PROF. (MRS.) O.U.

AMAECHI,
Dr ANONABA

ADVACED CONTACT LENS

PCURRENT CHALLENGES, RECENT ADVANCES AND

POSSIBLE FUTURE OF CONTACT LENS PRACTICE
 Table of contents

1. CURRENT CHALLENGES IN CONTACT LENS PRACTICE

A. EMPIRICAL VERSUS DIAGNOSTIC FITTING IN A COVID WORLD
B. OVERNIGHT ORTHOKERATOLOGY VERSUS SOFT MULTIFOCAL CONTACT LENS WEAR FOR MYOPIA MANAGEMENT
C. PRESBYOPIA-CORRECTING PHARMACEUTICALS AND CONTACT LENS WEAR
2. RECENT ADVANCES IN CONTACT LENS PRACTICE
A. . Advances in GP Sclerals
B. Advances in Myopia Treatment
C. Advances in Presbyopia Management
D. Advances in Flexible Contact Lenses
E. Advances in Dry Eye
F. Advances in Inflammation Treatment
3. POSSIBLE FUTURE OF CONTACT LENS PRACTICE
A. Disease monitoring lenses
B. Enhancing vision
C. Myopia management with contact lens
 Group memebers
1. OKOLI ANITA OLUCHUKWU
2. EKPENDU IKENNA CHIDUZIE
3 AZUMA JOSEPH OKORO
4. ONYESOM VICTORIA
5. MONG CHIMA ONWUKA
6. FRANCIS FAVOUR CHIAMAKA
7. EKEKWE CHISOM RUTH
8. OKAFOR HENRY EBUBECHUKWU
9. NDUKA MIRACLE CHINONYEREM
10. ALAOMA BENNETH EKELEDIRICHUKWU
11. SAM-AGU MARY-JANE OLACHI
12. UJOATUONU CHARLES
2017/112971/REGULAR
2017/113076/REGULAR
2017/113180/REGULAR
2017/113240/REGULAR
2017/113351/REGULAR
2017/113372/REGULAR
2017/113379/REGULAR
2017/113491/REGULAR
2017/113544/REGULAR
2017/113547/REGULAR
2017/113556/REGULAR
2017/113598/REGULAR
 INTRODUCTION

In 2021, members of the American Optometric Association (AOA) Contact Lens & Cornea
Section (CLCS) were asked to identify challenges (controversies)in contact lens practice.
Based on their input, this 2022 “Clinical Controversies” article encompasses both current
and future considerations.
The COVID-19 pandemic has emphasized not only the importance of eyecare providers, it
also has emphasized that contact lenses are safe to wear when appropriate safety
standards are observed. The focus on the current myopia pandemic continues to intensify
along with increasing education on this topic. Recently, the first U.S. Food and Drug
Administration (FDA)-approved pharmaceutical option for correcting presbyopia was
introduced. Such options will change the future of eye care. Read on for a potpourri of
controversies from the AOA CLCS.
CURRENT CHALLENGES IN
CONTACT LENS PRACTICE
 Empirical Versus Diagnostic Fitting in a Covid World
1: Empirical Versus Diagnostic Fitting in a Covid World
Empirical Fitting The 2018 International Organization for Standardization (ISO) guidelines for
multiuse disinfection, coupled with the recent SARS-CoV-2 pandemic, underscore the need for
alternatives to reusable lenses and to diagnostic fitting.1 Advancing technologies have answered
the call.
In the mid-2010s, videokeratographers began to showcase advanced contact lens fitting
algorithms based on elevation maps.2-4 These algorithms have continued to improve, and they
can provide an excellent initial design for many corneal GP lenses. Such empirically designed
lenses
8

can offer an outstanding first-lens experience for patients, and often they are the only lenses that
patients need.
 Diagnostic Fitting
During the height of the COVID-19 pandemic, there were serious concerns about
office protocols and a need to limit patient contact. While the literature
supported the use of contact lenses,12 there was a legitimate concern about the
safety of reusable in-office diagnostic lenses. As practices return to normal, a
question remains: Is it acceptable to reuse contact lenses for fitting purposes?
This discussion does not typically apply when fitting most standard soft lenses;
manufacturers supply practitioners with single-use lenses that can be discarded
after every patient. There are greater concerns about other lens designs,
specifically specialty soft lenses, GP lenses (including scleral lenses), and hybrid
lenses.
 Overnight Orthokeratology Versus Soft Multifocal
Contact Lens wear for Myopia Management

Overnight Orthokeratology One of the more common

concerns that parents have about ortho-k is its safety.
Practitioners go to great lengths in their practices and as a
profession to educate patients and parents on the risks of
sleeping in their contact lenses. When using overnight ortho-
k, we tell parents that we want to prescribe a therapy to help
manage their child’s myopia by having them sleep in their
contact lenses. It’s a common concern, but the research is
clear that ortho-k is a safe and effective way to manage
myopia.
Soft Multifocal Lenses Originally prescribed for presbyopia,
both aspheric (center-distance) and concentric-ring-design
multifocal lenses have been prescribed for myopia
management. In addition to axial length and refractive error,
factors such as add power and pupil size need to be
considered when prescribing lenses to manage myopia. With
this background in mind, two arguments that favor the use of
soft multifocal lenses for myopia management can be
considered.
 PRESBYOPIA-CORRECTING PHARMACEUTICALS AND CONTACT LENS WEAR

Presbyopia-Correcting Pharmaceuticals:
Eye Drops: Recent research has explored the use of eye drops containing miotic agents or
other compounds that temporarily improve the eye's ability to focus on near objects. These
drops aim to relax the eye's ciliary muscle, enhancing the depth of focus for reading or other
close tasks.
Oral Medications: Some pharmaceutical companies are investigating oral medications that
can influence the eye's ability to accommodate. These medications work by affecting the
ciliary muscle's contraction and relaxing mechanisms, allowing for improved near vision.
Challenges:
Maintaining appropriate dosage and effectiveness of eye drops. Potential side effects and
long-term safety of oral medications.
Presbyopia-Correcting Contact Lenses:
Multifocal Lenses: These lenses have multiple zones with varying prescriptions, allowing
wearers to see clearly at different distances simultaneously. They provide a seamless
transition between near, intermediate, and distant vision.
Monovision Lenses: Monovision involves wearing a contact lens with distance correction
in one eye and a lens with near correction in the other eye. The brain learns to rely on
the appropriate eye for different tasks, providing functional vision for both distances.
Hybrid Lenses: These lenses combine features of both rigid gas-permeable and soft
contact lenses, offering comfort and improved vision for presbyopic individuals.
RECENT ADVANCES IN CONTACT LENS PRACTICE
 Advances in GP Sclerals

Although we have had notable improvements in GP lens materials and lens design over the past
few decades, arguably the most important advance is in the resurgence of GP sclerals.
The original practical contact lenses, introduced in Europe more than a century ago, were large
glass shells covering the entire front of the eye. Eventually called “sclerals” or “haptics”—as
opposed to the later and smaller corneal rigid or semi-scleral hydrogels—because they do not
touch the cornea but rather align with, and rest upon, the less sensitive sclera, this lens design has
undergone a recent resurgence. Led by “pioneers” Drs. Don Ezekiel, Perry Rosenthal, and Rob
Breece, scleral lenses, now made from high-tech oxygen permeable plastics, have shown an ability
to serve a previously underserved—but admittedly small in numbers—group of desperate patients
who suffer from various eye disease states.
Scleral lenses were first made from glass and then, after World War II,
from polymethylmethacrylate (PMMA). They were abandoned for the
most part in the 1950s in favor of corneal PMMA lenses and then later
in favor of GPs and the popular hydrogels invented by Professor Otto
Wichterle. These newer designs offered good vision correction and
enhanced ocular tolerance, the former through tear exchange, the
latter through size and flexibility, for the cosmetically driven, primarily
mildly and modestly myopic populations.
 Advances in Myopia Treatment

Another area of slow, incremental progress has been in the linked—but not
precisely the same— endeavors of myopia prevention and treatment.
Undoubtedly stimulated by both the developments in refractive surgeries
and parents eager to offer their children options to avoid both the
cosmetic/optical as well as ophthalmic disease consequences of myopia
progression, research has slowly begun to understand both myopia
development and appropriate preventive and therapeutic interventions.
1. Multifocal Contact Lenses: Multifocal contact lenses are designed to correct both distance and
near vision simultaneously. Recent advancements have improved the design and fitting of these
lenses, making them a viable option for myopia control. They work by creating a myopic defocus
on the peripheral retina, which has been shown to slow down the progression of myopia in children.

2. Orthokeratology (Ortho-K): Ortho-K lenses are specially designed gas-permeable lenses that
are worn overnight to reshape the cornea temporarily. They correct myopia and also induce
peripheral myopic defocus during waking hours, which has been linked to myopia control effects.
Recent lens designs and materials have enhanced comfort and efficacy, making ortho-K a popular
choice for myopia management.
3. Peripheral Defocus Contact Lenses: These lenses are designed to alter the peripheral optics of
the eye in a way that slows the progression of myopia. By creating myopic defocus in the
peripheral retina, these lenses aim to reduce the stimulus for axial elongation of the eye.
4. Soft Bifocal Contact Lenses: These lenses incorporate different prescriptions for distance and near vision.
Similar to multifocal lenses, they induce myopic defocus on the retina and show promise in managing
myopia progression.

5. Customized Contact Lenses: Advancements in technology have enabled the creation of personalized
contact lenses based on an individual's corneal shape and visual needs. Customized
21

designs optimize the optical properties of the lens for each wearer, potentially leading to improved
outcomes in myopia control.

6. Atropine-Infused Contact Lenses: Atropine eye drops have been used for myopia control, but recent
innovation involves incorporating low-dose atropine within contact lenses. This allows for controlled
delivery of the medication, minimizing side effects while providing myopia control benefits.
 Advances in Presbyopia Management
Advances in contact lens practice and application have revolutionized the
management of presbyopia, catering to various patient needs and preferences.
Here are some in-depth insights into these advancements:
1. Precision Design: Modern presbyopic contact lenses are designed using
advanced computer modeling and simulation techniques. This precision design
allows for better control of the optics, minimizing visual disturbances and
maximizing visual clarity at all distances.
2. Diffractive and Simultaneous Vision Designs: Diffractive contact lenses split
light into different focal points, enabling clear vision at varying distances.
Simultaneous vision designs provide multiple prescriptions in different parts of
the lens, allowing the brain to automatically choose the appropriate focal
point.
3. Center-Near and Center-Distance Designs: These designs have a central area optimized for either near or
distance vision, while the peripheral areas provide the opposite prescription. Wearers can look through the
center for their desired distance, providing a natural transition between visual tasks.
4. Neuroadaptation Training: With advanced multifocal lens designs, optometrists now offer neuroadaptation
training to help patients adjust to the lenses more quickly. This training involves specific exercises to
improve the brain’s ability to switch between different prescriptions seamlessly.
5. Customized Fitting Process: Optometrists use advanced corneal mapping and measurement technologies
to create customized contact lens designs tailored to each patient’s unique eye shape, size, and visual
requirements.

6. Hybrid Lens Technology: Hybrid lenses combine the benefits of rigid gas permeable and soft contact
lenses. The rigid center provides crisp vision, while the soft skirt enhances comfort. These lenses are
particularly beneficial for presbyopic patients who need both distance and near corrections.
 Advances in Inflammation Treatment
Advances in Inflammation Treatment
At first manufacturers thought that lens disposability would solve this problem by eliminating
exposure to potentially contaminated and/or toxic solutions. Then, when this first paradigm failed,
enhanced oxygen permeability (silicone hydrogels) became the proposed “Holy Grail” answer.
Unfortunately, while both advances resulted in improved lens tolerance and much improved corneal
physiology, neither has changed the rate at which microbial corneal infection occurs during extended
wear
However, for an obscure reason or reasons, it is clear that lens wear extended through one or more
sleep cycles increases bacterial corneal infection risk, especially with the gram negative bacteria
Pseudomonas sp. Fleiszig has proposed that the in-vivo corneal surface has many interacting anti-
bacterial defenses only surmounted by multiple failures and microbes “educated” by exposure of
some time length to our cells. Such advances in our understanding may soon change the way we
manage patients to preclude such events as well as the way we treat patients suffering such disease.
Well-known failures of two multipurpose lens care solutions since withdrawn from the contact lens
marketplace have added to our understanding of how to protect patients from such risks.
In addition to our enhanced understanding of both avoidance and treatment strategies, research
suggests that pre-immunization may be a most successful management strategy for AK in particular.
The clinician's role is to first distinguish non-infectious immune response from infection. Ocular
infection must be treated aggressively and appropriately to reduce the risk of vision loss through
corneal scarring/distortion and further damage to other ocular structures. If ocular infection has been
eliminated from the differential diagnosis, then reducing the signs and symptoms of often
inappropriate non-infectious driven immunological response becomes the clinician's objective.
Fortunately, we are gaining many enhanced pharmacological tools to assist us in managing non-
infectious inflammation, including mast cell stabilizers, antihistamines, and immunomodulators. I
suspect that the pharmologic industry will provide us, and our patients, with ever more finely directed
drugs as we progress into the 21st century.
 Advances in Flexible Contact Lenses
There have been many advances in flexible contact lenses in recent years, making
them more comfortable, versatile, and capable of providing a wider range of benefits.
Some of the most notable advances include:
The development of new materials that are more flexible and biocompatible:This has
made it possible to create contact lenses that are more comfortable to wear and less
likely to cause eye irritation.
The miniaturization of electronic components: This has allowed researchers to
integrate sensors, microprocessors, and other electronic devices into contact
lenses, making them capable of monitoring eye health, delivering medication, and
even displaying information.
Advances in manufacturing technique:. These advances have made it possible to produce flexible
contact lenses that are more precise and consistent in their quality.
As a result of these advances, flexible contact lenses are now being developed for a wide range of
applications, including:
Vision correction: Flexible contact lenses can be used to correct nearsightedness, farsightedness,
and astigmatism.
Eye health monitoring: Flexible contact lenses can be used to monitor eye pressure, glucose levels,
and other important health indicators.
Medication delivery: Flexible contact lenses can be used to deliver medication directly to the eye,
which can be helpful for treating conditions such as glaucoma and dry eye.
Information display: Flexible contact lenses can be used to display information such as the time,
date, and weather conditions.
 ADVANCES IN DRY EYE

Whenever contact lenses are discussed, those who bemoan the lack of growth in wearers cite the
dual issues of dry eyes/end-of-day lens discomfort and inadequate presbyopic correction. I
already have discussed my personal impression of enhancement in presbyopic lens optics.
Similarly, there have been some, but admittedly not as impressive, advances in diagnosing and
then treating subjective and objective tear deficiencies. To my mind, the “breakthrough” here has
yet to come but is anticipated, and certainly incremental progress is ongoing.
I believe that we will find that there are many types of dry eyes, not just one, and each will require a
somewhat different treatment paradigm. How many of you have experienced, as I have, occasional
patients who have very low tear breakup times and/or Schirmer results but still demand, and
surprisingly well tolerate, contact lenses without subjective or objective complications?
Certainly we encounter terrible dry eye conditions, some primary, some secondary, that
can lead to ocular surface compromise. Most of these patients should not wear cosmetic
contact lenses, but even some will benefit not only optically but physiologically from
therapeutic lens wear, often with GP sclerals. Milder dry eye states “merely” complicate
any desired lens wear often without clinical signs, leading to symptoms and failure to
tolerate contact lenses with subsequent “dropout.” Also, some patients only suffer dry
eye clinical signs and symptoms when wearing contact lenses.
These latter two groups can be helped, perhaps, by treatments that we now know include
lid hygiene, artificial tear supplementation, nutritional modification, perhaps local
immunomodulation, and perhaps tear drainage duct punctal occlusion. As our
understanding improves, I suspect, so will our diagnostic and management/treatment
paradigms.
 Advances in Inflammation Treatment

When Prescribing Glasses:

Factors such as visual needs according Age, strong accommodative Elements, Risk
amblyopia, Age related Emmetropization and associated conditions such
Strabismus should be taken into account before prescribing glasses for children
POSSIBLE FUTURE OF CONTACT LENS
PRACTICE
DISEASE MONITORING CONTACT LENSES
Disease monitoring contact lenses, also known as Smart Contact Lenses, are a
type of wearable technology designed to monitor various health parameters
through the eye. They can be equipped with sensors to measure things like
glucose levels for diabetes management or intraocular pressure for glaucoma
monitoring. These lenses could provide real-time data to users and healthcare
professionals, helping in early disease detection and management.

Glucose Monitoring: Some companies were working on contact lenses that could
measure glucose levels in tears, offering a non-invasive way for diabetes patients
to monitor their blood sugar levels without pricking their fingers. These lenses
could transmit data to a mobile device for real-time monitoring.
Intraocular Pressure Monitoring: Glaucoma patients could benefit from contact
lenses that measure intraocular pressure, a key factor in glaucoma management.
These lenses could help individuals and their doctors track pressure changes and
adjust treatments as needed.
Augmented Reality: While not strictly for disease monitoring, there were
developments in creating contact lenses with augmented reality capabilities.
These lenses could overlay digital information onto the user's field of vision,
opening up possibilities for enhanced visual experiences and applications.
Ocular Surface Health Monitoring: Some smart contact lenses were being
designed to monitor the health of the ocular surface. These lenses could detect
early signs ofconditions like dry eye disease or corneal infections by analyzing
tear composition and other factors.

ADVANTAGES:
Non-Invasive Monitoring: Disease monitoring contact lenses offer a non-invasive
way to collect real-time data about various health parameters. This can be
particularly beneficial for individuals who dislike or struggle with traditional
monitoring methods, such as frequent blood tests.
Enhancing vision

1:They produce a more “natural” field of vision. Because they sit on the surface of your
eyes and move with them, contact lenses provide seamless vision correction. Their benefits
extend to your peripheral vision and they won’t have the same types of visual disruptions that
glasses do, such as reflections or fogginess.
2:They give you freedom of movement during activities and sports. When glasses might fly off
your face, contact lenses stay put. You can play sports, go running, or dance freely at a
concert.
3:They don’t stand out on your face. Contacts won’t clash with an otherwise perfectly
matching ensemble, and they won’t block other people’s view of your expertly applied eye
makeup and lashes. For most contact wearers, contacts are functionally invisible.
4:Some contacts enable you to change your eye color. If you’ve ever wanted to see
what you look like with a differently colored iris, contacts can make that happen.
Certain colored contacts come in both bold and subtle hues, so you can sport
anything from dramatic violet lenses to ones that lightly accent your eyes.
5:They allow you to wear a variety of non-prescription sunglasses. Throwing on a pair
of sunglasses is easy when you’re already wearing contact lenses, and you won’t
have to pay for prescription sunglasses.
Losing or replacing your contacts isn’t as costly. Unlike glasses, contacts usually
aren’t designed to last for years. Losing a pair of disposable lenses won’t set your
wallet back as much (although you should still try your best to keep track of them!).
 Myopia management with contact lenses
It is reported that almost half the world’s population will be myopic by the
year 2050;63 but a statistic of greater significance to practitioners in the UK
and Ireland is that Western Europe is expected to reach this unfortunate
milestone around a decade earlier. In fact, by the year 2030, an estimated
~45% of the population in Western Europe will have already become myopic
Axial myopia is attributed to a discord between increasing axial length and
the refractive capabilities of the cornea and crystalline lens.64 Typically, a
1mm increase in axial length equates to approximately ~2.5 to 3DS of axial
myopia,65-66 but differences can exist between different demographics.
Methods of myopia management using contact lenses
While time outdoors may deter the onset of myopia, for individuals who are already myopic
various myopia inhibiting solutions are gradually making their way to market. Current solutions
include spectacle lenses, contact lenses and on the horizon is the potential for myopia specific
pharmaceutical preparations.

Rigid gas permeable corneal lenses

Some older texts advocated the use of rigid corneal lenses to manage myopia, while this practice
has now largely fallen out of favour it still persists in some parts of the world.75 There is,
however, limited evidence of a genuine treatment effect.76 Any positive impact is thought to be
linked to a mechanical flattening of the cornea rather than a slowing of axial elongation.
Orthokeratology in myopia
Orthokeratology (OK) has long been used as a reversible non-surgical alternative to refractive surgery. Lenses
are worn at night to temporarily reshape the cornea providing temporary relief from refractive error during the
day.77-78 While in this article OK is referred to in the context of correcting myopic refractive error, the
technique has also been used to correct hyperopic, presbyopic and astigmatic errors.

Soft contact lenses for myopia management

Until recently a lack of licensed soft lens products, for myopia management, led some ECPs to off-label
prescribing of multifocal lenses intended for presbyopia. While these lenses generated pockets of impressive
data, a published review of myopia management, that was limited to randomised controlled trials (RCTs),
concluded bifocal soft contact lenses were of little benefit. Nevertheless, since this landmark review was
undertaken, several key RCTs of soft lenses for myopia management have now been published, demonstrating
an impressive slowing of both axial elongation and myopia using dual focus and extended depth of focus lenses.
THANK YOU