Beruflich Dokumente
Kultur Dokumente
MEASUREMENT
454 The role of tears in contact lens performance and its measurement
that compensates for the micro-irregularities second antimicrobial activity is mechanical
of the anterior epithelial surface (see Chapter and associated with the mucus system that
(0). The PLTF similarly compensates for the forms a strand that traps small particles such
irregularities such as scratches and/or depos as bacteria and eliminates them (Holly &
its that rapidly appear at the surface of both Lemp, 1977).
rigid gas permeable (RGP) (Allary et al., The presence of a contact lens alters the
1989a,b), and hydrophilic contact lenses tears' antibacterial activity. Several studies
(Allary et al., 1989b; Guillon et al., 1992) have shown that the conjunctival flora is
during use. altered by the presence of a contact lens
(Rehim & Samy, 1988), usually with a reduc
tion in antibacterial activity. Recently, how
Protective action
ever, studies have suggested no effect
(Elander et al., 1992), and at least one study
Removal of foreign bodies
(Boles et al., 1991) has shown that ionic lenses
There are two aspects to the removal of that attract high levels of lysozyme during
foreign bodies. First, there is the well known wear offer an enhanced antibacterial activity.
removal of airborne particles and/or chemi
cal irritants that takes place by the flushing of
Lubrication
the anterior ocular surfaces via reflex lacri
mation, but also as important is the action of The presence of relatively large amounts of
the basal lacrimation that removes the mucin along the lid margins and the sponta
necrotic epithelial cells from the anterior ocu neous mucin spread over the whole corneal
lar surface (Lemp, 1976), via the normal surface during blink (Lemp et al., 1970)
blinking action and the specific role of the ensures that no direct solid-to-solid contact
mucous component of the tear film (Holly & takes place during blink. This lubricating
Lemp, 1977). In fact this latter role is the key action is essential for an efficient, trauma
to successful contact lens wear, in particular free blink action. Similarly, when a contact
for extended wear. For that modality of wear lens is worn the mucin coating contributes to
it has been shown that unless all epithelial ensuring a trauma-free contact lens move
metabolic debris, that may be trapped ment. In fact, variation in the nature of the
between the contact lens and the cornea, are lens coating during overnight wear leads to a
totally flushed within four hours of· eye highly viscous PLTF at waking and reduces
opening, adverse ocular reactions will most contact lens movement at that time of day
likely take place (Mertz & Holden, 1981). (Guillon, 1991; Guillon & Guillon, 1991).
Introductory comments
Geographic tear distribution
The lacrimal system can be divided into
The tear volume that totals approximately three components: secretory, distributional
7 111 (Mishima et al., 1%6) to 8.5 111 and excretory. The secretory component is
(Furukawa & Polse, 1978) is best described in made up of a series of glands distributed
two parts: the exposed tear volume (ETV), throughout the anterior ocular surface. The
which is in direct contact with the air, and distribution relates to the distribution of
the unexposed tear volume (UTV) (Port & tears over the ocular surface. The excretory
Asaria, 1990). The exposed part of the lacri component refers to the elimination of tears
mal fluid that constitutes just under half the from the eye.
total volume (Mishima et al., 1966) is the
most significant one as far as contact lens
wear is concerned. The E1V is divided into
the preocular part, a thin continuous layer
covering the cornea and exposed conjunctiva
and a marginal part, called alternatively lid
tear meniscus or lid tear prism, situated
along the upper and lower lids. It is esti
mated that between 72.5 and 90% (Mishima
et al., 1966; Holly, 1981; Kwok, 1984; Bron,
1985; Guillon & Guillen, 1988a; Port &
Asaria, 1990) of the ETV is found within the
lid tear meniscus. On average the lid tear
meniscus has a volume of 5.25 111 and the
pre-ocular part a volume of 1.75 111 (Mishima
et al., 1966). The most critical part of the tear
film is the junction between the lid tear
meniscus and pre-ocular tear. At that point
the surface tension forces present make the
formation of a continuous film near impos Figure 21.2 Schematic representation of junction
sible (Holly, 1978) (Fig. 21.2). The result is a between tear meniscus and pre-ocular tear film
line of minimal thickness, often referred to as (by courtesy of McDonald, 1968).
Pre-ocular tear film characteristics 457
GI8nds
of Kr.u••
Tear production
The secretory component is responsible for
both the basal and reflex tear secretions. The Mar. GI8nda /'
blinking process, that lasts on average 0.3 s :.: .;: _: _: • TEAR FLUID
(Doane, 1980). Holly (1973a) was the first to £~!!~II;;t'i~ ADSORBED MUCIN LAYER
r "
describe this process fully, and a summary of I l( I CORNEAL EPITHELIUM
STABLE TEAR FILM
this description is of help to explain contact BREAK UP
lens on-eye wettability and the relevance of
the various clinical tests. The closing of the ~~ pff)
lids has three effects (Forst, 1982): '§gJ/,:yj?g
tears. TEARS
2. It redistributes the mucin over the ocular Figure 21.5 Diagrammatic representation of the
surface, to render it highly wettable. mechanism of dry spot formation (by courtesy of
3. It squashes the lipids between the upper Holly, 1973a).
and lower lid edges.
affect the pre-ocular tear film (Ehlers, 1965).
During lid clusure the lipids are prevented
from migrating under the lids due to the lid Tear Excretion
edge mucous and fonn a thick film in the
narrow space between the two eyelids The tears leave the ocular surface via three
(Holly, 1980). mechanisms: (1) the exchange of tears across
The opening of the eyelids redistributes the conjunctival surface: (2) loss due to
the aqueous tear immediately, along with a evaporation; and (3) tear drainage at the
monomolecular lipid layer at its anterior sur puncti. In humans it has been estimated that
face (Holly, 1973b). A secondary upper lipid between 8% (Schirmer, 1903) and 20% (Mau
motion accompanied by a slight increase in rice, 1973) of the tear film is eliminated each
the aqueous layer follows. The process minute by exchange across the conjunctival
results in a stable tear film less than Is after surface. The amount of tears lost by evapora
eye opening. tion depends greatly upon environmental
In between blinks, the tear film destabi conditions, in particular, relative humidity
lizes relatively rapidly, leading to the forma and turbulent air flow (Holly, 1973b). ;\
tion of dry spots that trigger the next blink. decrease of the first and an increase of the
Dry spots are thought to be due to the second contribute towards increasing the
migration of the superficial lipids towards evaporation. A recent study indicates that
the ocular surface, rendering it hydrophobic evaporation could eliminate tears at a rate of 10
by contaminating the mucous coating (Fig. to 15% per minute (Tomlinson et al., 1991).
21.5) (Holly 1973a). The rapidity of the con Finally during blinking, tears are pushed
tamination is increased by the local thinning towards the puncti at the inner canthus, where
of the aqueous tear film when, as during they are passed in the nasolacrimal duct.
contact lens wear, the overall tear film is
21.3 CLINICAL EVALUAnON TECHNIQUES
thinner than normal. The latter is a very
important determining factor in producing a
21.3.1 INTRODUcrORY REMARKS
low tear film stability.
In between blinks, a vector flow also exists Numerous routine and/or research clinical
which is limited to the upper and lower tear techniques have been used to study the tears
prisms (Holly & Lernp, 1977) and does not of the contact lens wearer (Guillon, 1990).
Clinical evaluation techniques 459
Initially the techniques used were those that 21.3.2 EVALUATION OF THE TEAR FILM
had been developed to study patients with STRUCI1JRE AND ADJACENT STRUCI1JRES
pathological dry eye, such as the Schirmer
test (Schirmer, 1903). Such tests proved to be Lid edge anomalies
of limited use for the evaluation of contact
lens wearers. More recently, clinical tech Introductory remarks
niques have been either modified and/or
Anomalies of the lid border, where the
developed with the prime objective the con
exposed tear film comes into contact with the
tact lens wearer (Guillon, 1990). Some of the
complex ocular structures present at the lid
techniques developed are limited to the
edge, must be considered when evaluating
research environment. In this category are all
the tears of the contact lens wearer (Guillon
the techniques that aim to measure tear
& Guillon, 1989b). This assessment is carried
evaporation, using evaporometers with dif
out under diffuse lighting and involves the
ferent levels of invasiveness (Hamano et al.,
assessment of both the upper and lower lid
1981; Cedarstaff & Tomlinson, 1983; Rolando
margins. The structures of particular interest
& Refojo, 1983) and techniques to measure
are the lashes and meibomian gland orifices.
tear flow rate using modified fluorophotom
eters (Benedetto et al., 1984; Occhinpinti et
al., 1988). Also in this category are the tech Observations and classifications
niques that use biodifferential interference
microscopy (Hamano et al., 1979) to study the Lashes The lashes are a potential source of
structure of the tear film. These techniques contamination of the tear film because of
will not be discussed in the current chapter. their close proximity to the tear meniscus.
This chapter is limited to research and/or Scaly lashes associated with epidermic prob
routine techniques that can be used or lems and contamination associated with
easily introduced in general clinical rou make-up are often encountered. The level of
tine. These techniques can be divided into contamination of both the lower and upper
two groups based upon the instrumenta lashes can be classified into five categories:
tion used. The majority are based around
l. Clean lashes.
the slit lamp biomicroscope and include
2. Scaly lashes.
easier, alternative ways of using the instru
Light make-up contamination.
ment or special attachments. The second
4. Medium make-up contamination.
group of techniques are those that stand
5. Heavy make-up contamination.
alone (e.g. Schirmer) or use other instru
ments such as the keratometer. The Any contamination present or scales due to
approach adopted in this chapter has been epidermic problems should be eliminated
to group the techniques into three catego before contact lens fitting is undertaken or
ries according to their aim: (1) evaluation during any refitting process. In the latter
of the tear film structure; (2) evaluation of case, if symptoms are present, elimination of
the tear volume; and (3) evaluation of the these problems is an essential requirement.
tear film stability.
The same techniques are directly appli Lid margin
cable to the evaluation of both the pre-ocular
and pre-lens tear films, and therefore Foam Abnormal meibomian secretion pro
described as one; when minor differences duces bubble-like formations mostly at the
are present they are highlighted. canthus and, in more severe cases, along the
lid margins. The appearance of these forma
460 The role of tears in contact lens performance and its measurement
tions, referred to as 'foam' are classified into
seven categories according to their location:
O. None.
1. Upper lid.
2. Lower lid.
3. Both lids.
4. Canthus.
5. Canthus and lower lid.
6. Canthus and both lids.
MICROSCUECTIVE
REFLECTING
OCULAR SURFACE ~
<,
Figure 21.11 Schematic diagram of wide field lighting system for tear film observation.
clear image of the tear film (Fig. 21)2), only SA = incident ray
AS = partial refraction
d
General physical interpretation of the
observations
The initial observations made revealed the
presence of interference fringes (Marx, 1921;
Vogt, 1921; Meesman, 1927) and the occa AL, and Cl2 will produce interference fringes on
Figure 21.22 Abnormal colour fringe lipid pat Figure 21.23 Meshwork/flow combination pat
tern. tern visible at low magnification.
Clinical evaluation techniques 469
implications of moderate or severe con
tamination depends upon the types of con
taminants.
Regardless of the lipid pattern present it is
essential to assess the level of the tear surface
contamination by mucus strands, epithelial
or atmospheric debris and make-up.
1. Mucus and other surface debris create
localized tear film instabilities, which
reduce the break-up time and favour
deposit formation. Great care should be
taken in fitting those patients and the
use of in-eye rewetting agents is recom
mended. Daily wear soft contact lenses
should be changed regularly, possibly
every month as part of a planned
replacement programme. Extended wear
should be avoided unless a regular
replacement programme is implemented
Figure 21.24 Amorphous/coloured fringe pattern or a disposable lens system (e.g. Acu
visible at low magnification.
vue) is used. Rigid lenses should be
changed regularly, preferably every six
Lipid layer thickness (nm) = months.
Palpebral aperture at appearance 2. Contamination by make-up products
200 nm X of first red colour fringe (mm) such as oily removers or creams com
pletely destabilizes the lipid layer (Fig.
Normal palpebra! aperture (mm)
21.25) and produces areas of non
wetting at the contact lens surface.
Lipid layer contamination classification The
Patient habits and make-up products
contamination of the superficial lipid layer
must be changed before contact lens
must be assessed regardless of the pattern
fitting is undertaken.
observed. The presence of contaminants
within the lipid layer always destabilizes
Aqueous layer The aqueous layer is only
the tear film. The classification of lipid
visible in the pre-lens tear film. Two aspects
contamination should be carried out
of the aqueous layer have been evaluated, its
according to the types of contaminants and
visibility and estimated thickness.
their severity. One such classification
(Table 21.3) has proved useful. The clinical 1. Aqueous layer visibility. The visibility
to the tear prism, and alters the slit width until ate tears in vivo. Whereas the test does not
it apparently matches the height of the tear identify the origin of any anomaly that may
prism. In order to obtain a value in milli affect the tears, it is the single quantitative
metres, it is only necessary to calibrate once evaluation that indicates whether or not the
the rotation of the knob that controls the slit tears are maintaining an efficacious wettabil
width using a microscope scale. ity, with or without contact lenses. The con
In the proposed routine the tear prism ventional way of measuring tear film stability
height is measured in three positions: has been to measure the tear film break-up
(1) immediately below the pupil centre; time (BUT). The BUT is defined as the elapsed
(2) 5 mm nasally; and (3) temporally. This time in seconds between eye opening follow
approach enables us not only to evaluate ing a full blink and the appearance of the first
the tear volume, but also to quantify the break within the tear film.
regularity of the tear prism. The results The tear film is not normally visible; tradi
obtained on a unselected population of 121 tionally the BUT has been measured after the
patients aged 17 to 82 years show the lower instillation of fluorescein. Fluorescein stains
tear prism height to be normally distrib the tears green; the breaks within this film
uted (Fig. 21.27)/ peaking at 0.22 mm and appear as black spots. However, as pointed
giving widely ranging values from a mini out by authors who have used the technique
mum of 0.1 mm to a maximum of 0.8 mm. recently (Hamano et al., 1982; Mengher et al.,
The evaluation also shows that, overall, 1985a; Patel et al., 1985; Guillon & Guillon,
men had a greater tear prism height than 1989a), the results obtained are not reliable.
women and that, in both cases, the tear The main drawback of the technique is its
prism height decreased with age. invasive nature. A drop of 1 or 2% fluores
cein is instilled in the lower canthus gener
21.3.4 EVALVATION OF THE TEAR FILM ally/ or impregnated paper is applied to the
STABILITY bulbar conjunctiva.
In order to colour the tears, the fluorescein
must break through the lipid layer and totally
General remarks
disrupt that layer, with the tendency of desta
The evaluation of the stability of the tear film bilizing the tear film. At the same time, the
is possibly the most important test to evalu instilled fluorescein introduces a large volume
472 The role of tears in contact lens performance and its measurement
of liquid in relation to the pre-ocular tear seven in total. They fall into two categories;
volume, and has the tendency momentarily to those with a small measurement field and
increase the stability of the tear film. Because those with a wide measurement field (Table
the relative influence of the two effects is 21.5).
highly variable from patient to patient, and The narrow field techniques are of limited
even from time to time, the results obtained use as they involve only a small part of the
with the technique are unreliable. The values cornea. In general, the smaller the field, the
obtained are not well correlated with the BUT lower the correlation with the full field mea
measured by non-invasive techniques (Meng surements. A recent study involving the
her et al., 1985a; Patel et al., 1985; Guillon & non-invasive break-up time (NIBUT) mea
Guillon, 1989b). The fluorescein BUT therefore surements by conventional slit lamp specular
cannot be used, even as a challenge test, and reflection; keratometry and hand-held kera
has the further drawback of being unsuitable toscopy, and with the Tearscope (Guillon et
for use while hydrogel lenses are being worn. al., 1992), showed that the best prediction of
The tests of interest are therefore the avail the wide angle measurements was with the
able non-invasive tests. The following is a hand-held "keratoscope. Hence this instru
description of these tests. ment and the modification to the keratom
eter target designed by Hirji and Callender,
Non-invasive break-up time measurements and known as the IR-CAL modiciation (Hirji
et al., 1989), are the most useful of the narrow
Introductory remarks field instruments.
The NIBUT instruments, both narrow and
The instruments used to measure the non wide field, also differ according to the nature
invasive break-up are, to our knowledge, of the target. Some have a dark background.
The intrinsic values obtained by any practi Verv few studies have considered in detail
tioner is technique-dependent, as indicated the effect of contact lenses on the structure
earlier, but even for a given technique, there and stability of the tear film. It is our recom
474 The role of tears in contact lens performance and its measurement
%
40...,....------------------,
carried out with hyperthin (0.035 mm), 38%
35
30
HEMA lenses (03' 04) (Guillon et al., 1989;
25
Guillon et al., 1992) shows that, both at issue
20 and after one week of extended wear, the
15 PLTF lipid layer is most commonly absent or
10 very thin (Fig. 21.29); this is a marked con
5 trast to the POTF lipid layer, which most
o commonly has a thicker flow or amorphous
5 10 15 20 25 30 35 40 >45
NIBUT IMe) pattern. Another study has shown that with
Figure 21.28 Non-invasive break-up time distri new, high water content lenses of conven
bution (by courtesy of Guillon & Guillon, 1989). tional thickness, Prima from Igel (67%) and
Bausch & Lomb 70 (70%), the PLTF lipid
layer is predominantly a wave pattern (Fig.
mendation that the pre-lens tear film should 21.30), and hence only marginally thinner
be evaluated carefully for all contact lens than the POTF lipid layer. It would be easy to
patients both at the time of fitting and dur conclude from these two studies that a high
ing aftercare. The interaction is complex and water content contact lens has a thicker lipid
the evaluation of the pre-ocular tear film layer. We prefer to limit oar conclusions to
alone is not sufficient to predict contact lens the fact that thick high water content contact
wettability for individual subjects. Also, the lenses hold a thicker lipid layer than hyper
pre-lens tear film (PLTF) changes are precur thin, low water content contact lenses.
sor to other contact lens surface changes, that The visibility of the aqueous fringes is
lead to adverse effects such as decrease in regulated by the relative intensity of the light
comfort and tear related problems. Monitor reflected at the interfaces of that layer. This is
ing the PLTF during aftercare permits us to influenced by a combination of factors,
decide whether a conventional soft or rigid mainly the lens surface refractive index, the
contact lens, or a regularly replaced contact thickness of the aqueous phase, and the
lens, needs to be changed (Guillon et al., presence and thickness of a superficial lipid
1992). layer. The visibility of these interference
fringes is at its lowest when a thick, highly
21.4.2 SOFf LENSES
reflective lipid layer is present (as in the
pre-ocular tear film), thus limiting the
amount of transmitted light available for
Pre-lens tear film structure
interference fringe formation in the aqueous
The structure of the PLTF is different to that layer. The visibility of the interference
of the pre-ocular tear film (POTF) for the colours produced by the aqueous layer will
same group of patients, and also differs with also be low when the aqueous layer present
different lens types and wear situations. is thick, thereby inducing a further decrease
Whereas one would like to generalize from in the visibility of its fringes by spatial
simple short-term experiments as to the narrowing and by intensity loss through
effect of the various parameters, such an successive reflections and by destructive
approach is not possible. In particular, the recombination of successive orders of inter
suggestion that the thickness of the lipid and ference. When the surface refractive index of
aqueous layers are greater with high water the contact lens material is near to that of
content materials (Young & Efron, 1991), is water, such as in high water content contact
too simplistic. lenses, the visibility is also low (Fig. 21.31).
For daytime measurements, a recent study The visibility of the underlying interference
Effects of contact lens wear 475
60 _Baseline
50 01 Week
40
'# 30
20
10
0 ....- --
None Spot Band Surface Uds edge
Prelens tear film breakup type at
issue and after 1 week wear
Figure 21.29 Pre-lens tear film lipid layer distribution with hyperthin low water content contact lenses
(Bausch & Lomb 03,04) by courtesy of Guillon et al., 1992).
55
50
45
40
~
35
!.-
Ql
u 30
c
Ql
't:I
'u 25
.=
20
15
10
5
0 s:
Do
~o
"
Ql
c
c
IV '"
Ul
II>
:> 0 IV
.J:::.
52 0 E
0
z
Q.
0 u ~ <l: u a
Meshwork fringes
Figure 21.30 Pre-lens tear film lipid layer distribution with conventional thickness high water content
contact lenses (Igel Prima and Bausch & Lomb 70) for both open eye wear 0 and immediately (3 min)
following overnight closed eye wear ~ (by courtesy of Guillon & Guillen, 1989b).
fringes will be maximized when the water lenses (Fig. 31.32), where a thick, invisible
content is low, such as in HEMA lenses. The aqueous layer is still the most common fea
surface also plays a part; when of poor qual ture.
ity the interference fringes will be minimal. A significant change in contact lens wetta
Because of the relative visibility, the thick bility takes place during overnight wear. In
ness of the aqueous fringes can be assessed an early study with high water content lenses
principally with low water content contact (Igel, Prima, and Bausch & Lomb 70) (Guillon
476 The role of tears in contact lens performance and its measurement
100
90
80
70
;e 60
!..
eo
g
eo 50
~
'0
E. 40
30
20
10
Figure 21.31 Pre-lens tear film aqueous layer visibility distribution with conventional thickness high
water content contact lenses (Igel Prima and Bausch & Lomb 70) for both open eye wear 0 and wear
immediately (3 min) following overnight closed eye wear ~ (by courtesy of Guillon & Guillen, 1989b).
60 _Baseline
50 01 Week
40
<fl. 30
20
10
o '-----I:=L..
Absent <5 5-10 >10 Thick not
Fringe no visible
Prelens tear film aqueous layer
at issue and after 1 week wear
Figure 21.32 Pre-lens tear film aqueous layer fringe distribution with hyperthin low water content
contact lenses (Bausch & Lomb 03,04) (by courtesy of Guillon et al., 1992).
& Guillon, 1989c), we have shown that much thicker mucous coating was also vis
approximately 3 min after eye opening, a ible. A recent study (Guillon & Guillon,
thicker lipid (Fig. 21.30) was present than 1991), with disposable lenses (Acuvue and
during open eye wear; at that time the aque NewVues) involving both the evaluation of
ous layer was essentially invisible (Fig. the PLTF immediately upon eye opening and
21.31). In addition, soon after eye opening, a 3 min later, has greatly increased our under
Effects of contact lens wear 477
standing of the change in wettability during tion between water content and PLTF stabil
overnight wear. Immediately upon eye open ity. This study, however, did not consider
ing the aqueous,layer is usually absent and other factors, such as contact lens thickness
the tear film is a very thick, lipid-coated and the nature of lens surface characteristics.
mucin layer. With the initiation of reflex Our studies have shown that the PLTF
blinking, the aqueous part of the tear film stability measured by the NIBUT with the
quickly reforms but, because the mucous tearscope is lower than that of the POTF,
coating was better than normal, a thick aque before contact lens insertion, for the same
ous layer forms within a few blinks, hence group of patients (Guillon & Guillon, 1988c).
the observations made in the first study were In this investigation the difference was
confirmed in the second, more extensive highly significant, with only 2% of eyes with
study. A clinical implication of those find a PLTF NIBUT of 45 s or more versus 60% for
ings is the reduced contact lens movement the POTF NIBUT. Also, the PLTF NIBUT,
present at waking compared to pre-closed both with conventional thickness high water
eye wear. This phenomenon is due to the content lenses (Guillon & Guillon, 1988c) and
viscous tear film that reduces movement and with low water content lenses (Guillon et al.,
not to the physical tightening of the lens fit 1992), peaked between 5 and 10 s. The lens
due to water loss and lens steepening. geometry also affects the PLTF for HEMA
lenses. Lenses with a standard thickness and
the ultra-thin lenses such as Z6 (Hydron) and
Pre-lens tear film stability
U3 (Bausch & Lomb) have a thicker, more
Young and Efron (1991), in addition to find stable PLTF than the hyperthin lenses such
ing a change in PLTF structure associated as Z4 (Hydron) and 03-04 (Bausch & Lomb),
with lens water content, also found a connec where the lipid layer at times may become
50
45
40
35
15
10
ou...o--~~,-
Figure 21.33 Pre-lens tear film non invasive break-up time distribution (0 open eye; ~ closed eye) (by
courtesy of Guillon & Guillon, 1989b).
478 The role of tears in contact lens performance and its measurement
invisible. In association with the changes in ocular tear film. This factor has been shown
tear film structure that take place overnight, to be associated with corneal desiccation
the PLTF stability is greatly altered. Immedi (Guillon et al., 1990). Another aspect of the
ately upon eye opening the PLTF NIBUT is, location of the initial break is its carity in the
in the majority of cases, extremely short (less central part of the contact lens (approxi
than 1 s), but, within a few minutes, becomes mately SOlo). The implication is that all the
longer than the PLTF found during normal narrow field instruments will fail to detect
open eye wear (Fig. 21.33). the initial break, and hence fail to measure
An important aspect of the measurement the true NIBUT, in the majority of cases.
of the break-up time is the classification of Finally, with regard to hydrogel lenses, we
the position and type of breaks that take have shown (Guillon et al., 1992) using the
place within the tear film. We classified the NIBUT measurement as a means of deter
types of break in five categories: none, spot/ mining when a lens needs to be changed,
band, surface and lid edge breaks. Spot/ a phenomenon that is highly patient
band and surface breaks are increasing levels dependent. Our recommendation is to change
of break severity. Most commonly a 'band' or a contact lens if the NlBUT is decreased by >
'surface' break takes place (Fig. 21.34); a high 25% lower than the base line value and is less
incidence of the latter is an indication of poor than 10 s.
in vivo wettability, whereas a high incidence
of spot break is usually associated with a 21.4.3 RIGID LENSES
stable pre-lens tear film.
The location of the initial break is an
Pre-lens tear film structure
important piece of clinical information. Most
often the initial break takes place in the
Lipid layer
upper and/or lower quadrants, and very
rarely in the nasal and temporal quadrants Contrary to the hydrogel lenses, the charac
(Fig. 21.35). The reason for this is the destabi teristics of the PLTF over rigid contact lenses
lization of the tear film at the junction are more affected by the lens geometry and
between the lid tear meniscus and the pre associated lens movements than by the
50
40
~
z;
Q) 30
o
c:
Q)
"0
'0 20
E
10
0
Cent Nas Inf Temp Sup >1 Zone
Figure 21.34 Distribution of different types of break that take place at the front of hyperthin low water
content contact lenses (Bausch & lomb 03,04) (by courtesy of Guillon et al., 1992).
Effects of contact lens wear 479
50 • BaseUne
40 01 Week
30
~
o
20
10
nature of the material (Madigan & Holden, only partially covers the PLTF of rigid contact
1986). This, however, does not imply that lenses. This absence of lipid Stems to be
material differences have no influence on independent of the material used, as it has
wettability (Benjamin, 1987). Typically, in been observed in approximately the same
front of PMMA or RGP lenses, the lipid layer percentage (45%) of new lenses with materi
is absent or so thin that it is neither visible als as different as PMMA, silicon acrylates
nor effective in preventing rapid destabiliza and fluorosilicon acrylates. Furthermore, as
tion of the PLTF. Therefore, in addition to these lenses are worn, the incidence of cases
classifying the lipid pattern when visible, we showing no lipid coverage increases, sug
rate the amount of the lens surface covered gesting a more abnormal pre-lens tear film
by lipids (Guillon et al., 1989): with long-term wear. When present, the
lipid layer is always thin, as demonstrated by
O. Lipid coverage absent.
the observed PLTF lipid patterns.
1. Lipid coverage> 0% and ~ 25%.
With RGP contact lens wearers, the ocular
2. Lipid coverage> 25% and ~ 50%.
surface away from the lens is covered by a
3. Lipid coverage> 50% and ~ 75%.
normal POTF with the superficial lipid layer
4. Lipid coverage> 75% and ~ 100%.
visible. We believe that the edge of the
Typically the pre-lens lipid layer on poly contact lens acts as a barrier to the propaga
(methyl methacrylate) (PMMA) lenses is tion of the superficial lipid layer over the
invisible and the aqueous layer forms a con surface of the thin, unstable, aqueous pre
tinuously thinning wedge, the thickness of lens tear film.
which can be measured by the photography
of the interference fringe pattern and the
Aqueous layer
determination of the orders of interference.
In the case of PMMA lenses, the intensity of PLTF aqueous thicknesses of up to 2.5 urn
the coloured fringes formed within the aque have been measured in front of PMMA cor
ous phase is at its maximum due to the neal lenses. These thicknesses increase to up
absence of lipid layer interference, the thin to 3.5 urn with the administration of one
ness of the aqueous layer, and the high drop of wetting solution containing 5% poly
refractive index of the contact lens material. vinyl pyrrolidine. However, even over this
The lipid layer is either totally absent or aqueous film of increased thickness, no vis
480 The role of tears in contact lens performance and its measurement
ible lipid layer has been observed. Dk RGP materials, with similar in vitro wet
The aqueous layer in front of RGP lenses is ting angle, than with conventional PMMA
also thin, and has been estimated to be lenses (Lydon & Guillon, 1986). Similarly the
between 1 and 4 urn, most commonly 2 to PLTF NlBUT of fluorosilicon acrylate
3 urn with silicon acrylates and fluorosilicon (Equalens 1) has been reported to be longer
acrylates. The aqueous layer thickness seems than the PLTF NlBUT of two silicon acrylate
to be patient-dependent but not material-, materials (Boston IV and Paraperm EW)
lens-care- or time-dependent over a six (Guillon & Guillon, 1988d). The latter con
month investigation. The mucous coating firms a previous report indicating also a low
found on the lens front surface of lenses that incidence of deposits with fluorinated poly
show good aqueous coverage and good wet mers (Feldman et al., 1987). However, more
tability is always slight to moderate. importantly than the average response, it is
Two studies have recently confirmed the interesting to note that some individuals do
above statement: (1) in a daily wear study of perform better with certain RGP materials,
six-months duration with Boston IV, Parap and therefore an extended trial fitting with
enn EW and Equalens I, the lipid layer was different materials is useful in problem cases.
absent in 44% of cases and covered the
whole contact lens surface in 22% of cases. REFERENCES
The mean aqueous thickness was estimated
at approximately 2 JA.m in that study; (2) in an Adler, F.H. (1%5) The cornea. In Physiology ot the
extended wear study with Equalens 2 and eye (4th edn), CV Mosby, St Louis.
Fluoropenn, also of a six-month duration, Allansmith, M.R., Kajiyama, G., Abelson, M.B.
and Simon, M.A. (1976) Plasma cell content of
the lenses generally supported a thin lipid main and accessory lacrimal glands and con
layer and aqueous layer of approximately junctiva. Am. J. Ophthalmol., 82, 819-26.
4~. Allary, J.c., Mapstone, V., Guillon, J.P. and Guil
lon, M. (1989a) Rigid gas permeable lens surface
evaluation. J. Br. Contact Lens Assoc. Trans. Ann.
Tear film stability Clin. cs«. 18-19.
The tear film stability is indicated by the Allary, J.c., Mapstone, V., Guillon, J.P. and Guil
lon, M. (1989b) Dark field examination of rigid
break-up time of the tear film at the front gas permeable and hydrogel lenses. Optom. Vis.
surface of the contact lens recorded by the Sci., 66, 89.
non-invasive technique (PLTF NlBUT). Allen, M., Wright, P. and Reid, L. (1972) The
PLTIF NlBUT measurements for rigid human lacrimal gland. A histochemical and
lenses show that the pre-rigid lens film is far organ culture study of the secretory cells. Arch.
more unstable than the pre-ocular tear film. Ophthalmol., 88, 493-7.
For example, a group of subjects with a POTF Benedetto, D.A., Clinch, T.E. and Laibson, P.R.
(1984) In vivo observation of tear dynamics
NlBUT of 26.3 s had a PLTF NlBUT of 4.7 s during fluorophotometry. Arch. Ophthalmol.,
with Excel 02 lenses (Guillon & Guillon, 102, 41~12.
1988b), which are reported to have good Benjamin, W.J. (1987) Care regimen and initial
wetting characteristics and a zero degree wetting of silicone acrylate surfaces in in vivo.
wetting angle. In fact the average PLTF Trans. Br. Contact Lens Assoc. Conj., 55-6.
NlBUT of rigid lenses is approximately 4 to Boles, S.F., Refojo, M.F. and Leong, F.-L. (1991)
6 s, hence even shorter than that of hydrogel Attachment of Pseudomonas aeruginosa to
human-worn disposable Etafilcon A contact
lenses (Guillon & Guillon, 1988c). Small lenses. Invest. Opthalmol. Vis. Sci., 32, (Supp!. 4),
material differences have been reported. A 729.
significantly longer PLTF NlBUT was Bothelo, S.Y. (1964) Tears and the lacrimal gland.
observed with modified PMMA and a low Sci. Am., 211,78-86.
References 481
Bron, A.J. (1985) Prospects for the dry eye. Trans. non stimulated and stimulated tears of normal
Ophthalmol. Soc. UK., 104, 801-26. subjects. Invest. Opthalmol. Vis. Sci., 31,1119-26.
Carney, L.G. and Hill, R.M. (1976) Human tear Furukawa RR. and Polse, K.A. (1978) Changes in
pH. Diurnal variations. Arch. Ophthalmol., 94, tear flow accompanying aging. Am. /. Optom.
821-4. Physiol. Opt., 55(2), 69-74.
Cedarstaff, T.H. and Tomlinson, A. (1983) Tear Greiner, J.V. Kenyon, K.R, Henriquez, A.5., Korb,
volume, quality and evaporation: a comparison O.R, Weidman, T.A. and Allansmith, M.R
of Schirmer, break-Up time and resistance (1980) Mucus secretory vesicles in conjunctival
hygrometry techniques. Ophthal. Physiol. Opt., epithelial cells of wearers of contact lenses.
3,239-45. Arch. Ophihalmol., 98, 1843-6.
Dilly, P.N. (1986) Conjunctival cells, subsurface Guillen, J.P. (1982) Tear film photography and
vesicles, and tear film mucus. In The Preocular contact lens wear. J. Br. Contact Lens Assoc., 5,
Tear Film in Health, Disease, and Contact Lens 84--7.
Wear (ed. F.J. Holly), Dry Eye Institute, Lub Guillen, J.P. (1986) Tear film structure and contact
bock, Texas, pp. 677-87. lenses. In The Pre-Ocular Tear Film in Health,
Doane, M.G. (1980) Interaction of eyelids and tears Disease and Contact Lens Wear (ed. F.J. Holly),
in corneal wetting and the dynamics of human Dry Eye Institute, Lubbock, Texas, pp. 914-39.
eyeblink. Am. J. Ophthulmol., 89, 507-16. Guillen, J.P. (1990) Tear Film Structure of the Con
Edmund, J. (1951) The Corneal Gloss. Thesis, Dan tact Lens Wearer. PhD thesis, The City Univer
ish Science Press, Copenhagen. sity, London.
Ehlers, N. (1965) The pre-corneal tear film. Biomi Guillen, M. (1991) Acuvue clinical research
croscopical, histological and chemical investi update. The Optician, 202 (5317), 13-15.
gations. Acta Ophthalmol. Suppl. 81, 5-136. Guillen, J.P. and Guillen, M. (1988a) Lid Hygiene
Elander, T.R., Goldberg, M.A., Salinger, CL., Tan, for Prospective and Current Contact Lens Wearers.
J.R., Levy, B. and Abbott, RL. (1992) Microbio Bausch and Lomb European Research Sympo
logical changes in the ocular environment with sium, Berlin.
contact lens wear. Contact Lens Assoc. Ophthal Guillen, J.P. and Guillen, M. (1988b) Tear film
mol. J., 18(1), 53-5. examination of the contact lens patient. Contax,
Feldman, G., Yamane, S.J. and Herskowitz, R May, 14-18.
(1987) Fluorinated materials and the Boston Guillen, M. and Guillon, J.P. (198&) The status of
Equalens. Contact Lens Forum. the pre soft lens tear film during overnight
Fischer, F.P. (1928) Uber die DarsteUung der wear. Am. /. Optom. Physio/. Opt., 65, 40.
Hornhaut - Oberflache und ihrer Veranderung Guillon, M. and Guillen, J.P. (1988d) Pre-lens tear
im Reflexbild. Arch. Augenheilk., 98, Ergan film characteristics of high Dk rigid gas perrne
zungheft 1-84. able lenses. Am. /. Opiom. Physiol. Opt., 65, 73.
Fischer, F.P. (1940) In Modern trend in ophthalmol Guillen, J.P. and Guillen, M. (1989a) How to Pre
ogy. (eds. F. Ridley and A. Sorsby), Butterworth dict Tear Related Contact Lens Problems. Poster
and Co Ltd, London. presented at the British Contact Lens Associa
Folch, J., Lees, M. and Sloane Stanley, G.H. (1957) tion International Contact Lens Conference,
A simple method for isolation and purification London, May 1989.
of total lipids from animal lipids. J. Bioi. Chem., Guillen, J.P. and Guillen, M. (1989b) How to
226,497-509. predict tear related contact lens problems.
Ford, L.C, Delange, R.J. and Petty, RW. (1976) Trans. Br. Contact Lens Assoc. Int. Contact Lens
Identification of a non lysosomal bactericidal Coni., 33-5.
factor (beta lysin) in human tears and aqueous Guillon, M. and Guillen, J.P. (1989c) Hydrogel lens
humour. Am. J. Ophihalmol., 81, 30--3. wettability during overnight wear. Ophthal.
Forst, G. (1982) Structure of the tear film during Physiol. Opt., 9, 355-9.
the blinking process. Ophthal. Physiol. Opt. 7, Guillen, M. and Guillen, J.P. (1991) Disposable
81-3. contact lenses. Contact lens and tear film inter
Forst, G. (1990) Assessment of the stability of the actions. Invest. Ophthalmol. Vis. Sci., 32 (Suppl),
preocular tear film with the interference 114.
method. Contact Lens [: 18(7), 185-90. Guillen, M., Guillen, J.P., Mapstone, V. and
Fullard, R.J. and Snyder, C (1990) Protein levels in Dwyer, S. (1989) Rigid gas permeable lenses in
482 The role of tears in contact lens performance and its measurement
vivo wettability. Trans. Br. Contact Lens Assoc. Holly, F.J. (1980) Tear film physiology and contact
Conf., 24-6. lens wear I. Pertinent aspects of tear film physi
Guillon, J.P., Guillon, M. and Malgourges, S. ology. Am.J. Optom. Physiol. Opt., 57(4), 252-7.
(1990) Desiccation staining with hydrogel Holly, F.J. (1981) Tear film physiology and contact
lenses: tear film and contact lens factors. Oph lens wear. I - pertinent aspects of tear film physi
thal. Physiol. Opt., 10, 343-50. ology. Am. f. Optom. Physiol. Opt., 58, 330-42.
Guillon, M., Allary, J.C, Guillon, J.P. and Ors Holly, F.J. and Lemp, M.A. (1971) Surface chemis
born, G. (1992) Clinical management of regular try of the tear film: implications for dry eye
replacement. Part 1 - Selection of replacement syndromes, contact lenses and ophthalmic
frequency. Int. Contact Lens Clin., 19 (5 and 6), polymers.J. Am. Con. Lens Soc., 5, 12-19.
104-20. Holly, F.J. and Lemp, M.A. (1977) Tear physiology
Haberick, F.J. and Lingelbach, B. (1981) Eine and dry eyes. Suru. Ophthalmol., 22, 69-87.
optishe methode zur darstellung von inho Jansen, P.T., Muytjens, H.L. and Van Bijsterveld,
mogenitaten des Tranenfilms mit demonstra O.P. (1984) Non lysozyme antibacterial factors
tion des verwendeten Schlierenopticschen in human tears (fact or fiction)? Invest. Ophthal
Verfahrens. Vortrag 14 Aschaffenburger Kon mol. Vis. ScL, 25, 115&-60.
taktlinsen Tatung. Jensen, O.A., Falbe-Hansen, I., Jacobsen, T. and
Hamano, H., Hori, M., Kawabe, H., Umeno, M. Michelsen, A. (1969) Mucosubstances of the
and Mitsunaga, S. (1979) Bio differential inter acini of the human lacrimal gland (orbital part).
ference microscopic observations on anterior I. Histochemical identification. Acta Ophthal
segment of eye. Third report: Observation of mologica, 47, 605-19.
surface states of contact lenses on the eye. f. Jordan, A. and Baurn, J. (1980) Basic tear flow:
Japan. Contact Lens Soc., 21, 264-70. does it exist? Ophthalmology (Rochester), 87,
Hamano, H. Hori, M., Kawabe, H. Umeno, M. 920-30.
Mitsunaga, S. Omnishi, Y. and Koma, I. (1980) Josephson, J.E. (1983) Appearance of the preocular
Change of surface patterns of precorneal tear tear film lipid layer. Am. f. Optom. Physiol. Opt.,
film due to secretion of meibomian gland. Folia 60,883-7.
Ophthalmol. Jpn., 31, 353-5. Knoll, H. and Walters, H. (1985) Pre-lens tear film
Hamano, H., Hori, M. and Mitsunaga, S. (1981) specular microscopy. Int. Contact Lens Clin.,
Measurement of evaporation rate from the pre 12(1),30.
corneal tear film and contact lenses. Contacto, Koby, F.E. (1924) Microscopie de l'oeil vivant. Mas
25(2),4-14. son et Cie, Paris.
Hamano, H., Hori, M. and Mitsunaga, S. (1982) Kwok, L.S. (1984) Calculation and application of
Clinical examinations and research on tears. In the anterior surface area of a human model
Menicon 30th Anniversary Special Compilation of cornea. Theor. BioI., 108, 295-313.
Research Reports (eds. K. Tanaka, N. Anan and Lamberts, D.W., Foster, C and Perry, H.P. (1979)
M. Mikami), Tokyo Contact Lens Company, Schirmer test after topical anaesthesia and the
Tokyo, Japan. tear meniscus height in normal eyes. Arc".
Hirji, N., Patel, S. and Callender, M. (1989) Human Ophthalmol., 97, 1082-5.
tear film pre rupture phase time (TP-RPT). A Lernp, M.A. (1976) Cornea and sclera. Arch. Oph
non invasive technique for evaluating the pre thalmol., 94(3), 473-90.
corneal tear film using a novel keratometer lemp, M.A., Holly. F.J., Iwata, S. and Dohlman,
mire. Ophthal. Physiol. Opt., 9:139-142. CH. (1970) The pre-corneal tear film. I. factors
Holly, F.J. (1973a) Formation and rupture of the in spreading and maintaining a continuous tear
tear film. Exp. Eye. Res., IS, 515-25. film over the corneal surface. Arch. Opthalmol.,
Holly, F.J. (1973b) Formation and stability of the 83,89-94.
tear film. In The Preocular Tear Film and Dry Eye Liotet, S. Cohen, M. and Sainte-Laudy, J. (1980)
Syndrome (eds. F.J. Holly and M.A. Lemp), Int. Un antibiotique naturel des larmes la lac
Ophthalmol. Clin., 13(1), 73-96. totransferrine. Journal Francais d'Ophthalmolo
Holly, F.J. (1978) Surface chemical evaluation of gie, 3(3), 159-63.
artificial tears and their ingredients. 1. Interfa Lydon, D.P.M. and Guillon, J.P. (1984) The integ
cial activity. Contact Lens and Intraocular Lens rity of the pre-lens tear film. In The Frontiers of
Med J., 4(2), 14-31. Optometry. Transactions of the First International
References 483
Congress. British College of Optometrists, Lon ments of human tear turnover rate. Curro Eye
don, pp. 106-35. Res., 7, 995-1000.
Lydon, D.P.M. and Cuillon, J.P. (1986) The integ Patel, S., Murray, D., McKenzie, A, Shearer, 0.5.
rity of the pre-lens tear film. Transactions of the and McGrath, B.D. (1985) Effects of fluorescein
First International Congress, Vol.2 (ed W.M. on tear break-up time and on tear thinning
Charman) British College of Ophthalmic time. Am. f. Optom. Physiol. Opt., 62, 188-90.
Optometrists, London. Port, M.J.A. and Asaria, T.S. (1990) The assess
Madigan, M. and Holden, B.A. (1986) Preliminary ment of human tear volume. f. Br. Contact Lens
report, lens wear and its effects on wetting Assoc., 13(1), 76-82.
angle. Int. Eyecare 2, 36-44. Rehim, M.H.A. and Samy, M. (1988) Effects of
Marx, E. (1921) De la sensibilite et du desseche different types of contact lenses on fungal flora
ment de la cornee. Ann. Oculist., 158, 774-89. or healthy eyes. Contact Lens J., 16, 237--40.
Maurice, D.M. (1973) The dynamics and drainage Ridley, F. and Sorsby, A. (1940) Modern Trends in
of tears. Int. Opthalmol. Clin., 13, 10J--11. Ophthalmology (eds F. Ridley & A. Sorsby),
Maurice, D. (1990) The Charles Prentice award Hoeber Inc., New York.
lecture 1989. The physiology of tears. Optom. Rolando, M. and Refojo, M. (1983) Tear evaporim
\'is. sa.. 67, 391-9. eter for measuring water evaporation from the
McClellan, B.H., Whitney, c.a.. Newmand, P.c. tear film under controlled conditions in
and Allansmith, M.R. (1973) Immunoglobulins humans. Exp. Eye Res., 36, 25-33.
in tears. Am. J. Ophth almol., 76 89-101. Ruskell, G.L. (1968) The fine structure of nerve
McDonald, J.E. (1968) Surface phenomena of tear terminations in the lacrimal glands of monkeys.
films. Trans. Am. Opthalmol. Soc., 66, 905-39. J. Anat., 103, 65-76.
McDonald, J.E. (1969) Surface phenomena of the Schirmer, O. (1903) Studien zur Physiologie und
tear film. Am. f. Gphthalmol., 67(1), 56-64. Pathologie der Tranenabsonderung und
Meesman, A. (1927) Die mikroskopie des lebenden Tranenabfuhr. Graefes Arch. Ophthatmol., 56,
Auges an dergutlstrandschen Spalt/ampe mit Atlas 197-291.
typischer Bejunde. Urban and Schwarzenberg Taylor, H.R. (1980) Studies on tear film in climatic
Berlin and Weimar, 3J--7. droplet keratopathy and pterygium. Arch. Oph
Mengher, L.S., Bron, A.J., Tonge, S.R. and Gilber, thalmol., 98, 86-8.
D.J. (1985a) Effect of fluorescein instillation on Terry, J.E. (1984) Eye diseases in the elderly. [. Am.
the pre corneal tear film stability. Curro Eye Res., Optom. Assoc., 55, 2J--9.
4,9-12. Terry, J.E. and Hill, R.M. (1978) Human tear
Mengher, L.S., Bron, A.J., Tonge, S.R. and Gil osmotic pressure: diurnal variation and the
berts, D.J. (1985b) A non invasive instrument closed eye. Arch. Ophthalmol., 96, 120-2.
for clinical assessment of the pre corneal tear Tiffany, J.M. and Bron, A.J. (1978) Role of tears in
film stability. Curr. Eye Res., 4, 1-7. maintaining corneal integrity. Trans. Opthal
Mertz, G.W. and Holden, B.A. (1981) Clinical mol. Soc. UK., 98, 335-8.
implications of extended wear research. Can. [. Tomlinson, A., Trees, G.R. and Occhipinti, J.R.
Optom., 43, 20J--5. (1991) Tear production and evaporation in the
Mishima, S., Gasser, A., Klyce, S.D. and Baum, J.L. normal eye. Ophtha!. Physiol. Opt., 11, 44-7.
(1966) Determination of tear volume and tear Van Haeringen, N.J. (1981) Clinical biochemistry
flow. Invest. Ophthalmol. Vis. Sci., 5,264-76. of tears. Surv. Ophihalmol., 26(2), 84-95.
Nicolaides, N. (1986) Recent findings on the Vogt, A. (1921) Atlas der Spaltlampenmikroskopie
chemical composition of the lipids of steer and des lebenden Auges, Springer Verlag, Berlin, pp.
human meibomian glands. In The Preocular 26-31.
Tear Film in Health, Disease and Contact Lens Wolff, E. (1946) The muco-cutaneous junction of
Wear (ed. F.J. Holly), Dry Eye Institute, Lub the lid margin and the distribution of the tear
bock, Texas, pp. 570-96. fluid. Trans. Ophthalmol. Soc. UK., 66, 291-308.
Nom, M.S. (1979) Semi quantitative interference Wolff, E. (1954) Anatomy of Eye and Orbit (4th
study of fatty layer of pre-corneal film. Acta. edn), Blakiston Co, New York, pp. 207-9.
Ophihalmol. (Kbh)., 57, 766-74. Young, G. and Efron, N. (1991) Characteristics of
Occhipinti, J.R., Mosier, M.A., La Motte, J. and the pre lens tear film during contact lens wear.
Monji, G.T. (1988) Fluorophotometric measure- Ophihal. Physiol. Opt., 11, 5J--8.