Contact Lenses (Encyclopedia of Nursing & Allied Health)
Contact lenses are small, light-weight plastic devices worn on the eye that correct refractive errors in vision. While they appear to be worn in direct contact with the cornea, they actually float on a layer of tears that separates them from the cornea.
Contact lenses correct or improve the vision of people with nearsightedness (myopia), farsightedness (hyperopia), presbyopia, and astigmatism. In recent years, some people also wear contact lenses not for medical reasons, but rather to change their eye color.
People allergic to certain plastics should not wear contact lenses manufactured from that type of material.
Patients with dry eye or severe seasonal allergies may find contact lenses uncomfortable and may prefer eye glasses. A careful patient history needs to be taken by the physician or contact lens technician to make sure these problems are addressed.
Eye care professionals should ensure that contact lens patients who have disposable or planned replacement lenses keep strictly to their replacement schedules. Contact lenses wear out over time and can damage patients' eyes. Deposits also can build up on the lenses, leading to lid and eye infections.
Patients who have lenses they can sleep in (extended wear lenses) also are advised not to keep their contact lenses in their eyes for longer periods than directed by their physician. Adherence to the schedules recommended by their physicians helps patients avoid infection and long-term damage to the cornea.
People employed in certain occupations may be prohibited from wearing contact lenses, or may be required to wear safety eyewear over the contact lenses. Physicians and employers should be consulted for recommendations.
Ophthalmologists (M.D.s) or optometrists (O.D.s) dispense contact lenses. The prices for lenses vary for the different types. Some physicians offer a "global fee" to their patients that includes the contact lens fitting, lenses, and follow-up visits.
Over 32 million people in the United States wear contact lenses. These lenses provide a field of view unobstructed by eyeglass frames. They do not fog-up or get splattered and are less noticeable than any eyeglass style. On the other hand, they take time to get accustomed to; require more measurements for fitting; require many follow-up visits to the eye doctor; can lead to complications such as infections and corneal damage (but only if not cared for properly or replaced as prescribed); and may not correct astigmatism as well as eye glasses.
Originally, hard contact lenses were made of a material called PMMA. Although still available, it is rarely used because it does not allow oxygen to pass through the lens. The more common types of contact lenses are:
- Rigid gas-permeable (RGP) daily-wear lenses are made of plastic that does not absorb water, but does allow oxygen to permeate from the atmosphere to the cornea. (This is important because the cornea has no blood supply and needs to acquire oxygen from the atmosphere through the film of tears that moves beneath the lens.) They must be removed and cleaned each night.
- Rigid gas-permeable (RGP) extended-wear lenses are made from plastic that also does not absorb water and is more permeable to oxygen than the plastic used for daily-wear lenses. They can be worn for up to a week, then cleaned, and reinserted.
- Daily wear soft lenses are made of plastic that is permeable to oxygen and absorbs water; therefore, they are soft and flexible. These lenses must be removed and cleaned each night, and they do not correct all vision problems. Many patients find it easier to become accustomed to soft lenses, but these lenses are more prone to ripping and do not last as long as rigid lenses.
- Extended-wear soft lenses are highly permeable to oxygen, are flexible by virtue of their ability to absorb water, and can usually be worn for up to one week. They do not correct all vision problems.
- Extended-wear disposable lenses are soft lenses worn continually for up to six days and then discarded, with no need for cleaning.
- One type of disposable soft lenses are worn for one day and then discarded by the patient. Doctors believe these lenses reduce the risk of infection due to poor cleaning habits or over-wearing lenses. They can be price prohibitive for some patients at $1 a day.
- Planned-replacement soft lenses are daily wear lenses that are replaced on a regular schedule, most common- ly every two weeks, monthly, or quarterly. They must also be cleaned.
Soft contact lenses come in a variety of materials. High Dk materials provide high oxygen permeability and allow greater comfort for patients. Advances in toric contact lenses also allow individuals with astigmatism to achieve better visual correction from contact lenses with more comfort.
There are also different kinds of RGP and soft multifocal contact lenses available. There are five basic designs and over one hundred brands that offer variations of these designs. The optics of bifocal contact lenses are improving dramatically, as baby boomers move into presbyopia and more research dollars are devoted to this area. Monovision, where one contact lens corrects for distance vision while the other corrects for near vision, also may be an option for presbyopic patients. However, monovision may affect depth perception and may not be appropriate for everyone. Contact lenses also come in a variety of tints. Soft contact lenses are available that can change eye color. Even though such lenses have no prescription, they must still be fitted and checked to ensure that an eye infection does not occur. People should never wear someone else's contact lenses. This can lead to infection or damage to the eye.
Before contact lenses are prescribed, the patient's eyes are examined by an optometrist or an ophthalmolo- gist. Contact lens technicians, ophthalmic nurses, and ophthalmic technicians also may assist with the exam, although frequently their findings are verified by the physician.
Eyeglass prescriptions, if necessary, are then given to patients. A separate contact lens-fitting exam is necessary if the patient wants contact lenses. This is sometimes performed by the doctor, but in many cases is completed by a contact lens technician.
Before prescribing contact lenses, a technician performs an evaluation. He or she conducts a written and oral interview with the patient to determine if the patient is a viable contact lens candidate. The technician then assesses the technical aspects of the patient's ocular status, since good eye health is required to wear lenses. The patient's palpebral aperture and visual iris diameter is measured to determine the appropriate diameter for the contact lens. The technician also tests the patient's tear quantity. A poor tear film is a contraindication for contact lenses use. Using instrumentation and information gained from the patient's eye exam, the technician determines what type of lens is best for the patient. For example, RGPs are commonly given to astigmatic patients because they provide clearer vision for these patients.
The contact lens technician selects the lens material and design, then determines the best trial lens. Based on the patient's experience with the trial lenses, the technician then determines the lens parameters. The physician reviews these findings to make the recommendation for the proper contact lenses. He or she ascertains the proper fit, and measures visual acuity and over-refraction to determine the proper lens prescription. Because a contact lens is an FDA-approved medical device placed directly onto the eye (unlike eye glasses), it cannot be issued until the eye's proper health has been ascertained via a follow- up examination. Unlike eyeglass prescriptions, a contact lens prescription includes not only the prescription, but also the contact lens material, diameter, brand, and curvature.
Before the patient is sent home with the lenses, the technician will give a detailed demonstration of inserting, removing, and cleaning the lenses. A written list of detailed instructions is usually dispensed with the lenses.
The doctor and technician schedule several return visits for the patient to evaluate the lens fit and performance. At these visits, eye care professionals determine whether the lens design or material needs to be modified.
Patients may be allergic to certain solutions that are used to clean or lubricate the lenses. For that reason, physicians instruct patients not to change solutions without prior approval. Contact lens wearers also are advised to seek immediate attention if they experience eye pain, a burning sensation, red eyes, intolerable sensitivity to light, cloudy vision, or an inability to keep the eyes open.
To avoid infection, it is important for contact lens wearers to exactly follow the instructions for lens insertion, removal, and cleaning. Soft contact lens wearers should never use tap water to rinse their lenses or to make up solutions. All contact lens wearers should always carry a pair of glasses and a contact lens case with them,
in case the contact lenses have to be removed due to eye irritation.
Wearing contact lenses increases the risk of corneal damage and eye infections, if the lenses are not properly cleaned, if the lenses are inserted or removed with dirty hands, or if the lenses are worn for a longer period of time than recommended. However, there is little increased risk of eye infection or damage if the lenses are worn as instructed and cared for properly. Dry eye and seasonal allergy symptoms may be exacerbated by wearing contact lenses.
The normal expectation is that people will achieve 20/20 vision while wearing corrective lenses.
Health care team roles
Nursing and allied health professionals play an important role in contact lens examination and fitting. With advances in technology, technicians now have duties that formerly only a physician performed.
Contact lens technicians take the lead role in the contact lens fitting by recording the pertinent patient history, measuring the eye for the proper lens fit, and testing the tear quantity.
Advanced and intermediate level ophthalmic technicians perform refractions and determine the patient's depth perception. These professionals also may perform corneal topography (mapping).
Some of these professionals seek certification through the American Board of Opticianry and the National Contact Lens Examiners or other organizations. These organizations offer seminars and testing that helps professionals keep current with technological advances.
Physicians have become increasingly dependent on these technicians and assistants as managed care dictates they see more patients per day. By delegating these task to qualified personnel, the physicians can see more patients per day without jeopardizing patients' ocular health.
Technicians emphasize the importance of cleaning contact lenses and adhering to any planned replacement schedule. They stress that while patients may save money by wearing lenses longer or skimping on cleaning solution, these actions increase the risk of eye infections or damage. Younger patients also are cautioned that sharing colored contact lenses with others can lead to eye infections. The importance of inserting and removing contact lenses with clean hands also is emphasized to all contact lens wearers.
Optometrists and ophthalmologists receive training in optometry schools or medical residencies for these procedures. Contact lens technicians may complete special training courses or be trained by the physician.
Astigmatism vision condition that occurs when the cornes is slightly irregular in shape. This irregularity prevents light from focusing properly on the retina.
Corneahe clear outer covering of the front of the eye.
Index of refraction constant number for any material that is an indicator of the degree of the bending of the light caused by that material.
Lens device that bends light waves.
Permeableapable of allowing substances to pass through.
Polycarbonate very strong type of plastic often used in safety glasses, sport glasses, and children's eye glasses. Polycarbonate lenses have approximately 50 times the impact resistance of glass lenses.
Polymer substance formed by joining smaller molecules. Examples of polymers include plastic, acrylic, cellulose acetate, cellulose propionate, nylon, etc.
Presbyopia condition affecting people over the age of 40 where the system of accommodation that allows focusing of near objects fails to work because of age-related hardening of the lens of the eye.
Retinahe inner, light-sensitive layer of the eye containing rods and cones; transforms the image it receives into electrical messages sent to the brain via the optic nerve.
Ultraviolet (UV) lightart of the electromagnetic spectrum with a wavelength just below that of visible light. It is damaging to living material, especially eyes and DNA.
Silbert, Joel, ed. Anterior Segment Complications of Contact
Lens Wear. New York: Churchill Livingstone, 1994.
Zinn, Walter J., and Herbert Solomon. Complete Guide to Eyecare, Eyeglasses & Contact Lenses. 4th ed. Hollywood, FL: Lifetime Books, 1997.
Gromacki, Susan. "Satisfying Baby Boomers and Their
Boomlets with Contact Lenses." Optometric Management 35(October 2000): 52-56.
American Academy of Ophthalmology. P.O. Box 7424, San
Francisco, CA 94120-7424. (415) 561-8500. <<a href="http://www.eyenet.org">http://www.eyenet.org>.
American Optometric Association. 2420 North Lindbergh
Boulevard, St. Louis, MO 63141. (800) 365-2219. <<a href="http://www.aoanet.org">http://www.aoanet.org>.
Contact Lens Council. 8201 Corporate Drive, Suite 850,
Landover, MD 20785. (800) 884-4CLC. <<a href="http://www.contactlenscouncil.org">http://www.contactlenscouncil.org>.
Optician Association of America. 10341 Democracy Lane,
Fairfax, VA 22030-2521. (800) 443-8997. <<a href="http://www.opticians.org">www.opticians.org>.
Hall, Brenda, and Stephen Jones. "Clinical Performance of a Monthly Lens and Patient Comfort." Contact Lens Spectrum 5(December 2000). <<a href="http://www.clspectrum.com/archive">http://www.clspectrum.com/archive>.
Jameson, Mary. "Education: The Key to Delegation." Contact Lens Spectrum (1996). <<a href="http://www.clspectrum.com/archive_results.asp?article=archive/1996/September/0996033.htm">http://www.clspectrum.com/archive_results.asp?article=archi... > (September1996).
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"Polymer Scientists Engineer Better Remedies."
Pustareri, Thomas J. "Contact Lenses for Today's Lifestyles."
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West, Walter D. "Delegating Technical Tasks to Your
Technicians." Contact Lens Spectrum (1997). <<a href="http://www.clspectrum.com/archive_results.asp?article=archive/1997/October/1097013.htm">http://www.clspectrum.com/archive_results.asp?article=archi... > (October 1997).
Contact Lens (How Products are Made)
The contact lens is a device worn in the eye to correct vision, although some people wear colored contact lens to enhance or change their eye color. The thin plastic lens floats on a film of tears directly over the cornea. For some forms of eye disease, contact lenses correct vision better than conventional spectacles. Many people prefer contact lenses over glasses for cosmetic reasons, and active sports enthusiasts prefer contact lens because of the freedom it provides them. There are basically three types of lenses: soft, hard, and gas-permeable. Soft contact lenses are usually more comfortable to wear, but they also tear more easily than hard contact lenses. Hard lenses also tend to "pop" out more frequently. Gas-permeable lenses are a compromise between the hard and soft, allowing greater comfort than hard lenses but less chance of tearing than soft lenses. Contacts are usually worn during the day and taken out every night for cleaning. Extended-wear lenses allow users to leave in their contacts for longer periods of time, even when they're sleeping. More recently, one-a-day contact lenses are gaining popularity among lens wearers. These contacts are worn for only one day and thrown away, eliminating the hassle of cleaning them every night.
The first contact lens was made by German physiologist Adolf Fick in 1887. Fick's lens was made of glass and was a so-called scleral lens because it covered the sclera, the white part of the eye. By 1912, another optician, Carl Zeiss, had developed a glass corneal lens, which fit over the cornea. Two scientists, Obrig and Muller, introduced a plastic scleral lens in 1938. It was made of the material commonly known as Plexiglas. Because it was lighter than glass, the Plexiglas lens was easier to wear. The first plastic corneal lens was made by Kevin Touhy in 1948.
To fit these early lenses, an impression was made of the patient's eyeball, and the lens was formed in the resulting mold. This procedure was doubtlessly uncomfortable, and the lenses themselves were often problematic to wear. Scleral lenses deprived the eye of oxygen, and many of these earlier lenses slipped out of place or popped out of the eye, and were often, oddly enough, difficult to remove. Touhy's first corneal lens had a diameter of 10.5 millimeters, and in 1954 Touhy reduced the diameter further to 9.5 millimeters, resulting in better wearability. Around this time the Bausch & Lomb company developed the keratometer, which measures the cornea, and eliminated the need for eyeball impressions.
The first successful soft contact lenses were developed by chemists in Czechoslovakia. In 1952, professors in the Department of Plastics at the Technical University in Prague set themselves a task of designing a new material that was optimally compatible with living tissue. They did not set out to create contact lenses, but by 1954 the team of Czech scientists had invented what is called a "hydrophilic" (for its affinity to water) gel, a polymer plastic that was suitable for eye implants. The scientists immediately recognized the new
The raw material for contact lenses is a plastic polymer. (A polymer is a blend of materials created by linking the molecules of different chemical substances.) Hard contact lenses are made of some variant of polymethyl methacrylate (PMMA). Soft contact lenses are made of a polymer such as poly hydroxyethyl methacrylate (pHEMA) that has hydrophilic qualities, that is, it can soak up water and still retain its shape and optic functions. The science of lens material is always being updated by lens manufacturers, and the specific material of any contact lens may differ depending on the maker.
The Manufacturing Process
Contact lenses may be produced by cutting a blank on a lathe, or by a molding process. The forming of the lens involves shaping the plastic into specified curvatures. The major curves of the lens are named the central anterior curve (CAC) and the central posterior curve (CPC). The CAC refers to the overall curve of the side of the lens that faces out. This outer contour produces the correct refractive change to fit the patient's visual needs. The CPC is the concave inner side of the lens. This conforms to the measurements of the patient's eye. Usually these two curves are formed first, and the lens is then called semi-finished. The lens is deemed finished when peripheral and intermediate curves are formed, and the edge is shaped.
- 1 Molding the lens can be carried out in several different ways. The lenses first developed in Prague were spin-cast. Three different fluids were poured into open rotating molds. The outside curvature of the lens was shaped by the mold, and the inside curvature was formed according to the speed of the rotation of the mold. The centrifugal force of the spinning mold led to the polymerization of the fluids so that the molecular chains linked to form the required hydrophilic plastic. A more reliable mass-production
- 2 The initial forming of the lens can also be done by cutting on a lathe. First a blank is made. The blank is a circle only slightly larger than the size of the finished lens. This can be cut from a plastic rod, or stamped from a plastic sheet. Next the blank is fastened to a steel button with a drop of molten wax. The button is then centered on a lathe, which begins to spin at high speed. A cutting tool, which may be a diamond or a laser, makes concave cuts in the blank to form the CPC. Indicators on the lathe measure the depth of the cuts to guide the lens operator.
The button holding the blank is next moved to a lapping machine. The lapping machine holds the blank against a lapper, which is a revolving disk coated with an abrasive compound. The shape of the lapper matches the CPC of the lens. The lapping machine spins the blank in one direction, and the lapper in the other. It also moves the blank in a small figure eight motion. The abrasion polishes the lens surface.
The polished lens is then mounted on a steel shaft called an arbor. The end of the arbor has been ground to match the CPC so the lens will fit on the shaft. The arbor is installed in a lathe, and the operator makes convex cuts in the lens to form the other major curve, the CAC. Now this side of the lens is polished, and the lapper is modified to fit the convex CAC. When this second side of the lens is polished, the lens is considered semi-finished.
- 3 The contact lens requires several more curves to be ground before the lens will fit exactly on the patient's eye. The final curves are the peripheral anterior and posterior curves and the intermediate anterior and posterior curves, which govern the shape of the lens nearest and next-nearest the edge. The lens is mounted on an arbor again by suction or with double-sided tape. The arbor is installed in the lathe or grinding machine. These shallower cuts may be ground with emery paper or cut with a razor blade. The diameter of the lens may also be trimmed at this time.
- 4 Quality control is very important for contact lenses, since they are medical devices and they must be custom fit. The lenses are inspected after each stage of the manufacturing process. The lenses are examined under magnification for anomalies. They are also measured by means of a shadow graph. A magnified shadow of the lens is cast on a screen imprinted with a graph for measuring diameter and curvature. Any errors in the lens shape show up in the shadow. This process may be automatically performed by computer.
- 5 After the lens has passed inspection, it is sterilized. Lens are boiled in a mixture of water and salt for several hours to soften the lens. Next, the lens are packaged. Standard packaging for lenses is a glass vial, filled with a saline solution and stoppered with rubber or metal. The hydrophilic material of soft contact lenses soaks up the saline solution, which is similar to human tears, and becomes soft and pliable. The lenses in this state are ready to wear.
The material for contact lenses is the subject of much research. Scientists are investigating different chemical recipes that may give plastic more desirable characteristics. One polymer currently being researched is a silicon-oxygen compound called siloxane. Siloxane forms a thin, flexible film and admits oxygen through to the eye 25 times better than current standard soft lenses. There are disadvantages to this compound, however: siloxane does not wet easily and it attracts lipids (fats) to its surface, causing it to cloud. Researchers have found a way to add flourine molecules to the siloxane compound, causing the material to resist lipids. Then they chemically attach a wetting agent, which changes its molecular shape when boiled in a saline solution, so that the material can soak up water like traditional soft lens. This material may ultimately lead to extended-wear contacts that can be worn for weeks at a time.
Researchers are also investigating new polymers that can be used for scleral lenses. For most people, comeal lenses are the norm, but the large scleral lenses are useful for patients with severely damaged corneas. Depending on the eye problem, some patients cannot regain their sight without a corneal transplant, but scleral lenses may help patients avoid eye surgery. Scleral lenses rest on the white part of the eye and form a vault over the cornea itself. This space over the cornea is filled with artificial tears, which serve to smooth out the cornea's damaged surface. In the past, scleral lenses have been uncomfortable because they do not allow enough oxygen to the eye, but investigations into new materials are focusing on more oxygen-permeable lenses.
Material for oxygen-permeable lenses has also been experimented on the space shuttle Endeavour. The designers of the experiment believe that microgravity conditions would promote a lens material that repels debris better and processes oxygen more effectively than polymers made in traditional labs. If commercially feasible, a new generation of contact lenses may be manufactured in space.
Where To Learn More
Ruben, Montague, ed. Soft Contact Lenses: Clinical and Applied Technology. John Wiley & Sons, 1978.
"Making Eye Contact." Ad Astra, September-October 1993, p. 5.
"This Contact Lens Is A Sight For Sore Comeas." Business Week, April 20, 1992, p. 94.
"Extending Extended-Wear Contacts." Science News, September 5, 1992, p. 153.