The Berkeley Contact Lens Extended Wear Study. Part I : Study design and conduct

OBJECTIVE

The primary aim of the Berkeley Contact Lens Extended Wear Study (CLEWS) was to test the hypotheses that extended wear of rigid gas-permeable (RGP) contact lenses with greater oxygen permeability (Dk) reduces the incidence of contact lens-associated keratopathy (CLAK) and increases the survival rate in RGP extended wear (EW). In this article we describe the clinical trial design in detail, present the results of subject recruitment and retention, and provide the baseline demographic and ocular characteristics of the CLEWS subjects, whose data will be analyzed to address the study aims in a companion article.

DESIGN

A randomized, concurrently controlled clinical trial.

INTERVENTION

Subjects were fitted with day wear (DW) high-Dk RGP lenses and then adapted to EW. Subjects who adapted to EW were then randomly assigned to either high- or medium-Dk RGP lenses for 12 months of 6-nights/week EW.

MAIN OUTCOME MEASURES

Slit-lamp assessment and grading of 17 possible keratopathies, measurement of refractive error and corneal curvature, and symptoms. Follow-up data were collected every 3 months.

RESULTS

From 545 subjects entering the DW adaptation phase, 201 adapted to EW and were randomly assigned to medium- or high-Dk lenses for 12 months of EW. The baseline characteristics of the two study groups were similar and did not differ from the 344 DW subjects who failed to adapt to EW. The distributions of oxygen transmissibility for the two study groups were disjoint, indicating that each group received distinctly different levels of hypoxia.

CONCLUSIONS

We show that CLEWS was appropriately designed to address the study hypotheses, was conducted with regard for the safety of the subjects, and adhered to rigorous protocols designed to control for bias and ensure the integrity of study data. We establish the internal validity of between-group statistical comparisons and characterize our study population to permit informed evaluation of the applicability of our results to the contact lens-wearing population in general.

The Berkeley Contact Lens Extended Wear Study. Part II : Clinical results

OBJECTIVE

To describe the principal clinical outcomes associated with 12 months use of rigid gas-permeable (RGP) extended wear contact lenses and address two primary study questions: (1) does extended wear (EW) of high oxygen transmissibility (Dk/t) RGP lenses reduce the incidence of ocular complications, and (2) does the wearing of high-Dk/t lenses reduce the rate of failure to maintain 6-night RGPEW over 12 months?

DESIGN

A randomized, concurrently controlled clinical trial.

INTERVENTION

Subjects who adapted to EW with high Dk (oxygen permeability) RGP lenses were randomized to either high Dk or medium-Dk RGP lenses for 12 months of 6-night EW.

MAIN OUTCOME MEASURES

Contact lens-associated keratopathies (CLAK), changes in refractive error and corneal curvature, and survival in EW.

RESULTS

Two hundred one subjects were randomized to medium or high-Dk lenses for 12 months of EW. Sixty-two percent of the subjects in each group completed 12 months of EW; however, the probability of failure was significantly greater for the medium-Dk group. Although the risk of complications was similar for the two groups, the number of CLAK events that led to termination were 16 versus 5 for the medium-Dk and high-Dk groups, respectively. This suggests that the type of adverse response or the inability to reverse an adverse event was different for the group being exposed to the lower oxygen dose.

CONCLUSIONS

The level of oxygen available to the cornea has a significant impact on maintaining successful RGP extended contact lens wear, but not on the initial onset of CLAK. The number of clinical events leading to termination was substantially higher for the medium Dk group, which suggests that corneal hypoxia is an important factor in the development of CLAK. Although overnight contact lens wear should be recommended with caution and carefully monitored for early detection of ocular complications, it appears that high-Dk RGP lenses can be a safe and effective treatment for correction of refractive error for most individuals who can adapt to EW.

Predicting RGP daily wear success

PURPOSE

While most clinicians agree that fitting of rigid gas permeable (RGP) lenses is the preferred treatment strategy for some types of patients, many patients have difficulty adapting to full-time daily wear of these lenses. The Contact Lens Extended Wear Study (CLEWS) is a randomized, controlled clinical trial in which subjects are first adapted to full-time RGP daily wear prior to randomization to either high or medium oxygen transmissibility (Dk/L) RGP lenses for 12 months of extended wear. The CLEWS pre-randomization data provide an opportunity to examine the reasons some patients fail to adapt to RGP daily wear and to determine whether a patient's demographic, historical, and ocular characteristics can be used to predict RGP daily wear success.

METHODS

From 1,809 individuals who expressed interest in RGP lenses, 411 subjects passed the CLEWS screening criteria and were fit with high Dk lenses (mean Dk = 92 x 10(-11) [cm2/sec][mL 02/mL x mmHg]). The fitting strategy included minimum apical alignment, lid attachment, centration, and average lens diameters of 9.2 mm. Success was defined as a minimum of 14 hours per day without adverse ocular responses that would contraindicate either full-day daily wear or extended wear.

RESULTS

Of the 411 subjects, 286 (69.6%) were successful with RGP extended wear. Among the 125 failures, 50 were based on clinician findings (e.g., cornea, vision, compliance), while 75 subjects chose to discontinue wear because of unacceptable comfort or poor vision. Multivariate linear logistic regression modeling shows that younger patients with greater corneal curvature (K) and less predicted residual astigmatism have a higher probability of RGP daily wear success.

CONCLUSIONS

Our study showed that RGP lenses can be fit with a relatively high rate of success and that many of those patients who elect to discontinue RGP daily wear report unacceptable comfort as the primary reason. We propose a Bayesian statistical method that will assist clinicians in selecting those candidates for RGP daily wear who are most likely to adapt successfully.

Effects of hypoxia and hypercapnia on contact lens-induced corneal acidosis

It has been assumed that contact lens wear (CLW) may induce stromal acidosis, which is a result of corneal hypoxia and the accumulation of CO2 (hypercapnia) at the tear-lens interface. However, it has not been directly shown whether hypoxia and hypercapnia are the only causes of CL-Induced corneal acidification. In this study, we provide preliminary data about the relative contributions of hypercapnia and hypoxia to CL-induced stromal acidification by monitoring pH while the cornea was exposed to a hyperbaric oxygen atmosphere. This paradigm minimized if not eliminated the pH effects of lens-induced hypoxia on all but one subject without altering the pH effect of hypercapnia. Seven subjects were fitted with hydrogel lenses; 5 with low O2 transmissibility (Dk/LO2 = 14.0 x 10(-9) (cm/s) (ml O2/[ml x mm Hg)]), and 2 with medium O2 transmissibility (Dk/LO2 = 17.2 x 10(-9) (cm/s) (ml O2/[ml x mm Hg])) lenses. After lens insertion, modified goggles were fitted to control the corneal environment by exposing 1 eye to 20%O2 and 80%N2 (air), and the contralateral eye to 80%O2 and 20%N2 (hyperbaric O2). Corneal thickness (CT) was measured before CL insertion and over 120 min of wear. We assumed that corneal hypoxia was present if CT increased during the test period. Stromal pH was measured using a slitlamp fluorophotometer before lens insertion and at 20-min intervals for a total of 80 min. After 80 min of wearing the low Dk/L lens under hyperbaric exposure, 4 of 5 subjects showed reduced pH (mean delta pH = 0.23 +/- 0.05) and no increase in CT, suggesting that only hypercapnia was contributing to acidosis. For the same lens, but with exposure to air, 4 of 5 subjects showed a larger drop in pH (mean delta pH = 0.62 +/- 0.48) compared to hyperbaric exposure and an increase in CT, indicating that both hypoxia and hypercapnia reduced pH. Subjects wearing the medium Dk/L lens showed a small but equal drop in pH under both air and hyperbaric conditions without changes in CT, suggesting that only hypercapnia was contributing to acidosis. These preliminary results suggest that both mechanisms contribute to the pH shift accompanying CLW and that the contribution of hypercapnia is approximately 30%. Finally, the effects of hypercapnia and hypoxia are dependent on individual metabolic requirements and the transmissibility of the lens to O2 and CO2.

Corneal response to different oxygen levels during extended wear

In this study we explored the relationship between hypoxic exposure level and corneal response by assuming that the partial pressure of oxygen (PO2) under a contact lens during eye closure is directly related to oxygen transmissibility (Dk/L). To study this relationship, we monitored a group of subjects who wore RGP lenses of various Dk/L values on an extended wear basis. The results revealed that as Dk/L increases, there is a substantial decrease in overnight corneal edema and epithelial microcysts. However, other responses seemingly related to purely mechanical properties (e.g., lens adherence, corneal topographical changes, and 3-9 limbal superficial punctate keratitis) appear to be independent of Dk/L. Results also suggest that sufficient PO2 levels under a contact lens can minimize endothelial morphological changes associated with hypoxia. We conclude that metabolically driven complications accompanying RGP extended wear can be substantially eliminated with lenses having Dk/L values of 80 x 10(-9) (cm x mL O2)/(sec x mL x mm Hg) or greater.

Ocular effects of hard gas-permeable-lens extended wear

Thirty-five myopic subjects were fitted with rigid gas-permeable lenses for 6 months of extended wear (EW). These lenses had an average oxygen transmissibility of 37 x 10(-9) (cm x ml x O2)/(s x ml x mm Hg). For six monthly morning visits subjects reported with one eye patched; corneal thickness, corneal curvature, refractive error, endothelial photomicroscopy, and slitlamp examinations were done on both eyes. The average morning corneal swelling was 5.9 +/- 3.3%. Corneal curvature showed 0.24 +/- 0.44 D flattening in the steep meridian and 0.20 D steepening in the flat meridian. Spectacle refraction and corrected visual acuity changes were small in the spherical and cylindrical components. Complications that were important clinically included 10% lens adherence syndrome, 20% superficial limbal keratitis, 6.5% epithelial microcysts, and some increase in endothelial polymegathism. No infections, red eye responses, or infiltrative keratitis were observed during the 6-month follow-up period. These results suggest that hard-lens EW is feasible and that lenses with this Dk/L value will meet oxygen requirements for many patients; however, some patients will require lenses of higher oxygen transmissibility to avoid undesirable complications.