Saba Akram

Spherical Soft Contact Lens

Fitting and the
Effects of Parameter Changes
 Pre evaluation work-up:
 History:
 A meticulous history should be taken prior
to contact lens fitting. Special importance
should be given to:
• Patient emotional status and motivation to
wear contact lenses.
• Medical problems, like allergic reactions.
• History of previous contact lens use and
any problem faced. Allergies or problems
with contact lens solutions
 General ocular examination:
 A complete general ocular examination of anterior and
posterior surface. Special care with:
• Eyeball is abnormally prominent or shrunken.
• Lids are abnormally tight or loose.

• Cornea should be meticulously examined for any

neovascularization, infiltrates, opacities, etc.

• Tear film adequacy should be adjudged.

• Conjuntiva should be evaluated for the presence of any

hyperaemia, follicles, papillae and concretions
 Refraction:
 Should be done promptly and expressed in minus
cylinder. Vertex distance must be taken in higher
power.
 Keratometry:
 Must performed carefully.
 The flattest reading of the two principal meridian
is labelled as k-reading.
 Corneal diameter:
 May be measure with the help of mm rule. For
practical purpose HVID horizontal visible irus
diameter is noted to denote corneal diameter.
 HEMA (hydroxymethymethacrylate)
 About 1-2 mm larger than corneal
diameter
 Advantages: 1. comfortable
2. well tolerated
 Disadvantages:
1. Wettability
2. Proteinaceous deposits
3. Can get torn
4. Limited life
5. Inferior optical quality
6. Cannot correct astigmatism
above 1.00 D
 A spherical contact lens is one in
which both the inner and outer optical
surfaces are portions of a sphere
 Corrects both short- and long-
sightedness
 Cheapest & most comfortable
 Easy to get in a disposable form
 SOFT LENSES
 Alternative names (past and present):
 • Hydrophilic
 • Hydrogel
 • Gel
 • Flexible
 • Limbal & Semi Scleral, Limbal &
Paralimbal
 • Pilable
 Soft Lenses

Range of TDs:
 ∅T = 13 -15 mm

Most common TDs:

 ∅T = 13.5 -14.5 mm
 General Soft Contact
Lens Fitting Philosophy
 SCLs should always be larger than the
cornea
 BOZR flatter than the cornea Lens
 movement, which is generated by the
blinking action of the lids, should be
such that the lens edge does not cross
the limbus.
General Soft Contact
Lens Fitting Philosophy
 When are Spherical Soft
Lenses Applicable
 The lens of first choice
 Spherical refractive errors (≤ 0.75 D cyl)
 When comfort is a prime issue
 Extreme refractive errors including aphakia
 Low Rxs - RGP comfort not balanced by the
small increase in vision
 Significant corneal astigmatism but with a
 spherical manifest Rx
 Fitting Requirements

Soft lenses must:

 • Centre on the eye
 • Conform to the anterior eye
 • Move adequately
 • Cover the corneas in all eye positions
 PERFORMANCE
REQUIREMENTS
 Soft lenses must:
 Produce good and stable vision
 Provide minimal physiological
disturbance
 Be wearable for practical periods
 Be comfortable
 Describing Lens
Centration
 Various methods of describing lens position
have evolved over time
 the two with the widest acceptance are
based on Cartesian coordinates as used in
applied mathematics, or a ‘bi-nasal’
variation of it.
 The difficulty for both of these systems is
the inconsistency of the horizontal
coordinates, i.e. +x for the right eye is a
nasal decentration while +x for the left eye
is a temporal decentration
Centration Examples:
Cartesian System
Centration Examples:
Cartesian System
 Describing Lens
Centration: Binasal System
 nasal centration is described as
positive (+ve) regardless of which eye
is being referred to
 The y coordinates are signed the same
as in the Cartesian system, i.e. up is
+ve and down –ve.
Describing Lens
Centration: Binasal System
Centration Examples:
Binasal System
Decentred Soft Lens
 Decentred Soft Lens
 A lens which is too loose will generally be
excessively mobile and will not centre well
 This is an example of a very loose fitting lens
which not only decentres significantly on down
gaze, but also does not completely cover the
cornea
 It is probable that in the up gaze position the lens
will slide off the cornea almost completely
 This lens is almost certainly uncomfortable and
the vision must be affected because some of the
lens periphery will cover the pupil zone (entrance
pupil).
 Fitting Descriptions
 Good, optimum, ideal
 • Steep, tight, bound
 • Flat, loose, mobile
 • Centered, decentred
 • Low riding, high riding
 • Superior, inferior, nasal, temporal
and combinations of the above
 WHAT GOVERNS LENS
FIT ??
 Relationship between sagittal heights of lens
and anterior eye (lens>eye)
 Anterior eye topography including cornea
 Blink-induced negative pressure under the lens
 Physical properties of the lens:
- physical properties of the material
- Rx
- thicknesses
- lens design
 Lid characteristics, lid/lens interaction
 Sagittal Height, Total
Diameter
 To alter the fit of a lens the relationship
between the sagittal heights of the lens
and the anterior eye must be changed
 a successful fit requires the inner
sagittal height of the lens to be greater
than that of the anterior eye
 To tighten the fit, the lens height must
be made even greater than that of the
anterior eye
 Sagittal Height, Total
Diameter
 to loosen the fit the height must be
made less than normal even though
this sagittal height may still be greater
than that of the anterior eye
 The sagittal height of the anterior eye
is governed by:
• Central corneal curvature.
• Degree of corneal asphericity.
• Corneal diameter
Effect of sagittal height
 Effects of Lens Design
 Assuming all other factors are identical,
lenses having the same sagittal height and
total diameter will not necessarily exhibit
similar behaviour if the back surface designs
are different
 Back surface design in particular is
influential in determining the ‘on-eye’
behaviour of a lens Factors to be considered
include the basis of the shape (spherical or
aspherical), the number of peripheral curves
(if any) and the radii and widths
Effects of Lens Design
 PARAMETER SELECTION
 Total diameter ∅T
 BOZR, r0
 Centre thickness, tc
 Optic Zone Diameter
 Water Content
 Material Selection
 Method of manufacture
 Total Diameter
 Measure HVID
Then either:
 Add 2mm to HVID and select trial lens
 set with nearest diameter or
 Follow manufacture's recommendation
and select suggested diameter
 Altering Soft Lens Fit:
Changing Total Diameter
 An increase in lens diameter will tighten the
fit if all other factors remain unaltered. This is
because the sagittal height is increased. A
decrease in diameter will loosen the fit.
To retain the same fit
 If the diameter is increased, the BOZR must
also be increased to offset the effect the
diameter change has on the ratio of sagittal
height to total lens diameter. Retention of
lens fit requires an approximately constant
ratio of sagittal height to total diameter
 Altering Soft Lens Fit:
Changing Total Diameter
Rule of Thumb (Soft Lenses):
 Increase diameter by 0.5 mm ≈
Increase BOZR by 0.3 mm
 If the lens diameter is increased by 0.5
mm then the BOZR should be
increased by 0.3 mm to retain the
same fitting characteristics
 ΔTD 0.5 mm ≈ Δ BOZR 0.3 mm
 Back Optic Zone Radius
(BOZR)
 Measure Ks (mm) then add either:
 0.3 - 0.9 mm to flattest K
 1 mm to average of Ks
 Select lens of nearest BOZR from ∅T
trial set
 Back Optic Zone Radius
(BOZR)
 Measure Ks
 Select trial lens from manufacturer's

fitting guide for ∅T lenses

 Add 0.7 mm or more to flattest K for
less flexible lens materials (thicker, low
water)
 Add 0.3 - 0.6 mm for standard and
flexible materials (thinner, high water)
 BOZR CALCULATION
 FLATTEST K = 7.80mm
 STEEPER K = 7.70 mm

Suggested Lens
 + 0.7 mm: BOZR = 8.50
 This data suggests a BOZR steps are
about 0.3 mm, select an 8.5 or 8.6
 These are guides or starting points
only but all methods yield similar
results
 BOZR
 Range: 7.90 - 9.30 mm
 More significant in thicker, less flexible
lenses
 Almost irrelevant in thin, very
 flexible lenses
 Steep corneas are fitted relatively
flatter than normal or flat corneas
 Altering Lens Fit: BOZR
 If all factors remain unaltered, especially
the total diameter of the lens, then
decreasing the BOZR will steepen the lens
fit
 increasing the BOZR will loosen the fit. This
is because these steps increase and
decrease the sagittal height
 To replicate a lens fit, both BOZR and total
diameter must be altered in order to
maintain the ratio of sagittal height to total
diameter
 Effect of Thickness
Change on Lens Fit
 Thick lenses interact more with the lids
and therefore move more on a blink.
The greater relative lens mass of such
lenses is of little consequence
compared with the other factors acting
on them. Thick lenses and/or lenses
with thick edges will also result in
greater lens decentration
 Effect of Thickness
Change on Lens Fit
 Very thin lenses, especially if their edges are
also very thin, interact less with the lids and
tend to move less. Thin lenses and/or lenses
with thin edges will also tend to centre better
 Because of their flexibility, very thin lenses
conform to the anterior eye shape very closely
such that the very thin post-lens tear film
makes lens movement difficult (thin film in
shear requires a displacing force which is
proportional to the inverse of the film thickness
. Such lenses move little with each blink
 Optic Zone Diameter
Selection
 Usually defined by FOZD
 Usually 8 - 11 mm
 For high Rxs, as small as 7.5 mm
 Must take pupil size in
photopic/scotopic
 illumination into account
 The Rx may influence choice:
 - larger if Rx is low
 - smaller if Rx is high
 Effect of FOZD on Lens
Fit
Smaller
 - more flexible periphery
 • less movement
 • greater lens decentration possible ?

Larger
 - less flexible periphery
 • more movement
 • less lens decentration possible ?
 Effect of Changing the Water
Content
 Any factor which alters lens rigidity
alters the fitting behaviour of a lens
 A lower rigidity increases lens
conformity which thins the post lens
tear film
 when a lens material is changed to one
with a higher water content, less
movement is expected
 Empirical Prescribing

Patient data required for lens choice:

• HVID
• Ks
• Spectacle Rx
• Vertex distance
 Empirical Prescribing
 Advantages:
 • Simple and quick for the practitioner
 • No trial lenses required
 - cheaper for manufacturer
 - no lens maintenance/storage by
practitioner
 - no public health issue with trial lens
reuse
 manufacturer to prescriber's advantage
 Empirical Prescribing
 Disadvantages:
 • Exceptions always exist
 • Patients don't experience lens wear before
delivery
 • Practitioner cannot observe patient's
response to
 lenses
 • Practitioner seen to be abdicating their
responsibility
 • Accuracy of outcome ?
 • Fit is more complicated than just HVID & Ks
 The Trial Fit
 Regarded as essential by some
 • Allows the 'feel' of a lens to be experienced
 • Patient reaction is assessable
 • Needs to be performed in average
illumination
 (pupil size)
 - assessments made with the aid of good
 illumination
 - low to moderate magnification
 • Now easier and safer - disposable trial lenses
 Trial Lens Settling
Period
 Record assessment after lenses settle
 Settling period normally 5 minutes
 Further assessment may be necessary
after 3-4 hours
 What to Assess During
Lens Trial
 Centration
 Position & movement on blink with eye in:
a. primary position
b. lateral gaze
c. up-gaze
d. rapid & extreme lateral eye movements
 • Lower lid push-up test in primary gaze
 • Edge condition
 What to Assess During
Lens Trial
 Observe lens decentration and/or lag
under the following circumstances
 Primary gaze (while 0.2 to 0.5 mm is
more common, 1.0 mm is probably
excessive, depending on lens flexibility).
 Up gaze (up to 1.5 mm acceptable
provided it is consistent).
 Lateral eye movements (up to 1.5 mm
acceptable providing it is consistent).
 Corneal Coverage
 centration (soft lenses often decentre
up and sometimes up and out)
 shape regularity A decentred lens, when
conforming to the anterior eye shape,
may affect the optical performance
 A decentred, conforming soft lens will
have some localized thinning of the
post lens tear film in the regions of
heaviest touch (greatest bearing
pressure
 Corneal Coverage
 The Need for Corneal Coverage
• Mechanical:
 Comfort.

A decentred lens, especially a mobile

decentred lens, may be less comfortable
than a centred lens exhibiting optimal
soft lens movement
 Corneal Coverage

The Need for Corneal Coverage

 Physiological
 corneal exposure can lead to discomfort
 corneal dessication
 tear film disturbance, lens & eye Wettability
 Loss of the aqueous phase may lead to lipid
contamination of the mucin layer potentially
affecting the eye’s wettability.
 About 1 mm symmetrical overlap, and in all
positions of gaze, is considered ideal