydrophilic polymers and agent. Johnson & Johnson Vision Care. US patent Ross, G., Mann, A., & ighe, B. (2007). Disclosure:
contact lenses manu actured there rom. GB pat- 6367929. the true story o daily disposable lens sur aces.
ent 1385677. Maissa, C., Franklin, V. J., Guillon, M., et al. (1998). [Poster presentation at the BCLA International
Dumbleton, K. A. (2003). Non in ammatory sili- In uence o contact lens material sur ace char- Con erence and Exhibition. Manchester: UK.]. 31
cone hydrogel contact lens complications. Eye acteristics and replacement requency on pro- May – 3 June, 2007.
Contact Lens, 29, S186–S189. tein and lipid deposition. Optom. Vis. Sci., 75, Schein, O. D., Glynn, R. J., Poggio, E. C., et al. (1989).
E ron, N., & Brennan, N. A. (1987). T e so contact 697–705. T e relative risk o ulcerative keratitis among us-
lens re ractometer. Optician, 194(5117), 29–41. Maissa, C., Guillon, M., & Garo olo, R. J. (2012). ers o daily-wear and extended-wear so contact
Gaylord, N. (1974). Oxygen permeable contact lens Contact lens-induced circumlimbal staining in lenses. A case-control study. Microbial Keratitis
composition methods and article o manu acture. silicone hydrogel contact lenses worn on a daily Study Group. N. Engl. J. Med., 321, 773–778.
Polycon Lab. US patent 3 808 178. wear basis. Eye Contact Lens, 38, 16–26. Skotnitsky, C., Sankaridurg, P. R., Sweeney, D. F.,
Gaylord, N. G. (1978). Methods o correcting visual Maldonado-Codina, C., & E ron, N. (2004). Impact et al. (2002). General and local contact lens in-
de ects; compositions and articles o manu acture o manu acturing technology and material com- duced papillary conjunctivitis (CLPC). Clin. Exp.
use ul therein. Syntex USA. US patent 4 120 570. position on the clinical per ormance o hydrogel Optom., 85, 193–197.
Harvitt, D. M., & Bonanno, J. A. (1999). Re-evalua- lenses. Optom. Vis. Sci., 81, 442–454. Subbaraman, L. N., & Jones, L. (2010). Kinetics o
tion o the oxygen di usion model or predicting Maldonado-Codina, C., & Morgan, P. B. (2007). lysozyme activity recovered rom and silicone hy-
minimum contact lens Dk / t values needed to In vitro water wettability o silicone hydrogel con- drogel contact lens materials. J. Biomater. Sci., 21,
avoid corneal anoxia. Optom. Vis. Sci., 76, 712–719. tact lenses determined using sessile drop and cap- 343–358.
Holden, B. A., & Mertz, G. W. (1984). Critical oxy- tive bubble techniques. J. Biomed. Mater. Res. A, Subbaraman, L. N., Glasier, M., Senchyna, M., et al.
gen levels to avoid corneal oedema or daily and 83, 496–502. (2006). Kinetics o in vitro lysozyme deposition
extended wear contact lenses. Invest. Ophthalmol. Maldonado-Codina, C., Morgan, P. B., Schnider, C. on silicone hydrogel, PMMA, and FDA groups I,
Vis. Sci., 25, 1161–1167. M., et al. (2004). Short-term physiologic response II, and IV contact lens materials. Curr. Eye Res.,
Holden, B. A., Sweeney, D. F., & Seger, R. G. (1986). in neophyte subjects tted with hydrogel and sili- 31, 787–796.
Epithelial erosions caused by thin high water con- cone hydrogel contact lenses. Optom. Vis. Sci., 81, Suwala, M., Glasier, M. A., Subbaraman, L. N., et al.
tact lenses. Clin. Exp. Optom., 69, 103–107. 911–921. (2007). Quantity and con ormation o lysozyme
Iwata, J., Hoki, ., & Ikawa, S. (2005). Long wearable McCabe, K. P., Molock, F. F., Hill, G. A., et al. (2004). deposited on and silicone hydrogel contact lens
so contact lens. Asahi Aime. US patent 6867245. Biomedical devices containing internal wetting materials using an in vitro model. Eye Contact
Iwata, J., Hoki, ., Ikawa, S., et al. (2006). Silicone hy- agents. Johnson & Johnson Vision Care US pat- Lens, 33, 138–143.
drogel contact lens. Asakikasei Aime and Cooper- ent 6822016. anaka, K., akahashi, K., Kanada, M., et al. (1979).
Vision. US patent 2006063852. McCarey, B. E., & Wilson, L. A. (1982). pH, osmolar- Copolymer or so contact lens, its preparation
Jones, L., & Dumbleton, K. (2005). Contact lens t- ity and temperature e ects on the water content and so contact lens made there rom. US patent
ting today. Silicone hydrogels. Part 1: technological o hydrogel contact lenses. Contact Intraocul. Lens 4139513.
developments. Optom. oday, November, 18, 23–29. Med. J., 8, 158–167. ighe, B. J. (1997). Contact lens materials. In A. J.
Jones, L., Jones, D., & Houl ord, M. (1997). Clini- McKenney, C. (1990). T e e ect o pH on hydrogel Philips, & L. Speedwell (Eds.), Contact Lenses
cal comparison o three polyhexanide-preserved lens parameters and tting characteristics a er (4th ed.) (pp. 50–92). Ox ord: Butterworth-
multi-purpose contact lens solutions. Cont. Lens hydrogen peroxide disin ection. J. Br. Contact Heinemann.
Anterior Eye, 20, 23–30. Lens Assoc. ( rans BCLA Annual Clinical Con er- ighe, B. J. (2004). Silicone hydrogels: structure,
Jones, L., MacDougall, N., & Sorbara, L. G. (2002). ence), 13, 46–51. properties and behaviour. In D. F. Sweeney (Ed.),
Asymptomatic corneal staining associated with the Morgan, P. B., & E ron, N. (1998). T e oxygen per- Silicone Hydrogels: continuous Wear Contact Lens-
use o bala lcon silicone–hydrogel contact lenses ormance o contemporary hydrogel contact lens- es (pp. 1–27). Ox ord: Butterworth-Heinemann.
disin ected with a polyaminopropyl biguanide- es. Cont. Lens Anterior Eye, 21, 3–6. Wichterle, O., & Lim, D. (1960). Hydrophilic gels or
preserved care regimen. Optom. Vis. Sci., 79, Morgan, P. B., Woods, C. A., ranoudis, I. G., et al. biological use. Nature, 185, 117–118.
753–761. (2016). International contact lens prescribing in Wichterle, O., & Lim, D. (1961). Method or produc-
Josephson, J. E., & Ca ery, B. E. (1987). Progressive 2015. CL Spectrum, 31, 28–33. ing shaped articles rom three dimensional hydro-
corneal vascularization associated with extended Nichols, J. J. (2015). Contact lenses 2014 (2014 an- philic high polymers. Czeskoslovenska Akademie
wear o a silicone elastomer contact lens. Am. J. nual report). CL Spectrum, Jan 2015, 22–27. Ved. US patent 2 976 576.
Optom. Physiol. Opt., 64, 958–959. Nichols, J. J., & Berntsen, D. A. (2003). T e assessment Winterton, L. C., Lally, J. M., Sentell, K. B., et al.
Kastl, P. R., Re ojo, M. F., & Dabezies, O. H. (1984). o automated measures o hydrogel contact lens re- (2007). T e elution o poly (vinyl alcohol) rom
Review o polymerization or the contact lens tter. ractive index. Ophthal. Physiol. Opt., 23, 517–525. a contact lens: the realization o a time release
In O. H. Dabezies (Ed.), T e CLAO Guide to Basic Nicolson, P. C., Baron, R. C., Chabrecek, P., et al. moisturizing agent / arti cial tear. J. Biomed. Ma-
Science and Clinical Science Vol. 6. (pp. 1–6; 24). (1996). Extended wear ophthalmic lens. Patent ter. Res. B. Appl. Biomater., 80, 424–432.
New York: Grune and Stratton. WO CIBA Vision 9631792.

60.e 1
 5
So ft Le ns Manufact ure
NATHAN EFRO N

8000–12 000 rpm) about its central axis. A diamond-tipped tool

Int ro d uct io n cuts the posterior sur ace lens shape into the button. A second
T ree techniques can be employed to manu acture so contact diamond tool advances rom the side to reduce the diameter to
lenses – lathe cutting, spin casting and cast moulding. As medi- the required size. T e sur ace is rendered smooth by either ne
cal devices that rest against the highly sensitive eyeball, contact machining or polishing. Modern sophisticated lathes are capa-
lenses need to be o the highest quality in terms o their physical ble o cutting xerogel sur aces to a tolerance o 8–15 nm. Such
construction. As devices that correct optical de ocus, the opti- smooth sur ace nishing precludes the need or polishing and
cal quality o contact lenses must also be o the highest order. is pre erred when non-spherical sur ace geometries are being
At the same time, it must be recognized that companies will generated. T is approach also serves to preserve the consistency
manu acture contact lenses only i they are pro table; the domi- o one sur ace to the next. T e dimensions o the lathed sur ace
nant orces in the market dictate that these high-quality prod- are calculated to allow or eventual expansion when the xerogel
ucts must be delivered at minimal cost, and one consequence is later hydrated.
o this is a simpli cation o lens parameters to streamline the T e button is removed rom the collet and the cut posterior
high-volume process.  sur ace o the button is mounted onto a support tool o a ront
sur ace lathe, using low-melting-point wax. It is essential during
this process that the button is mounted and xed in an abso-
Me t ho d s o f Manufact ure lutely concentric and level aspect to the support tool in order to
A key requisite o any technology employed to manu acture a minimize unwanted prism being introduced by the ront sur-
medical appliance is that the nal product is sa e, predictable ace cutting. A diamond-tipped tool cuts the anterior sur ace
and o high quality, so that it meets the intended need. T e three down to the required thickness, and the sur ace is smoothed.
technologies discussed below have been developed to meet T e most advanced lathes o er ‘W’ axis cutting options that can
these requirements. generate rotationally non-symmetric sur aces whilst the pri-
mary ront sur ace is being cut. Polishing tools may be used to
smooth the lens edge, although some advanced lathes obviate
LATHE CUTTING
this step.
T is process essentially involves the use o a special contact lens A er inspecting and measuring all relevant dry lens param-
lathe to cut an anhydrous cylindrical button o material (xero- eters, the lens is hydrated in normal, unpreserved saline until
gel) into the required shape, and then hydrating this to orm it is ully equilibrated and impurities have been extracted. T e
the nished so lens. Lathe manu acture ranges rom labour- hydrated lens is re-inspected or nal wet parameter con or-
intensive, manual-based cutting systems to sophisticated and mity, sealed in small glass vials and autoclaved at 120°C or at
ully automated manu acturing lines, depending on the capital least 15–20 minutes to e ect sterilization. Advances in lathing
budget or skill levels available (Fig. 5.1). Even with the use o technology and computer-controlled processing have led to the
automation, however, the number and variability o manu ac-
turing steps that are necessary or lathe cutting means that man-
u acturing so lenses using this technology is necessarily more
expensive than using spin casting or cast moulding.
T ere ore, lathe cutting is generally reserved or the produc-
tion o custom-ordered or extreme range lenses that contain
design eatures not amenable to mass production, such as lenses
o high spherical power and / or high toric power, or aberration-
correcting so lenses or keratoconus (Marsack et al., 2008).
T e raw xerogel is supplied to the lens manu acturer in the
orm o ‘rods’ or ‘buttons’. A rod is a solid cylindrical piece o
xerogel, about 16 mm in diameter and 400 mm long. T e rod
is then sliced, orthogonally to the long axis, into buttons about
10 mm thick. More commonly, the xerogels are abricated and
supplied in button orm. When this occurs buttons have usually
been pre-trimmed to an industry standard size so that they can
be machined in most o the available lathes.
T e button is rst secured to a back sur ace lathe in a clamp or Fig . 5.1 A lab oratory using the lab our-inte nsive me thod o lathe cut-
‘collet’, and this assembly is set spinning at a high rate (typically ting to manu acture so t contact le nse s.
61
62 PART 2 So ft Co nt act Le nse s

development o semiautomatic systems whereby stacks o but- SPIN CASTING

tons are automatically ed into lathes; however, even this tech-
nology cannot match the mass-production capabilities o cast In this process, a convex ‘male-shaped’ stainless steel tool, or
moulding. ‘insert’, is produced on a high-precision engineering lathe and
Fig. 5.2 is a schematic ow diagram illustrating the pro- lapped to provide an accurate sur ace that matches the dry
cess o manu acturing a so contact lens using lathe-cutting dimensions o the proposed anterior sur ace o the contact lens.
technology. Modern non- errous materials are also suitable or producing the
T e process o manu acturing rigid contact lenses by lathe mould tool and these materials can be generated on ‘nano-accu-
cutting is very similar to the process described above – the key rate’ single point turning lathes. T ese lathes can cut mould tools
di erence being that, with so lens manu acture, the xerogel to a sur ace nish that renders polishing unnecessary. T e nal
must eventually be hydrated and sterilized, whereas rigid lenses sur ace shape o the master mould tool is veri ed using inter er-
need only to be cut to their nal shape and polished. Other ometry or other similar non-contact measuring methods. Any
notable manu acturing di erences concerning materials o high given tool is used to make hundreds o thousands o moulds.
gas permeability are tighter manu acturing tolerances and the T e metal tool is impressed against heated liquid polypropyl-
requisite or more critical control o cutting and mounting tem- ene or polyvinyl chloride (PVC), which then cools and sets to
peratures in order to preserve their in vivo wetting properties. orm a solid plastic concave emale mould. A multiple number
A pictorial account o this process o rigid contact lens manu- o metal tools (typically 8×–12×) is used to produce the same
acture, and an explanation o how toric lenses are made using number o plastic moulds simultaneously. T e moulding meth-
lathe cutting, is given in Chapter 12.  ods and tooling used must be very accurate in order to preserve

Fig . 5.2 The p roce ss o manu acturing a so t contact le ns b y lathe cutting . (1) The d ry p olyme r is sup p lie d as a rod or b utton. (2) A p olyme r b ut-
ton is p lace d on a lathe ; the b utton sp ins and a d iamond tool is ad vance d toward s the b utton to g e ne rate the le ns b ack sur ace . (3) The b utton is
re le ase d rom the b ack sur ace lathe . (4) The b utton is mounte d on a ront sur ace lathe with ad he sive wax; the b utton sp ins and a d iamond tool is
ad vance d toward s the b utton to g e ne rate the le ns ront sur ace . (5) The d ry le ns is re move d rom the lathe and the e d g e s are p o lishe d . (6) The le ns
is insp e cte d at 17× mag nif cation. (7) The d ry le ns is p lace d in saline to hyd rate the le ns, which swe lls to its f nal so t le ns orm. (8) The hyd rate d so t
le ns is insp e cte d at 10× mag nif cation. (9) The so t le ns is inse rte d into a g lass vial containing saline . (10) The g lass vial is se ale d and lab e lle d . (11) The
se ale d g lass vial containing the le ns is ste rilize d in an autoclave . (12) The ind ivid ual g lass vials are d isp atche d .
 5 So ft Le ns Manufact ure 63

the concentricity o the resultant plastic part. Any moulding mitigated this limitation. T e process o spin casting is illus-
runout will create unwanted prism in the lens during the spin- trated in Fig. 5.4. 
ning process. T is type o injection cast moulding is generally
conducted in a controlled environment (usually to a class 100K CAST MO ULDING
level). It is imperative or a spin-cast manu acturing process to
control the level o potential contaminants to a minimum as it is Cast moulding has become the dominant technology in high-
an open-moulding system. volume lens manu acture. As with spin casting, a series o highly
T e xerogel lens orm is created by pouring liquid monomers polished steel tools is used to abricate polypropylene moulds;
into the concave moulds, which spin at a controlled rate about however, matching male and emale moulds are required or
the central mould axis. cast moulding. Again, modern non- errous materials are suit-
T is spinning takes place in a controlled atmosphere o able or producing the mould tool and can be generated to
nitrogen or similar oxygen-deprived atmosphere (Fig. 5.3). extremely ne levels o accuracy and sur ace nish. T ese mas-
T is is necessary as the spin mould is an open system and thus ter tools are used to make hundreds o thousands o male and
exposes one sur ace o the lens (posterior) to air as it is being emale moulds (Fig. 5.5).
cured. Oxygen in air is a natural scavenger o the initiator and T e variations ound in di erent manu acturing acilities
will ultimately inhibit the polymerization process. around the world, however, attest to signi cant development in
T e speed o rotation, combined with both the mould tool challenging this norm. Modern moulding machines can create
shape and monomer dose, ultimately determines the nal lens reproducible results (a critical requirement or the high vol-
parameters. T e shape o the back sur ace is primarily governed by ume production o contact lenses, particularly daily disposable
centri ugal orce generated by the rate o spin o the mould, sur ace lenses) with higher numbers o tools. Some machines can suc-
tension orces between the mould and polymer, and the e ects o cess ully carry as many as 36 cavities (18 males and 18 emales)
gravity. A greater speed o rotation o the mould will result in more in one mould base. Moulding parameters, tool accuracy, cool-
polymer mass being shi ed towards the lens periphery, and more ing and balancing are critical i this is to be success ul. T e man-
negative lens power. Due to this system o manu acture, certain u acturer will seek a balance between output and accuracy with
process controls such as monomer dosing must be more accurate the moulding process.
than those ound in ull cast moulding o contact lenses. Cast moulding generally takes place in a continuous, auto-
As the mould spin rate stabilizes, ultraviolet radiation mated production line (Fig. 5.6). Monomer in liquid orm is
and / or heat is introduced to initiate polymerization. T e lens is introduced into a concave emale mould, which de nes the
removed rom the mould, and the mould is discarded. Certain shape o the lens ront sur ace. An ultraviolet-transparent male
spinning processes hydrate the lens in the original plastic mould mould is mated to the emale mould and the two are clamped
and it is never removed. T is process has been proven advanta- together in a care ully controlled environment.
geous and cost-e ective or the mass production o daily dis- T e contact lens edge is ormed when the two sides o the
posable lenses. mould come together. T ere is considerable science and art in
Other spinning systems still require that the edges o the the control o the polymerization process and the pressure that
lens are polished and that the lens be inspected, hydrated, re- is applied to the mould to orm the lens. A crucial aspect o this
inspected, packaged and autoclaved. Spin casting can produce a process is to arrange or the excess polymer (so-called ‘ ash’) to
much higher output volume than lathe cutting, and in the latest be squeezed out while leaving the edge intact.
systems can match the high volume o lenses that can be pro- Once the polymer is encapsulated in the mould, it is ‘cured’ –
duced by cast moulding. T e primary restriction o spin-cast a process in which the assembled moulds are exposed to either
manu acture lies in its inability to generate a ully ormed edge UV light or thermal radiation, or a combination o both, to e ect
rom the posterior to anterior sur ace; however, sophisticated polymerization so as to orm the dry contact lens. Most cast-
design modelling, combined with accurate tooling, has largely moulding processes are designed so that when the dry lens is
removed rom the mould there is no need to polish the edge.
T e moulds are disassembled and discarded, and the lens that is
released rom the moulds – still in rigid orm – is hydrated in saline.
Inspection is undertaken either manually (Fig. 5.7) or using
automated video-based computer-controlled image analysis.
Finally, the lens blister packs are sealed, labelled (Fig. 5.8), auto-
claved, and packaged in boxes. Fig. 5.9 is a ow diagram o the
cast moulding process.
It should be recognized that the above descriptions are
highly simpli ed accounts o sophisticated engineering pro-
cesses. Various manu acturers have introduced a number
o unique variations, such as wet-state polymerization, the
employment o reusable glass moulds (Hough, 1998), use o
the male hal o the mould or nal lens packaging, and vertical
production lines to optimize the use o costly oor space. Also,
toric and bi ocal lenses can be manu actured using either spin-
casting or cast-moulding technology by engineering the master
tools to contain the desired lens orms; these design elements
will then be aith ully transposed to the moulds and then to the
Fig . 5.3 A manu acturing line or sp in casting so t contact le nse s. nal lens. 
64 PART 2 So ft Co nt act Le nse s

Fig . 5 .4 The p ro ce ss o manu acturing a so t co ntact le ns b y sp in casting . (1) A male to o l is machine d ro m stainle ss ste e l; the co nto ur o the
to o l he ad will d e f ne the shap e o the ante rio r le ns sur ace . The same to o l is use d to make hund re d s o tho usand s o mo uld s. (2) A e male mo uld
is mad e b y p re ssing the male to o l into mo lte n p o lyp ro p yle ne , which co o ls and se ts. (3) The e male mo uld is mo unte d , with the concavity ac-
ing up ward s, in a sp ind le that sp ins ab o ut the le ns axis, and liq uid mo no me rs are intro d uce d into the sp inning mo uld . (4) The mo no me rs in the
sp inning mo uld are irrad iate d with ultravio le t lig ht to initiate le ns p o lyme rizatio n. (5) The d ry le ns is re mo ve d ro m the mo uld , the le ns e d g e
may b e p o lishe d and the mo uld is d iscard e d . (6) The e d g e o the d ry le ns is insp e cte d at 10× mag nif catio n. (7) The d ry le ns is p lace d in saline ,
which hyd rate s the le ns, causing it to swe ll to its f nal so t le ns o rm. (8) The hyd rate d so t le ns is insp e cte d at 10× mag nif catio n. (9) The so t le ns
is inse rte d into a b liste r p ack co ntaining saline . (10) The b liste r p ack is se ale d with a sp e cial o il, and a lab e l is stuck o n to this. (11) The se ale d
b liste r p ack co ntaining the le ns is ste rilize d in an auto clave . (12) The ind ivid ual b liste r p acks are inse rte d into p ackag e s, typ ically in multip le s o
e ithe r thre e o r six le nse s.

Fig . 5.5 Ge ne rating a me tal maste r tool. Fig . 5.6 A manu acturing lab oratory or cast mould ing so t contact
le nse s.
 5 So ft Le ns Manufact ure 65

Fig . 5.7 An insp e ction lab oratory or q uality che cking so t cast-mould - Fig . 5.8 A b liste r p acking line or p acking and lab e lling so t cast-
e d contact le nse s. mould e d contact le nse s.

Fig . 5.9 The p roce ss o manu acturing a so t contact le ns b y cast mould ing . (1) Male and e male tools are machine d rom stainle ss ste e l; the contour
o the male tool he ad will d e f ne the shap e o the ante rior le ns sur ace , and the contour o the e male tool he ad will d e f ne the shap e o the p oste rior
le ns sur ace . The same tools are use d to make hund re d s o thousand s o mould s. (2) Male and e male mould s are mad e b y p re ssing the tools into
molte n p olyp rop yle ne , which cools and se ts. (3) The e male mould is mounte d in an accurate alig ning f xture , with the concavity acing up ward s, and
liq uid monome rs are introd uce d into the concavity. (4) The male mould is re g iste re d ove r the e male mould and the two mould s are clip p e d tog e the r.
(5) Exce ss p olyme r is sq ue e ze d out rom the sid e s o the mould . (6) The monome rs insid e the mould asse mb ly are irrad iate d with ultraviole t lig ht
or the rmal e ne rg y to initiate le ns p olyme rization. (7) The d ry le ns is re move d rom the mould and the mould s are d iscard e d . The f nal stag e s o le ns
p rod uction are e sse ntially the same as or sp in casting , which is illustrate d in ste p s 6–12 in Fig . 5.4.
66 PART 2 So ft Co nt act Le nse s

Re p ro d ucib ilit y and Q ualit y o f NO N-EDGE (BO DY) DEFECTS

Mass-p ro d uce d Le nse s
• Split – partial or ull separation o lens material that is not
Practitioners who prescribe lenses, and patients who wear continuous with lens edge.
lenses, need to be assured o the reproducibility o lenses that • Blemish – hazy, low-transparency region o lens, on lens
have been manu actured using mass-production techniques. sur ace or within lens.
Young et al. (1999) determined the reproducibility o 24 lenses • Eccentric optic zone – optic zone not concentric with lens
in three lens powers (−1.00 D, −3.00 D and −6.00 D) o eight perimeter.
common requent replacement spherical so contact lens types. • Multiple pieces – lens separated into sections.
T ey ound that the mean power o all the lenses was higher Some lenses contained more than one de ect, and a high
than their labelled powers, although all were within the toler- prevalence o nicks, tears, roughness and blemishes was
ance ranges. Reproducibility was observed to be worse or all observed. At the time, other authors reported similar ndings
lenses at higher powers. All but two lens types had mean diam- (Wodis et al., 1990; Holden et al., 1991; Lowther, 1991). T ese
eters within tolerance. A slight reduction o optical quality at studies accorded a valuable service to the contact lens industry
high powers was noted. Measures o back optic zone radius, in the early 1990s as they ocused attention on the importance
centre thickness and overall diameter showed reasonably good o the quality o mass-produced lenses, especially edge quality.
repeatability. Advances in cast-moulding manu acturing technology over the
In a similar study conducted on three brands o daily past quarter o a century, uelled by the attention drawn to the
disposable contact lenses, E ron et al. (1999) ound that above issues, has led to a substantial overall improvement in
450 lenses o −3.00 D in power displayed an overall high lens quality.
degree o accuracy and reproducibility. hey concluded At a microscopic, subclinical level, it can be observed that
that, with a single inconsequential exception, all measured di erent manu acturing techniques can have a signi cant e ect
parameters were ound to all well within clinically accept- on the nished lens sur ace. Fine concentric rings can o en be
able limits or providing wearers o these lenses with consis- seen on the sur ace o so lenses that have been manu actured
tent vision and it. by lathe cutting; these ‘lathe marks’ are o en visible under high
E ron and Veys (1992) examined the quality o three types o magni cation using the slit-lamp biomicroscope. Using atomic
early-generation disposable lenses at 17× magni cation using orce microscopy, Bhatia et al. (1997) observed that the sur ace
an Optimec JFC Contact Lens Analyzer. An overview o the o unused cast-moulded lenses varied rom smooth to rough
observed de ects revealed that they could be divided into two with sur ace eatures unique to the polymers and manu actur-
broad categories – edge de ects and non-edge (body) de ects ing process.
(Fig. 5.10). Maldonado-Codina and E ron (2005) investigated the
Each o these categories could be urther divided into our impact o manu acturing method and material composition
subcategories, as ollows: on the sur ace characteristics o ve types o hydrogel contact
lenses: three polyhydroxyethyl methacrylate (pHEMA) lenses,
each manu actured by a di erent technique, namely, lathing,
EDGE DEFECTS
spin casting and cast moulding, a HEMA / methacrylic acid
• Nick – small piece o lens material missing rom lens edge. cast-moulded lens and a HEMA / glycerol methacrylate cast-
• ear – partial or ull separation o lens material continuous moulded lens. Front and back lens sur aces were examined
with lens edge (Fig. 5.11). using scanning electron microscopy (SEM) and atomic orce
• Roughness – uneven edge pro le. microscope (AFM). T e sur aces o the lathed lenses were
• Excess material or ash – lens mass or surplus material covered in lathing / polishing marks. In general, at a micro-
extending beyond lens circum erence.  scopic level, the anterior sur ace appeared rougher. All three
cast-moulded lenses had more processing debris than did the

Fig . 5.10 Syste m or classi ying the typ e s o d e e cts that can b e ob - Fig . 5.11 Te ars in the e d g e o a d isp osab le so t le ns ob se rve d at 100×
se rve d on contact le nse s. Ed g e d e e cts are ind icate d in b old ont, and mag nif cation. Such e d g e d e e cts are uncommon with mod e rn cast-
b od y d e e cts in p lain ont. mould ing te chnolog y.
 5 So ft Le ns Manufact ure 67

lathed and spun-cast pHEMA lenses. Overall, the sur aces o a technician involved in the servicing and maintenance o the
the lathed lens were ‘rougher’ than those o the cast-moulded manu acturing machines, was apparently exposed to the liquid
lens. Maldonado-Codina and E ron (2005) concluded that sur- monomers in the machines. T e constituent monomers used in
ace topographies o hydrogel contact lenses are dependent on the contact lens manu acture were 2- hydroxyethyl methacry-
method o manu acture. T ey also noted that cast-moulded late (2-HEMA), glycerol monomethacrylate (GMA) and ethyl-
lenses are associated with apparently ‘stickier’ sur aces, which eneglycol dimethacrylate (EGDMA). Other substances handled
may be indicative o sur ace degradation or cure-related issues included machine oil, acetone, and isopropyl alcohol.
during the manu acturing process. Although acrylates are