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Optometry class OP2502 > Contact lenses 2 - rigid lenses > Flashcards

Contact lenses 2 - rigid lenses Flashcards

1
Q

How can RGPs be used to temporarily reshape the cornea? What does this achieve?

A

via orthokeratology (Ortho-K) or overnight vision correction (OVC). Allows the patient to see clearly during the day without need for glasses or CLs

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2
Q

what are the advantages of soft contact lenses compared to corneal RGP?

A

-good initial comfort
-straight forward to fit
-higher replacement frequency so less lens deposits and its easier to change prescription
-good for both full time or occasional wear

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3
Q

what are the disadvantages of soft contact lenses compared to corneal RGP?

A

-lead to a higher risk of infection and complication compared to corneal RGP
-they are not customisable

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4
Q

what are the disadvantages of RGP compared to soft CLs?

A

-the fitting process is longer as lenses need to be ordered individually and manufactured
-adaptation is required to reduce corneal sensitivity and allow for increased wearing time which takes about 2 weeks
-initial lens cost is high so lens replacement is expensive
-need careful cleaning
-not for contact sports of dusty environment

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5
Q

what are the advantages of RGP compared to soft CLs?

A

-rigid lens surface offers better quality of vision
-reduced risk of infection so less complications
-can be tailor made and fully customisable with a large range of parameters
-lenses are typically replaced every year so are a good value for money

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6
Q

what type of back surface do rigid corneal lenses usually have?

A

multicurve or aspheric

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7
Q

what are the 3 components to RGP lens designs? what are each of them and what is their selection based on?

A

BOZR - Back Optic Zone Radius
* Radius of curvature of the back of the lens
* Selected based on corneal curvature (keratometry readings)

BOZD – Back Optic Zone Diameter
* Diameter of the optic
* Selected based on pupil size in low light (max pupil)

TD – Total Diameter
* Total diameter of lens
* Selected based on Horizontal Visible Iris Diameter (HVID)

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8
Q

how is a rigid lens fitted to a specific patient ? (answer in steps)

A
  1. The lens Back Optic Zone Radius (BOZR) is selected to align with the corneal surface
  2. This is so the curvature of the back surface of the lens mimics that of the front surface of the cornea
  3. pressure is evenly distributed across the whole area under the lens
  4. A thin tear lens is formed beneath the RGP
  5. there is sufficient clearance at the edge of the lens to allow tear exchange and facilitate lens removal
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9
Q

how do you care for rigid lenses?

A

Using a separate cleaner and conditioning solution

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10
Q

what is rigid lens cleaner used for?

A

to emulsify or
solubilise cell debris, mucous,
lipid & protein- making soak
more effective

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11
Q

what is rigid lens conditioning solution for?

A

-disinfecting and wetting the lens surface
-lens storage
-to lubricate the lens and cushion cornea and eyelids on insertion
-to render the lens surface hydrophilic to promote pre-lens tear film stability

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12
Q

what kind of case is not suitable for rigid lenses?

A

barrel case

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13
Q

how are RGP lenses stored so they can be kept clean?

A

in practise, lenses are put into a lens case with conditioning solution prior to collection to promote surface wetting. After, patients store RGP lenses in solution in a CL case

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14
Q

how do you show patients how to wear and care for rigid lenses?

A

-explain the function of cl solution
-demonstrate lens and contact lens case cleaning
-importance of regular contact lens case replacement
-avoid water contamination

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15
Q

what are the adaptation and wearing time recommendations for rigid lenses?

A
  • 1-2 hours the first day
  • Px should increase this by 1-2 hours each day, depending on comfort
  • Encourage the patient to contact the practice if they’re struggling to
    adapt however
  • After adaptation, it’s not uncommon for rigid lenses to be worn for 12-16 hours per day
  • Max wearing time (WT) will be indicated by the practitioner
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16
Q

how long after the trial period is aftercare typically booked?

A

typically 2 weeks after the teach because the patient needs time to adapt to the lenses and build up their wearing time

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17
Q

what are the general steps to a patient teach

A
  1. how to apply and remove lenses
  2. advise on wearing and adaptation schedule
  3. explain how to wear and care for lenses
  4. advise the patient what to do if they have a problem
  5. arrange a follow-up appt
  6. provide a written copy of the advice 7. update the patient record `
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18
Q

how do you assess corneal radius of curvature?

A

keratometry and topography

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19
Q

what are the two types of keratometry?

A

one position (Bausch & Lomb type) and two position (Javal-Schiotz type)

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20
Q

what part of the cornea does keratometry measure?

A

the central 3-4mm where radius of curvature is along the 2 principle meridians

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21
Q

why and how does corneal radius differ in horizontal and vertical meridians

A

because the central cornea is toric so The flat (biggest) radius of curvature (r1) is along the horizontal meridian and the steep (smallest) radius of curvature (r2) is along the vertical meridian

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22
Q

Why do we measure corneal curvature?

A

-allows a selection of appropriate radius of curvature rigid contact lens (NOT FOR SELECTING SOFT LENS BC)
-gives a measure of the amount of corneal astigmatism
-gives useful baseline measure to compare any future changes

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23
Q

what do you need to write down when doing keratometry?

A

-the numbers you find
-the type of instrument you use
-the quality of the mires grade 0-4 where 0 is a clear image with no distortion and 4 gross distortion so reading is impossible

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24
Q

what are the 3 parts of rigid lens edge design?

A
  • EC = edge clearance
  • REL = radial edge lift
  • AEL = axial edge lift
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25
Q

what is the EC compared to EL?

A

the gap between the cornea and the back surface of the peripheral curves (observed during fluorescein fit) whereas EL is a design characteristic of the lens and is definable in axial or radial form

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26
Q

what has to happen for a rigid lens to be well fitting

A
  • The back surface of the lens mimics the front surface of the
    cornea
  • Pressure exerted on the cornea is evenly distributed across the
    whole area under the lens
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27
Q

why do you need a rigid lens to fit well

A
  • Limits the effect of the lens on the corneal surface
  • Makes the lens comfortable
  • Sufficient edge clearance to allow tear exchange and facilitate lens removal
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28
Q

what can you use to check rigid lens fit?

A

fluorescein and cobalt blue or a burton lamp

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29
Q

why check rigid lens fit with fluorescein?

A
  • Allows visualisation of the tear lens
  • Allows interpretation of how the back surface of the lens relates to the cornea
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30
Q

check screenshots for rigid lens fit with fluorescein

A

ok

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31
Q

why do RGPs have much less complications that soft CLs? what does this also mean?

A

Tears circulate under the lens in tear exchange but this also means RGPs move much more than soft lenses

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32
Q

what does an RGP that’s too flat do?

A

moves a lot more and the periphery of the lens lifts away from the cornea

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33
Q

why cant keratometry be used to fit soft CLs?

A

as they go over the cornea whereas RGPs fit the cornea exactly

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34
Q

what us delta K?

A

the numerical difference between the flattest and steepest curve

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35
Q

how much corneal astigmatism is 0.05mm delta K?

A

0.25DC corneal astigmatism

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36
Q

when do you need a toric RGP?

A

when:
-There’s more than 2.50 D toric astigmatism
-There’s ≥0.75D lenticular astigmatism

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37
Q

what shape are the central and peripheral cornea?

A

central is spherical/ toric

peripheral is aspheric

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38
Q

what are the principle meridians of the cornea?

A

the flattest and steepest curves which are typically 90 degrees apart in regular astigmatism

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39
Q

what makes up total ocular astigmatism?

A

corneal astigmatism + lenticular astigmatism

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40
Q

how does BOZR need to be changed in relation to corneal astigmatism? why?

A

The greater the level of corneal astigmatism the greater we need to steepen the BOZR (hence reduce the number)

because reducing the BOZR reduces the clearance in the steeper meridian and so improves comfort and lens stability

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41
Q

check google docs page 14 for filled out lecture handout

A

ok

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42
Q

what is BOZD compared to pupil size and TD?

A
  • Generally, 1.5mm larger than av/max. pupil size
  • Generally, 1.5 - 2.0mm smaller than TD
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43
Q

what is TD compared to HVID?

A
  • Generally, 2mm smaller than HVID
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44
Q

TD is smaller when?

A

if toric cornea >2.00DC

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45
Q

what does increasing TD mean when selecting a trial lens?

A

generally stabilises the fit but also increases the extent of lid attachment

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46
Q

what is dynamic fit vs static fit?

A

dynamic is how the lens moves and centres on the eye whereas static fit is how the back surface of the lens relates to the cornea

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47
Q

why is it more optically important than a soft CL to make sure an RGP has proper centration?

A

Centration on RGP is more crucial than a soft lens as the optical area on an RGP is much smaller than that of a soft CL so decentration means Px will look through the peripheral curve rather than the BOZD which contains the prescription and so poor centration = reduced quality of vision

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48
Q

what are the slit lamp settings when assessing dynamic RGP lens fit?

A

-wide beam
-dim beam
-low mag of x6 or x10

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49
Q

what does interpalpebral mean?

A

when assessing lid interaction, describes a lens that sits wihin the palpebral aperture

50
Q

what does lid attachment mean when assessing dynamic lens fit?

A

when looking at lid interaction, it means that when the PX blinks, the lens gets pulled up to a different position so centration is being controlled by the top lid

51
Q

why is too much movement on blink bad?

A

-makes the lens uncomfortable
-disrupts vision

52
Q

why is it bad if there is no movement on blink in an RGP?

A

as it needs to move to maintain tear exchange and removal of debris

53
Q

when applying fluorescein to measure static fit, how should you apply the fluorescein?

A

insert the fluorescein into the superior bulbar conjunctiva whilst the Px is looking down

54
Q

what’s dimple veiling?

A

air is trapped under the lens because there is very narrow edge clearance so the air is stuck hence lens is steep fitting

55
Q

how can you amend a CL that is
-too steep?
-too flat?

A

-Too steep so flatten by reducing the sag so either increase BOZR or reduce the TD
-Too flat so you need to steepen by increasing the sag so either reduce the BOZR or increase total diameter (TD)

You should start by amending the BOZR as that’s more easy to change usually start with +-0.1mm (the bigger the number the smaller the BOZR) (this needs checking)

56
Q

what’s the difference between regular and irregular astigmatism?

A

regular astigmatism is where the two principle meridians are at 90 to each other whereas irregular is where the two principle meridians are not at 90 to each other and this could be congenital or due to disease, or injury

57
Q

what is with the rule astigmatism?

A

The refractive error is greater in the vertical meridian (cyl axis 180 ± 30). Ks steeper in vertical meridian.

58
Q

what is against the rule astigmatism?

A

The refractive error is greater in the horizontal meridian (cyl axis
90 ± 30). Ks steeper in the horizontal meridian.

59
Q

what is oblique astigmatism?

A

The two principle meridians are more than 30° from horizontal or vertical

60
Q

what is residual astigmatism?

A

-ocular astigmatism - corneal astigmatism
-so its the lenticular astigmatism that cant get corrected by a spheric RGP as they only correct corneal astigmatism

61
Q

what is induced astigmatism

A

When a toric back surface is placed on a toric cornea so the refractive indices of the CL and tear film beneath are different

62
Q

how is the tear lens affected by lens fit?

A

if the lens is not on alignment then the tear lens will induce unwated power so
-steep lens creates a positive tear lens
-flat lens created negative tear lens

63
Q

what are the fluorescein fitting characteristics of a steep fitting lens?

A

-centre = central pooling
-mid periphery = central touch
-periphery = very narrow edge clearance <0.4mm

64
Q

what are the fluorescein fitting characteristics of an alignment fitting lens?

A

-centre = apical clearance (ideal amount of fluorescein is under the lens
-mid periphery = alignment/ slight touch
-periphery = even clearance around 0.4-0.5mm

65
Q

what are the fluorescein fitting characteristics of a flat fitting lens?

A

-centre = central touch
-mid periphery = pooling
-periphery = wide edge clearance >0.5mm

66
Q

when amending an RGP fit, why do you amend the BOZR before the TD

A

changing the BOZR by just 0.1mm has the same effect on sag as changing the TD by 1mm so its easier to change BOZR

67
Q

what is the characteristic fluorescein pattern for a spherical lens on a toric cornea that has with the rule astigmatism?

A

dumbell shaped

68
Q

look at the toric corneas fluorescein patterns diagram

A

ok - check screenshots

69
Q

What are the issues with fitting spherical RGPS on a toric cornea?

A

-causes reduced comfort due to area of alignment being reduced
-Excessive edge clearance in steeper meridian will lead
to unwanted lid interaction with the lens and discomfort
-poor centration means in WTR lens rocks along steeper meridian or decenters inferiorly and in ATR lens decentres horizontally
-lens flexure reducing effectiveness in correcting the astigmatism
-corneal moulding which can affect vision qualoty

70
Q

give 6 scenarios when you would consider a toric lens

A
  • Greater than 2.50D corneal astigmatism
  • ≥ 0.75D residual (lenticular) astigmatism (ocular astigmatism – corneal astigmatism)
  • Spherical lens unstable, excessive decentring
  • Patient’s cornea become significantly more toric towards the periphery
  • Large amounts of lens flexure
  • Poor comfort with a spherical lens
71
Q

what are the RGP options for toric corneas?

A

-use small diameter rigid lens
-use aspheric rigid lens
-use a toric rigid lens

72
Q

why may small diameter rigid lenses be good for toric corneas?

A

they minimise exaggeration between 2 different meridians which reduces edge clearance in steeper meridian

73
Q

why may aspheric rigid lenses be good for toric corneas?

A

they have a narrower edge lift to reduce edge clearance in the steeper meridian

74
Q

name 6 different rigid lens designs in chronological order

A
  • Single curve
  • Bicurve – C2
  • Tricurve – C3
  • Tetracurve/Multicurve – C4
  • Aspheric
  • Constant Axial Edge Lift (CAEL)
75
Q

what was the first hard lens design?

A

PMMA single curve

76
Q

why did single curve rigid lens have limited success?

A

As the lens did not fit properly because it was fitted 0.3mm flatter than the flatest K

77
Q

why did the bicurve lens design not work out?

A

as the transition between the central and peripheral curve was very sharp which reduced comforti

78
Q

give an example of a bicurve lens specification and what each number means

A

7.8:6.80/8.6:9.65/-3.00D

-7.8 is the BOZR (central radius)
-6.80 is the diameter of the initial curve
-8.60 is the radius of the peripheral curve
-9.65 is the diameter of the whole curve so initial curve and the peripheries

79
Q

what does a bicurve lens design consist of?

A

an intial radius and a flatter peripheral radius

80
Q

what does a tricurve consist of and why does it make it better than a bicurve design?

A

Has a central radius and 2 flatter peripheral curves where final peripheral curve is much flatter than the first peripheral radius

because:
-Allows it to align with the cornea to lift away from the periphery and give a good edge clearance for good tear exchange beneath the lens
-Allows it to be removed off the cornea easier

81
Q

what is the basic design of most modern lenses?

A

tricurve lens design

82
Q

what does a tetracurve lens design consist of?

A

a central radius and then 3 or more peripheral curves which replicates the flattening of the cornea even further than a tricurve

83
Q

what defines wether a lens (or any surface) is aspheric?

A

eccentricity (describes departure of the curve from a circle

84
Q

what is a formula to determine asphericity of a surface

A

P = 1-e^2 where P value defines the rate of flattening with eccentricity

85
Q

what is the mean corneal eccentricity and P value

A

Corneal mean eccentricity = 0.45, P=0.8

86
Q

what is axial edge lift?

A

the degree of flattening of the lens which is the distance of the lens edge between the extension of the BOZR and the peripheral curve

87
Q

what type of rigid lens design is now becoming more popular and why

A

Constant Axial Edge Lift (CAEL) lens as they further refine multicurve lens design to give a constant linear clearance
between the edge of the lens and the cornea, over the whole range of BOZR for a given TD

88
Q

how is axial edge lift different for steeper and flatter lenses?

A

AEL is greater with steeper lenses than with flatter lenses

89
Q

what are ideal properties of rigid lens material?

A
  • Easy to manufacture
  • Cheap
  • Hard
  • Dimensional stable
  • Limited flexure
  • Optically transparent
  • Inert
  • Wettable
  • Deposit resistant
  • Scratch resistant
  • Durable
  • Good oxygen permeability
90
Q

name the first RGP material. Why was it used? Why is it now disused?

A

-polymethyl methacrylate = PMMA
-had good compatibility with ocular surface so replaced glass scleral lenses
-has negligible oxygen permeability where some patients would get hypoxia and they were very rigid so had poor comfort and caused corneal moulding on toric corneas

91
Q

why is cellulose acetate butyrate no longer used as a material for rigid lenses?

A
  • Low Dk (4-8)
  • Thermoplastic - can only be moulded (dimensionally
    unstable when lathed)
  • Lens flexure & distortion
  • Scratches easily
92
Q

what is cellulose butyrate acetate made of?

A

plastic made with a cellulose base

93
Q

what are the positives of silicone acrylates?

A

-they are a copolymer of silicone and acrylate so combines rigidity of PMMA and Dk of silicone
-good dimensional stability
-limited lens flexure
-softer and more flexible than PMMA

94
Q

what are the negatives of silicone acrylates as material for RGPs?

A

-low-medium Dk due to negative surface charge
-attracts protein deposits which can be difficult to remove

95
Q

how and why are Fluorosilicone acrylates synthesised?

A

Fluorine monomer added to silicone acrylate as fluorine improves wettability, tear film
stability, deposit resistance and Dk

96
Q

give 3 examples of silicone acrylates

A

-polycon I
-Boston II
-Boston IV

97
Q

give 4 examples of fluorosilicone acrylates

A

-Fluoroperm
-Boston XO
-Boston XO2
-Optimum Extra

98
Q

what is the first choice material for new RGP lens fit ?

A

Fluorosilicone acrylates

99
Q

what are the positives of fluorosilicone acrylates as RGP material?

A
  • Very high Dk (40-100+)
  • Better wettability
  • Reduced deposition
100
Q

what are the negatives of fluorosilicone acrylates as RGP material?

A
  • Require careful
    manufacture
  • Greater lens flexure
  • Surface scratches easily
101
Q

what are the advantages of rigid lenses?

A

-Cheaper in the long term
-Better tear exchange
-Good for correcting astigmatism
-They produce really good quality of vision
-Do not dehydrate like soft lenses so better for people with dry eye and ocular surface problems
-Ortho-K are a type of RGPs which correct myopia over night by flattening the cornea while they are worn
-Tailor made so have a large range of parameters
-Better for the environment

102
Q

what patients would you recommend rigid lenses to?

A

-Poor quality of vision with soft so astigmatism or presbyopes
-Irregular cornea e.g. keratoconus or corneal graft
-Unusual Rxs/ those that are not in soft lens range
-pxs with dry eye
-px at risk of complications e.g. previous inflammatory events
-budget conscious patients
-environment conscious patients
-those who want to use ortho K

103
Q

name 2 alternatives to rigid corneal lenses

A

-miniscleral lenses
-hybrid lenses

104
Q

What costs are involved in fitting rigid lenses?

A

-initial fitting fee
-cost of the lenses themselves (£70-150, toric/ multifocal £200+)
-lens solution (£8-10)
-frequency of lens replacement

105
Q

What is an emperical lens fitting?

A

where lenses are ordered based on keratometry/ topography, HVID and refraction

106
Q

what are the positives of empirical lens fitting?

A

-software is often used to create customized lenses
-can be more efficient than using fitting set

107
Q

what are the negatives of empirical lens fitting?

A

-baseline measurements must be accurate
-fitting process can end up taking longer if the lens parameters need adjusting

108
Q

when collecting rigid lenses, what happens in collection appt 1

A

-lens application with topical anaesthetic
-px goes for a walk around town for 30 mins while the lenses settle
-va and over refraction is checked
-dynamic and static fit is recorded
-patient is told to arrive to the next collection appt with their lenses in 30 mins before the appt and that will be when the lenses come in

109
Q

when collecting rigid lenses, what happens in collection appointment 2?

A

-assess fit of both lenses
-do px teach
-WT 1-2 hours, increase 1-2
hours daily depending on
comfort, max WT 14 hours
-Next appt is aftercare - 2 weeks

110
Q

how does BOZR change with TD?

A

for every +0.50mm increase in TD (or BOZD) , increase the BOZR by +0.05mm to maintain the equivalent fit

111
Q

how does power (BVP) change with BOZR?

A

for every +0.05mm increase in BOZR, you increase the power by +0.25DS

112
Q

What are some important questions to ask in the aftercare session?

A

-what type of contact lenses are they e.g. daily disposable
-how often do they get worn/ how long have they worn them for?
-how often do they get replaced
-what is their vision with them like
-what is the comfort out of 10 on insertion and removal? hours of worn comfort
-problems since last seen e.g. dryness, redness

113
Q

in the aftercare, how could you investigate problems?

A

with open questions
* Nature of problem?
* LOFTSEA
* When?
* How long?

114
Q

in the aftercare, if the patient reports discomfort, how do you follow it up?

A
  • Does comfort vary throughout the replacement period?
  • When are they uncomfortable?
  • Environmental/visual task related
  • On application or end of day?
  • Do you get discomfort without your lenses?
  • Ocular problem or contact lenses?
115
Q

give some questions you can ask that establish compliance

A
  • Talk me through your routine when you remove your lenses.
  • When did you last sleep in your lenses?
  • In an average week, how often do you shower in your lenses?
  • When did you last swim in your lenses?
  • How often do you re-use your daily disposables?
116
Q

what can you do if your patient is non-complaint?

A
  • Praise compliance
  • Correct non-compliance appropriately
  • Try not to be dismissive
  • Reinforce why it is important
  • Promote compliance not only in terms of reducing the risk of infection but also in terms of
    maximising comfort
  • Summarise your advice at the end of the H&S, remind again during advice at end of appointment & record what you have said
  • Give written material to support your advice
117
Q

why is it important patients have good comfort in their lenses?

A

as there’s lots of evidence that non-compliance is associated with poorer levels of comfort

118
Q

what would you say to a patient who has admitted to swimming in their CLs?

A

-Explain to them in lay terms
-Wearing close fitting swimming goggles - would be better to wear prescription goggles
-If you’re going to wear lenses at least wear dailies, then only wear them for swimming so you take them out as soon as you get out of the pool

119
Q

when would you recall a patient post aftercare?

A

Dependent on your advice
* If refit, see px at next convenient appt
* If end of trial consider 3/12 recall (help address early drop-out)
* Routine 6/12 recall soft and rigid planned overnight wear
* Routine 12/12 recall soft daily reusable & rigid lens wearers
* Routine 24/12 recall for established daily disposable wearer with good compliance

120
Q

what do you need to make sure you do before a patient leaves their aftercare appt?

A
  • Unless refit needed, you have a legal obligation to give the px a copy of their CL
    prescription with the date of next AC
  • Remind the px they can come in sooner if there are any issues in the meantime
  • Advise px if full eye examination is due before their next aftercare
121
Q

what kind of questions should you discuss with your patient once you have checked the cls in aftercare appt

A
  • Summary?
  • Recommendations?
  • Refit?
  • Change modality, material?
  • Change solution?
  • Just because it’s not broken…
  • Talk about new products, offer trial of new lens
  • Compliance advice?
122
Q

what are the steps in an aftercare routine?

A
  • Patient discussion (to include H&S)
  • VA and OR
  • Lens assessment – fit & lens condition (Px should be re-fitted if the lens isnt suitiable)
  • Lens removal
  • (Keratometry? )
  • Anterior Eye Examination (with fluorescein)
  • Advice, recommendations, issue CL specification (recommend alternatives and offer a trial)
  • Recall

Optometry class OP2502 (11 decks)

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