A contact lens (also known simply as a contact) is a corrective, cosmetic, or therapeutic lens usually placed on the cornea of the eye. Modern soft contact lenses were invented by the Czech chemists Otto Wichterle and Drahoslav Lim, who also invented the first gel used for their production.
Contact lenses usually serve the same corrective purpose as conventional glasses, but are lightweight and virtually invisible—many commercial lenses are tinted a faint blue to make them more visible when immersed in cleaning and storage solutions. Some cosmetic lenses are deliberately colored to alter the appearance of the eye.
It has been estimated that 125 million people use contact lenses worldwide (2%), including 28 to 38 million in the United States and 13 million in Japan. The types of lenses used and prescribed vary markedly between countries, with rigid lenses accounting for over 20% of currently-prescribed lenses in Japan, Netherlands and Germany but less than 5% in Scandinavia.
People choose to wear contact lenses for many reasons, often due to their appearance and practicality. When compared to spectacles, contact lenses are less affected by wet weather, do not steam up, and provide a wider field of vision. They are more suitable for a number of sporting activities. Additionally, ophthalmological conditions such as keratoconus and aniseikonia may not be accurately corrected with glasses.
Leonardo da Vinci is frequently credited with introducing the general principle of contact lenses in his 1508 Codex of the eye, Manual D, where he described a method of directly altering corneal power by submerging the eye in a bowl of water. Leonardo, however, did not suggest his idea be used for correcting vision—he was more interested in learning about the mechanisms of accommodation of the eye.
René Descartes proposed another idea in 1636, in which a glass tube filled with liquid is placed in direct contact with the cornea. The protruding end was to be composed of clear glass, shaped to correct vision; however the idea was impracticable, since it would make blinking impossible.
In 1801, while conducting experiments concerning the mechanisms of accommodation, scientist Thomas Young constructed a liquid-filled "eyecup" which could be considered a predecessor to the contact lens. On the eyecup's base, Young fitted a microscope eyepiece. However, like Leonardo's, Young's device was not intended to correct refraction errors.
Sir John Herschel, in a footnote of the 1845 edition of the Encyclopedia Metropolitana, posed two ideas for the visual correction: the first "a spherical capsule of glass filled with animal jelly", and "a mould of the cornea" which could be impressed on "some sort of transparent medium". Though Herschel reportedly never tested these ideas, they were both later advanced by several independent inventors such as Hungarian Dr. Dallos (1929), who perfected a method of making molds from living eyes. This enabled the manufacture of lenses that, for the first time, conformed to the actual shape of the eye.
It was not until 1887 that a German glassblower, F.E. Muller, produced the first eye covering to be seen through and tolerated. In the next year, the German physiologist Adolf Eugen Fick constructed and fitted the first successful contact lens. While working in Zürich, he described fabricating afocal scleral contact shells, which rested on the less sensitive rim of tissue around the cornea, and experimentally fitting them: initially on rabbits, then on himself, and lastly on a small group of volunteers. These lenses were made from heavy brown glass and were 18–21mm in diameter. Fick filled the empty space between cornea/callosity and glass with a dextrose solution. He published his work, "Contactbrille", in the journal Archiv für Augenheilkunde in March 1888.
Fick's lens was large, unwieldy, and could only be worn for a few hours at a time. August Müller in Kiel, Germany, corrected his own severe myopia with a more convenient glass-blown scleral contact lens of his own manufacture in 1888.
Also in 1887, Louis J. Girard invented a similar scleral form of contact lens.
Glass-blown scleral lenses remained the only form of contact lens until the 1930s when polymethyl methacrylate (PMMA or Perspex/Plexiglas) was developed, allowing plastic scleral lenses to be manufactured for the first time. In 1936, optometrist William Feinbloom introduced plastic lenses, making them lighter and more convenient. These lenses were a combination of glass and plastic.
In 1949, the first "corneal" lenses were developed. These were much smaller than the original scleral lenses, as they sat only on the cornea rather than across all of the visible ocular surface, and could be worn up to sixteen hours per day. PMMA corneal lenses became the first contact lenses to have mass appeal through the 1960s, as lens designs became more sophisticated with improving manufacturing (lathe) technology.
One important disadvantage of PMMA lenses is that no oxygen is transmitted through the lens to the conjunctiva and cornea, which can cause a number of adverse clinical effects. By the end of the 1970s, and through the 1980s and 1990s, a range of oxygen-permeable but rigid materials were developed to overcome this problem. Collectively, these polymers are referred to as "rigid gas permeable" or "RGP" materials or lenses. Although all the above lens types—sclerals, PMMA lenses and RGPs—could be correctly referred to as being "hard" or "rigid", the term hard is now used to refer to the original PMMA lenses which are still occasionally fitted and worn, whereas rigid is a generic term which can be used for all these lens types. That is, hard lenses (PMMA lenses) are a sub-set of rigid lenses. Occasionally, the term "gas permeable" is used to describe RGP lenses, but this is potentially misleading, as soft lenses are also gas permeable in that they allow oxygen to move through the lens to the ocular surface.
The principal breakthrough in soft lenses was made by the Czech chemists Otto Wichterle and Drahoslav Lim who published their work "Hydrophilic gels for biological use" in the journal Nature in 1959. This led to the launch of the first soft (hydrogel) lenses in some countries in the 1960s and the first approval of the "Soflens" material by the United States Food and Drug Administration (FDA) in 1971. These lenses were soon prescribed more often than rigid lenses, mainly due to the immediate comfort of soft lenses; by comparison, rigid lenses require a period of adaptation before full comfort is achieved. The polymers from which soft lenses are manufactured improved over the next 25 years, primarily in terms of increasing the oxygen permeability by varying the ingredients making up the polymers.
In 1999, an important development was the launch of the first silicone hydrogels onto the market. These new materials encapsulated the benefits of silicone—which has extremely high oxygen permeability—with the comfort and clinical performance of the conventional hydrogels which had been used for the previous 30 years. These lenses were initially advocated primarily for extended (overnight) wear although more recently, daily (no overnight) wear silicone hydrogels have been launched.
For those with certain color deficiencies, a red-tinted "X-Chrom" contact lens may be used. Although the lens does not restore normal color vision, it allows some colorblind individuals to distinguish colors better.
ChromaGen lenses have been used and these have been shown to have some limitations with vision at night although otherwise producing significant improvements in colour vision. An earlier study showed very significant improvements in colour vision and patient satisfaction
Later work that used these ChromaGen lenses with dyslexics in a randomised, double-blind, placebo controlled trial showed highly significant improvements in reading ability over reading without the lenses This system has been granted FDA approval in the United States.
A cosmetic contact lens is designed to change the appearance of the eye. These lenses may also correct the vision, but some blurring or obstruction of vision may occur as a result of the color or design. In the United States, the FDA frequently calls non-corrective cosmetic contact lenses decorative contact lenses.
Theatrical contact lenses are a type of cosmetic contact lens that are used primarily in the entertainment industry to make the eye appear pleasing, unusual or unnatural in appearance, most often in horror and zombie movies, where lenses can make one's eyes appear demonic, cloudy and lifeless, or even to make the pupils of the wearer appear dilated to simulate the natural appearance of the pupils under the influence of various illicit drugs.
Scleral lenses cover the white part of the eye (i.e. sclera) and are used in many theatrical lenses. Due to their size, these lenses are difficult to insert and do not move very well within the eye. They may also hamper the vision as the lens has a small area for the user to see through. As a result they generally cannot be worn for more than 3 hours as they can cause temporary vision disturbances.
Although many brands of contact lenses are lightly tinted to make them easier to handle, cosmetic lenses worn to change the color of the eye are far less common, accounting for only 3% of contact lens fits in 2004.
The first contact lenses were made of glass, which caused eye irritation, and were not wearable for extended periods of time. But when William Feinbloom introduced lenses made from polymethyl methacrylate (PMMA or Perspex/Plexiglas), contacts became much more convenient. These PMMA lenses are commonly referred to as "hard" lenses (this term is not used for other types of contact lens).
However, PMMA lenses have their own side effects: no oxygen is transmitted through the lens to the cornea, which can cause a number of adverse clinical events. In the late 1970s, and through the 1980s and 1990s, improved rigid materials—which were also oxygen-permeable—were developed. Collectively, these polymers are referred to as rigid gas permeable or 'RGP' materials or lenses. One advantage of hard lenses is that, due to their non-porous nature, they do not absorb chemicals or fumes. The absorption of such compounds by other types of contacts can be a problem for those who are routinely exposed to painting or other chemical processes.
Rigid lenses offer a number of unique properties. In effect, the lens is able to replace the natural shape of the cornea with a new refracting surface. This means that a regular (spherical) rigid contact lens can provide good level of vision in people who have astigmatism or distorted corneal shapes as with keratoconus.
While rigid lenses have been around for about 120 years, soft lenses are a much more recent development. The principal breakthrough in soft lenses made by Otto Wichterle led to the launch of the first soft (hydrogel) lenses in some countries in the 1960s and the approval of the 'Soflens' material (polymacon) by the United States FDA in 1971. Soft lenses are immediately comfortable, while rigid lenses require a period of adaptation before full comfort is achieved. The polymers from which soft lenses are manufactured improved over the next 25 years, primarily in terms of increasing the oxygen permeability by varying the ingredients making up the polymers.
A small number of hybrid rigid/soft lenses exist. An alternative technique is piggybacking of contact lenses, a smaller, rigid lens being mounted atop a larger, soft lens. This is done for a variety of clinical situations where a single lens will not provide the optical power, fitting characteristics, or comfort required.
In 1999, 'silicone hydrogels' became available. Silicone hydrogels have both the extremely high oxygen permeability of silicone and the comfort and clinical performance of the conventional hydrogels. These lenses were initially advocated primarily for extended (overnight) wear, although more recently daily (no overnight) wear silicone hydrogels have been approved and launched.
While it provides the oxygen permeability, the silicone also makes the lens surface highly hydrophobic and less "wettable." This frequently results in discomfort and dryness during lens wear. In order to compensate for the hydrophobicity, hydrogels are added (hence the name "silicone hydrogels") to make the lenses more hydrophilic. However the lens surface may still remain hydrophobic. Hence some of the lenses undergo surface modification processes which cover the hydrophobic sites of silicone. Some other lens types incorporate internal rewetting agents to make the lens surface hydrophilic.
Extended lens wearers may have an increased risk for corneal infections and corneal ulcers, primarily due to poor care and cleaning of the lenses, tear film instability, and bacterial stagnation. Corneal neovascularization has historically also been a common complication of extended lens wear, though this does not appear to be a problem with silicone hydrogel extended wear. The most common complication of extended lens use is conjunctivitis, usually allergic or giant papillary conjunctivitis (GPC), sometimes associated with a poorly fitting contact lens.
Like eyeglasses, contact lenses can have one (single vision) or more (multifocal) focal points.
For correction of presbyopia or accommodative insufficiency multifocal contact lenses are almost always used; however, single vision lenses may also be used in a process known as monovision: single vision lenses are used to correct one eye's far vision and the other eye's near vision. Alternatively, a person may wear single vision contact lenses to improve distance vision and reading glasses to improve near vision.
Rigid gas permeable bifocal contact lenses most commonly have a small lens on the bottom for the near correction, when the eyes are lowered to read, this lens comes into the optical path. RGPs must translate (move vertically) to work properly, and thus the gaze of the eye can change from the near to the distant sections, much like bifocal eyeglasses.
Multifocal soft contact lenses are more complex to manufacture and require more skill to fit. All soft bifocal contact lenses are considered "simultaneous vision" because both far and near vision corrections are presented simultaneously to the retina, regardless of the position of the eye. Of course, only one correction is correct, the incorrect correction causes blur. Commonly these are designed with distance correction in the center of the lens and near correction in the periphery, or vice versa.
Although many companies make contact lenses, there are four major manufacturers:
Smaller Manufacturers are:
The practitioner or contact lens fitter typically determines an individual's suitability for contact lenses during an eye examination. Corneal health is verified; ocular allergies or dry eyes may affect a person's ability to wear contact lenses successfully. Especially after the age of 35 years dry eyes often makes wearing contact lenses too risky, especially soft lenses.
The parameters specified in a contact lenses prescription may include:
Many people already wearing contact lenses order contact lenses over the internet at their own risk. In the US, The Fairness to Contact Lens Consumers Act, which became law in February, 2004, was intended to ensure the availability of contact lens prescriptions to patients. Under the law consumers have a right to obtain a copy of their contact lens prescription, allowing them to fill that prescription at the business of their choice.
Studies conducted on side effects from long-term wearing of contact lenses, i.e. over 5 years, such as by Zuguo Liu PhD, MD and Stephen C. Pflugfelder MD: "The effects of long-term contact lens wear on corneal thickness, curvature, and surface regularity", Ophthalmology , Volume 107 , Issue 1 , Pages 105 - 111, concludes that: Long-term contact lens wear appears to decrease the entire corneal thickness and increase the corneal curvature and surface irregularity.
It has also been suggested elsewhere that the thinning of the cornea results in patients being unable to have cataract operations later on in life because of their reduced corneal thickness.
Rigid contact lenses may be removed by pulling with one finger on the outer or lateral canthus, then blinking to cause the lens to lose adhesion. The other hand is typically cupped underneath the eye to catch the lens. There also exist small tools specifically for removing lenses, which resemble small plungers made of flexible plastic; the concave end is raised to the eye and touched to the lens, forming a seal stronger than that of the lens with the cornea and allowing the lens to be removed from the eye.
While daily disposable lenses require no cleaning, other types require regular cleaning and disinfecting in order to retain clear vision and prevent discomfort and infections by various microorganisms including bacteria, fungi, and Acanthamoeba, that form a biofilm on the lens surface. There are a number of products that can be used to perform these tasks:
Some products must only be used with certain types of contact lenses: it is important to check the product label to make sure that it can be used for a given type of lens. Water alone should never be used to clean the contact lens itself as it will not adequately disinfect the lens. The use of water to clean contact lenses may lead to lens contamination and has been known in some cases to cause irreparable harm to the eye. It is also important to follow the product's directions carefully to reduce risk of eye infection or eye irritation. In addition, one should remember to wash the contact cases or lens covers thoroughly with water and multipurpose solution or hydrogen peroxide to avoid formation of biofilms on its surfaces.
It is important to ensure that the product does not become contaminated with microorganisms: the tips of the containers for these solutions should never touch any surface, and the container should be kept closed when not in use. To counteract minor contamination of the product and kill microorganisms on the contact lens, some products may contain preservatives such as thiomersal, benzalkonium chloride, benzyl alcohol, and other compounds. In 1989, thiomersal was responsible for about 10% of problems related to contact lenses: because of this, many products no longer contain thimerosal. Preservative-free products usually have shorter shelf life. For example, non-aerosol preservative-free saline solutions can typically be used for only two weeks once opened. The introduction of silicone-hydrogel soft contact lens materials in 1999 made selection of the proper disinfecting solution more important. One study has noted several incompatibilities between these new lens materials and some solutions resulting in corneal staining.
One specific research topic of interest is how microbes such as Pseudomonas aeruginosa invade the eye and cause infection. Although the pathogenesis of microbial keratitis is not well understood, many different factors have been investigated. One group of researchers showed that corneal hypoxia exacerbated Pseudomonas binding to the corneal epithelium, internalization of the microbes, and induction of the inflammatory response. One way to alleviate hypoxia is to increase the amount of oxygen transmitted to the cornea. Although silicone-hydrogel lenses almost eliminate hypoxia in patients due to their very high levels of oxygen transmissibility, they also seem to provide a more efficient platform for bacterial contamination and corneal infiltration than other conventional hydrogel soft contact lenses. A recent study showed that Pseudomonas aeruginosa and Staphylococcus epidermis adhere much more strongly to silicone hydrogel contact lenses than conventional hydrogel contact lenses and that adhesion of Pseudomonas aeruginosa was 20 times stronger than adhesion of Staphylococcus epidermidis. This might help to explain one reason why Pseudomonas infections are the most predominant.
Another important area of contact lens research deals with patient compliance. Compliance is a major issue surrounding the use of contact lenses because patient noncompliance often leads to contamination of the lens, storage case, or both. The introduction of multipurpose solutions and daily disposable lenses have helped to alleviate some of the problems observed from inadequate cleaning but new methods of combating microbial contamination are currently being developed. A silver-impregnated lens case has been developed which helps to eradicate any potentially contaminating microbes that come in contact with the lens case. Additionally, a number of antimicrobial agents are being developed that have been embedded into contact lenses themselves. Contact lenses with covalently attached Selenium molecules have been shown to reduce bacterial colonization without adversely affecting the cornea of a rabbit eye and octylglucoside used as a contact lens surfactant significantly decreases bacterial adhesion. These compounds are of particular interest to contact lens manufacturers and prescribing optometrists because they do not require any patient compliance to effectively attenuate the effects of bacterial colonization.
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