Latent autoimmune diabetes of adulthood (LADA) is associated with small fibre neuropathy

AIM

To assess if latent autoimmune diabetes of adulthood (LADA) is associated with small fibre neuropathy.

METHODS

Participants with LADA (n=31), Type 2 diabetes (n=31) and healthy control participants without diabetes (n=31) underwent a detailed assessment of neurologic deficits, quantitative sensory testing, electrophysiology, skin biopsy and corneal confocal microscopy.

RESULTS

The groups were matched for age (healthy control without diabetes: 53.5±9.1 vs. Type 2 diabetes: 58.0±6.5 vs. LADA: 53.2±11.6 years), duration of diabetes (Type 2 diabetes: 10.0±8.3 vs. LADA: 11.0±9.1 years) and blood pressure. However, BMI (P=0.01) and triglycerides (P=0.0008) were lower and HbA_1c (P=0.0005), total cholesterol (P=0.01) and HDL (P=0.002) were higher in participants with LADA compared with Type 2 diabetes. Peroneal motor nerve conduction velocity (P=0.04) and sural sensory nerve conduction velocity (P=0.008) were lower in participants with latent autoimmune diabetes in adults compared with Type 2 diabetes. Intra-epidermal nerve fibre density (P=0.008), corneal nerve fibre density (P=0.003) and corneal nerve branch density (P=0.006) were significantly lower in participants with LADA compared with Type 2 diabetes. There were no significant differences in the other neuropathy parameters.

CONCLUSIONS

Despite comparable age and duration of diabetes, participants with LADA demonstrate more severe neuropathy and particularly small fibre neuropathy, compared with participants with Type 2 diabetes.

Standardizing corneal nerve fibre length for nerve tortuosity increases its association with measures of diabetic neuropathy

AIMS

Recent studies on corneal markers have advocated corneal nerve fibre length as the most important measure of diabetic peripheral neuropathy. The aim of this study was to determine if standardizing corneal nerve fibre length for tortuosity increases its association with other measures of diabetic peripheral neuropathy.

METHODS

Two hundred and thirty-one individuals with diabetes with either predominantly mild or absent neuropathic changes and 61 control subjects underwent evaluation of diabetic neuropathy symptom score, neuropathy disability score, testing with 10-g monofilament, quantitative sensory testing (warm, cold, vibration detection) and nerve conduction studies. Corneal nerve fibre length and corneal nerve fibre tortuosity were measured using corneal confocal microscopy. A tortuosity-standardised corneal nerve fibre length variable was generated by dividing corneal nerve fibre length by corneal nerve fibre tortuosity. Differences in corneal nerve morphology between individuals with and without diabetic peripheral neuropathy and control subjects were determined and associations were estimated between corneal morphology and established tests of, and risk factors for, diabetic peripheral neuropathy.

RESULTS

The tortuosity-standardised corneal nerve fibre length variable was better than corneal nerve fibre length in demonstrating differences between individuals with diabetes, with and without neuropathy (tortuosity-standardised corneal nerve fibre length variable: 70.5 ± 27.3 vs. 84.9 ± 28.7, P < 0.001, receiver operating characteristic area under the curve = 0.67; corneal nerve fibre length: 15.9 ± 6.9 vs. 18.4 ± 6.2 mm/mm², P = 0.004, receiver operating characteristic area under the curve = 0.64). Furthermore, the tortuosity-standardised corneal nerve fibre length variable demonstrated a significant difference between the control subjects and individuals with diabetes, without neuropathy, while corneal nerve fibre length did not (tortuosity-standardised corneal nerve fibre length variable: 94.3 ± 27.1 vs. 84.9 ± 28.7, P = 0.028; corneal nerve fibre length: 20.1 ± 6.3 vs. 18.4 ± 6.2 mm/mm², P = 0.084). Correlations between corneal nerve fibre length and established measures of neuropathy and risk factors for neuropathy were higher when a correction was made for the nerve tortuosity.

CONCLUSIONS

Standardizing corneal nerve fibre length for tortuosity enhances the ability to differentiate individuals with diabetes, with and without neuropathy.

Retinal nerve fibre layer thinning associated with diabetic peripheral neuropathy

AIMS

To investigate the relationship between retinal nerve fibre layer thickness and peripheral neuropathy in patients with Type 2 diabetes, particularly in those who are at higher risk of foot ulceration.

METHODS

Global and sectoral retinal nerve fibre layer thicknesses were measured at 3.45 mm diameter around the optic nerve head using optical coherence tomography (OCT). The level of neuropathy was assessed in 106 participants (82 with Type 2 diabetes and 24 healthy controls) using the 0-10 neuropathy disability score. Participants were stratified into four neuropathy groups: none (0-2), mild (3-5), moderate (6-8), and severe (9-10). A neuropathy disability score ≥ 6 was used to define those at higher risk of foot ulceration. Multivariable regression analysis was performed to assess the effect of neuropathy disability scores, age, disease duration and retinopathy on RNFL thickness.

RESULTS

Inferior (but not global or other sectoral) retinal nerve fibre layer thinning was associated with higher neuropathy disability scores (P = 0.03). The retinal nerve fibre layer was significantly thinner for the group with neuropathy disability scores ≥ 6 in the inferior quadrant (P < 0.005). Age, duration of disease and retinopathy levels did not significantly influence retinal nerve fibre layer thickness. Control participants did not show any significant differences in thickness measurements from the group with diabetes and no neuropathy (P > 0.24 for global and all sectors).

CONCLUSIONS

Inferior quadrant retinal nerve fibre layer thinning is associated with peripheral neuropathy in patients with Type 2 diabetes, and is more pronounced in those at higher risk of foot ulceration.

Visual sensitivity loss in the central 30° of visual field is associated with diabetic peripheral neuropathy

AIMS/HYPOTHESIS

Impaired central vision has been shown to predict diabetic peripheral neuropathy (DPN). Several studies have demonstrated diffuse retinal neurodegenerative changes in diabetic patients prior to retinopathy development, raising the prospect that non-central vision may also be compromised by primary neural damage. We hypothesise that type 2 diabetic patients with DPN exhibit visual sensitivity loss in a distinctive pattern across the visual field, compared with a control group of type 2 diabetic patients without DPN.

METHODS

Increment light sensitivity was measured by standard perimetry in the central 30° of visual field for two age-matched groups of type 2 diabetic patients, with and without neuropathy (n = 40/30). Neuropathy status was assigned using the neuropathy disability score. Mean visual sensitivity values were calculated globally, for each quadrant and for three eccentricities (0-10°, 11-20° and 21-30°). Data were analysed using a generalised additive mixed model (GAMM).

RESULTS

Global and quadrant between-group visual sensitivity mean differences were marginally but consistently lower (by about 1 dB) in the neuropathy cohort compared with controls. Between-group mean differences increased from 0.36 to 1.81 dB with increasing eccentricity. GAMM analysis, after adjustment for age, showed these differences to be significant beyond 15° eccentricity and monotonically increasing. Retinopathy levels and disease duration were not significant factors within the model (p = 0.90).

CONCLUSIONS/INTERPRETATION

Visual sensitivity reduces disproportionately with increasing eccentricity in type 2 diabetic patients with peripheral neuropathy. This sensitivity reduction within the central 30° of visual field may be indicative of more consequential loss in the far periphery.

Corneal confocal microscopy detects improvement in corneal nerve morphology with an improvement in risk factors for diabetic neuropathy

AIM

We have assessed whether corneal confocal microscopy can be used to detect alterations in nerve morphology following an improvement in risk factors associated with diabetic neuropathy.

METHODS

Twenty-five patients with diabetes with mild to moderate neuropathy and 18 control subjects underwent corneal confocal microscopy to quantify corneal nerve fibre (density, branch density, length and tortuosity) at baseline and after 24 months from first visit. This was not planned as an intervention trial and was simply an observational follow-up.

RESULTS

At baseline, nerve fibre density (18.8 ± 2.1 vs. 46.0 ± 3.8 number/mm(2), P = 0.001), nerve branch density (6.9 ± 1.5 vs. 35.6 ± 6.7 number/mm(2), P < 0.0001), nerve fibre length (8.3 ± 0.9 vs. 13.5 ± 0.8 mm/mm(2), P < 0.0001) and nerve fibre tortuosity (19.8 ± 1.6 vs. 22.7 ± 2.2, P < 0.05) were significantly lower in patients with diabetes than in control subjects. At follow-up, glycaemic control (HbA(1c) 64 ± 3 to 58 ± 2 mmol/mol, P = 0.08), total cholesterol (4.9 ± 0.2 to 4.2 ± 0.2 mmol/l, P = 0.01), systolic blood pressure (145.8 ± 4.9 to 135.9 ± 3.7 mmHg, P = 0.09) and diastolic blood pressure (77.8 ± 2.7 to 70.8 ± 2.5, P = 0.03) improved. Nerve fibre density (24.1 ± 2.0, P = 0.05), nerve branch density (11.1 ± 1.3, P < 0.01) and nerve fibre tortuosity (22.6 ± 1.5, P = 0.05) increased significantly, with no change in nerve fibre length (8.4 ± 0.5). Improvement in nerve fibre density correlated significantly with the improvement in HbA(1c) (r = -0.51, P = 0.008). Via four multifactorial regressions, this confirms the negative association between HbA(1c) and nerve fibre density (P = 0.02).

CONCLUSIONS

This study shows that corneal confocal microscopy may be employed in longitudinal studies to assess progression of human diabetic neuropathy and also supports the hypothesis that improvements in risk factors for diabetic neuropathy, in particular HbA(1c) , may lead to morphological repair of nerve fibres.

Increased Langerhan cell density and corneal nerve damage in diabetic patients: role of immune mechanisms in human diabetic neuropathy

AIM/HYPOTHESIS

Immune mechanisms have been proposed to play a role in the development of diabetic neuropathy. We employed in vivo corneal confocal microscopy (CCM) to quantify the presence and density of Langerhans cells (LCs) in relation to the extent of corneal nerve damage in Bowman's layer of the cornea in diabetic patients.

METHODS

128 diabetic patients aged 58 ± 1 yrs with a differing severity of neuropathy based on Neuropathy Deficit Score (NDS-4.7 ± 0.28) and 26 control subjects aged 53 ± 3 yrs were examined. Subjects underwent a full neurological evaluation, evaluation of corneal sensation with non-contact corneal aesthesiometry (NCCA) and corneal nerve morphology using corneal confocal microscopy (CCM).

RESULTS

The proportion of individuals with LCs was significantly increased in diabetic patients (73.8%) compared to control subjects (46.1%), P = 0.001. Furthermore, LC density (no/mm(2)) was significantly increased in diabetic patients (17.73 ± 1.45) compared to control subjects (6.94 ± 1.58), P = 0.001 and there was a significant correlation with age (r = 0.162, P = 0.047) and severity of neuropathy (r = -0.202, P = 0.02). There was a progressive decrease in corneal sensation with increasing severity of neuropathy assessed using NDS in the diabetic patients (r = 0.414, P = 0.000). Corneal nerve fibre density (P < 0.001), branch density (P < 0.001) and length (P < 0.001) were significantly decreased whilst tortuosity (P < 0.01) was increased in diabetic patients with increasing severity of diabetic neuropathy.

CONCLUSION

Utilising in vivo corneal confocal microscopy we have demonstrated increased LCs in diabetic patients particularly in the earlier phases of corneal nerve damage suggestive of an immune mediated contribution to corneal nerve damage in diabetes.

Corneal surface temperature decreases with age

Infrared temperature measurement has found numerous applications in the detection and diagnosis of ocular and systemic disease. In the study of ocular temperature it is important to consider all parameters which might influence recorded measurements. Examples of such parameters include room temperature, time of day and age of subject. This communication discusses the effect of age on ocular temperatures measured with a modern, wide field, colour-coded infrared detector. It is demonstrated that ocular surface temperature decreases by -0.010 degrees C per year throughout life, although the rate of change increases after middle age.

The oxygen performance of contemporary hydrogel contact lenses

The oxygen performance of a hydrogel contact lens is arguably its most important property when considering the possible physiological response of the eye. However, information about this aspect of a contact lens can frequently be difficult to obtain, and there are numerous pitfalls in the interpretation and application of the available data. This paper presents the oxygen permeability and oxygen transmissibility of 17 different lens types as measured by one technician in one laboratory across a short time interval. The clear relationship between water content and oxygen permeability is confirmed, and the transmissibilities of three lens types across a wide power range are reported.

Incidence of keratitis of varying severity among contact lens wearers

AIM

To determine the incidence of non-severe keratitis (NSK) and severe keratitis (SK) among wearers of current generation contact lenses.

METHODS

A 12 month, prospective, hospital based epidemiological study was conducted by examining all contact lens wearers presenting with a corneal infiltrate/ulcer to a hospital centre in Manchester. A clinical severity matrix was used to differentiate between NSK and SK, based on the severity of signs and symptoms. The size of the hospital catchment population and the wearing modalities (daily wear (DW) or extended wear (EW)) and lens types being used were estimated from relevant demographic and market data.

RESULTS

During the survey period, 80 and 38 patients presented with NSK and SK, respectively. The annual incidences (cases per 10,000 wearers) for each wearing modality and lens type were: DW rigid--NSK 5.7, SK 2.9; DW hydrogel daily disposable--NSK 9.1, SK 4.9; DW hydrogel (excluding daily disposable)--NSK 14.1, SK 6.4; DW silicone hydrogel--NSK 55.9, SK 0.0; EW rigid--NSK 0.0, SK 0.0; EW hydrogel--NSK 48.2, SK 96.4; EW silicone hydrogel--NSK 98.8, SK 19.8. The difference in SK between EW hydrogel and EW silicone hydrogel was significant (p = 0.04).

CONCLUSIONS

A clinical severity matrix has considerable utility in assessing contact lens related keratitis. There is a significantly higher incidence of SK in wearers who sleep in contact lenses compared with those who only use lenses during the waking hours. Those who choose to sleep in lenses should be advised to wear silicone hydrogel lenses, which carry a five times decreased risk of SK for extended wear compared with hydrogel lenses.

Corneal confocal microscopy: a non-invasive surrogate of nerve fibre damage and repair in diabetic patients

AIMS/HYPOTHESIS

The accurate detection, characterization and quantification of human diabetic neuropathy are important to define at risk patients, anticipate deterioration, and assess new therapies. Corneal confocal microscopy is a reiterative, rapid, non-invasive in vivo clinical examination technique capable of imaging corneal nerve fibres. The aim of this study was to define the ability of this technique to quantify the extent of degeneration and regeneration of corneal nerve fibres in diabetic patients with increasing neuropathic severity.

METHODS

We scanned the cornea and collected images of Bowman's layer (containing a rich nerve plexus) from 18 diabetic patients and 18 age-matched control subjects.

RESULTS

Corneal nerve fibre density (F(3)=9.6, p<0.0001), length (F(3)=23.8, p<0.0001), and branch density (F(3)=13.9, p<0.0001) were reduced in diabetic patients compared with control subjects, with a tendency for greater reduction in these measures with increasing severity of neuropathy.

CONCLUSION/INTERPRETATION

Corneal confocal microscopy is a rapid, non-invasive in vivo clinical examination technique which accurately defines the extent of corneal nerve damage and repair and acts as a surrogate measure of somatic neuropathy in diabetic patients. It could represent an advance to define the severity of neuropathy and expedite assessment of therapeutic efficacy in clinical trials of human diabetic neuropathy.

A population study of the normal cornea using an in vivo, slit-scanning confocal microscope

PURPOSE

To document qualitative and quantitative changes in the normal, healthy human cornea with age using the confocal microscope.

METHODS

The central corneas of 120 subjects (mean age, 41 years; range, 11 to 80 years) were examined using an in vivo slit-scanning real-time confocal microscope. Images of the corneal stroma and endothelium from both eyes of each subject were semiautomatically analyzed in an observer-masked, randomized manner.

RESULTS

Anterior keratocyte density, posterior keratocyte density, and endothelial cell density were shown to be unaffected by the sex of the subject with p values of 0.46, 0.55, 0.50, respectively (multivariate analysis of variance). No statistically significant difference was detected between right and left eyes for all corneal layers examined. The anterior keratocyte density, posterior keratocyte density, and endothelial cell density decreased at a rate of 0.48, 0.22, and 0.33% per year, respectively. A positive correlation was found between the coefficient of cell variation and age.

CONCLUSIONS

This data constitutes essential normative data that can be used as a control in further research into abnormal corneal conditions.

Thermal consequences of photorefractive keratectomy

PURPOSE

Photorefractive keratectomy (PRK) is still a widely used method for the correction of refractive error despite the advent of laser in situ keratomileusis (LASIK). However, both procedures are associated with significant side effects such as corneal haze and regression. Several factors have been implicated in the etiology of haze, one of which is thermal loading of the cornea. The purpose of this study was to investigate the temperature changes occurring during PRK when performed at different ablation depths.

METHODS

Noncontact, color-coded ocular thermography was performed with an infrared detector apparatus during PRK ablation on 19 ovine corneas. Five different refractive corrections were carried out ranging from -2.00 diopters (D) (ablation depth, 31.2 microm) to -10.00 D (ablation depth, 137.9 microm).

RESULTS

A temperature rise at the corneal surface was demonstrated in all 19 corneas. The mean rise in temperature was 7.35 +/- 1.13 degrees C with a maximum rise in temperature of 8.97 degrees C. A positive correlation was found between the refractive correction and the peak rise in temperature (r2 = 0.57, p< 0.0001). The rate of temperature change was greater for smaller treatments than for larger treatments (r2 = 0.79, p < 0.0001). Corneas undergoing larger treatments were subject to greater rises in temperature for longer periods of time.

CONCLUSIONS

This study suggests that the cornea undergoes a significant rise in temperature as a result of the PRK process. Further investigation is required to determine what effect this thermal loading has on the corneal wound healing response after PRK.

Morphology of corneal nerves using confocal microscopy

PURPOSE

The aim of the current study was to evaluate the distribution and morphology of corneal nerves as seen by means of white light confocal microscopy.

METHODS

This study analyzed images of corneal nerves that were obtained using the Tomey Confoscan slit scanning confocal microscope (40x/0.75 objective lens). The images were classified according to their location within the cornea. The objective and subjective evaluation of the images involved measuring, grading, or judging a number of parameters from both individual pictures and from each single nerve fiber within any image.

RESULTS

The in vivo observations made in this work are in agreement with those of previous histologic studies. The general scheme of corneal innervation is described as originating from thick and straight stromal nerve trunks that extend lateral and anteriorly and give rise to plexiform arrangements of progressively thinner nerve fibers at several levels within the stroma. From there, nerve fibers perforate Bowman's layer and eventually form a dense neural plexus just beneath the basal epithelial cell layer, which is characterized by tortuous and thin beaded nerve fibers interconnected by numerous nerve elements; nerve fibers from this plexus are known to be responsible for the innervation of the epithelium.

CONCLUSION

This study provides convincing evidence of the suitability of confocal microscopy to image corneal nerves, the only drawback being the limited resolution in terms of the differentiation of the ultrastructure of nerve bundles.

A prospective study of contact lens wear in diabetes mellitus

A prospective, controlled, observer-masked study was conducted to investigate the suitability of contact lenses for patients with diabetes mellitus. Forty diabetic patients and 40 non-diabetic control subjects were fitted with soft hydrogel contact lenses to be worn on a daily wear basis for 12 months. The ocular response was assessed using slit lamp biomicroscopy, ultrasonic pachometry, corneal aesthesiometry and visual acuity measures. Compared to non-diabetic subjects, diabetic patients displayed significantly reduced corneal transparency, variable vision and reduced comfort with the contact lenses (p < 0.05). There were no significant differences between the two groups with respect to ocular hyperaemia, corneal staining, corneal thickness, corneal sensitivity or high contrast visual acuity. Contrary to previous reports, the response of the diabetic eye to contact lenses--as observed clinically--does not differ appreciably from that of the non-diabetic eye. These results suggest that current generation daily wear soft contact lenses can be a viable mode of vision correction for diabetic patients.

Validation of grading scales for contact lens complications

The validity of use of two artist-rendered and two photographic sets of grading scales (grading 'systems') designed for gauging the severity of contact lens-related ocular pathology was assessed in terms of precision and reliability. Thirteen observers each graded 30 images--by interpolation or extrapolation to the nearest 0.1 increment--of each of the three contact lens complications (corneal staining, conjunctival redness and papillary conjunctivitis) that were common to all four grading systems. This entire procedure was repeated approximately two weeks later, yielding a total data base comprising of 9360 individual grading estimates. Analysis of variance revealed statistically significant differences in both precision and reliability between systems, observers and conditions (p < 0.03 for system reliability; p = 0.0001 for all other combinations). The artist-rendered systems generally afforded lower grading estimates and better grading reliability than the photographic systems. Corneal staining could be graded less reliably than conjunctival redness and papillary conjunctivitis. Grading reliability was generally unaffected by the severity of the condition being assessed. Notwithstanding the above differences, all four grading systems are validated for clinical use and practitioners can initially expect to use these systems with average 95% confidence limits of +/- 1.2 grading scale units (observer range +/- 0.7 to +/- 2.5 grading scale units). In view of the significant between-system differences revealed in this study, it is advisable to consistently use the same grading system. It may be possible to reduce between-observer differences by applying personalised correction factors to normalise grading estimates.

Confocal microscopy of the normal human cornea

The slit-scanning confocal microscope is a new clinical paradigm that allows the living human cornea to be viewed at a magnification of 680 x and a lateral resolution of 1 mum. As such, it allows corneal morphology to be inspected at a cellular level. The corneas of both eyes of 119 subjects who were evenly distributed in age from 10-80 years were examined using a Tomey ConfoScan P4 in-vivo slit-scanning real-time confocal microscope (Erlangen, Germany). Good quality representative images of the various corneal layers were selected for detailed qualitative analysis and are displayed here. A grid of corneal layer versus age was constructed from these images; this tool can be used as a normative confocal microscopy reference against which suspected corneal abnormalities can be assessed.

The role of tear physiology in ocular surface temperature

PURPOSE

To determine whether the more rapid cooling of the tear film in dry eyes is related to other tear film parameters, a battery of tear physiology tests was performed on dry eye patients and control subjects.

METHODS

Tear evaporation rate was measured with a modified Servomed (vapour pressure) evaporimeter and ocular temperature with an NEC San-ei 6T62 Thermo Tracer in 9 patients diagnosed as having dry eye and in 13 healthy control subjects. Variability in temperature across the ocular surface was described by the temperature variation factor (TVF). Lipid layer structure and tear film stability were assessed with the Keeler Tearscope and tear osmolality was measured by freezing point depression nanolitre osmometry.

RESULTS

The data were explored by principal component analysis. The subjects with and without dry eye could be separated into two distinct groups entirely on the basis of their tear physiology. Dry eye patients exhibited higher tear evaporation rates, osmolalities and TVF, lower tear film stabilities and poorer-quality lipid layers than the control subjects. A significant linear relationship was found to exist between tear evaporation rate and TVF for all subjects (R2 = 0.242, p = 0.024).

CONCLUSIONS

Rapid cooling of the tear film in dry eyes appears to be related to the reduced stability of the tears and the increased rate of evaporation. The higher latent heat of vaporisation, associated with the increased evaporation in dry eyes, may account for the increased rate of cooling of the tear film in this condition.

Hydrogel contact lens ageing

PURPOSE

To determine if hydrogel lens water content decreases over wearing periods of up to four weeks; that is, demonstrate an 'ageing' effect.

METHODS

Six subjects (4 males, 2 females; age range: 34.8 +/- 11.0 years) wore each of the following lenses for one month: Acuvue, Frequency 38, Gentle Touch and Proclear. Pre-insertion and post-removal lens water content was measured daily by the subjects using an Atago CL-1 Soft Contact Lens Refractometer for a 28 day period. Post-insertion and pre-removal comfort was recorded over the same period.

RESULTS

A significant lens ageing effect was noted whereby the pre-insertion lens water content decreased significantly over the 28 day cycle for all lenses (P < 0.05). The pattern for daily dehydration remained consistent for the 28 day period for the Acuvue lens and the Gentle Touch lens but decreased for the Frequency 38 lens and the Proclear lens. Comfort decreased significantly by the end of the day for three of the four lens types investigated.

CONCLUSIONS

It is apparent that the extent of lens dehydration changes over time, and that this pattern of change is different for different lens types. The associated loss of oxygen performance with dehydration is demonstrated. These data will assist practitioners in understanding the clinical effects of soft lens dehydration over time.

Ocular temperature in carotid artery stenosis

PURPOSE

To explore the potential application of wide-field, color-coded infrared ocular thermography in the investigation of carotid artery stenosis (CAS).

METHODS

Ocular thermography and color duplex ultrasonography were undertaken in a masked study of 24 asymptomatic, consecutively presenting patients who were examined for vascular occlusive disease.

RESULTS

Linear regression analysis indicated that there was a significant negative correlation between ocular surface temperature and the degree of CAS (r = -0.67, p < 0.001). Similar results were demonstrated between the relative difference in CAS (right - left) and the relative difference in ocular surface temperature (right - left) (r = -0.67, p < 0.001).

CONCLUSIONS

These results indicate that the circle of Willis and the other anastomoses within the brain are unable to compensate fully for the reduction in blood flow on the affected side. Noncontact ocular temperature measurement has potential as both a screening test and a supplementary diagnostic clinical test for CAS.

Accuracy and reproducibility of one-day disposable contact lenses

One-day disposable contact lenses are experiencing rapid market growth in certain markets, such as the United Kingdom. Because of the huge numbers of lenses required to satisfy this modality of wear, both practitioners and patients need to be reassured about the quality of these products. Analysis of the accuracy and reproducibility of each of three currently available 1-day disposable lenses was conducted with respect to the following lens parameters: total diameter, back optic zone radius, center thickness, water content, and back vertex power. Fourteen of the 15 parameters measured (three lenses x five parameters per lens) were found to fall within ISO-defined tolerances. Reproducibility was similar for the three lens types and was considered clinically acceptable. Practitioners and patients can be confident that the current generation of 1-day disposable lenses can be relied on to give consistent ocular and visual performance.

Hydrogel contact lens dehydration and oxygen transmissibility

PURPOSE

Oxygen transmissibility is a key determinant of the physiological response of the cornea to contact lens wear. Because transmissibility is related to hydrogel water content, we conducted a study to determine the change in water content during lens wear and to quantify the impact any such change would have on transmissibility.

METHODS

In a double masked clinical investigation, two subjects each wore 17 different pairs of contact lenses. Water content was measured before lens wear at 35 degrees C and immediately after 4 hours of contact lens wear. Contact lens oxygen transmissibilities were calculated on each occasion.

RESULTS

The absolute changes in water content for the 17 lenses varied from +0.5% to -5.3%. For some lenses, this change in water content altered the lens oxygen transmissibilities to a clinically significant degree. The changes in water content and oxygen transmissibilities were greatest with FDA Group IV lenses.

CONCLUSIONS

Dehydration during contact lens wear can alter the oxygen transmissibility of hydrogel lenses, and in some situations, this factor may be clinically significant.

Clinical performance of an innovative back surface multifocal contact lens in correcting presbyopia

PURPOSE

This prospective study was designed to subjectively and objectively evaluate the performance of an aspheric multifocal back surface rigid gas permeable (RGP) contact lens. The multifocal element of this lens design consisted of an aspheric optical zone that varied according to the patient's ametropia, corneal topography, and required reading addition.

METHODS

We fit 28 presbyopic subjects with an aspheric multifocal back surface RGP contact lens (age range: 45 to 68 years). Reading additions ranged from +0.75 D to +2.50 D. Subjects were assessed initially and at 2, 6, and 12 weeks for ocular changes, visual performance, and subjective responses.

RESULTS

We required 116 RGP lenses to achieve an acceptable fit and visual acuity in 28 subjects (55 eyes). At the final visit, the distance logMAR acuity with the multifocal contact lens (+0.12 +/- 0.10) was not statistically different (t = -0.623, P = -0.5388) from spectacle acuity at the initial visit (+0.10 +/- 0.12). The near logMAR acuity with the multifocal contact lens at the final visit (0.36 +/- 0.12) was not statistically different from that for near acuity with spectacles at the initial visit (0.33 +/- 0.13). No slit lamp signs worsened during the study. A reduction in myopia of 0.67 D was noted by the final visit. Spectacle blur was noted if the acuity at the initial refraction was compared to the acuity with the same refraction at the final visit (t = -3.287, P = 0.0028) but not when the refractive changes were incorporated (t = 1.058, P = 0.3127). All subjects rated the performance of the lenses very highly: comfort, 86%; distance acuity, 83%; near acuity, 73%; and stability of vision, 74%. Twenty-four subjects (86%) chose the multifocal contact lens as their preference.

CONCLUSION

We demonstrated that a multifocal design is able to provide acceptable distance and near correction for presbyopic patients. The aspheric geometry required can be optimized for a given patient by considering his/her degree of ametropia, as well as the corneal topography.

The parameter stability of a high dk rigid lens material

The use of rigid materials with high oxygen permeability (Dk) is on the increase, their major benefit being the reduction of hypoxia. However, there is a reluctance to use these materials possibly due to increased surface scratching, reduced wettability, increased deposition, reduced life expectancy and parameter instability. Considering parameter stability, various studies have demonstrated contradictory results or used high Dk materials based on the silicone acrylate polymer. This study was designed to investigate whether the parameters of a high Dk rigid fluorocarbon contact lens material changed during daily wear and extended wear schedules. Thirty five subjects, divided into group groups, Group I wore the lens on a daily wear basis, whereas those in Group II wore the lens on a monthly extended wear basis. The parameters and integrity of the lenses were monitored in both groups every 3 months. For lens integrity a statistically significant increase in surface scratching was demonstrated for the lenses worn by the subjects of both groups over the time of the study (Group I, F=7.990, P <0.0001 [ANCOVA]; Group II, F=6.241, P=0.003 [ANCOVA]). The only parameter to show a statistically significant variation over the study period was that of centre thickness for the lenses worn by the subjects in Group I (F=3.976, P=0.0063 [ANCOVA]), with a mean reduction in centre thickness of 0.022 mm at the 12 month visit. No change was noted for either group or between groups for the other parameters measured. This study demonstrates that the parameters of rigid contact lenses manufactured from high Dk fluorocarbons are stable with only a non-clinically significant reduction in centre thickness for the contact lenses worn by the subjects in Group I.

Grading scales for contact lens complications

Grading scales have been developed to assist practitioners in recording the level of severity of ocular complications of contact lens wear. Eight common complications are depicted in five levels of severity--from grade 0 (normal) to grade 4 (severe). The intersubject variance in grading was determined to be 1.0 scale units, which by coincidence concurs exactly with the key design strategy of the grading scales that each grading step of 1.0 corresponds to a clinically significant difference in severity.

Non-compliance in optometric practice

The purposes of this paper is to explore how some of the recent and future changes relating to the optometric profession could affect non-compliant behaviour among patients. Non-compliance has been widely documented and discussed in numerous health care fields and is understood to be the responsibility of both the practitioner and patient working in a health care partnership. At least one third of patients have been reported to be non-compliant with health care recommendations which can result in the poor outcome of a treatment, secondary medical problems, dissatisfaction, frustration and the wasting of health resources. In recent years contact lens complications have been linked with non-compliant behaviour with contact lens care and maintenance regimens which has led to several media scares over contact lens related hygiene risks and has heightened interest in the issue of non-compliance in the field of optometry. Shared care schemes have already been adopted in some areas of the United Kingdom and if therapeutic pharmaceutical agents are introduced to the list of drugs permitted for use by optometrists in the future the issue of non-compliance will become even more poignant. Every optometrist needs to be aware of the high probability of non-compliant behaviour among patients, the consequences of this non-compliance and the steps that can be taken to enhance compliance in different areas of eye-care.

Contact lens wear and diabetes mellitus

An estimated 30,000 diabetic patients in the United Kingdom currently wear contact lenses. Anecdotal clinical experience indicates that such patients have an increased risk of developing potentially sight-threatening ocular complications such as ulcerative keratitis. The corneal complications associated with diabetes, for example structural changes in the epithelial and endothelial cells, have led to some controversy regarding the suitability of contact lenses for diabetic patients. There have been few published studies documenting the ocular response of the diabetic eye to current generation contact lens materials. The purpose of this paper is to review the anterior eye manifestations of diabetes and to discuss how such changes could influence contact lens wear.

Refractive index of rigid contact lens materials

A simple hand-held refractometer was used to measure the refractive index of 27 rigid gas permeable contact lens materials. As a general rule, lenses with refractive indices lower than 1.458 are made from fluorosilicone acrylates; lenses with refractive indices in the range of 1.458 to 1.469 are made from either fluorosilicone acrylates or silicone acrylates; and lenses with refractive indices greater than 1.469 are made from silicone acrylates. It is demonstrated how refractometry can be used by contact lens practitioners for the identification and verification of rigid contact lenses.

Corneal temperature changes during photorefractive keratectomy

PURPOSE

Corneal temperature changes in photorefractive keratectomy (PRK) have been implicated in the aetiology of subepithelial haze. This study was undertaken to quantify the temperature change during this surgical procedure.

METHODS

Non-contact, colour-coded ocular thermography was performed by using an infrared detection system during PRK on a group of 12 subjects.

RESULTS

Mean (+/-SD) central ocular surface temperature (OST) after epithelial debridement was 29.15 +/- 0.39 degrees C. Mean peak OST during PRK was 37.77 +/- 0.67 degrees C, with most of the temperature increase occurring during the first 15 s. Factors such as ablation depth, optical correction, and procedure duration were not demonstrated to have a significant effect on corneal temperature during the procedure, suggesting a complex relation between-PRK parameters and the change in corneal temperature.

CONCLUSIONS

Previous work suggested that corneal collagen denatures at approximately 39 degrees C, and it has been demonstrated that corneal temperature may be elevated to this level during routine PRK. Further research is indicated into the effects of preoperative cooling and pausing in treatment to reduce temperature changes.

A prospective study of the effect of education on non-compliant behaviour in contact lens wear

The contact lens practitioner and patient present a specific case for the study of non-compliance in areas such as hygiene, solution use, appointment attendance and wearing times. Education is one of the factors thought to influence compliance among patients in general health care situations and contact lens practitioners are encouraged to educate patients in the care and maintenance of contact lenses. A prospective, randomized, controlled and double masked study was performed to assess the effect of a 'compliance enhancement strategy' on levels of compliance among contact lens wearers over twelve months. Eighty experienced contact lens patients were randomly allocated to two experimental groups. A standard level of contact lens instruction was applied to the first group and in addition the compliance enhancement strategy was applied to patients assigned to the second group. The strategy consisted of extra education for patients using a video, booklets, posters, a checklist and a health care contract. Patients were given free supplies of ReNu multipurpose solution and Medalist 38 soft contact lenses (Bausch and Lomb, Rochester, New York). Compliance levels were assessed at a twelve month aftercare appointment by demonstration and questionnaire. The results indicate that the compliance enhancement strategy had little significant effect on the compliance levels of the patients to who it was applied. The population of contact lens wearers were generally very compliant and the contact lenses and care regimen were clinically successful. The possibility that the assessment of non-compliance was not adequately sensitive to highlight small differences in non-compliant behaviour is discussed. The standard level of education applied to this sample of contact lens patient were adequate to ensure generally high levels of compliance with the simple care and maintenance regimen recommended.

The truth about compliance

When confronted with an adverse response to contact lens wear, practitioners are often quick to 'blame the victim'. Although patient compliance may well be lacking, the reasons for this need to be considered carefully, along with all of the other possible contributing factors, if the safety of contact lens wear is to be improved. This Presidential Address briefly reviews what the contact lens literature has revealed about patient compliance in the context of what has been known for many years in general eye care and, indeed, general medicine. Essentially, compliance with contact lens systems is poor (40-90% of patients are noncompliant) and difficult to predict in individual patients. Neither a compliance-enhancement strategy (intense education) nor reduction of the cost of goods has any significant effect upon the level of compliance. Assessment of personality is not a reliable compliance predictor. A compliance enhancement model is proposed which encompasses the following four components: (a) the clinic and the practitioner, (b) the patient, (c) the advice that is given, and (d) the contact lens industry.

A survey of contact lens wear among diabetic patients in the United Kingdom

A survey of attitudes to the fitting of contact lenses to diabetic patients was sent to 1122 optometric, ophthalmological and dispensing members of the British Contact Lens Association; 418 completed questionnaires were analysed. Sixty-two per cent of practitioners considered rigid lenses to be the safest form of lens wear. Most preferred daily lens wear and advised frequent aftercare visits, regular soft lens replacement, special attention to hygiene and restricted wearing time. A survey of 218 diabetic patients attending three diabetic clinics revealed that 3% wore contact lenses, which is a similar percentage to the non-diabetic population. Eight patients had been advised that they could not wear contact lenses because of their diabetes. It is concluded that controlled clinical trials of contact lens wear by diabetic patients are required to supplant anecdotal opinions (such as those reported here) with sound scientific data in order to form a proper rationale for the safe fitting of contact lenses to this group of patients.

Distribution of oxygen across the surface of the human cornea during soft contact lens wear

PURPOSE

To determine whether tear mixing occurs beneath soft contact lenses, we examined the effect of blinking on the oxygen distribution across the corneal surface beneath a nonuniform thickness lens.

METHODS

A custom-designed twin polarographic oxygen sensor assembly was used to simultaneously measure the equivalent oxygen percentage (EOP) at central and peripheral corneal locations of 10 human subjects beneath a -6.00 D thin-design hydroxyethyl mathacrylate (HEMA) lens. A -0.25 D lens served as a control. Each lens was worn for 5 min under static (no blinking) and dynamic (12 and 60 blinks/min) conditions.

RESULTS

A significantly greater EOP (p = 0.006) was observed at the central (vs. peripheral) cornea during static and dynamic lens wear; central and peripheral oxygenation were unaffected by blinking.

CONCLUSIONS

Tear mixing is insignificant beneath thin-design HEMA lenses; therefore, oxygenation across the corneal surface beneath such lenses is best predicted from the lens thickness profile rather than average thickness.

Life expectancy of rigid gas permeable and high water content contact lenses

PURPOSE

The purpose of this study was to evaluate the life expectancy of various rigid gas permeable (RGP) lens materials used on a daily wear basis and to compare these results with the life expectancy of a matched group of soft lens wearers.

METHODS

We retrospectively analyzed the records of 600 contact lens wearing patients (300 soft contact lens users and 300 RGP lens users fit between September 1987 and September 1994. None of the subjects wore lenses on a planned replacement system. For the purpose of the study, RGP lenses were divided into three groups: < or = 40 Dk were considered low-Dk; 41-89 Dk were considered mid-Dk; and > or = 90 Dk were considered high-Dk. All soft lenses were high water content lenses (> or = 60% water content). Lenses were included if they were replaced due to loss, breakage, deposition, or poor wettability but not if replaced because of changes in fit or prescription.

RESULTS

The mean (+/- SD) life-spans of each lens type in months were 19.9 +/- 17 for low-Dk RGP lenses, 15.9 +/- 13.3 for mid-Dk RGP lenses, 9.0 +/- 8.2 for high-Dk RGP lenses, and 6.4 +/- 5.2 for high water content soft lenses. Statistical analysis using a one-way ANOVA on ranks indicated that these results were statistically significant (P < 0.0001).

CONCLUSIONS

Patients should be informed that high-Dk lenses (RGP and soft) provide substantial clinical benefits and that they should except to replace high-Dk RGP lenses after approximately 6 months. This lends further credence to the use of high-Dk lenses on a planned replacement basis.

Regular replacement of extended wear rigid gas permeable contact lenses

PURPOSE

While the benefits of planned replacement of soft contact lenses have been investigated, the question of whether there are any clinical benefits to planned replacement of rigid gas permeable (RGP) lenses does not appear to have been addressed experimentally. We aimed to determine the benefits of regular replacement of extended wear RGP contact lenses.

METHODS

We conducted a prospective, single-center, controlled, double-masked study of 39 RGP lens wearers. The subjects were divided into two groups and wore extended wear Quantum 2 lenses (Dk = 120) for 12 months. Subjects in Group I replaced lenses every 3 months, whereas those in Group II were not scheduled to replace their lenses. The integrity of the lenses and the ocular responses to lens wear were monitored in both groups every three months.

RESULTS

Compared to lenses worn by subjects in Group I, lenses worn by Group II subjects showed significantly more mucous coating, lens binding, and corneal staining over time (P < 0.05; ANCOVA). There was no difference in microcystic or tarsal conjunctiva response, lens comfort, refractive change, or visual acuity between the two groups.

CONCLUSIONS

We advocate that to maintain optimal lens integrity and ocular health, RGP lenses used for extended wear should be replaced every 3 to 6 months.

Scratch resistance of rigid contact lens materials

Practitioners have long recognised the importance of determining the extent of scratching on the surface of rigid contact lenses when deciding on lens replacement. Despite this, little research has been undertaken to define this problem. The extent of scratching of rigid contact lens materials was evaluated and this property was related to material oxygen permeability and refractive index. One hundred and forty lenses made from 28 different rigid materials were evaluated in a masked and randomised manner. Scratches were created on the front surface of the lenses using an apparatus that was specifically designed and constructed for this experiment. The extent of scratching was quantitatively evaluated using a computer-based scanning and image analysis system. The oxygen permeability of all materials was measured using the polarographic method. An Atago N3000 hand-held refractometer was used to measure the refractive index of these materials. Three significant correlations were revealed: an inverse relationship (r = -0.813, P < 0.0001) between oxygen permeability and refractive index; a positive relationship (r = 0.511, P < 0.008) between oxygen permeability and the extent of scratching; and an inverse relationship (r = -0.539, P < 0.0058) between refractive index and the extent of scratching. The information generated in this study concerning scratch resistance of rigid contact-lens materials may assist the contact lens industry and contact lens practitioners in developing and prescribing rigid lenses with optimal performance characteristics.

Infrared thermography of the tear film in dry eye

Infrared ocular thermograms were recorded for a group of 36 dry eye patients and for 27 age- and sex-matched controls. Mean ocular surface temperature was greater in the dry eye group (32.38 +/- 0.69 degrees C) compared with the control group (31.94 +/- 0.54 degrees C; p < 0.01). In addition, there was a greater variation of temperatures across the ocular surface in the dry eye group, illustrated by the difference in temperature between the limbus and the centre of the cornea (0.64 +/- 0.20 degrees C in dry eye patients compared with 0.41 +/- 0.20 degrees C in the control group; p < 0.001). This parameter was also shown to be greater in dry eye patients who displayed either a fast tear break-up time or a poor Schirmer's test result. Infrared thermography is a non-invasive and objective technique that may prove a useful research tool for study of the tear film, its deficiencies and its various treatment modalities.

Non-compliance in contact lens wear

Non-compliance is emerging as a critical issue in the contact lens field. This problem has been studied at depth in general health care situations and is seen as the responsibility of both practitioner and patient (client) working in a health care partnership. The contact lens practitioner and patient present a specific case for the study of non-compliance in areas such as hygiene, solution use, appointment attendance and wearing times. From 40 to 91% of contact lens patients have been reported as non-complaint in the use of recommended care and maintenance regimens and many of these are confused or ignorant about their behaviour. In order to arrive at a general set of conclusions from the studies published to date, it is important to understand the methodology of each study, it purpose, the definition of non-compliance used and the way the results were analysed and described. This review summarizes the research into non-compliance in the contact lens field to data. A set of general conclusions is drawn and a model for compliance in the context of contact lens practice is proposed.

Non-compliance in general health care

An increased interest in non-compliance has been demonstrated by the great number of papers recently published on the subject. A review of the relevant literature shows a pattern emerging of at least one third of clients being non-compliant. This can result in a hazard to health, a waste of health resources and much frustration for practitioners and clients in many areas of health care. There are multiple factors which appear to be related to non-compliance in a complex and interdependent way. These factors can be described under three main headings: the client, the treatment and disorder, and the clinic interactions. Compliance is summarized as the shared responsibility of practitioner and client in a health care partnership. The purpose of this paper is to review the extensive literature on compliance in general health care and to present a set of guidelines for the enhancement of compliance in the form of a general model.

The role of pili in the attachment of Pseudomonas aeruginosa to unworn hydrogel contact lenses

Contamination of contact lenses is thought to increase the risk of infectious keratitis, yet factors promoting attachment of bacteria to contact lenses are not fully understood. It has been suggested that strains of Pseudomonas aeruginosa attach to mucosal surfaces via pili which are appendages found on some strains. This study investigated the role of pili and the effect of incubation time on the attachment of P. aeruginosa to 20 unworn hydrogel lenses representative of each of the four FDA categories. Ten lenses were incubated for 15 minutes and another ten for 180 minutes. Lenses were incubated with either PAK + P. aeruginosa which possessed pili or its isogenic mutant pair, PAK-, which was genetically similar except for the absence of pili. Bacteria were quantified, following homogenization of the contact lens, by viable counts. Non-piliated bacteria were significantly more likely to adhere to the lenses (p < 0.001). A significant interaction between lens type and incubation time was observed (p < 0.05); thus it is difficult to generalize about either of these effects in isolation. These results show that surface characteristics may confer an attachment advantage to bacteria.

Potential applications of ocular thermography

Thermography is an investigative technique which allows rapid color-coded display of the temperature across a wide surface by means of infrared detection. We describe an ocular thermographic study of a normal population and present case studies describing the application of this technique for patients with ocular disease. We found that 95% of the normal population have an interocular temperature difference (temperature of center of right cornea minus temperature of center of left cornea) of 0.60 degrees or less. There appears to be a greater difference in temperature between the limbus and the center of the cornea in patients with dry eyes. This technique has potential for evaluating tear film disorders and inflammatory conditions, for monitoring the progress of such conditions, and for evaluating the efficacy of various treatments.

Extended contact lens wear enhances Pseudomonas aeruginosa adherence to human corneal epithelium

Extended wear of soft contact lenses is associated with an increased risk of Pseudomonas aeruginosa infection of the cornea. To assess the role of bacterial adherence in the pathogenesis of these infections, superficial corneal epithelial cells and leukocytes from ten patients who use extended-wear soft lenses and ten control eyes were compared for their propensity to attach P. aeruginosa in vitro. Cells were washed from the cornea by saline irrigation, incubated with a 10-ml solution containing 10(7) colony-forming units/ml of bacteria at 35 degrees C for 30 min, collected on a filter, and prepared using a modified acridine orange staining method. Fluorescence microscopy showed bacterial adherence to corneal epithelial cells, leukocytes, and ocular mucus. The mean number of bacteria adhering to epithelial cells was 2.6 for control eyes and 6.6 for the lens-wearing eyes (P = 0.002). The percentage of epithelial cells attaching greater than or equal to four bacteria was higher for lens-wearing eyes than control eyes (57.4% versus 26.0%, P = 0.0005). There was no significant difference between contact lens-wearing eyes and control eyes in the number of leukocytes collected or in the number of bacteria attached to these cells. These results show that P. aeruginosa adherence to epithelial cells is enhanced in those who use extended-wear soft contact lenses, and this may contribute to the increased incidence of P. aeruginosa keratitis for this population.

Microbial flora in eyes of current and former contact lens wearers

Microbial flora from the right eye conjunctival sac of 84 consecutively presenting contact lens patients were compared with cultures from both surfaces of their lens after aseptic removal and with the flora of their storage cases. Similar results were obtained from contact lens and conjunctival cultures of each individual; however, there was no correlation between storage case isolates and lens or conjunctival flora, suggesting that in uncomplicated lens wear, the eye is highly efficient in eradicating microorganisms introduced via handling. Conjunctival flora during daily contact lens wear was similar to the conjunctival flora of a matched control group of non-lens wearers. However, bacteria that are considered to be part of the normal ocular flora were isolated significantly more often from former contact lens wearers. The data also indicated that the use of nonperoxide chemical lens disinfection was associated with a higher proportion of positive cultures for pathogenic microorganisms than the use of other forms of disinfection, for both current and former contact lens wearers. The isolation of potential pathogens was particularly common among elderly subjects using thick contact lenses for extended wear. These changes to conjunctival flora may contribute to the increased risk of ocular infection associated with contact lens wear.

Conjunctival flora in extended wear of rigid gas permeable contact lenses

A longitudinal study was performed to examine the effect of rigid gas permeable (RGP) contact lenses (Boston Equalens II and Quantum II) on the conjunctival flora of 45 young healthy subjects. Microbial flora were determined before delivery of lenses. Subjects wore lenses on an extended wear basis, removing them every 7 days for cleaning and disinfection. Cultures were repeated after 2 months of lens wear and the microbial flora were found to be significantly altered compared to the prelens wear results (0.05 greater than p greater than 0.02). Changes to conjunctival flora included an increase in the number of eyes from which potentially pathogenic microorganisms were isolated, an increase in the number of eyes that were culture-negative, and a decrease in the number of eyes harboring only normal conjunctival flora. The increase in potentially pathogenic flora was not specific for Gram-negative bacteria, which are most often associated with infectious keratitis during contact lens wear.

Clinical application of the oxygen transmissibility of powered contact lenses

Stipulation of the oxygen transmissibility (Dk/L) of a contact lens based upon oxygen permeability (Dk) and nominal lens thickness (L) can be misleading since center thickness, average thickness, and hence Dk/L of a contact lens vary with lens power. While earlier confusion regarding determination of Dk has now been resolved, this data has yet to be fully incorporated into a clinically applicable model. We developed a graphical solution describing variations in Dk/L with power for a representative sample of currently available hydrogel and rigid contact lenses. The Dk/L is found to be optimal for lenses of low minus power (approximately -2.50 D). The model presented here will assist practitioners in assessing the potential oxygen performance of different lens designs with respect to a given power. We advocate that lens manufacturers print the average Dk/L on lens packaging, according to the model described in this paper, along with the parameters that are usually stated.