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Purpose: Multizone contact lenses control myopia progression by proposed introduction of myopic defocus. This project investigated how much of the pupil area and how many dioptres of myopic defocus are introduced by different lens zone geometries with near- and off-axis viewing., Methods: Ten young myopic adults (18-25 years) binocularly wore four soft contact lenses including a single vision (SV), concentric-ring dual-focus (DF), centre-distance multifocal (MF) and a RingBoost™ (RB) multi-zone design containing a combination of coaxial and non-coaxial zones. A modified aberrometer captured aberrations and pupil sizes at four target vergences between -0.25 and -4.00 D (on-axis) and across the central ±30° of the horizontal retina (off-axis). Defocus was quantified as the difference between the measured refractive state and the target vergence within each zone of a multi-zone design within the pupil and compared with that of equivalent zone areas of the SV lens. The percentage of the pupil containing myopic defocused light for each lens was calculated., Results: Defocus within the distance correction zones of multi-zone lenses was similar to that of the SV lens. When viewing on-axis at -0.25 D target vergence, on average 11% of the pupil was myopic with SV, whereas 62%, 84% and 50% of the pupil was myopic for the DF, MF and RB designs, respectively. At -4.00 D target vergence, all lenses exhibited a systematic decrease in the percentage of pupil area having myopic defocus (SV: 3%; DF: 18%; MF: 5% and RB: 26%). The off-axis proportions were similar across multi-zone lenses; however, multi-zone lenses retained approximately 1.25-3.0× more myopic defocus than the SV lens., Conclusions: Subjects accommodated using the distance-correction zones of multi-zone lenses. Multi-zone contact lenses introduced significant myopic defocus on-axis and across the central ±30° retina. However, the magnitude and proportion of defocus were influenced by zone geometry, add power and pupil size., (© 2023 The Authors. Ophthalmic and Physiological Optics published by John Wiley & Sons Ltd on behalf of College of Optometrists.)

Purpose: This study examined the optical impact of a DF contact lens during near viewing in a sample of habitual DF lens wearing children., Methods: Seventeen myopic children aged 14 to 18 years who had completed 3 or 6 years of treatment with a DF contact lens (MiSight 1 Day; CooperVision, Inc., San Ramon, CA) were recruited and fit bilaterally with the DF and a single-vision (Proclear 1 Day; CooperVision, Inc.) contact lens. Right eye wavefronts were measured using a pyramidal aberrometer (Osiris; CSO, Florence, Italy) while children accommodated binocularly to high-contrast letter stimuli at five target vergences. Wavefront error data were used to compute pupil maps of refractive state., Results: During near viewing, children wearing single-vision lenses accommodated on average to achieve approximate focus in the pupil center but, because of combined accommodative lag and negative spherical aberration, experienced up to 2.00 D of hyperopic defocus in the pupil margins. With DF lenses, children accommodated similarly achieving approximate focus in the pupil center. When viewing three near distances (0.48, 0.31, and 0.23 m), the added +2.00 D within the DF lens treatment optics shifted the mean defocus from +0.75 to -1.00 D. The DF lens reduced the percentage of hyperopic defocus (≥+0.75 D) in the retinal image from 52 to 25% over these target distances, leading to an increase in myopic defocus (≤-0.50 D) from 17 to 42%., Conclusions: The DF contact lens did not alter the accommodative behavior of children. The treatment optics introduced myopic defocus and decreased the amount of hyperopically defocused light in the retinal image., Competing Interests: Conflict of Interest Disclosure: NSL and PSK received financial support from CooperVision. MR is a consultant to CooperVision. PC, BA, and AB are employees of CooperVision. The sponsor participated in study design, analysis, and interpretation. All authors were responsible for the preparation of this article and the decision to submit this article for publication. The investigators at Aston University (NSL, SJ) had full access to the study data; the Indiana University investigators (VR, DM, MJ, MR, PSK) had partial access to the study data and take full responsibility for their presentation in this article. The lead author affirms that the article is an honest, accurate, and transparent account of the study being reported and that no important aspects of the study have been omitted. All investigators take responsibility for the integrity of the data and have critically reviewed the article for important intellectual content., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Optometry.)

Purpose: To quantify the amount of myopic defocus, contrast modulation and other optical characteristics of two novel spectacle lenses (MiYOSMART by Hoya and Stellest by Essilor) with the inclusion of lenslets in their designs were investigated computationally and experimentally. This paper examined the hypothesis that despite the non-coaxial nature of the optics, image degradation will exist due to the fragmented nature of the base optic when imaging through the lens regions populated by lenslets., Methods: Optical power was evaluated by computing wavefront vergence and curvature from wavefront slope measured with the Optocraft aberrometer within 1.0 and 6.0 mm apertures across MiYOSMART hexagons and Stellest rings. Point-spread functions (PSFs) were computed using physical (wave) optics and geometrical ray optics principles, and compared with experimental measurements using a 4f optical system. Simulated retinal images and modulation transfer functions (MTFs) were computed from PSF-derived optical transfer functions (OTFs)., Results: Mean lenslet power in MiYOSMART was +3.95 ± 0.10 D through the hexagons and +6.00 ± 0.15 D in Stellest in rings 1-5 and decreased by 0.42 D/ring reaching 3.50 D in the final one. Stellest lenslets included up to -0.015 microns of primary spherical aberration. PSFs and retinal images revealed simultaneous contributions of the base optic and lenslets. MTFs showed a decrease in contrast at low (1-10 c/deg) spatial frequencies (SFs) comparable to 0.25 D of defocus, and retention of diminished levels of contrast at higher SFs., Conclusions: Varying sagittal power and consistent curvature power across the lenslets is an identifying signature of the novel non-coaxial lens design included in both spectacle lenses. Lenslet array structure itself plays a significant role in determining image characteristics. For both lenses, the blur created by the fragmented base optic contributes to the image quality. The reduced MTFs over a wide range of spatial frequencies result in lowered image contrast., (© 2023 The Authors. Ophthalmic and Physiological Optics published by John Wiley & Sons Ltd on behalf of College of Optometrists.)

Continuous monitoring of intraocular pressure, particularly during sleep, remains a grand challenge in glaucoma care. Here we introduce a class of smart soft contact lenses, enabling the continuous 24-hour monitoring of intraocular pressure, even during sleep. Uniquely, the smart soft contact lenses are built upon various commercial brands of soft contact lenses without altering their intrinsic properties such as lens power, biocompatibility, softness, transparency, wettability, oxygen transmissibility, and overnight wearability. We show that the smart soft contact lenses can seamlessly fit across different corneal curvatures and thicknesses in human eyes and therefore accurately measure absolute intraocular pressure under ambulatory conditions. We perform a comprehensive set of in vivo evaluations in rabbit, dog, and human eyes from normal to hypertension to confirm the superior measurement accuracy, within-subject repeatability, and user comfort of the smart soft contact lenses beyond current wearable ocular tonometers. We envision that the smart soft contact lenses will be effective in glaucoma care., (© 2022. The Author(s).)

Purpose: To develop an optical model of a child's eye to reveal the impact of target distance and accommodative behaviour on retinal image quality when fitted with multi-zone lenses., Methods: Pupil size, aberration levels and accommodative lag were adjusted for models viewing stimuli at 400, 100, 33 and 20 cm. Distributions of defocus across the pupil and simulated retinal images were obtained. An equivalent 16-point letter was imaged at near viewing distances, while a 0.00 logMAR (6/6) letter was imaged at 400 cm. Multi-zone lenses included those clinically utilised for myopia control (e.g., dual-focus, multi-segmented and aspherical optics)., Results: Viewing distance adjustments to model spherical aberration (SA) and pupil radius resulted in a model eye with wider defocus distributions at closer viewing distances, especially at 20 cm. The increasing negative SA at near reduced the effective add power of dual-focus lenses, reducing the amount of myopic defocus introduced by the centre-distance, 2-zone design. The negative SA at near largely compensated for the high positive SA introduced by the aspheric lens, removing most myopic defocus when viewing at near. A 0.50 D accommodative lag had little impact on the legibility of typical text (16-point) at the closer viewing distances., Conclusions: All four multi-zone lenses successfully generated myopic defocus at greater viewing distances, but two failed to introduce significant amounts of myopic defocus at the nearest viewing distance due to the combined effects of pupil miosis and negative SA. Typical 16-point type is easily legible at near even in presence of the multi-zone optics of lenses utilised for myopia control and accommodative lag., (© 2022 The Authors. Ophthalmic and Physiological Optics published by John Wiley & Sons Ltd on behalf of College of Optometrists.)

Purpose: High sampling density optical metrology combined with pupil- and image-plane numerical analyses were applied to evaluate a novel spectacle lens containing multiple small zones designed to slow myopia progression., Methods: High-resolution aberrometry (ClearWave, www.lumetrics.com) was used to sample wavefront slopes of a novel spectacle lens, Defocus Incorporated Multiple Segments (DIMS) (www.hoya.com), incorporating many small, positive-powered lenslets in its periphery. Using wavefront slope and error maps, custom MATLAB software ('Indiana Wavefront Analyzer') was used to compute image-plane point-spread functions (PSF), modulation transfer functions (MTF), simulated images and power distributions created by the dual-focus optic for different pupil sizes and target vergences., Results: Outside of a central 10 mm zone containing single distance optical power, a hexagonal array of small 1 mm lenslets with nearest-neighbour separations of 0.5 mm were distributed over the lens periphery. Sagittal and curvature-based measures of optical power imperfectly captured the consistent +3.50 D add produced by the lenslets. Image plane simulations revealed multiple PSFs and poor image quality at the lenslet focal plane. Blur at the distance optic focal plane was consistent with a combination of diffraction blur from the distance optic and the approximately +3.50 D of defocus from the 1 mm diameter near optic zones., Conclusion: Converging the defocused beams generated by the multiple small (1 mm diameter) lenslets to a blurred image at the distance focal plane produced a blur magnitude determined by the small lenslet diameter and not the overall pupil diameter. The distance optic located in between the near-add lenslets determines the limits of the optical quality achievable by the lens. When compared to the optics of a traditional concentric-zone dual-focus contact lens, the optics of the DIMS lens generates higher-contrast images at low spatial frequencies (<7 cycles per degree), but lower-contrast at high spatial frequencies., (© 2020 The Authors Ophthalmic & Physiological Optics © 2020 The College of Optometrists Ophthalmic & Physiological Optics.)

Significance: The prevalence of myopia and use of electronic displays by children has grown rapidly in recent years. We found that children viewing electronic displays, however, experience hyperopic defocus levels similar to those previously reported for other stimuli., Purpose: This study aimed to compare accommodative behavior of nonmyopic and myopic children viewing a computer screen or mobile phone., Methods: Accommodative behavior was examined in 11 nonmyopic and 8 myopic children (11.32 ± 2.90 and 14.13 ± 2.30 years, respectively; P = .04; refractions, +0.51 ± 0.51 and -2.54 ± 1.29, respectively) using an open-field autorefractor (Grand Seiko) at target vergences from -0.25 to -5.00 D. Different size (scaled or nonscaled) and type (text or movie) stimuli were presented on an LCD monitor (distant) or an iPhone (near), with subjects viewing monocularly or binocularly in an illuminated or dark room., Results: At the typical reading distances (20 and 33 cm), all 19 children exhibited some amount of accommodative lag. Stimulus type had little impact on accommodation. However, slightly but statistically significant lower slopes were observed (Bonferroni-corrected significance level of P ≤ .01) for low room lighting (0.96 vs. 0.91; t test, t = 3.88; P = .003), nonscaled targets (0.99 vs. 0.92; t test, t = 4.28; P = .001), and monocular viewing (0.99 vs. 0.90; t test, t = 4.0; P = .002) in the nonmyopic group only. When viewing nonscaled stimuli binocularly (natural viewing), the means and standard deviations of accommodative lags (averaged across room lights on and off, and text and movie) were generally larger for the nonmyopes at all distances and were largest at 33 cm (0.73 ± 0.18 D for the nonmyopes and 0.49 ± 0.23 for the myopes; t test, t = 2.62; P = .01)., Conclusions: Generally small (≤0.50 D) amounts of hyperopic defocus are present in children binocularly viewing handheld electronic devices (nonmyopes slightly more than myopes). Modern electronic devices do not expose children to unusually high levels of hyperopic defocus.

Purpose: The axial separation between the iris and the intraocular lens (IOL) in pseudophakic eyes can cause rays originating from the far temporal field to miss the IOL, resulting in negative dysphotopsia (ND). We developed an experimental model to test the hypothesis that obstruction of rays from the far temporal field can generate ND and an accompanying loss of visual sensitivity in the far temporal field., Methods: The right eyes of 10 phakic subjects were fitted with soft contact lenses containing a 5.50-mm central clear zone and a 12-mm outer diameter opaque annulus. In three of the subjects, eyes were dilated with 1% tropicamide solution, and effective aperture diameters were determined optically (pupil camera) and psychophysically (narrow beam detection). Visual field extent (Goldmann bowl) and temporal and inferotemporal meridian sensitivities (Octopus perimeter) were measured. A wide-angle model was constructed to quantify the impact of the annular opacity on retinal illuminance., Results: All 10 subjects observed a dark crescent in the far temporal and inferotemporal fields. The opaque annulus reduced effective horizontal pupil diameters from 8 mm to 5.5 mm on-axis and from >2 mm to <1 mm at 90°. Perimetry revealed a 10° reduction in temporal and inferotemporal field extent and increasing loss of sensitivity beyond 70°. The wide-angle model confirmed significant vignetting (>50% beyond 70°), approaching zero retinal illuminance beyond 85°., Conclusions: Vignetting of rays originating from the far temporal field by axially separated apertures can create symptoms mirroring perceptual reports of negative dysphotopsia in symptomatic pseudophakic patients.

We live in a three-dimensional world and the human eye can focus images from a wide range of distances by adjusting the power of the eye's lens (accommodation). Progressive senescent changes in the lens ultimately lead to a complete loss of this ability by about age 50, which then requires alternative strategies to generate high-quality retinal images for far and close viewing distances. This review paper highlights the biomimetic properties and underlying optical mechanisms of induced anisometropia, small apertures, dynamic lenses, and multi-optic lenses in ameliorating the visual consequences of presbyopia. Specifically, the advantages and consequences of non-liner neural summation leveraged in monovision treatments are reviewed. Additionally, the value of a small pupil is quantified, and the impact of pinhole pupil location and their effects on neural sensitivity are examined. Different strategies of generating multifocal optics are also examined, and specifically the interaction between ocular and contact or intraocular lens aberrations and their effect on resulting image quality are simulated. Interestingly, most of the novel strategies for aiding presbyopic and pseudophakic eyes (for example, monovision, multifocality, pinhole pupils) have emerged naturally via evolution in a range of species., (© 2019 Optometry Australia.)

Significance: Measurement of ocular aberrations is a critical component of many optical corrections., Purpose: This study examines the accuracy and repeatability of a newly available high-resolution pyramidal wavefront sensor-based aberrometer (Osiris by Costruzione Strumenti Oftalmici, Firenze, Italy)., Methods: An engineered model eye and a dilated presbyopic eye were used to assess accuracy and repeatability of aberration measurements after systematic introduction of lower- and higher-order aberrations with calibrated trial lenses (sphere +10.00 to -10.00 D, and astigmatic -4.00 and -2.00 D with axis 180, 90, and 45°) and phase plates (-0.57 to 0.60 μm of Seidel spherical aberration defined over a 6-mm pupil diameter). Osiris aberration measurements were compared with those acquired on a previously calibrated COAS-HD aberrometer for foveal and peripheral optics both with and without multizone dual-focus contact lenses. The impact of simulated axial and lateral misalignment was evaluated., Results: Root-mean-square errors for paraxial sphere (corneal plane), cylinder, and axis were, respectively, 0.07, 0.11 D, and 1.8° for the engineered model and 0.15, 0.26 D, and 2.7° for the presbyopic eye. Repeatability estimates (i.e., standard deviation of 10 repeat measures) for the model and presbyopic eyes were 0.026 and 0.039 D for spherical error. Root-mean-square errors of 0.01 and 0.02 μm, respectively, were observed for primary spherical aberration and horizontal coma (model eye). Foveal and peripheral measures of higher- and lower-order aberrations measured with the Osiris closely matched parallel data collected with the COAS-HD aberrometer both with and without dual-focus zonal bifocal contact lenses. Operator errors of focus and alignment introduced changes of 0.018 and 0.02 D/mm in sphere estimates., Conclusions: The newly available clinical pyramidal aberrometer provided accurate and repeatable measures of lower- and higher-order aberrations, even in the challenging but clinically important cases of peripheral retina and multifocal optics.

Significance: The challenges associated with clinical assessment of individuals with Down syndrome contribute to a wide range of estimates on the prevalence of keratoconus in the Down syndrome population. This work focuses on two topographical indices previously identified with keratoconus detection, applying them to a topographical data set meeting strict sampling criteria., Purpose: The purpose of this study was to quantify the level of keratoconus-like topographical morphology in a large sample of eyes from individuals with Down syndrome, as identified by two keratoconus detection metrics: inferior-superior dioptric asymmetry (I-S) and KISA%. Severity of the asymmetry was also cast within the context of established Collaborative Longitudinal Evaluation of Keratoconus study disease severity classification criteria., Methods: Corneal topography data on both eyes of 140 subjects with Down syndrome and 138 control subjects were collected. Both I-S and KISA% were calculated from the topography data of eyes with sufficient sampling. Steep and flat keratometry data are reported for subjects with measurements on both eyes in the context of values recorded by the Collaborative Longitudinal Evaluation of Keratoconus study in frank keratoconus to examine within-eye and between-eye asymmetry and severity., Results: Keratoconus detection thresholds were exceeded in 20.8% of the eyes of subjects with Down syndrome and 2.2% of the eyes of controls using I-S and 11.8% of the eyes of subjects with Down syndrome and 0.0% of the eyes of controls using KISA%. Examination of the level of intraeye difference between flat and steep keratometry data for individuals with Down syndrome detected as having corneal morphology consistent with moderate keratoconus yields an average of 1.81 D of toricity, whereas the Collaborative Longitudinal Evaluation of Keratoconus study reported 3.28 D of toricity., Conclusions: Morphology consistent with keratoconus as codified in the detection metrics I-S and KISA% is present in a large percentage of the eyes of individuals with Down syndrome. Differences were observed in the distribution of severity of corneal morphology in individuals with Down syndrome and the keratoconus population at large.

The evidence-basis based on existing myopia control trials along with the supporting academic literature were reviewed; this informed recommendations on the outcomes suggested from clinical trials aimed at slowing myopia progression to show the effectiveness of treatments and the impact on patients. These outcomes were classified as primary (refractive error and/or axial length), secondary (patient reported outcomes and treatment compliance), and exploratory (peripheral refraction, accommodative changes, ocular alignment, pupil size, outdoor activity/lighting levels, anterior and posterior segment imaging, and tissue biomechanics). The currently available instrumentation, which the literature has shown to best achieve the primary and secondary outcomes, was reviewed and critiqued. Issues relating to study design and patient selection were also identified. These findings and consensus from the International Myopia Institute members led to final recommendations to inform future instrumentation development and to guide clinical trial protocols.

Significance: The effectiveness of multifocal contact lenses (MFCLs) at slowing myopia progression may hinge on the accommodative behavior of young eyes fit with these presbyopic style lenses. Can they remove hyperopic defocus? Convergence accommodation as well as pupil size and the zonal geometry are likely to contribute to the final accommodative responses., Purpose: The aim of this study was to examine the accommodation behavior of young adult eyes wearing MFCLs and the effectiveness of these MFCLs at removing foveal hyperopic defocus when viewing near targets binocularly., Methods: Using a high-resolution Shack-Hartmann aberrometer, accommodation and pupil behavior of eight young adults (27.25 ± 2.05 years) were measured while subjects fixated a 20/40 character positioned between 2 m and 20 cm (0.50 to 5.00 diopters [D]) in 0.25-D steps. Refractive states were measured while viewing binocularly and monocularly with single-vision and both center-distance and center-near +2.00 D add MFCLs. Refractive state was defined using three criteria: the dioptric power that would (1) minimize the root mean square wavefront error, (2) focus the pupil center, and (3) provide the peak image quality., Results: Refractive state pupil maps reveal the complex optics that exist in eyes wearing MFCLs. Reduced accommodative gain beyond the far point of the near add revealed that young subjects used the added plus power to help focus near targets. During accommodation to stimuli closer than the far point generated by the add power, a midperipheral region of the pupil was approximately focused, resulting in the smallest accommodative errors for the minimum root mean square-defined measures of refractive state. Paraxial images were always hyperopically or myopically defocused in eyes viewing binocularly with center-distance or center-near MFCLs, respectively. Because of zone geometry in the concentric MFCLs tested, the highly aberrated transition zone between the distance and near optics contributed a significant proportion and sometimes the majority of light to the resulting images., Conclusions: Young eyes fit with MFCLs containing significant transition zones accommodated to focus pupil regions between the near and distance optics, which resulted in less than optimal retinal image quality and myopic or hyperopic defocus in either the pupil center or pupil margins.

Significance: To maximize efficiency of the normally lengthy and costly multizone lens design and testing process, it is advantageous to evaluate the potential efficacy of a design as thoroughly as possible prior to lens fabrication and on-eye testing. The current work describes an ex vivo approach of optical design testing., Purpose: The aim of this study was to describe a system capable of examining the optical characteristics of multizone bifocal and multifocal optics by subaperture stitching using liquid crystal technologies., Methods: A liquid crystal spatial light modulator (SLM) was incorporated in each of two channels to generate complementary subapertures by amplitude modulation. Additional trial lenses and phase plates were placed in pupil conjugate planes of either channel to integrate the desired bifocal and multifocal optics once the two optical paths were recombined. A high-resolution Shack-Hartmann aberrometer was integrated to measure the optics of the dual-channel system. Power and wavefront error maps as well as point spread functions were measured and computed for each of three multizone multifocal designs., Results: High transmission modulation was achieved by introducing half-wavelength optical path differences to create two- and five-zone bifocal apertures. Dual-channel stitching revealed classic annular rings in the point spread functions generated from two-zone designs when the outer annular optic was defocused. However, low efficiency of the SLM prevented us from simultaneously measuring the eye + simulator aberrations, and the higher-order diffraction patterns generated by the cellular structure of the liquid crystal arrays limited the visual field to ±0.45 degrees., Conclusions: The system successfully simulated bifocal and multifocal simultaneous lenses allowing for future evaluation of both objective and subjective evaluation of complex optical designs. However, low efficiency and diffraction phenomena of the SLM limit the utility of this technology for simulating multizone and multifocal optics.

Purpose: An iPad-based letter contrast sensitivity test was developed (ridgevue.com) consisting of two letters on each page of an iBook. The contrast decreases from 80% (logCS = 0.1) to 0.5% (logCS = 2.3) by 0.1 log units per page. The test was compared to the Pelli-Robson Test and the Freiburg Acuity and Contrast Test., Methods: Twenty normally sighted subjects and 20 low-vision subjects were tested monocularly at 1 m using each test wearing their habitual correction. After a 5-minute break, subjects were retested with each test in reverse order. Two different letter charts were used for both the Pelli-Robson and iPad tests, and the order of testing was varied systematically. For the Freiburg test, the target was a variable contrast Landolt C presented at eight possible orientations and used a 30-trial Best PEST procedure. Repeatability and agreement were assessed by determining the 95% limits of agreement (LoA) ± 1.96 SD of the differences between administrations or tests., Results: All three tests showed good repeatability in terms of the 95% LoA: iPad = ± 0.19, Pelli-Robson = ± 0.19, and Freiburg = ± 0.15. The iPad test showed good agreement with the Freiburg test with similar mean (± SD) logCS (iPad = 1.98 ± 0.11, Freiburg = 1.96 ± 0.06) and with narrow 95% LoA (± 0.24), but the Pelli-Robson test gave significantly lower values (1.65 ± 0.04). Low-vision subjects had slightly poorer repeatability (iPad = ± 0.24, Pelli-Robson = ± 0.23, Freiburg = ± 0.21). Agreement between the iPad and Freiburg tests was good (iPad = 1.45 ± 0.40, Freiburg = 1.54 ± 0.37), but the Pelli-Robson test gave significantly lower values (1.30 ± 0.30)., Conclusions: The iPad test showed similar repeatability and may be a rapid and convenient alternative to some existing measures. The Pelli-Robson test gave lower values than the other tests.

Purpose: The purpose of the current study was to examine the on- and off-eye optical performance of two types of soft contact lenses (hydrogel and silicone hydrogel)., Methods: The monochromatic aberrations (λ = 850 nm) of contact lenses were measured on-eye using a clinical Shack-Hartmann ocular aberrometer. In addition, we used an off-eye single-pass contact lens aberrometer (λ = 540 nm) in which the soft contact lens was placed within a wet cell. Comparison of the lower and higher order aberrations measured with these two methods required compensation for different wavelengths and knowledge of the refractive index of the contact lens materials., Results: The measured on-eye sphere and spherical aberration values were generally similar to those measured off-eye and those specified by the lens manufacturers for both types of soft contact lenses. However, there were notable differences, especially for high plus-powered lenses, which typically exhibited lower sphere power on the eye than expected from the lens specifications and from the off-eye measured powers, both of which were almost identical. Longitudinal spherical aberration varied with lens power in the hydrogel lenses, as expected from geometric optics theory. Longitudinal spherical aberration measurements on- and off-eye, however, deviated significantly from that expected of a thin lens with spherical surfaces due to surface asphericities. The difference between on- and off-eye optics can be modeled as a tear lens or as relative lens thickness changes caused by lens flexure., Conclusions: The results of the current study reveal that the major difference between the on-eye lens optics and the manufacturers' specifications is not due to lens errors but due to eye-lens interactions, which could be either lens flexure or a tear lens forming behind the soft contact lens.

Purpose: Electronic data capture is becoming increasingly common for collecting real-time patient responses. The purpose of this study was to investigate compliance with a daily electronic questionnaire regarding night-time contact lens visual performance., Method: Forty-eight subjects (34 females) were fit and dispensed two contralateral pairs of soft contact lenses (SCLs) for one week each. Subjects were sent a nightly e-mail at 8PM containing a secure, individualized link to an electronic questionnaire asking 30 questions of varying response styles (e.g., multiple choice, short answer, etc.) about SCL visual performance. Subjects were instructed to complete the questionnaire before going to bed., Results: The overall completion rate based on 676 electronic questionnaires was 95.1%. Of these, only 3.6% were completed late (<24h). The percentage of subjects completing all questionnaires was significantly higher on weekdays (96.5%; Sunday through Thursday) than on weekends (91.1%; Friday and Saturday). Fisher exact tests indicated no significant association with gender for either weekday (p=0.25) or weekend (p=0.73). Although odds ratio estimates suggested that participants 23 and older were more likely to complete the questionnaire (weekday: OR=4.39, p=0.10; weekend: OR=2.93, p=0.19), these associations did not reach statistical significance., Conclusions: E-mail based questionnaires provide an effective method for acquiring time specific responses, making them a viable clinical and research tool. The day(s) of the week on which assessments occur need to be strongly considered, as on-time compliance may be affected on weekend evenings, or possibly situations in which a typical schedule may not be followed., (Copyright © 2012 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.)

Purpose: Recent research suggests multizone/dual-focus (DF) lens corrections may aid in controlling the progression of myopia. Recently, such a soft contact lens has become commercially available in Hong Kong (MiSight, CooperVision). The purpose of the current study was to evaluate the visual acceptability of this new lens design., Methods: In a double-masked, randomized, crossover trial, 24 subjects (aged 18 to 25 years) wore MiSight contact lenses and Proclear Multifocal +2.00 diopters Add D (MF) soft contact lenses. Patient-reported outcomes (0 to 100 scale) and objective measures of visual performance were acquired for best-spectacle distance correction (BC) and with each contact lens after 1 week of daily use at HIHC (high illumination-high contrast) at distance and LILC (low illumination-low contrast) at distance, intermediate, and near., Results: There were no significant differences in HIHC distance acuity between BC and either the DF or MF lens and no difference between the DF and MF lenses. However, when measured under LILC, there were significant mean differences between each study lens and BC viewed at distance and intermediate. The LILC logMAR visual acuity was not significantly different between the DF and MF lenses at any viewing distance. Although average visual quality and ghosting ratings for both DF and MF study lenses were significantly lower than habitual under all conditions, there were no significant differences between the DF and MF lenses (p = 0.448)., Conclusions: Good acuity, similar to that attainable with typical MF lens correction, is attainable with a new contact lens designed to control myopia progression. However, like other contact lenses that contain multiple refractive zones, some decrease in visual performance may be experienced.

Purpose: Patient-reported subjective responses have become increasingly popular in describing contact lens visual performance and discriminating between designs. The purpose of the current study is to evaluate the ability of patient-reported measures of vision to quantify the perceptual effects of defocus., Methods: Ten young (18-35 years) subjects rated their subjective visual performance monocularly on 3 scales following wear of their optimal monocular distance correction and nine different blurring lenses (-0.50 to +1.50 in 0.25 D steps) in a trial frame. The three scales used were a 0-100 numeric rating scale (NRS), a 100 mm visual analog scale (VAS), and a 5 point ("Poor", "Fair", "Average", "Good", "Excellent") categorical rating scale (CRS)., Results: Mixed linear modeling results found no significant effects either for eye or trial number, but did find a significant effect due to blurring lens power (p<0.0001), with ratings decreasing with increasing levels of blur for all scales. Results were not significantly different between the NRS and VAS at any level of blur, with limits of agreement falling within 22% of the measurement scale. CRS ratings were about 15 units lower than the other scales on average, with limits of agreement that varied with lens power and were roughly 3 times as large. Across scale internal consistency was 0.94., Conclusions: The NRS and VAS yield virtually identical rating responses, but both differing slightly, however from the CRS. Each scale successfully discriminated levels of blur smaller than 0.25 D with only a single measurement., (Copyright © 2012 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.)

Objectives: The defocused portion of the image obtained in wearers of bifocal and multifocal contact lenses often appears as a "ghost." Relatively few methods exist to quantify the ghosting perceived with lenses. The purpose of this study is to validate and implement a questionnaire to help patients quantify the ghost images perceived with bifocal or multifocal corrections., Methods: Ten subjects viewed simulated bifocal vision images displayed on a monitor. Images contained a focused and a defocused (ghost) component of a specific dimension (direction, position offset, intensity, and focus). Using a test card, the subjects identified the ghosting dimension level displayed on the monitor. An additional 54 presbyopic subjects wearing a multifocal correction monocularly viewed a well-focused stimulus and then compared the perceived image to that of the other well-corrected eye looking at the ghosting test card to quantify their visual experience of the 4 proposed ghosting dimensions., Results: Regardless of ghost letter size and orientation, subject responses were within 1 rating unit of expected on >95% of all trials for all 4 dimensions when asked to directly match a single dimension of ghosting. With bifocal images containing random amounts of these 4 dimensions most response errors were also within ± 1 unit. In presbyopes wearing a multifocal lens, the focus dimension was most strongly associated with overall ratings of ghosting., Conclusions: The subjects can accurately and reliably report on ghost intensity, focus, direction and position offset, and well-focused ghosts are most correlated with the overall perceptual saliency of ghosting.

Objectives: To establish if evaluations of multifocal contact lens performance conducted at dispensing are representative of behavior after a moderate adaptation period., Methods: Eighty-eight presbyopic subjects, across four clinical sites, wore each of four multifocal soft contact lenses (ACUVUE BIFOCAL, Focus Progressives, Proclear Multifocal, and SofLens Multifocal) for 4 days of daily wear. Comprehensive performance assessments were conducted at dispensing and after 4 days wear and included the following objective metrics: LogMAR acuity (contrast, 90% and 10%; illumination, 250 and 10 cd/m; distance, 6 m, 100 cm, and 40 cm), stereopsis (RANDOT), reading critical print size and maximum speed and range of clear vision at near. Subjective assessments were made, with 100-point numerical rating scales, of comfort, ghosting (distance, near), visual quality (distance, intermediate, and near), and the appearance of haloes. At two sites, subjects (n = 39) also rated visual fluctuation (distance, intermediate, and near), facial recognition, and overall satisfaction., Results: Among the objective variables, significant differences (paired t test, P<0.05) between dispensing and 4 days were found only for range of clear vision at near (2.9 +/- 2.0 cm; mean difference +/- standard deviation) and high contrast near acuity in low illumination (-0.013 +/- 0.011 LogMAR). With the exception of insertion comfort, all subjective variables showed significant decrements over the same period. Overall satisfaction declined by an average of 10.9 +/- 5.1 points., Conclusions: Early assessment is relatively unrepresentative of performance later on during multifocal contact lens wear. Acuity based measures of vision remain substantially unchanged over the medium term, apparently because these metrics are insensitive indicators of performance compared with subjective alternatives.

Purpose: The multicenter Collaborative Longitudinal Evaluation of Keratoconus (CLEK) Study is a prospective, observational study of 1209 keratoconus patients. We report methods to define incident corneal scarring and baseline factors predictive of incident corneal scarring in nonsurgical eyes of CLEK Study keratoconus patients through their fifth year of follow-up., Methods: Of the 1,209 patients, 878 patients with at least one unscarred cornea at baseline were included in this study. The cumulative 5-year incidence of scarring is defined as the proportion of patients who developed central corneal opacification as detected by a clinician examining the patient with a slit-lamp biomicroscope and by masked readings of corneal photographs at the CLEK Photography Reading Center. Logistic regression analysis was used to test for relationships between baseline factors and incident corneal scarring. Baseline factors analyzed included age, sex, race, atopic disease, contact lens wear, family history of keratoconus, corneal curvature, and central corneal fluorescein staining, among others., Results: The 5-year incidence of corneal scarring was 13.7% (120 of 878) overall, 16.7% (102 of 609) for contact lens-wearing eyes, and 38.0% (46 of 121) for contact lens-wearing eyes with corneal curvature greater than 52 D. Baseline factors predictive of incident scarring included corneal curvature greater than 52 D (odds ratio [OR] = 4.79; 95% confidence interval [CI], 3.08, 7.45; P < 0.001), contact lens wear (OR = 2.50; 95% CI, 1.40, 4.76; P = 0.003), marked corneal staining (OR = 2.38; 95% CI, 1.49, 3.76; P = 0.0002), and age less than 20 years (OR = 6.34; 95% CI, 2.57, 15.00; P < 0.0001)., Conclusions: Multivariate analyses of 5-year prospective data from the CLEK Study cohort showed that baseline corneal curvature, contact lens wear, corneal staining, and younger age were predictive of the development of corneal scarring. The 5-year incidence of scarring is 13.7% for the overall sample and 38.0% for those eyes with corneal curvature greater than 52 D that wore contact lenses. Contact lens wear increased the risk of incident scarring more than 2-fold. These findings suggest a causal contribution of contact lens wear to corneal scarring in keratoconus and imply that corneal scarring might be reduced by modifying the contact lens fit.

Purpose: There are numerous reports of corneal ectasia after laser in situ keratomileusis (LASIK) for myopia without a consistent definition of this condition or a definitive etiology. We conducted a retrospective analysis of published case reports to describe common characteristics of this postoperative event and compared them with findings from a group of successful LASIK patients., Methods: A MEDLINE search for "LASIK" and "ectasia" yielded 21 relevant articles published before May 2003 (n = 86 eyes, 59 patients). A comparison group (n = 103 eyes, 63 patients) was selected from a clinic-based sample of successful LASIK patients with 12 months of follow-up after treatment. Descriptive statistics are reported as median and interquartile range. Comparisons were performed using the Wilcoxon rank sum, Wilcoxon signed rank, and chi-square tests., Results: Time to diagnosis of ectasia after LASIK was 13 months (6 to 20 months). Residual myopia in the ectasia group was -3.69 D (-6.00 to -2.13 D) and was significantly greater than the comparison group, -0.38 D (-0.75 to 0.00 D), P < 0.001. After surgery, eyes with ectasia had increased corneal toricity 2.87 D (2.00 to 4.9 D) with increased oblique astigmatism 1.3 D (0.23 to 2.89 D) relative to eyes in the comparison group 0.00 D (0.00 to 0.08 D), and a loss of 2 lines (-0.5 to -6 lines) of best spectacle-corrected visual acuity (all P < 0.001). Thirty-five percent of reported cases resulted in subsequent corneal transplantation., Conclusions: Preoperative characteristics of corneal ectasia include worse visual acuity, less corneal thickness, greater residual myopia, and greater corneal toricity than nonectatic eyes. Treatment factors associated with corneal ectasia after LASIK are greater stromal ablation and less residual stromal bed thickness. Postoperative characteristics of corneal ectasia are myopic refractive error with increased astigmatism, worse spectacle-corrected visual acuity, increased corneal toricity with topographic abnormality, and progressive corneal thinning.

Purpose: To evaluate the stability of clinical monochromatic aberrometry measurements over a wide range of time scales., Methods: Monochromatic aberrations in four normal eyes were measured with a clinical Shack-Hartmann aberrometer. A chin rest or a supplemental bite bar attachment was used to stabilize head and eye position. Five repeated measurements were taken within one test (5 frames, t < 1 second) without realignment. With realignment between each measurement, aberration measurements were repeated five times (t < 1 hour) on each day, at the same time of day on five consecutive days, and again on 5 days at monthly intervals. A control experiment studied the effect of systematically misaligning the eye to determine whether fixation errors can account for the variation in the repeated measurements., Results: Variability of wavefront root mean square (RMS) error (excluding defocus and astigmatism) was tracked across repeated measurements. Variances for different time scales were: 8.10 x 10(-5) microm2 (t < 1 second), 3.24 x 10(-4) microm2 (t < 1 hour), 4.41 x 10(-4) microm2 (t < 1 week), 9.73 x 10(-4) microm2 (t < 1 year). Bite bar and chin rest data were almost identical. Rotational fixation error up to 3 degrees accounts for only part of the variability., Conclusions: Increased variability in aberration maps between days and months indicates biological fluctuations that are large enough to prevent achievement of "perfect vision," even in the unlikely event that spherical and astigmatic refractive errors are corrected perfectly. However, lack of stability does not justify withholding treatment. A lasting benefit of aberration correction is expected despite temporal variability.

Purpose: To validate the accuracy, tolerance, and repeatability of the complete ophthalmic analysis system aberrometer (COAS, Wavefront Sciences Inc.) with model eyes and normal human eyes., Method: Model eyes were constructed from six polymethyl methacrylate, single-surface lenses with known characteristics. Accuracy of second-order aberrations was verified by measuring defocus and astigmatism induced by series of spherical and cylindrical trial lenses. Accuracy of higher-order aberrations was evaluated by comparing ray-tracing predictions with measured spherical aberration and coma of the aspheric model eyes. Tolerance to axial and lateral misalignment was measured by controlled displacements of the model eye relative to the aberrometer. Repeatability was tested on the same model eyes with repeated measurements taken within 1 s or within half an hour with realignment between each trial. Analyses were based on a 5-mm pupil diameter., Results: Defocus and astigmatism were accurately measured within the working range of the instrument automatic focus adjustment (e.g., measured defocus was within +/-0.25 diopters over a -6.50 to +3.00 D range of refractive error). Accuracy of spherical aberration and coma agreed closely with theoretical predictions (e.g., for all six aspheric models, the mean absolute difference between predicted and measured Z(4)0 was 0.007 microm). Axial displacements over the range +/-2.5 mm had little effect on measurements for myopic and emmetropic model eyes. Also, lateral displacements over the range +/-1.5 mm did not produce significant coma. The standard deviations of repeated measurements of higher-order root mean square on model eyes were <1% of the mean with repeated measures within 1 s and 10% of the mean for five individual measurements with realignment in between each. Tolerance to small lateral displacements was also observed for human eyes., Conclusion: The complete ophthalmic analysis system aberrometer can measure second-, third-, and fourth-order aberrations accurately and repeatedly on model eyes.

Background: Occasional disagreement over spectacle lens prescription accuracy between the optical laboratory and the practitioner is to be expected, especially with a progressive addition lens (PAL). The PAL continues to evolve in design, yet retains some unique, inherent problems. The purpose of this study was to determine if the source of these problems results from the lens design, laboratory error, or verification procedures., Methods: Six Varilux Comfort Orma Supra progressive addition lenses were surfaced to plano distance power, and then verified using manual and automatic lensmeters. The same lenses were then re-surfaced for various sphere and cylinder powers, and verified in the same manner. The results of each trial were spherocylindrically averaged, and compared to the desired result. The lenses were also verified by several incorrect methods to investigate positional tolerance during verification and possible verification errors., Results: The averages for the lenses surfaced to the "prescribed" power were not far from the expected power by all measurement techniques when measured at the central DRP location. Positional errors of as little as 2 mm from the DRP center, however, can lead to erroneous results., Conclusion: Unless correct verification procedures are carefully followed, progressive lenses can be mistakenly identified as being in error when they are not.