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

T h i r d Ed i t i o n

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

EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO

iii
© 2018 Elsevier Ltd. All rights reserved.

First published 2002

Reprinted 2005
Second edition 2010
Reprinted 2013
T ird edition 2018

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 CO NTENTS

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

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

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

GRAEME YO UNG

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

RICHARD G LINDSAY

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

NATHAN EFRO N
PHILIP B MO RGAN

2 Ante rior Eye 10

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

PART 2 So ft Co nt act Le nse s

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

CARO LE MALDO NADO -CO DINA

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

NATHAN EFRO N

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

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

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

GRAEME YO UNG
NATHAN EFRO N | SUZANNE E EFRO N

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

RICHARD G LINDSAY
JO HN MEYLER | DAVID RUSTO N

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

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

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

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

NATHAN EFRO N LAURA E DO WNIE | RICHARD G LINDSAY

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

NATHAN EFRO N JO SEPH T BARR

v
vi CO NTENTS

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

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

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

NATHAN EFRO N | SUZANNE E EFRO N NATHAN EFRO N

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

SUZANNE E EFRO N NIZAR K HIRJI

31 Post-ke ratop lasty 287

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

B Contact Le ns Tole rance s 440

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

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

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

H Constant Ed g e Cle arance Rig id Le ns

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

40 Comp lications 385

NATHAN EFRO N Ind e x 459
 CO NTRIBUTING AUTHO RS

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

Emeritus Pro essor, College o Optometry, T e Ohio State PGCe rt O cThe r
University, Columbus, Ohio, USA Locum Optometrist, Broadbeach, Queensland, Australia
27 High Ametropia 22 inted Lenses
29 T erapeutic Applications
No e l A Bre nnan, MScO p t o m, PhD, FAAO , 30 Post-re ractive Surgery
FCLSA
Clinical Research Fellow and Global Plat orm Lead, Myopia Klaus Ehrmann
Control, Johnson & Johnson Vision Care Inc., Jacksonville, Director – echnology, Brien Holden Vision Institute,
Florida, USA University o New South Wales, Sydney, Australia
24 Extended Wear 7 Sof Lens Measurement
14 Rigid Lens Measurement
Ad rian S Bruce , BScO p t o m, PhD, FAAO , FVCO
Lead Optometrist, Australian College o Optometry, Paul Giffo rd , PhD, MSc, BSc(Ho ns), MCO p t o m,
Melbourne, Victoria, Australia; Senior Fellow, Department FBCLA, FIACLE, FAAO
o Optometry and Vision Sciences, University o Melbourne, Private Practice, Brisbane, Queensland, and Adjunct Senior
Parkville, Victoria, Australia Lecturer, University o New South Wales, Sydney, Australia
37 Preliminary Examination 32 Orthokeratology
41 Digital Imaging
Nizar K Hirji, BSc, PhD, MBA, FCO p t o m,
M-L Chant al Co le s, BS, O D FAAO , FIMg t
Optometrist, Johnson & Johnson Vision Care Inc., Optometrist and Principal Consultant, Hirji Associates,
Jacksonville, Florida, USA Birmingham, UK; Visiting Pro essor o Optometry,
24 Extended Wear University o Manchester, Manchester, UK; Visiting
Pro essor o Optometry, City University, London, UK
W Ne il Charman, BSc, PhD, DSc, FO p t So cAm, 43 Practice Management
FCO p t o m(Ho n)
Emeritus Pro essor, T e University o Manchester, Manchester, UK Brie n A Ho ld e n, O AM, PhD, DSc(Ho n),
3 Visual Optics BAp p Sc, LO Sc (d e ce ase d )
6 Sof Lens Optics Founding Chie Executive O cer, Brien Holden Vision
13 Rigid Lens Optics Institute, University o New South Wales, Sydney, Australia
33 Myopia Control
Laura E Do w nie , PhD, BO p t o m, PGCe rt O cThe r,
FACO , FAAO , Dip Mus(Prac), AMusA Milt o n M Ho m, O D, FAAO FACAAI(Sc)
Lecturer and NHMRC ranslating Research Into Practice Private Practice, Azusa, Cali ornia, USA
( RIP) Fellow, Department o Optometry and Vision 41 Digital Imaging
Sciences, T e University o Melbourne, Parkville,
Victoria, Australia Lynd o n W J o ne s, PhD, FCO p t o m, Dip CLP,
26 Keratoconus Dip O rt h, FAAO , FIACLE, FBCLA
University Research Chair, Pro essor, School o Optometry
Nat han Efro n, AC, DSc, PhD, BScO p t o m, FACO , and Vision Science, and Director, Centre or Contact
FAAO , FIACLE, FCCLSA Lens Research, University o Waterloo, Waterloo, Ontario,
Pro essor Emeritus, School o Optometry, Queensland Canada
University o echnology, Brisbane, Queensland, Australia 36 Diagnostic Instruments
1 History
5 Sof Lens Manu acture J o hn G Law re nso n, BSc, PhD, MCO p t o m
11 Rigid Lens Materials Pro essor o Clinical Visual Science, City, University o
12 Rigid Lens Manu acture London, London, UK
18 Daily Disposable Sof Lenses 2 Anterior Eye
19 Reusable Sof Lenses
21 Scleral Lenses Richard G Lind say, BScO p t o m, MBA, FAAO ,
22 inted Lenses FCLSA, FVCO
25 Sport Private Practice, East Melbourne, Victoria, Australia
29 T erapeutic Applications 9 Sof oric Lens Design and Fitting
39 Af ercare 16 Rigid oric Lens Design and Fitting
40 Complications 26 Keratoconus
42 Compliance
vii
viii CO NTRIBUTING AUTHO RS
Caro le Mald o nad o -Co d ina, BSc(Ho ns), MSc,
PhD, MCO p t o m, FAAO , FBCLA
Senior Lecturer in Optometry, T e University o Manchester,
Manchester, UK
4 Sof Lens Materials
J o hn Me yle r, BSc(Ho ns), FCO p t o m, Dip CLP
Senior Director, Global Pro essional Af airs, Johnson &
Johnson Vision Care Companies, Wokingham,
Berkshire, UK
23 Presbyopia
Philip B Mo rg an, BSc(Ho ns), PhD, MCO p t o m,
FAAO , FBCLA
Pro essor o Optometry and Director, Eurolens Research,
T e University o Manchester, Manchester, UK
10 Sof Lens Care Systems
17 Rigid Lens Care Systems
Sarah L Mo rg an, BSc(Ho ns), MPhil, MCO p t o m,
FAAO , FBCLA
Staf Development Consultant, Manchester, UK;
Vision Sciences Fellow in Optometry, T e University
o Manchester, Manchester, UK
38 Patient Education
Aliso n Ng , PhD, MCO p t o m
Post Doctoral Fellow, Centre or Contact Lens Research,
University o Waterloo, Waterloo, Ontario, Canada
36 Diagnostic Instruments
Clare O ’Do nne ll, BSc(Ho ns), MBA, PhD,
MCO p t o m, FAAO , FBCLA
Head o Eye Sciences, Optegra Manchester Eye Hospital,
Didsbury; Reader, Aston University, Birmingham, UK
34 Diabetes
David Rust o n, BSc, FCO p t o m, Dip CLP, FAAO ,
FIACLE
Director, Global Pro essional Af airs, Johnson & Johnson
Vision Care Companies, Wokingham, Berkshire, UK
23 Presbyopia
Pad maja Sankarid urg , BO p t o m, MIP, PhD
Associate Pro essor, Program Leader – Myopia, Manager,
Intellectual Property, Brien Holden Vision Institute,
University o New South Wales, Sydney, Australia
33 Myopia Control
Marc Schulze , PhD, Dip lIng (AO ), FAAO
Clinical Scientist, Centre or Contact Lens Research,
University o Waterloo, Waterloo, Ontario, Canada
36 Diagnostic Instruments
Srut hi Srinivasan, PhD, BS O p t o m, FAAO
Clinical Research Manager and Senior Clinical Scientist,
Centre or Contact Lens Research, University o Waterloo,
Waterloo, Ontario, Canada
36 Diagnostic Instruments
Lo re t t a B Szczo t ka-Flynn, O D, PhD, FAAO
Pro essor, Department o Ophthalmology and Visual Science,
Case Western Reserve University; Director, Contact Lens
Service, University Hospitals Case Medical Center,
Cleveland, Ohio, USA
39 Af ercare
J o e Tanne r, BO p t o m
Pro essional Services Manager, CooperVision Australia and
New Zealand
19 Reusable Sof Lenses
Cind y Tro mans, BSc(Ho ns), PhD, MCO p t o m,
Dip (Tp )IP, FEAO O
Consultant Optometrist, Manchester Royal Eye Hospital;
Honorary Clinical Lecturer, Department o Ophthalmology,
T e University o Manchester, Manchester, UK
28 Babies and Children
Barry A We issman, O D, PhD, FAAO
Pro essor o Optometry, Southern Cali ornia College o
Optometry at Marshall B Ketchum University, Fullerton,
Cali ornia, USA; Emeritus Pro essor o Ophthalmology,
Stein Eye Institute, David Gef en School o Medicine at
UCLA, Los Angeles Cali ornia, USA
31 Post-keratoplasty
He le n Wilso n, BSc(Ho ns), MCO p t o m, Dip Tp (IP),
Dip O C, Dip Glauc
Principal Optometrist, Manchester Royal Eye Hospital,
Manchester, UK.
28 Babies and Children
J ame s S W Wo lffso hn, BSc(Ho ns), PGCe rt HE,
PGDip Ad vClinO p t o m, MBA, PhD, FCO p t o m,
FHEA, FSB, FAAO , FIACLE, FBCLA
Pro essor and Deputy Executive Dean, School o Li e and
Health Sciences, Aston University, Birmingham, UK
35 History aking
Craig A Wo o d s, BSc(Ho ns), PhD, MCO p t o m,
Dip CLP, PGCe rt O cThe r, FAAO , FACO , FBCLA
Pro essor, Head o Clinical Partnerships, Deakin Optometry,
School o Medicine, Deakin University, Geelong, Australia
20 Planned Replacement Rigid Lenses
Grae me Yo ung , BSc, MPhil, PhD, FCO p t o m,
Dip CLP, FAAO
Director, Visioncare Research, Farnham, Surrey; Honorary
Pro essor, School o Li e and Health Sciences, Aston
University, Birmingham, UK
8 Sof Lens Design and Fitting
15 Rigid Lens Design and Fitting
 PREFACE TO THE THIRD EDITIO N
T is book strives to achieve the ‘middle ground’ among contact
lens textbooks. It is not intended to be a brie clinical manual o
contact lens tting; nor is it intended to be a weighty tome with
extensive research coverage. Like its predecessors, this third
edition o Contact Lens Practice seeks to be a comprehensive,
easily accessible book that provides in ormation o immediate
relevance to contact lens practitioners, underpinned by well-
ounded evidence and expert clinical insight by the authors
o the various chapters, each o whom is an expert in the area
covered.
T is new edition is not just a cosmetic make-over. T ere
have been extensive revisions to most chapters, many o which
have been written by authors who are new or this edition.
T ere is also a new chapter on myopia control – an area o
considerable interest at present in view o the current myo-
pia epidemic (especially in Asia), and the potential or tting
contact lenses that can arrest myopia progression to a cer-
tain degree. T e chapter on daily disposable lenses has been
updated and expanded, which is particularly important given
that this modality now represents nearly one-third o contact
lenses prescribed worldwide.
I hope that students using this book nd it to be a valuable
guide to their studies and acquisition o knowledge in the sci-
ence and art o contact lens tting, and I trust that this work
will be a valuable companion to practitioners in their ef orts to
satis y the needs o those patients tted with contact lenses.
Professor Nathan Efron AC
ix
TRIBUTES
Here we pay tribute to two contributors to Contact Lens Practice
who have passed away since the second edition o this book was
published.
Keith Edwards, who wrote the chapter on History Taking
in the rst two editions o this book, lost a long- ought battle
with cancer in 2014. Keith was an inspirational educator, cli-
nician and researcher who had an impact internationally in
the eld o contact lenses and intraocular lenses. Following
his Optometry degree at City University, he worked in private
practice and served as secretary o the London Re raction Hos-
pital and examinations advisor at the College o Optometrists.
He was an inaugural director o Optometric Educators Ltd and
later worked or Madden and Layman, which was acquired by
Bausch & Lomb in the late 1980s. He expanded his role rom
UK Pro essional Services to Director o Global Clinical Devel-
opment or Surgical at Bausch & Lomb, which took him to the
US, where his nal job was as Vice-President o Clinical and
Regulatory A airs at LENSAR.
x
Brien Holden, who co-authored the chapter in this book on
Myopia Control, passed away suddenly in 2015. He was Chie
Executive O cer o the Brien Holden Vision Institute and Pro-
essor at the School o Optometry and Vision Science at the
University o New South Wales, Australia. Pro essor Holden
was a global leader in eye care and vision research, and an inter-
nationally renowned and awarded scientist and humanitarian.
He was widely acknowledged as the most inf uential optome-
trist o our generation. His career was spent inspiring scientists
and health-care pro essionals around the world with his dream
o ‘vision or everyone, everywhere’. Pro essor Holden was the
recipient o seven honorary doctorates rom universities around
the world, and was awarded an Order o Australia Medal or his
work in eye health and vision science.

I am grate ul to the contributing authors o this third edition o
Contact Lens Practice. All have worked diligently to update their
chapters, or write new chapters, to bring the latest clinically rel-
evant in ormation to the ore.
I continue to enjoy the strong support o the long-standing
publisher o all o my books – Elsevier. In particular, I am grate-
ul to Russell Gabbedy (Commissioning Editor) and Alexan-
dra Mortimer (Development Editor) or their encouragement
and support during the planning and production o this book.
T anks also to Samuel Crowe, or assisting e ciently with vari-
ous aspects o production.
Editing a book o this size and scope is a substantial undertak-
ing, and in this regard I wish to o er special thanks to my lovely
wi e, Suzanne, who has served as a ‘virtual co-editor’ by way o
ACKNO WLEDGEMENTS
spending many long hours assisting me in assembling, editing,
organizing and proo reading the contributed material. She has
done a wonder ul job. I really could not have completed this task
without her assistance. I also thank Suzanne or co-authoring
Chapters 22 and 29 with me, and or revising and authoring
Chapter 30.
Let me also pay tribute to the photographers and illustra-
tors, many o whom were not contributing authors o this
book, or their extraordinary skills and insights in creating
such antastic imagery. I also thank them or giving me per-
mission to use this material in the book. I apologize i I have
made any errors in attribution; please let me know i I have
erred in this regard, and I shall correct this at the f rst reprint-
ing opportunity.
xi
This pa ge inte ntiona lly le ft bla nk
 PART

1
Int ro d uct io n

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

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

Early The o rie s (1508–1887)

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

Fig . 1.4 Thomas Young .

Fig . 1.6 Ad ol Gaston Eug e ne Fick.

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

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

Glass Scle ral Le nse s (1888)

T ere was a great deal o activity in contact lens research in the late
1880s, which has led to debate as to who should be given credit
or being the rst to t a contact lens. Adol Gaston Eugene Fick
(Fig. 1.6), a German ophthalmologist working in Zurich, appears
to have been the rst to describe the process o abricating and
tting contact lenses in 1888; speci cally, he described the tting
o a ocal scleral contact shells rst on rabbits, then on himsel and
nally on a small group o volunteer patients (E ron and Pearson,
1988). In their textbook dated 1910, Müller and Müller, who were
manu acturers o ocular prostheses, described the tting in 1887
o a partially transparent protective glass shell to a patient re erred
to them by Dr Edwin T eodor Sämisch (Müller and Müller,
1910). Pearson (2009) asserts that the tting was done by Albert
C Müller-Uri. Fick’s work was published in the journal Archiv ür
Augenheilkunde in March 1888, and must be accorded historical
precedence over later anecdotal textbook accounts.
French ophthalmologist Eugène Kalt (Fig. 1.7) tted two
keratoconic patients with a ocal glass scleral shells and obtained
Fig . 1.7 Eug è ne Kalt.
a signi cant improvement in vision. A report o this work, pre-
sented to the Paris Academy o Medicine on 20 March, 1888
by Kalt’s senior medical colleague, Pro essor Photinos Panas,
acknowledges and there ore e ectively con rms that the work
o Fick occurred earlier (Pearson, 1989).
Credit or tting the rst powered contact lens must be given
to August Müller (Fig. 1.8) (no relation to Müller and Müller,
mentioned above), who conducted his work while he was a med-
ical student at Kiel University in Germany (Pearson and E ron,
1989). In his inaugural dissertation presented to the Faculty o
Medicine in 1889, Müller described the correction o his own
high myopia with a powered scleral contact lens. Paradoxically,
Müller subsequently lost interest in ophthalmology and went on
to practise as an orthopaedic specialist.

Fig . 1.8 Aug ust Mülle r. (Courte sy of Richard Pe arson.)
T e lenses worn by Müller were made by an optical engineer,
Karl Otto Himmler (1841–1903), whose rm enjoyed, until the
outbreak o World War II, an international reputation or the
manu acture o microscopes and their accessories. Himmler
must there ore be acknowledged as the rst manu acturer o
optically ground contact lenses (Pearson, 2007).
Little development occurred in the 50 years subsequent to
these early clinical trials. Improvements in methods o scleral
lens tting were described by clinicians such as Dallos, who
emphasized the importance o designing the lens to acilitate
tear ow beneath the lens (Dallos, 1936). Dallos also went on
to develop techniques or taking impressions o the human eye
and grinding the lenses rom these impressions.
Plast ic Scle ral Le nse s (1936)
Carl Zeiss o Jena, Germany applied or a patent that proposed
the manu acture o contact lenses rom ‘cellon, celluloid or an
organic substance with similar mechanical and optical prop-
erties’, which was eventually issued in 1923 (Pearson, 2015).
Cellon is cellulose acetate and celluloid is cellulose nitrate plas-
ticized with camphor; there ore, this is a re erence to a lens
made o a plastic material. T is was also the rst mention o
the manu acture o contact lenses by moulding. T e Zeiss pat-
ents envisaged that contact lenses made rom plastic materi-
als would be less expensive, have some exibility that would
improve the t, be ‘unbreakable’ and o er ocular protection
(Pearson, 2015).
It appears that in Germany there may have been some largely
unsuccess ul attempts to t plastic lenses rom around 1930.
It was reported in that year that Zeiss contact lenses moulded
rom cellon and celluloid lacked the degree o polish achieved
with glass lenses and were unstable owing to the in uences o
humidity and temperature. More serious ndings were that they
put a ‘tourniquet’ on the conjunctiva in the region o the lim-
bus and caused extensive corneal erosion. T ese un avourable
results were possibly due to the act that they were made with a
single back scleral radius o 12 mm (Pearson, 2015).
1 Hist o ry 5
T e Rohm and Haas company introduced transparent plas-
tic (polymethyl methacrylate: PMMA) into the USA in 1936,
and in the same year Feinbloom (1936) described a scleral lens
consisting o an opaque plastic haptic portion and a clear glass
centre. Soon a er, scleral lenses were abricated entirely rom
PMMA using lathing techniques. T e earliest report o the t-
ting o PMMA lenses appears to have been made by T ier in
1939. T ese lenses were said to be ‘about hal the weight o ordi-
nary glass, unbreakable and quicker to manu acture’. T ey did
not provoke any irritation, but the optical zone needed to be
repolished every 6 months (Pearson, 2015).
A key rationale or using PMMA or the manu acture o
contact lenses was that this material was considered to be bio-
logically inert in the eye. T is view was ormed by military
medical o cers who examined the eyes o pilots who su ered
eye injuries during World War II as a result o ragments rom
shattered cockpit windscreens (as would occur during aerial
dog ghts) becoming permanently embedded in the eye. T ese
eyes remained unreactive or years a er such accidents. Other
advantages o PMMA included its light weight, break resistance
and being easy to lathe and polish.
Plast ic Co rne al Le nse s (1948)
T e development o corneal lenses – or rigid lenses, as they are
re erred to today – began as the result o an error in the labora-
tory o optical technician Kevin uohy. During the lathing o a
PMMA scleral lens, its haptic and corneal portions separated.
uohy became curious as to whether the corneal portion could
be worn, so he polished the edge, placed it in his own eye and
ound that the lens could be tolerated (Bra , 1983). Further tri-
als were conducted, leading to the development o the rigid con-
tact lens (rigid lenses were previously re erred to as ‘hard’ lenses
i they were manu actured rom PMMA). uohy led a patent
or his invention in February 1948.
So began an era o popularization o the contact lens. T e
spherical uohy lens design su ered rom two main drawbacks:
considerable apical bearing, which caused central corneal abra-
sion and oedema, and excessive edge li , which made the lens
easy to dislodge. It was soon realized that these problems could be
overcome by altering the peripheral curvature o the posterior lens
sur ace, heralding the development o multicurve and aspheric
designs, which remain in widespread use today, albeit with supe-
rior gas-permeable materials (PMMA is now virtually obsolete).
Silico ne Elast o me r Le nse s (1965)
Silicone rubber orms a unique category amongst contact lens
materials. It is a ‘so lens’ in terms o its physical behaviour and
lenses are abricated rom this material in the orm o a so lens.
Unlike all other so lens materials, silicone elastomer does not
contain water and in this respect is analogous to a hard lens
material. Silicone elastomer is highly permeable to oxygen and
carbon dioxide and there ore provides minimal inter erence to
corneal respiration; however, it is di cult to manu acture and
its sur ace is hydrophobic and must be treated to allow com ort-
able wear. T e considerable di culties involved in enhancing
sur ace wettability have limited the clinical application o this
lens, and ew advances have been made since it was originally
tted. T e precise date o silicone elastomer lenses becoming
commercially available is unclear. T ere was some patent activ-
ity in the mid 1960s to early 1970s, and Mandell (1988) claims
6 PART 1 Int ro d uct io n
to have personally observed ten patients who were wearing such
lenses in 1965, noting very poor clinical results.
So ft Le nse s (1972)
Possibly the greatest understatement that can be ound in the
literature pertaining to contact lens development is the nal
sentence o a paper entitled ‘Hydrophilic gels or biological use’,
published in Nature on 9 January, 1960, by Wichterle and Lim
(1960): ‘Promising results have also been obtained in experi-
ments in other cases, or example, in manu acturing contact
lenses, arteries, etc.’
Initial attempts by Otto Wichterle (Fig. 1.9) to produce so
lenses abricated rom hydroxyethyl methacrylate (HEMA), and
manu actured using cast moulding, met with limited success.
Unable to attract support rom the Institute o Macromolecular
Research in Czechoslovakia (now the Czech Republic) where
he worked, and indeed discouraged by his superiors, Wichterle
was orced to conduct urther secret experiments in his own
home. Working with a children’s mechanical construction kit,
Wichterle developed the spin-casting technique (Fig. 1.10) and
Fig . 1.9 O tto Wichte rle . (Courte sy of De b b ie Swe e ne y.)
Fig . 1.10 The p rototyp e sp in-casting machine b uilt at home b y Wich-
te rle using his son’s toy Me ccano construction se t.
eventually managed to persuade his peers to conduct urther
trials at the Institute. He claims to have produced ‘the rst suit-
able contact lenses’ in late 1961 (Wichterle, 1978), which pre-
sumably approximates to the rst occasion when a so lens was
actually worn on a human eye. T e patent to develop so con-
tact lenses commercially was subsequently acquired by Bausch
& Lomb in the USA, who introduced so lenses into the world
market in 1972.
Lenses manu actured rom HEMA were an immediate
market success, primarily by virtue o their superior com ort
and enhanced biocompatibility. However, clinical experi-
ence and laboratory studies indicated that the poor physi-
ological response o the anterior eye during wear o the early
thick HEMA lenses could be enhanced by making so lenses
more permeable to oxygen – speci cally by making them
thinner and o a higher water content. Much o the research
and development in contact lenses up to the present time
has been concerned with the development o materials and
lens designs that optimize biocompatibility, primarily by
enhancing corneal oxygenation and minimizing absorption
o proteins, lipids and other tear constituents (McMahon and
Zadnik, 2000).
Rig id Gas-p e rme ab le Le nse s (1974)
In most respects, PMMA is considered to be an ideal contact
lens material; however, its single drawback is its impermeability
to gases that are exchanged at the corneal sur ace as part o aer-
obic metabolism. Speci cally, oxygen is prevented rom moving
rom the atmosphere into the cornea, and carbon dioxide ef ux
into the atmosphere is impeded. T is drawback has been the
major driving orce in the development o rigid lens materials
that are permeable to gases.
One o the rst rigid gas-permeable materials to be tried was
cellulose acetate butyrate, which a orded some oxygen perme-
ability but was subject to warpage. In 1974, Norman Gaylord
managed to incorporate silicone into the basic PMMA struc-
ture, heralding the introduction o a new amily o contact lens
polymers known as silicone acrylates (Gaylord, 1974). Subse-
quently, other ingredients such as styrene and uorine have
been incorporated into rigid materials in attempts to enhance
material biocompatibility urther.
Disp o sab le Le nse s (1988)
In the early days o so lens development, patients would typi-
cally use the same pair o lenses until the lenses became too
uncom ortable to wear, caused severe eye reactions, or were
damaged or lost. It became apparent that lens deposition and
spoilation over time were major impediments to success ul
long-term lens wear. Although regular lens replacement was
an obvious solution to some o these problems, the high unit
cost o lenses proved to be a signi cant disincentive. In the early
1980s, orward-thinking practitioners – notably Klas Nilsson
o Gothenburg, Sweden – convinced patients o the bene ts o
replacing lenses on a regular basis (6-monthly in Nilsson’s case)
and began prescribing lenses in this way. A subsequent land-
mark scienti c publication co-authored by Nilsson – known as
the ‘Gothenburg study’ (Holden et al., 1985) – unequivocally
proved the bene ts o regular lens replacement. So was born the
concept o regular lens replacement, albeit relatively expensive
or the patient at the time.

I regular lens replacement were to become the norm, some-
thing had to be done about lens cost. A group o Danish cli-
nicians and engineers, led by ophthalmologist Michael Bay,
developed a moulding process so that low-cost, multiple indi-
vidual lens packs could be produced (Mertz, 1997). T is prod-
uct – known as ‘Danalens’ – was released into the Scandinavian
market in 1984 and must be recognized as the rst truly dispos-
able lens. However, the initial manu acturing process was crude
and numerous problems with the lenses and packaging were
reported (Benjamin et al., 1985; Bergmanson et al., 1987).
T e pharmaceutical giant Johnson & Johnson, which had
not previously been involved in the contact lens business,
purchased the Danalens technology in 1984 and completely
overhauled the lens polymer ormulation, packaging system
and moulding technology (Mertz, 1997). T e result was the
Acuvue lens, an inexpensive weekly-replacement extended-
wear lens, which was released in the USA in June 1988, and
worldwide shortly therea er. T e success o this lens elevated
Johnson & Johnson to a leadership position in the contact lens
market. All other major contact lens companies ollowed suit,
and today the majority o so lenses prescribed worldwide
(85%) are designed to be replaced monthly or more requently
(Morgan et al., 2015).
Daily Disp o sab le Le nse s (1994)
T e ultimate requency with which lenses can be replaced
is daily. A Scottish company, Award (which was acquired by
Bausch & Lomb in 1996), developed a manu acturing technique
whereby the male hal o the mould that ormed the lens became
the lens packaging. T is technique urther reduced the unit cost
o a lens, making daily disposability a viable proposition. T e
‘Premier’ daily disposable lens was launched in the UK in 1994.
Johnson & Johnson released the ‘1-Day Acuvue’ daily dispos-
able lens into western regions o the USA around the same time,
leading to an ongoing dispute as to which company (Award or
Johnson & Johnson) was the rst to release a daily disposable
contact lens into the market (Meyler and Ruston, 2006). CIBA
Vision entered the daily disposable lens market in 1997 with a
product called ‘Dailies’.
Silico ne Hyd ro g e l Le nse s (1998)
T e allure o a so contact lens made rom a material with a
phenomenally high oxygen per ormance never escaped the
contact lens industry. T e development o such a lens would be
critical to solving hypoxic lens-related problems, which severely
limit the clinical utility o contact lenses, especially or extended
wear. Silicone elastomers were the obvious answer, but, or rea-
sons outlined above, success ul lenses could never be produced
rom this material. Polymer scientists in the contact lens indus-
try had long recognized that many o the problems associated
with silicone elastomers or contact lens abrication could theo-
retically be overcome by creating a silicone–hydrogel hybrid.
A er more than a decade o intensive research and devel-
opment, two spherical-design silicone hydrogel lenses were
introduced into the market in 1998: Focus Night & Day (CIBA
Vision) and Purevision (Bausch & Lomb). T e introduction o
these lenses is considered by many to be the most signi cant
advance in contact lens material technology since the devel-
opment o HEMA by Wichterle in the 1960s. Within a decade
o these products entering the market, all major contact lens
1 Hist o ry 7
manu acturers had introduced silicone hydrogel lenses; this
lens type is now available in toric and multi ocal designs and
a range o replacement modalities, including daily disposable
lenses.
Myo p ia Co nt ro l Le nse s (2010)
In 2010, CooperVision released into some Asian markets a daily
disposable so lens that is designed to arrest the rate o progres-
sion o myopia. A variety o optical designs can be employed
to achieve this so-called ‘anti-myopia’ e ect. T e CooperVision
MiSight lens has a ‘dual- ocus’ design that contains a large cen-
tral correction area surrounded by concentric zones o alternat-
ing distant and near powers. T e near power is intended as a
‘treatment’ zone to prevent myopic progression (see Chapter 33
or a detailed account o myopia control lenses).
Co nt act Le ns ‘Flat Pack’ (2011)
Japanese manu acturer Menicon introduced an ultra-thin orm
o packaging – known as the ‘ at pack’ – or their ‘Magic’ brand
o daily disposable contact lenses. As well as being highly e -
cient or storage and convenient or the user, this orm o pack-
aging reduces lens contamination because the lens back sur ace
is always presented to the patient upon opening the pack, which
means that the person can pick up and insert the lens into the
eye without touching and contaminating the posterior lens sur-
ace, which comes into contact with the eye (Nomachi et al.,
2013). T e contact lens is essentially sandwiched within a 1 mm
thick aluminium oil sleeve that is resistant to evaporation, thus
preserving the small amount o uid trapped within the pack
that moisturizes the lens.
Fig. 1.11 presents a historical timeline o key developments
in the contact lens eld rom the time contact (scleral) lenses
were rst tted to human eyes in the late 1880s up to the
present.
The Fut ure
So lenses are likely to dominate the uture contact lens mar-
ket. Although rigid lenses are seldom tted today or purely
cosmetic reasons, there are many clinical indications or rigid
lenses, such as keratoconus, distorted corneas, irregular and / or
high astigmatism, certain anterior eye pathologies and par-
ticipation in extreme sports. Accordingly, specialized rigid
lens ttings will continue to be an important aspect o contact
lens practice, albeit at relatively low levels. T e recent renewed
interest in scleral or mini-scleral lenses is unlikely to have a sig-
ni cant impact on the overall proportion o lenses prescribed
owing to the specialist nature o tting such lenses.
T e convenience and ocular health bene ts o daily dispos-
able lenses are likely to see this modality o lens wear continue
to increase in popularity. T is trend will be accelerated with
improvements in methods and e ciency o lens mass produc-
tion, which in turn will drive prices down and make these lenses
more a ordable. O course, any increase in daily disposable
lens usage will be matched by a commensurate decrease in the
demand or, and use o , contact lens care solutions.
Silicone hydrogels are set to continue as the main material
type rom which lenses are abricated in view o their abil-
ity to obviate hypoxic complications o lens wear; however,
the possibility o the arrival in the uture o an entirely new
8 PART 1 Int ro d uct io n

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

category o lens material with even greater bene ts should not
be discounted.
Contact lenses are likely to be used increasingly or the cor-
rection o presbyopia; this trend may be uelled by the devel-
opment o superior multi ocal lens designs and the increasing
availability o such products as daily disposable lenses. Look-
ing urther into the uture, contact lenses that switch power
electronically or through some other means may acilitate
enhanced presbyopic correction.
Extended wear is the ultimate modality in terms o patient
convenience, but it is unlikely that this modality o lens wear
will break through the ‘glass ceiling’ o a prescribing rate o
around 10% o lenses tted in the oreseeable uture, in view o
the ve times greater risk o microbial keratitis when sleeping in

all orms o contact lenses (Schein et al., 1989). Again, develop-
ment or invention o an entirely new category o lens material
with superior ocular biocompatibility or an ability to minimize
microbial colonization would need to be developed be ore
extended wear can capture an appreciably greater slice o the
contact lens market.
As better toric lens designs become available, especially in
daily disposable modality, toric lenses tting is likely to increase
steadily to represent approximately 45% o all so lenses pre-
scribed, which is the level at which all astigmatism ≥ 0.75 D is
being corrected. We may see a resurgence in tinted lens tting
as the newly developed coloured silicone hydrogel lenses gain in
popularity and similar products enter the market.
Finally, current developments in innovative contact lens appli-
cations – such as lens sur ace modi cations to include channels
and patterns or improving post-lens tear exchange (Weidemann
1 Hist o ry 9
and Lakkis, 2005; Lin et al., 2006), alternative anti-myopia designs
(Sankaridurg et al., 2011), anti-in ective and anti-in ammatory
lenses (Weisbarth et al., 2007; Zhu et al., 2008), drug delivery
(Mohammadi et al., 2014), glucose monitoring and other orms
o metabolic sensing (Farandos et al., 2015), intraocular pressure
measurement (Chen et al., 2014), digital in ormation acquisition
and display (e.g. a contact lens version o Google Glass [Google
Inc., Mountain View, CA]) and liquid crystal diode optical
switching (Milton et al., 2014) – may open up whole new markets
or contact lenses and move at least part o the industry in new
and interesting directions. Contact lens practitioners may need to
acquire new knowledge and tting skills so that they can embrace
any such innovative developments.
Acce ss t he co mp le t e re fe re nce s list o nline at
ht t p :/ / www.e xp e rt co nsult .co m.
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9.e 1
 2
Ant e rio r Eye
JO HN G LAWRENSO N

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

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

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

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

2.1 Me asure me nt s
Parame t e r Value
Are a 1.1 cm 2
Diame te r
Horizontal 11.8 mm
Ve rtical 10.6 mm
Rad ius of curvature
Ante rior ce ntral 7.8 mm
Poste rior ce ntral 6.5 mm
Thickne ss
Ce ntral 0.54 mm
Pe rip he ral 0.67 mm
Re fractive ind e x 1.376
Powe r 42 D Fig . 2.1 Transve rse se ction throug h the corne a. The stroma, which
re p re se nts 90% o the thickne ss o the corne a, is b ound e d b y the e p i-
(Data ad ap te d rom Bron e t al., 1997.) the lium (aste risk) and e nd othe lium (arrow).
10

shedding and replacement to maintain corneal integrity. T ree
distinct epithelial cell types are recognized: a single row o basal
cells, 2–3 rows o wing cells and 2–3 layers o super cial (squamous)
cells. In addition, several non-epithelial cells are present (e.g.
lymphocytes, macrophages and Langerhans cells). T e epithelium
orms a permeability barrier to water, ions and hydrophilic
molecules above a certain size, as well as orming an e ective
barrier to the entry o pathogens. Further epithelial specialization
enhances adhesion between cells, to withstand shearing and
abrasive orces. Furthermore, throughout the thickness o the
epithelium, adjacent cells are connected to one another by water
channels (aquaporins) that are engaged in transcellular water
transport and gap junctions to allow the trans er o ions and small
molecules between cells (Bron et al., 2015).
Super cial cells are structurally modi ed or their barrier
unction and interaction with the tear lm. Scanning elec-
tron microscopy o sur ace cells shows extensive nger-like
and ridge-like projections (microvilli and microplicae), which
increase the epithelial sur ace area. Light, medium and dark
cells can be distinguished depending on the number and pat-
tern o sur ace projections (P ster, 1973). It has been sug-
gested that dark cells, which are relatively ree o these sur ace
eatures, are close to being desquamated into the tear lm. By
contrast, the newly arrived light cells possess a more extensive
array o sur ace projections. In high-power transmission elec-
tron micrographs, microvilli and microplicae show an extensive
lamentous covering known as the glycocalyx. T e glycocalyx
is ormed rom membrane-bound mucin glycoproteins and is
important or spreading and attachment o the precorneal tear
lm. In accordance with their barrier unction, a complex net-
work o tight junctions links super cial cells that exclude water-
soluble dyes such as uorescein (Bron et al., 2015).
Wing cells are so named because o their characteristic
shape, with lateral extensions and a concave in erior sur ace to
accommodate the apices o the basal cells. T eir nuclei tend to
be spherical or elongated in the plane o the cornea. T e cell
borders o the polygonal wing cells show prominent in oldings
that interdigitate with adjacent cells, and numerous desmo-
somes. T is arrangement results in a strong intercellular adhe-
sion. T e cytoplasm contains prominent cytoskeletal elements
(predominantly actin and cytokeratin intermediate laments),
and although the usual complement o organelles is present they
are ew in number.
Fig . 2.2 Corne al e p ithe lium (d e tail). Thre e ce ll typ e s are p re se nt:
b asal ce lls (aste risk), wing ce lls (arrowhe ad ) and sq uamous ce lls (arrow).
BL= Bowman’s laye r.
2 Ant e rio r Eye 11
Basal cells consist o single-layer columnar cells with a verti-
cally oriented oval nucleus. Ultrastructurally, they are similar in
appearance to wing cells. T e plasma membrane similarly shows
pronounced in olding and the cytoplasm contains prominent
intermediate laments. A variety o cell junctions are present
including: desmosomes, which mediate adhesion between cells;
hemidesmosomes, which are involved in the attachment o basal
cells to the underlying stroma; and gap junctions, which allow or
intercellular metabolic coupling. Basal cells orm the germative
layer o the cornea, and mitotic cells are o en seen at this level.
Basal Lamina and Bowman’s Layer. T e basal lamina
(basement membrane) is synthesized by basal cells. It varies
in thickness between 0.5 and 1 µm, and under the electron
microscope can be di erentiated into an anterior clear zone
(lamina lucida) and a posterior darker zone (lamina densa).
T e basal lamina is part o a complex adhesion system, which
mediates the attachment o the epithelium to the underlying
stroma (Fig. 2.3). Hemidesmosomes link the cytoskeleton via a
series o anchoring brils to anchoring plaques in the anterior
stroma. T e molecular components o this adhesion complex
have been identi ed and include type VII collagen, integrins,
laminin and bullous pemphigoid antigen (Gipson et al., 1987).
Bowman’s layer (anterior limiting membrane) varies in thick-
ness between 8 and 14 µm. With the light microscope it appears as
an acellular homogeneous zone. Ultrastructurally, it is composed
o a randomly oriented array o ne collagen brils, which merge
with the brils o the anterior stroma (Hogan et al., 1971). Fibrils
are composed primarily o collagen types I, III and V. Collagen VII,
associated with anchoring brils, is also present. T ere is evidence
that Bowman’s layer is ormed and maintained primarily by the epi-
thelium, although its unction is unclear. T e absence o Bowman’s
layer rom the cornea o most mammals, and the act that corneas
devoid o this layer over the central cornea ollowing photore rac-
tive keratectomy (PRK) apparently unction normally, suggest that
it is not critical to corneal integrity (Wilson and Hong, 2000).
Stroma. T e stroma is approximately 500 µm thick, and
accounts or 90% o the thickness o the cornea. It is composed
predominantly o collagen brils (70% dry weight) embedded in
a highly hydrated matrix o proteoglycans. A variety o collagen
Fig . 2.3 Sche matic re p re se ntation o the ad he sion syste m o the cor-
ne al e p ithe lium. Inte rme d iate lame nts in the cytoske le ton (CS) are
linke d throug h he mid e smosome s (HD) via anchoring b rils (AF) to an-
choring p laq ue s (AP) in the ante rior stroma. BL= b asal lamina; D = d e s-
mosome .
12 PART 1 Int ro d uct io n
Fig . 2.4 Se ction throug h the stroma. Ke ratocyte s (arrowe d ) are locat-
e d b e twe e n lame llae .
Fig . 2.5 Ele ctron microg rap h o stromal lame llae that cross e ach othe r
ap p roximate ly at rig ht ang le s. Note the re g ular arrang e me nt o colla-
g e n b rils within lame llae .
types have been identi ed. ype I is the major bril- orming
collagen, with lesser amounts o types III and V. Non- bril-
orming collagens, including types VI and XII, are ound in the
inter brillar matrix (Meek and Boote, 2009). A section taken
perpendicular to the corneal sur ace reveals that the collagen
brils are arranged in 200–250 layers (lamellae) running parallel
to the sur ace (Fig. 2.4). Lamellae are approximately 2 µm thick
and 9–260 µm wide, and extend rom limbus to limbus. Fibrils
o adjacent lamellae make large angles with each other. In the
super cial stroma the angles are less than 90°, but brils become
orthogonal in the deeper stroma (Hogan et al., 1971; Meek and
Boote, 2009). T is pre erred orthogonal orientation gradually
changes in avour o circum erentially aligned collagen at the
limbus. T is particular arrangement o collagen imparts a high
tensile strength or corneal protection, which is important given
its exposed position. Within lamellae, all collagen brils are
parallel with uni orm size and separation (Fig. 2.5). Accurate
Fig . 2.6 Flat se ction throug h the stroma staine d with g old chlorid e .
Ke ratocyte s (arrowe d ) d isp lay a ste llate ap p e arance .
physiological measurements o collagen bre diameter and
spacing can be obtained or the hydrated cornea with the aid o
X-ray di raction. Using this technique, the mean bril diameter
in the human cornea is 31 nm, with an inter brillar spacing o
55 nm (Meek and Leonard, 1993). T is narrow bril diameter
and constant separation, which is a characteristic o corneal
collagen, are necessary prerequisites or transparency.
T e inter brillar space contains a matrix o proteoglycans
(approximately 10% o dry weight). T ese molecules are highly
sulphated, and along with bound chloride ions create a polyan-
ionic stromal inter brillar matrix that induces osmotic swelling.
As well as playing a major role in corneal hydration, collagen–
proteoglycan interactions are also thought to be important in
determining the size and spatial arrangement o stromal colla-
gen brils (Scott, 1991; Quantock and Young, 2008).
Collagen and proteoglycans are maintained by keratocytes.
T ese cells occupy 3–5% o stromal volume and lie between col-
lagen lamellae, attened in the plane o the cornea (Fig. 2.6).
Keratocyte density examined by con ocal microscopy and bio-
chemical methods (Møller-Pederson and Ehlers, 1995; Prydal
et al., 1998) is non-uni orm. Density decreases rom super cial
to deep stroma (Hollingsworth et al., 2001) and increases rom
centre to periphery. Keratocytes display a large central nucleus
and long slender processes extend rom the cell body. Processes
rom adjacent cells sometimes make tight junctions with each
other. Cell organelles are not numerous but the usual comple-
ment o organelles, including endoplasmic reticulum, Golgi
apparatus and mitochondria, can be observed (Hogan et al.,
1971).
Newer lamellar corneal transplantation techniques have
been developed that allow selective replacement o the diseased
corneal layers. Deep anterior lamellar keratoplasty (DALK),
which is increasingly being used to treat keratoconus and cor-
neal scarring, involves replacement o the a ected stroma while
retaining the host’s healthy Descemet’s membrane and endo-
thelium. Separation between the posterior stroma and Des-
cemet’s / endothelium can be achieved by intrastromal injection
o air, viscoelastic or saline. Dua and co-workers per ormed a
histological examination o donor corneas using air bubble sep-
aration and claimed to have identi ed a novel ‘pre-Descemet’s
posterior stromal layer’, which was widely publicized (Dua et al.,

Fig . 2.7 Hig h-p owe re d microg rap h o the p oste rior stroma. De s-
ce me t’s me mb rane (DM) is locate d b e twe e n the stroma (S) and the e n-
d othe lium (arro w).
Fig . 2.8 Thre e -d ime nsional re p re se ntation o the p oste rior corne a
showing the e nd othe lium (e ), De sce me t’s me mb rane (d ) and stroma (s).
A stromal lame lla has b e e n re f e cte d to re ve al an intralame llar ke rato-
cyte (k).
2013). However, the current consensus amongst corneal experts
is that this layer is not suf ciently unique to constitute a new
corneal layer (Jester et al., 2013).
Descemet’s Membrane. Descemet’s membrane is the basement
membrane o the corneal endothelium. It lies between the
endothelium and the overlying stroma (Fig. 2.7). At birth it is
3–4 µm thick, and increases to a thickness o 10–12 µm in the
adult. In the periphery o aged corneas, Descemet’s membrane
displays periodic sections o thickening, which are known as
Hassall–Henle warts. T e anterior one-third o Descemet’s
membrane represents that part produced in etal li e and, under
the electron microscope, is characterized by a periodic banded
pattern (Fig. 2.8). T e posterior two-thirds, which is ormed
postnatally, has a more homogeneous granular appearance.
Descemet’s membrane has a unique biochemical composition
in contrast with other basement membranes (Lawrenson
et al., 1998). T e major basement membrane collagen type is
type IV, whereas in Descemet’s membrane type VIII collagen
predominates.
Endothelium. T e endothelium is a monolayer o squamous
cells that lines the posterior sur ace o the cornea (Fig. 2.9)
and plays a critical role in maintaining corneal transparency
(Bonanno, 2012). As it has a limited capacity or mitosis to
2 Ant e rio r Eye 13
Fig . 2.9 Tang e ntial (f at) se ction throug h the corne al e nd othe lium: a
sing le laye r o p olyg onal ce lls with irre g ular b ord e rs can b e ob se rve d .
replace damaged or e ete cells, there is a progressive reduction
in endothelial cell number with age. At birth the cornea
contains a total o approximately 500 000 cells, which represents
a mean density o 4500 cells / mm 2. During in ancy, cell loss
is particularly marked and a 26% reduction occurs in the rst
year o li e (Sherrard et al., 1987). T erea er the rate o loss
progressively declines into old age. Since gra ed corneas appear
to maintain transparency and unctional normality with an
endothelial cell density o less than 1000 cells / mm 2, it seems
that normal cell density represents a considerable ‘physiological
reserve’ (Klyce and Beuerman, 1998). When viewed en ace, or
example using a specular microscope, the endothelium appears
as a mosaic o polygonal (typically hexagonal) cells (E ron et al.,
2001). In response to pathology, trauma, age and prolonged
contact lens wear, the endothelial mosaic becomes less regular,
and shows a greater variation in cell size (polymegethism) and
shape (pleomorphism) as cells spread to ll gaps caused by
cell loss. Under the electron microscope, the lateral borders o
the cells are markedly convoluted and adjacent cells are linked
by tight junctions (with less- requent gap junctions) (Hogan
et al., 1971). T e complement o organelles seen in endothelial
cells re ects their high metabolic activity, with numerous
mitochondria and a prominent rough endoplasmic reticulum.
CO RNEAL INNERVATIO N
Source and Distrib ution of Corne al Ne rve s
T e cornea is the most richly innervated sur ace tissue in
the body. Corneal nerves are responsible or the detection o
somatosensory stimuli and play an important role in initiating
the blink re ex, wound healing and tear secretion (see Sha-
heen et al., 2014, or a recent review). T e majority o corneal
nerves are sensory and derive rom the nasociliary branch o
the trigeminal nerve (Ruskell and Lawrenson, 1994). T ere is
also evidence or the existence o a modest sympathetic inner-
vation rom the superior cervical ganglion (Mar urt and Ellis,
1993). Branches rom the nasociliary nerve either pass directly
to the eye as long ciliary nerves or traverse the ciliary ganglion,
leaving it as short ciliary nerves that enter the eye close to the
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 Et præceps Anio ac Tiburni lucus et uda
Mobilibus pomaria rivis.”

By the way, nobody who has not endeavoured to render Latin

poetry into English can appreciate the vigour and terseness of the
older language. Here are six lines in the one version and four in the
other, required to translate three of the original, perhaps without
producing after all so full a meaning or so complete a picture.
Nevertheless, and notwithstanding his poetical predilections for
the country, Horace, like many other people, seems of his two
homes to have always preferred the one at which he was not. An
unhappy prejudice little calculated to enhance the comfort and
content of daily life.
Had he settled anywhere in the neighbourhood of our hermitage
here, he need not have accused himself of this fickle longing, which
he denounces by the somewhat ludicrous epithet of “ventose.” He
might have combined the advantages of town and country,
alternating the solitude of the desert with the society of his fellow-
men, blowing the smoke out of his lungs while inhaling the fresh
breezes off the Serpentine, stretching his own limbs and his horses’
by walks and rides round Battersea, Victoria, and Hyde Parks.
If you look for rus in urbe, where will you find it in such perfection
as within a mile of the Wellington statue in almost any direction you
please to take? If you choose to saunter on a hot June day towards
the Ranger’s Lodge or the powder-magazine, I could show you a
spot from which I defy you to see houses, spires, gas-towers, or
chimneys, anything, indeed, but green grass and blue sky, and
towering elms motionless, in black massive shade, or quivering in
golden gleams of light. A spot where you might lie and dream of
nymph and faun, wood-god and satyr, Daphne pursued by Phœbus,
Actæon flying before Diana, of Pan and Syrinx and Echo, and all the
rustic joys of peaceful Arcady—or of elves and brownies, fair
princesses and cruel monsters, Launcelot, Modred, and Carodac, Sir
Gawain the courteous with his “lothely ladye,” the compromising cup,
the misfitting mantle, all the bright pageantry, quaint device, and
deep, tender romance that groups itself round good King Arthur and
the Knights of his Round Table—or of Thomas the Rhymer as he lay
at length under the “linden tree,” and espied, riding towards him on a
milk-white palfrey, a dame so beautiful, that he could not but believe
she was the mother of his lord, till undeceived by her own
confession, he won from her the fatal gift of an unearthly love. And
here, perhaps, you branch off into some more recent vision, some
dream of an elfin queen of your own, who also showed you the path
to heaven, and gave you an insight into the ways of purgatory, ere
she beckoned you down the road to Fairyland, that leads—ah! who
knows where? From this sequestered nook you need not walk a
bowshot to arrive at the seaboard of the Serpentine; and here,
should there be a breath of air, if you have any taste for yachting,
you may indulge it to your heart’s content. The glittering water is
dotted with craft of every rig and, under a certain standard, of almost
every size. Yawls, cutters, schooners, barques, brigs, with here and
there a three-masted ship. On a wind and off a wind, close-hauled
and free, rolling, pitching, going about, occasionally missing stays,
and only to be extricated from the “doldrums” by a blundering, over-
eager water-dog, the mimic fleet, on its mimic ocean, carries out its
illusion so completely that you can almost fancy the air off the water
feels damp to your forehead, and tastes salt upon your lips.
An ancient mariner who frequents the beach below the boat-house
feels, I am convinced, thoroughly persuaded that his occupation is
strictly professional, that he is himself a necessity, not of
amusement, but business. He will tell you that when the wind veers
round like that, “suddenways, off Kensington Gardens, you may look
out for squalls;” that “last Toosday was an awful wild night, and some
on ’em broke from their moorings afore he could turn out. The
Bellerophon, bless ye, was as nigh lost as could be, and that there
Water Lily, the sweetest thing as ever swam—she sprang her boom,
damaged her bowsprit, and broke her nose. He was refitting all
Wens’day, he was, up to two o’clock, and a precious job he had!”
Every one who constantly “takes his walks abroad” in the Great
City, becomes a philosopher in spite of himself, of the Peripatetic
School, no doubt, but still a philosopher; so you sympathise mildly
with the mariner’s troubles; for to you no human interests are either
great or small, nor does one pursuit or person bore you more than
another. You hazard an opinion, therefore, that the Water Lily is
somewhat too delicate and fragile a craft to encounter boisterous
weather, even on such an inland sea as this, and find, to your
dismay, that so innocent an observation stamps you in his opinion as
not only ignorant, but presumptuous. He considers her both
“wholesome,” as he calls it, and “weatherly,” urging on you many
considerations of sea-worthiness, such as her false keel, her
bulwarks, her breadth of beam, and general calibre. “Why, she’s
seven-and-twenty,” says he, rolling a peppermint lozenge round his
tongue, just as a real seaman turns a quid; “now look at the Sea-
Sarpent lying away to the eastward yonder, just beyond the point
where the gravel’s been washed adrift. She’s fifty-two, she is, but I
wouldn’t trust her, not in lumpy water, you know, like the schooner.
No. If I was a-building of one now, what I call, for all work and all
weathers, thirty would be my mark, or from that to thirty-five at the
outside!”
“Thirty-five what? Tons?” you ask, a little abashed, and feeling you
have committed yourself.
“Tons!” he repeats, in a tone of intense disgust—“tons be blowed!
h’inches! I should have thought any landsman might ha’ knowed that
—h’inches!” and lurching sulkily into his cabin under the willow-tree,
disappears to be seen no more.
Later, when September has begun to tinge the topmost twigs with
gold, and autumn, like a beautiful woman, then indeed at her
loveliest, who is just upon the wane, dresses in her deepest colours,
and her richest garments, go roaming about in Kensington Gardens,
and say whether you might not fancy yourself a hundred miles from
any such evidences of civilisation as a pillar-post or a cab-stand.
It was but the other day I sauntered through the grove that stands
nearest the Uxbridge Road, and, while an afternoon mist limited my
range of vision and deadened the sounds of traffic on my ears, I
could hardly persuade myself that in less than five minutes I might if I
liked make the thirteenth in an omnibus.
 Alone? you ask—of course I was. Yet, stay, not quite alone, for
with me walked the shadow that, when we have learned to prefer
solitude to society, accompanies us in all our wanderings, teaching
us, I humbly hope, the inevitable lesson, permanent and precious in
proportion to the pain with which the poor scholar gets his task by
heart.
Well, I give you my word, the endless stems, the noiseless
solitude, the circumscribed horizon, reminded me of those forest
ranges in North America that stretch interminable from the waters of
the St. Ann’s and the Batsicon to the wild waves breaking dark and
sullen on the desert seaboard of Labrador.
I am not joking. I declare to you I was once more in moccasins,
blanket-coat, and bonnet-rouge, with an axe in my belt, a pack on
my shoulders, and a rifle in my hand, following the track of the
treborgons[3] on snow-shoes, in company with Thomas, the French
Canadian, and François, the half-breed, and the Huron chief with a
name I could never pronounce, that neither I nor any man alive can
spell. Ah! it was a merry life we led on those moose-hunting
expeditions, in spite of hard work, hard fare, and, on occasion, more
than a sufficiency of the discomfort our retainers called expressively
misère. There was a strange charm in the marches through those
silent forests, across those frozen lakes, all clothed alike in their
winter robe of white and diamonds. There was a bold, free, joyous
comfort in the hole we dug through a yard and a half of snow,
wherein to build our fire, boil our kettle, fry our pork (it is no use
talking of such things to you, but I was going to say, never forget a
frying-pan on these expeditions; it is worth all the kitchen-ranges in
Belgravia), to smoke our tobacco, ay, and to take our rest.
There was something of sweet adventurous romance in waking at
midnight to see the stars flash like brilliants through the snow-
encrusted branches overhead, wondering vaguely where and why
and what were all those countless worlds of flame. Perhaps to turn
round again and dream of starry eyes in the settlements, then closed
in sleep, or winking drowsily at a night-light, while the pretty watcher
pondered, not unmindful of ourselves, pitying us, it may be, couching
here in the bush, and thinking in her ignorance how cold we were!
 Then when we reached our hunting-ground and came up with our
game at last, though, truth to tell, the sport as sport was poor
enough, there was yet a wild delightful triumph in overtaking and
slaying a gigantic animal that had never seen the face of man. The
chase was exciting, invigorating, bracing; the idea grand, heroic,
Scandinavian.

“An elk came out of the pine-forest;

He snuffed up east, he snuffed up west,
Stealthy and still;
His mane and his horns were shaggy with snow,
I laid my arrow across my bow,
Stealthily and still;
The bowstring rattled—the arrow flew,
And it pierced his blade-bone through and through,
Hurrah!
I sprang at his throat like a wolf of the wood,
And I dipped my hands in the smoking blood,
Hurrah!”

Kingsley had not written Hypatia then. Kingsley never went

moose-hunting in his life. How could he so vividly describe the gait
and bearing of a forest elk stalking warily, doubtfully, yet with a kingly
pride through his wintry haunts? Probably from the instinctive sense
of fitness, the intuition peculiar to poets, that enabled him to feel
alike with a fierce Goth sheltering in his snow-trench, and a soft,
seductive southern beauty, languishing, lovely and beloved, in spite
of dangerous impulses and tarnished fame, in spite of wilful heart,
reckless self-abandonment, woman weakness, and the fatal saffron
shawl.
I tell you that I could not have been more completely alone in
Robinson Crusoe’s island than I found myself here within a rifle-shot
of Kensington Palace, during a twenty minutes’ walk, to and fro, up
and down, threading the stems of those tall, metropolitan trees; nor
when my solitude was at last disturbed could I find it in me to grudge
the intruders their share of my retreat. More especially as they were
themselves thoroughly unconscious of everything but their own
companionship, sauntering on, side by side, with murmured words,
and loving looks, and steps that dwelt and lingered on the path,
because impossible roses seemed springing into bloom beneath
their very feet, and that for them Kensington Gardens were indeed
as the gardens of Paradise.
I knew right well for me the mist was gathering round, ghostly and
damp and chill. It struck through my garments, it crept about my
heart, but for these, thank God! the sky was bright as a midsummer
noon. They were basking in the warmth and light of those gleams
that come once or twice in a lifetime to remind us of what we might
be, to reproach us, perhaps, gently for what we are. They did not
speak much, they laughed not at all. Their conversation seemed a
little dull, trite, and commonplace, yet I doubt if either of them has
forgotten a word of it yet. It was pleasant to observe how happy they
were, and I am sure they thought it was to last for ever. Indeed I wish
it may!
But the reflections of a man on foot are to those of a man on
horseback as the tortoise to the hare, the mouse to the lion, tobacco
to opium, chalk to cheese, prose to poetry.

“As moonshine is to sunshine, and as water is to wine.”

Get into the saddle, leap on a thorough-bred horse, if you have got
one. Never mind his spoiling you for every other animal of meaner
race, and come for a “spin” up the Ride from Hyde Park Corner to
Kensington Gate, careful only to steady him sufficiently for the safety
of Her Majesty’s subjects, and the inquisition, not very rigorous, of
the policemen on duty. For seven months in the year, at least, this is
perhaps the only mile and a half in England over which you may
gallop without remorse for battering legs and feet to pieces on the
hard ground. Away you go, the breeze lifting your whiskers from the
very roots (I forgot, you have no whiskers, nor indeed would such
superfluities be in character with the severe style of your immortal
beauty). Never mind, the faster you gallop the keener and cooler
comes the air. Sit well down, just feel him on the curb, let him shake
his pretty head and play with his bridle, sailing away with his hind-
legs under your stirrup-irons, free, yet collected, so that you could let
him out at speed, or have him back in a canter within half-a-dozen
strides; pat him lovingly just where the hair turns on his glossy neck
like a knot in polished woodwork, and while he bends to meet the
caress, and bounds to acknowledge it, tell me that dancing is the
poetry of motion if you dare!
Should it not be the London season—and I am of opinion that the
rus in urbe is more enjoyable to both of us at the “dead time of year”
than during the three fashionable months—do not, therefore, feel
alarmed that you will have the ride to yourself, or that if you come to
grief there will be nobody to pick you up! Here you will meet some
Life-Guardsman “taking the nonsense” out of a charger he hates;
there some fair girl, trim of waist, blue of habit, and golden of
chignon, giving her favourite “a breather,” ready and willing to
acknowledge that she is happier thus, speeding along in her side-
saddle, than floating round a ball-room to Coote and Tinney’s softest
strains with the best waltzer in London for a partner.
But your horse has got his blood up, and you yourself feel that
rising within, which reminds you of the merry youthful days, when
everything in life was done, so to speak, at a gallop. You long to
have a lark—you cannot settle down without a jump or two at least.
You look wistfully at the single iron rail that guards the footway, but
refrain: and herein you are wise. Nevertheless, you shall not be
disappointed; you have but to jog quietly out of the Park, through
Queen’s Gate, turning thereafter to your right, and within a quarter of
a mile you shall find what you require. Yes, in good truth, our rus in
urbe, to be the more complete, is not without a little hunting-ground
of its own. Mr. Blackman has laid out a snug enclosure, walled in on
all sides and remote from observation, where man and horse may
disport themselves with no more fear of being crowded and jostled
than in Launde Woods or Rockingham Forest during the autumnal
months. Here you will find every description of fence in miniature,
neat and new and complete, like the furniture in a doll’s baby-house
—a little hedge, a little ditch, a little double, and a very little gate,
cunningly constructed on mechanical principles so as to let you off
easily should you tamper with its top bar, the whole admirably
adapted to encourage a timid horse or steady a bold one.
 All this is child’s-play, no doubt—the merest child’s-play, compared
with the real thing. Yet there is much in the association of ideas; and
a round or two over this mimic country cannot but bring back to you
the memory of the merriest, ay, and the happiest, if not the sweetest,
moments of your life. Mounted, with a good start, in a grass country,
after a pack of foxhounds, there is no discord in the melody, no bitter
in the cup—your keenest anxiety the soundness of the level water-
meadow, your worst misgiving the strength of the farther rail, the
width of the second ditch. The goddess of your worship bids your
pulses leap and your blood thrill, but never makes your heart ache,
and the thorns that hedge the roses of Diana can only pierce skin-
deep.
Wasn’t it glorious, though you rode much heavier then than you do
now,—wasn’t it glorious, I say, to view a gallant fox going straight
away from Lilburne, Loatland Wood, Shankton Holt, John-o’-Gaunt,
or any covert you please to name that lies in the heart of a good-
scenting, fair-fenced, galloping country? Yourself, sheltered and
unseen, what keen excitement to mark his stealing, easy action,
gliding across the middle of the fields, nose, back, and brush carried
in what geometricians call a “right” line, to lead you over what many
people would call a “serious” one! A chorus ringing from some
twenty couple of tongues becomes suddenly mute, and the good
horse beneath you trembles with delight while the hounds pour over
the fence that bounds the covert, scattering like a conjuror’s pack of
cards, ere they converge in the form of an arrow, heads and sterns
down, racing each other for a lead, and lengthening out from the
sheer pace at which a burning scent enables them to drive along!
They have settled to it now. You may set to and ride without
compunction or remorse. A dozen fields, as many fences, a friendly
gate, and they have thrown their heads up in a lane. Half-a-score of
sportsmen, one plastered with mud, and the huntsman now come
up; you feel conscious, though you know you are innocent, that he
thinks you have been driving them! You remark, also, that there is
more red than common in the men’s faces and the horses’ nostrils;
both seem to be much excited and a little blown.
 The check, however, is not of long duration. Fortunately, the
hounds have taken the matter in hand for themselves, ere the only
person qualified to do so has had time to interfere. Rarpsody, as he
calls her, puts her nose down and goes off again at score. You
scramble out of the lane, post-haste, narrowly escaping a fall. Your
horse has caught his wind with that timely pull. He is going as bold
as a lion, as easy as a bird, as steady as a rock. You seem to have
grown together, and move like one creature to that long swinging
stride, untiring and regular as clock-work. A line of grass is before
you, a light east wind in your face, two years’ condition and the best
blood of Newmarket in his veins render you confident of your steed’s
enduring powers, while every field as he swoops over it, every fence
as he throws it lightly behind him, convinces you more and more of
his speed, mettle, and activity. What will you have? The pleasures of
imagination, at least, are unlimited. Shall it be two-and-twenty
minutes up wind and to ground as hard as they can go? Shall it be
thirty-five without another check, crossing the best of the Vale, and
indulging the good horse with never a pull till you land in the field
where old Rhapsody, with flashing eyes and bristles all on end, runs
into her quarry, rolling him over and herself with him, to be buried in
the rush of her eager worrying followers? Would you prefer twelve
miles from point to point, accomplished in an hour and a half,
comprising every variety of country, every vicissitude of the chase,
and ending only when the crows are hovering and swooping over a
staunch, courageous, travel-wearied fox, holding on with failing
strength but all-undaunted spirit for the forest that another mile would
reach but that he is never to see again? You may take your choice.
Holloa! he has disappeared!—he has taken refuge in his cupboard.
Not even such a skeleton as mine can sustain the exorcism of so
powerful a spell as fox-hunting! So be it. Who-whoop! Gone to
ground? I think we will leave him there for the present. It is better not
to dig him out!
 CHAPTER IX
HAUNTED

A hundred years ago there was scarce a decent country house in

England or Scotland that did not pride itself on two advantages—the
inexhaustible resources of its cellar and the undoubted respectability
of its ghost. Whether the generous contents of the one had not
something to do with the regular attendance of the other, I will not
take upon me to decide; but in those times hall, castle, manor-house,
and even wayside inn were haunted every one. The phantoms used
to be as various, too, as the figures in a pantomime. Strains of
unaccountable music sometimes floated in the air. Invisible carriages
rolled into courtyards at midnight, and door-bells rang loudly, pulled
by unearthly visitors, who were heard but never seen. If you woke at
twelve o’clock you were sure to find a nobleman in court-dress, or a
lady in farthingale and high-heeled shoes, warming a pair of ringed
and wasted hands at the embers of your wood-fire; failing these, a
favourite sample of the supernatural consisted of some pale woman
in white garments, with her black hair all over her shoulders and her
throat cut from ear to ear. In one instance I remember a posting-
house frequented by the spirit of an ostler with a wooden leg; but
perhaps the most blood-chilling tale of all is that which treats of an
empty chamber having its floor sprinkled with flour to detect the
traces of its mysterious visitant, and the dismay with which certain
horror-stricken watchers saw footsteps printing themselves off, one
by one, on the level spotless surface—footsteps plain and palpable,
but of the Fearful Presence nothing more!
As with houses in those, so is it with men in these days. Most of
the people I have known in life were haunted; so haunted, indeed,
that for some the infliction has led at last to madness, though in most
instances productive only of abstracted demeanour, wandering
attention, idiotic cross-purposes, general imbecility of intellect, and,
on occasion, reckless hilarity, with quaint, wild, incoherent talk.
These haunted head-pieces, too, get more and more dilapidated
every day; but how to exorcise them, that is the difficulty! What spells
shall have power to banish the evil spirit from its tenement, and lay it
in the Red Sea? if indeed that is the locality to which phantoms
should properly be consigned. Haunted men are, of all their kind, the
most unhappy; and you shall not walk along a London street without
meeting them by the dozen.
The dwelling exclusively on one idea, if not in itself an incipient
symptom, tends to produce, ere long, confirmed insanity. Yet how
many people have we seen going about with the germs of so fearful
a calamity developing into maturity! This man is haunted by hope,
that by fear,—others by remorse, regret, remembrance, desire, or
discontent. Each cherishes his ghost with exceeding care and
tenderness, giving it up, as it were, room after room in the house, till
by degrees it pervades the whole tenement, and there is no place
left for a more remunerative lodger, healthy, substantial, and real. I
have seen people so completely under the dominion of expectation,
that in their morbid anticipation of the Future, they could no more
enjoy the pleasures afforded by the Present than the dead. I have
known others for whom the brightest sunshine that ever shone was
veiled by a cloud of apprehension, lest storms should be lurking
below their horizon the while, who would not so much as confess
themselves happy because of a conviction such happiness was not
to last,—and for whom time being—as is reasonable—only temporal
could bring neither comfort nor relief. It is rarer to find humanity
suffering from the tortures of remorse, a sensation seldom
unaccompanied, indeed, by misgivings of detection and future
punishment; still, when it does fasten on a victim, this Nemesis is of
all others the most cruel and vindictive. Regret, however, has taken
possession of an attic, in most of our houses, and refuses
obstinately to be dislodged. It is a quiet, well-behaved ghost enough,
interfering but little with the ordinary occupations of the family,
content to sit in a dark corner, weeping feebly and wringing its
hands, but with an inconvenient and reprehensible tendency to
emerge on special occasions of rejoicing and festivity, to obtrude its
unwelcome presence when the other inmates are gladdened by any
unusual beauty of sight or sound.
 Discontent, perhaps, should hardly be dignified with the title of a
ghost. He resembles rather those Brownies and Lubbers of northern
superstition, who, unsightly and even ludicrous in appearance, were
not yet without their use in performing the meaner offices of a
household. If properly treated and never dragged into undue notice,
the Brownie would sweep up the hearth, bring in the fuel, milk the
cows, and take upon him the rough work generally, in an irregular,
uncouth, but still tolerably efficient style. So perhaps a spirit of
discontent, kept within proper bounds, may prove the unsuspected
mainspring of much useful labour, much vigorous effort, much
eventual success. The spur is doubtless a disagreeable instrument
to the horse, and its misapplication has lost many a race ere now;
but there is no disputing that it can rouse into action such dull torpid
temperaments as, thus unstimulated, would never discover their own
powers nor exert themselves to do their best.
But I should draw a wide distinction between the discontent which
instigates us to improve our lot, and the desire, the desiderium, the
poisonous mixture of longing and sorrow, defiance and despair,
which bids us only rend our garments, scatter ashes on our heads,
and sit down in the dust unmanly to repine. It is the difference
between the Brownie and the Fiend. Of all evil spirits I think this last
is the most fatal, the most accursed. We can none of us forget how
our father Abraham, standing at his tent door on the plains of
Mamre, entertained three angels unawares. And we, too, his
descendants, are always on the look-out for the visitors from heaven.
Do they ever tarry with any of us for more than a night’s lodging?
Alas! that the very proof of our guest’s celestial nature is the
swiftness with which he vanishes at daybreak like a dream. But
oftener the stranger we receive, though coming from another world,
is not from above. His beauty, indeed, seems angelic, and he is clad
in garments of light. For a while we are glad to be deceived,
cherishing and prizing our guest, the more perhaps for those very
qualities which should warn us of his origin. So we say to him, “Thou
art he for whom we have been looking. Abide with us here for ever.”
And he takes us at our word.
 Henceforth the whole house belongs to the ghost. When we go to
dinner, he sits at the head of the table. Try to shame him away with
laughter, and you will soon know the difference between mirth and
joy. Try to drown him with wine. No. Don’t try that. It is too dangerous
an experiment, as any doctor who keeps a private mad-house will
tell you. Our duties we undertake hopelessly and languidly, because
of his sneer, which seems to say, “What is the use? Am I not here to
see that you reap no harvest from your labour, earn no oblivion with
your toil?” And for our pleasures—how can we have any pleasures in
that imperious presence, under the lash of that cruel smile?
Even if we leave our home and walk abroad, in hope to free
ourselves from the tenacious incubus, it is in vain. There is beauty in
the outside world, quiet in the calm distant skies, peace in the still
summer evening, but not for us—nevermore for us—

“Almost upon the western wave

Rested the broad bright sun,
When that strange shape drove suddenly
Betwixt us and the sun.”

Ay, therein lurks our curse. We bear the presence well enough when
cold winds blow and snow falls, or when all the landscape about is
bleak and bare and scathed by bitter frosts. The cruel moment is that
in which we feel a capability of enjoyment still left but for our
affliction, a desire to bask in his rays, a longing to turn our faces
towards his warmth—

“When that strange shape drives suddenly

Betwixt us and the sun.”

There is no exorciser from without who can help us. Alas! that we
can so seldom help ourselves. The strength of Hercules could not
preserve the hero from his ghastly fate. Our ghost is no more to be
got rid of by main force than was Dejanira’s fatal tunic, clinging,
blistering, wrapping its wearer all the closer, that he tore away the
smarting flesh by handfuls. Friends will advise us to make the best of
it, and no doubt their counsel is excellent though gratuitous, wanting
indeed nothing but the supplementary information, how we are to
make the best of that which is confessedly at its worst. Enemies
opine that we are weak fools, and deserve to be vanquished for our
want of courage—an argument that would hold equally good with
every combatant overpowered by superior strength; and all the time
the ghost that haunted us sits aloft, laughing our helplessness to
scorn, cold, pitiless, inexorable, and always

“Betwixt us and the sun.”

If we cannot get rid of him, he will sap our intellects and shorten
our lives; but there is a spell which even this evil spirit has not power
to withstand, and it is to be found in an inscription less imitated
perhaps than admired by the “monks of old.”
“Laborare est orare,” so runs the charm. Work and worship, and a
stern resolve to ignore his presence, will eventually cause this devil
to “come out of the man.” Not, be sure, till he has torn and rent him
cruelly—not till he has driven him abroad to wander night and day
amongst the tombs, seeking rest, poor fevered wretch, and finding
none, because of his tormentor—not till, in utter helplessness and
sheer despair, stunned, humbled, and broken-hearted, the demoniac
has crept feebly to the Master’s feet, will he find himself delivered
from his enemy, weary, sore, and wasted, but “clothed, and in his
right mind.”
Amongst the many ghost stories I have read there is one of which
I only remember that it turned upon the inexplicable presence of a
window too much in the front of a man’s house. This individual had
lately taken a farm, and with it a weird, long-uninhabited dwelling in
which he came to reside. His first care, naturally enough, was to
inspect the building he occupied, and he found, we will say, two
rooms on the second floor, each with two windows. The rooms were
close together, and the walls of not more than average thickness. It
was some days ere he made rather a startling discovery. Returning
from the land towards his own door, and lifting the eyes of
proprietorship on his home, he counted on the second story five
windows in front instead of four! The man winked and stared and
wondered. Knowing he was not drunk, he thought he must be
dreaming, and counted them over again—still with the same result.
Entering his house, he ran up-stairs forthwith, and made a strict
investigation of the second floor. There were the two rooms, and
there were the four windows as usual. Day after day he went through
the same process, till by degrees his wonder diminished, his
apprehensions vanished; his daily labour tired him so that he could
have slept sound in a graveyard, and by the time his harvest was got
in, the subject never so much as entered his head.
Now this is the way to treat the haunted chamber in our own brain.
Fasten its door; if necessary, brick up its window. Deprive it of air
and light. Ignore it altogether. When you walk along the passage
never turn your head in its direction, no, not even though the dearest
hope of your heart lies dead and cold within; but if duty bids you, do
not shrink from entering—walk in boldly! Confront the ghost, and
show it that you have ceased to tremble in its presence. Time after
time the false proportions, once so ghastly and gigantic, will grow
less and less—some day the spectre will vanish altogether. Mind, I
do not promise you another inmate. While you live the tenement will
probably remain bare and uninhabited; but at the worst an empty
room is surely better than a bad lodger! It is difficult, you will say,
thus to ignore that of which both head and heart are full. So it is.
Very difficult, very wearisome, very painful, yet not impossible! Make
free use of the spell. Work, work, till your brain is so overwrought it
cannot think, your body so tired it must rest or die. Pray humbly,
confidingly, sadly, like the publican, while your eyes can hardly keep
open, your hands droop helpless by your side, and your sleep shall
be sound, holy, unhaunted, so that with to-morrow’s light you may
rise to the unremitting task once more.
Do not hope you are to gain the victory in a day. It may take
months. It may take years. Inch by inch, and step by step, the battle
must be fought. Over and over again you will be worsted and give
ground, but do not therefore yield. Resolve never to be driven back
quite so far as you have advanced. Imperceptibly, the foe becomes
weaker, while you are gaining strength. The time will come at last,
when you can look back on the struggle with a half-pitying wonder
that he could ever have made so good a fight. Do not then forget to
be grateful for the aid you prayed so earnestly might be granted at
your need; and remember also, for your comfort, that the harder won
the victory, the less likely it is you will ever have to wage such cruel
battle again.
“Would it not be wiser,” observed Bones quietly, “never to begin
the conflict? Not to take possession of the haunted house at all?”
There is a pseudo-philosophy about some of his remarks that
provokes me intensely.
“Would it not be wiser,” I repeated, in high disdain, “to sit on the
beach than put out to sea, to walk afoot than ride on horseback, to
loll on velvet cushions in the gallery, than go down under shield into
the lists, and strike for life, honour, and renown? No. It would not be
wiser. True wisdom comes by experience. He who shrinks from
contact with his fellow-men—who fears to take his share of their
burdens, their sorrows, their sufferings, is but a poor fool at best. He
may be learned in the learning of the schools, but he is a dunce in all
that relates to ‘the proper study of mankind’; he is ignorant of human
nature, its sorrows, its passions, its feelings, its hidden vein of gold,
lying under a thick crust of selfishness and deceit; above all, he
knows nothing of his inmost heart, nothing of the fierce, warlike joy in
which a bold spirit crushes and tramples out its own rebellion—
nothing of that worshipper’s lofty courage who

‘Gives the first watch of the night

To the red planet Mars,’

who feels a stern and dogged pride in the consciousness that he

‘Knows how sublime a thing it is

To suffer and be strong.’

No: in the moral as in the physical battle, though you be pinned to

the earth, yet writhe yourself up against the spear, like the ‘grim Lord
of Colonsay,’ who, in his very death-pang, swung his claymore, set
his teeth, and drove his last blow home.
 “Besides, if you are to avoid the struggle entirely, how are you ever
to learn the skill of self-defence, by which a thrust may be parried or
returned? the art of tying an artery or stanching a wound? How are
you to help others who cannot help yourself? A man is put into this
world to do a certain share of the world’s work; to stop a gap in the
world’s fencing; to form a cog, however minute, in the world’s
machinery. By the defalcation even of the humblest individual, some
of its movements must be thrown out of gear. The duty is to be got
through, and none of us, haunted or unhaunted, ghost or no ghost,
may shirk our share. Stick to your post like a Roman soldier during
the watches of the night. Presently morning will come, when every
phantom must vanish into air, every mortal confront that inevitable
reality for which the dream we call a lifetime is but a novitiate and a
school.”
 CHAPTER X
WEIGHT CARRIERS

Fifty years ago, when the burning of a bishop at Smithfield would

scarce have created more sensation in clerical circles than a
Ritualistic Commission or a Pan-Anglican Synod, our divines took
their share of secular pastime far more freely than at present. It was
the parson who killed his thirty brace of partridges, and this, too, with
a flint-and-steel gun, over dogs of his own breaking, on the broiling
1st of September. It was the parson who alone got to the end of that
famous five-and-forty minutes from “The Church Spinneys,” when a
large field were beat off to a man, and the squire broke his horse’s
back. It was the parson who knew more about rearing pheasants,
circumventing wild ducks, otter-hunting, fly-fishing, even rat-catching,
than any one else in the parish; and it was the parson, too, who
sometimes took the odds about a flyer at Newmarket, and landed a
good stake by backing his own sound ecclesiastical opinion.
Concerning one of these racing divines I remember the following
anecdote:—
Returning from afternoon service on a Sunday, he happened to
witness a trial of speed between two of his school-children.
Unequally matched in size, the big boy, as was natural, beat the little
one, but only by a couple of yards. The parson stood still, watched
them approvingly, and meditated.
“Come here,” said he to the winner. “Go into my study, and fetch
me my big Bible.”
The urchin obeyed, and returned bearing a ponderous quarto
volume. “Now,” continued his reverence, “start fair, and run it over
again.”
The competitors wished no better fun, and finished this time with a
dead heat.
 “Good boys! Good boys!” said the parson, reflectively. “Ah! I
thought the weight would bring you together.”
Yes; how surely the weight brings us together! How often have we
not seen the universal handicap run out over the course of daily life?
Some of us start so free, so light-hearted, so full of hope and
confidence, expecting no less than to gallop in alone. Presently the
weight begins to tell; the weight that we have voluntarily accepted, or
the weight imposed on us by the wisdom of superior judgment. We
labour, we struggle, we fail; we drop back to those whom we thought
so meanly of as our competitors; they reach us, they pass us, and
though punishment be not spared, they gain the post at last, perhaps
many, many lengths ahead! And even if we escape the disgrace of
having thus to succumb, even if our powers be equal to the tax
imposed on them, we are not to expect an easy victory; there is no
“winning in a canter” here. Every effort tells on mettle, nerve, and
spirits; on heart, body, and brain. We want them all, we summon
them, we use them freely, and then, it may be within one stride of
victory, comes the cruel and irretrievable breakdown.
Men, like horses, must be content to carry weight. Like horses,
too, though some are far more adapted than others to the purpose,
all learn in time to accommodate themselves, so to speak, in pace
and action to their inevitable burden. How they fight under it at first!
How eager, and irritable, and self-willed it renders them; how violent
and impetuous, as if in haste to get the whole thing over and done
with. But in a year or two the back accustoms itself to the burden; the
head is no longer borne so high, the proud neck bends to the curb,
and though the stride be shortened, the dashing, bird-like buoyancy
gone for ever, a gentle, docile temper has taken its place, with
sufficient courage and endurance for all reasonable requirements
left. Neither animal, indeed, is ever so brilliant again; but thus it is
that both become steady, plodding, useful creatures, fit to perform
honestly and quietly their respective duties in creation.
We think we know a great deal in England of athletics,
pedestrianism, and the art of training in general. It may astonish us
to learn how a Chinese postman gets himself into condition for the
work he has to do. The Celestials, it would appear, like meaner
mortals, are extremely particular, not to say fidgety, about the due
transmission of their correspondence. Over that vast empire extend
postal arrangements, conducted, I believe, as in our own country, by
some mandarin of high rank, remarkable for their regularity and
efficiency. The letters travel at a uniform rate of more than seven
English miles an hour; and as they are conveyed by runners on foot,
often through thinly-populated districts in which it is impossible to
establish frequent relays, the pedestrian capabilities of these
postmen are of the greatest importance. This is how a Chinaman
prepares himself to accomplish his thirty miles in less than four
hours.
He has a quantity of bags constructed which he disposes over his
whole person, like Queen Mab’s pinches—

“Arms, legs, back, shoulders, sides, and shins.”

Into these he dribbles handfuls of flour before he starts for walking

exercise, increasing the quantity little by little every day till the bags
are quite full, and he carries clinging to every part of his body several
pounds of dead weight, nor considers himself fit for his situation till
he can move under it with the freedom and elasticity of a naked man.
He will then tell you that, on throwing off his self-imposed burden, he
finds all his muscles so invigorated by their own separate labours,
his strength so stimulated, his wind so clear, his condition so perfect,
that he shoots away over the plains, mountains, and tea-gardens of
the Flowery Land less like John Chinaman with a letter-bag than an
arrow from a bow. What would our old friend Captain Barclay, of
peripatetic memory, say to such a system as this?
I doubt if the Chinaman’s theory of training be founded on sound
principles; but I am quite sure that in bearing our moral burden we
cannot dispose it over too extended a surface, or in too many
separate parcels. I see fathers of families carrying surprising
weights, such as make the bachelor’s hair stand on end from sheer
dismay, with a buoyancy of step and carelessness of demeanour
only to be accounted for by an equal distribution of pressure over the
entire victim. A man who has his own business to attend to, his