Oxygen demands with hybrid contact lenses.

PURPOSE: The purpose of this study was to assess the corneal response, as measured by corneal oxygen uptake, of keratoconic corneas to SoftPerm and SynergEyes hybrid contact lenses at the central cornea, 2.0 and 4.5 mm temporal to the central cornea, and 1 mm temporal to the limbus. METHODS: Corneal oxygen uptake rates were measured with a Clark-type polarographic electrode on the right eyes of 14 subjects and the left eye of 1 subject, all with keratoconus. Measurements were made at the central cornea, 2.0 and 4.5 mm temporal to the central cornea, and 1 mm temporal to the limbus. They were made for the open eye condition, as well as following 300 s of SoftPerm and SynergEyes hybrid contact lens wear. A one-way analysis of variance (ANOVA) was used to determine the effect of measurement location on oxygen uptake rates under uncovered eye conditions. To determine the difference among oxygen uptake rates relative to those of the uncovered eye at each measurement location for each hybrid lens, a two-way repeated measures ANOVA was used. Multiple comparisons with Tukey-Kramer adjustment were used post hoc to determine which locations were significantly different. RESULTS: For the uncovered keratoconic cornea, there was no significant difference among the oxygen uptake rates associated with the three corneal locations; however, the oxygen uptake rates measured 1 mm temporal to the limbus were significantly higher than those measured at the three corneal locations. Comparison of oxygen uptake rates measured with the SoftPerm and SynergEyes lenses relative to those of the uncovered eye at each location revealed significantly higher rates at the peripheral cornea than at the central cornea. At all locations, the relative oxygen uptake rates obtained with the SynergEyes lenses were lower than those obtained with the SoftPerm lenses. CONCLUSIONS: The SynergEyes lens allows significantly more oxygen to reach the cornea during wear than the SoftPerm lens at the central cornea, as well as 2.0 mm and 4.5 mm temporal to the central cornea.

Corneal oxygen uptake associated with piggyback contact lens systems.

PURPOSE: The purpose of this study was to determine the effects of static (without blinking) and dynamic (with blinking once every 5 seconds) wear of piggyback contact lens systems on corneal oxygen uptake. METHODS: Corneal oxygen uptake rates were measured on the right eyes of 11 human subjects by using a polarographic electrode. Measurements were made for the normal open eye and after 5 minutes of wear of 4 rigid lens materials (Dk/t 0-82.5), 4 soft lens materials (Dk/t 13-122), and 16 combinations of rigid and soft lens materials. The piggyback systems were worn under both static and dynamic conditions. Repeated-measures analysis of variance was used to compare oxygen uptake rates associated with the wear of the rigid lens components, soft lens components, piggyback systems, and static versus dynamic wearing conditions. Spearman correlation coefficients and regression analyses were used to examine relationships between corneal oxygen uptake rates. RESULTS: Measurable differences were found among oxygen uptake rates associated with the rigid lens components, soft lens components, and piggyback systems. Blinking resulted in no reduction in corneal oxygen uptake with the piggyback systems. Corneal oxygen uptake associated with the wear of the piggyback systems could not be predicted from those associated with the rigid and soft lens components of the systems. CONCLUSIONS: Piggyback combinations of rigid and soft lens components with the highest transmissibilities resulted in the least increase in corneal oxygen uptake beyond that of the normal open eye.

Factors influencing the measurement of oxygen shortfall of the human cornea: sequencing of test conditions.

PURPOSE: The effects of sequencing of test conditions, in this case contact lens thicknesses, on the measurement of the oxygen shortfall of human corneas were studied. METHODS: Corneal oxygen uptake rates were measured with a Clark-type polarographic electrode on the central, unanesthetized right corneas of 14 human subjects. Measurements were made under the following conditions: (1) the normal open eye; (2) after 5 min of static (without blinking) wear of each of seven rigid gas permeable lenses of seven center thicknesses (0.18, 0.12, 0.16, 0.20, 0.24, 0.28, and 0.32 mm); (3) after 5 min of static wear of a polymethylmethacrylate (PMMA) contact lens. Lens thicknesses were randomly assigned numbers, which were sequenced in seven cycles. Two subjects were assigned to each sequencing cycle, and each subject participated in two identical sessions. RESULTS: The interaction of order x thickness was determined to be insignificant (F=0.99; p=0.5101). The effect of lens order was also insignificant (F=0.76; p=0.6239), indicating that the order of lens placement did not affect the measured corneal oxygen shortfall. Not surprisingly, the analysis indicated a significant effect of lens thickness on corneal oxygen shortfall (F=3.94; p=0.0032). CONCLUSIONS: The sequencing of lenses of various thicknesses on the cornea does not affect the measurement of corneal oxygen shortfall.

Corneal oxygen uptake: A review of polarographic techniques, applications, and variables.

Factors that influence the polarographic measurement of the oxygen uptake of the cornea are reviewed. These factors include the technique, electrode assembly, oxygen reservoir, membrane material and thickness, oxygen tension of the corneal environment, duration of exposure to environmental conditions and time to application of the probe all influencing measured oxygen uptake rates. Subject factors include lid position, palpebral aperture size, blinking, corneal thickness, and corneal integrity. Contact lens wear influences corneal oxygen uptake, with lens material and design parameters influencing rates obtained both under static (without blinking) and dynamic (with blinking) conditions. Measurement of corneal oxygen uptake rates remains an excellent method to quantify the oxygen supply in contact lens systems that include the contact lens, the tears, and the cornea, in which oxygen flux is influenced by the thickness and diffusion characteristics of each component.

Rigid gas-permeable contact lens base curve radius and transmissibility effects on corneal oxygen uptake.

PURPOSE: The purpose of this study is to determine the effects of rigid gas-permeable contact lens thickness, base curve radius, and material permeability on corneal hypoxic stress. METHODS: Corneal oxygen uptake rates were measured with a Clark-type polarographic electrode on the right eye of 10 human subjects for the normal open eye (air) and after 5 minutes of static wear of rigid contact lenses of four cornea-to-contact lens base curve fitting relationships: 0.2 mm steeper-than-K (STK), 0.1 mm STK, on K, and 0.1 mm flatter-than-K (FTK). There were also four materials (polymethylmethacrylate [Dk=0], lotifocon B [OP-2, Dk=15.9], lotifocon A [OP-3, Dk=30], lotifocon C [OP-6; Dk=60]) and three center thicknesses (0.14, 0.28, and 0.53 mm for the OP-6 lenses and 0.14 mm for all other materials) with all other parameters being constant. Each subject participated in two identical sessions. A repeated-measures analysis of variance was performed to compare the mean response across lens materials/thicknesses and the four curvature values. RESULTS: Significant differences were found only for lens material/thickness (p<0.0001). Although OP-2 and OP-6 (0.53 mm) were manufactured to have the same Dk/t, post hoc comparisons showed that the oxygen uptake rate with OP-6 (0.53 mm) was significantly lower. The same is also true for OP-3 and OP-6 (0.28 mm), with OP-6 (0.28 mm) having a significantly lower oxygen uptake rate. CONCLUSIONS: In contrast to past studies with PMMA, cornea-to-contact lens base curve fitting relationship, with the lens materials and designs studied here, did not affect corneal hypoxic stress, and thick, high Dk lenses resulted in less change in corneal response than did thin, lower Dk lenses of the same Dk/t. This is attributed to the lens reservoir effect that has been previously described.

Interferometric imaging of the full thickness of the precorneal tear film.

A method is described for recording interference images from the full thickness of the precorneal tear film (PCTF). Simultaneous images are recorded by two video cameras. One camera responds to broadband spectral illumination and records interference from the superficial lipid layer of the tear film. The other camera uses narrowband illumination and records interference from both the lipid layer and the full thickness of the PCTF. Thus the full-thickness interference fringes are derived from the difference between, or ratio of, narrowband broadband images. This method has the potential for evaluating the role of both tear film flow and evaporation in tear film thinning and breakup. It therefore may be applied to the analysis of dry eye disease.

The effects of high-Dk rigid contact lens center thickness, material permeability, and blinking on the oxygen uptake of the human cornea.

PURPOSE: The human corneal oxygen uptake responses associated with the static (nonblinking) and dynamic (blinking) wear of five rigid gas-permeable materials with high oxygen permeabilities were determined for three different center thicknesses and compared with the responses for the normal open eye and severe hypoxic stress (static wear of polymethylmethacrylate). METHODS: Corneal oxygen uptake rates were measured with a Clark-type polarographic electrode during two sessions with each of 10 human subjects. Measurements were made on the right eye for the normal open eye (air) and after 5 minutes of static and dynamic wear of polymethylmethacrylate and five rigid gas-permeable contact lens materials: Fluoroperm 92 (paflufocon A, Dk = 92), Fluoroperm 151 (paflufocon D, Dk = 151), 1992 Menicon SF-P (melafocon A, Dk = 102), 1995 Menicon SF-P (melafocon A, Dk = 159), and Menicon Z (tisilfocon A, Dk = 163-250). Lenses were manufactured in three different center thicknesses (0.12, 0.16, and 0.20 mm), with all other parameters remaining constant. Repeated-measures analysis of variance was used and included lens material (five levels), blinking condition (two levels), and lens thickness (three levels) as within-subject effects. RESULTS: Significant differences were found in corneal oxygen responses to lens material (p < 0.001) and lens thickness (p < 0.001), with lenses of lower oxygen permeability and thicker lenses being associated with higher oxygen uptake. No statistically significant differences were noted between static or dynamic wear of the lens materials (p = 0.59). CONCLUSIONS: For those very high Dk rigid lens materials studied here, moderate changes in lens thickness or material permeability may result in modest differences in corneal hypoxic relief, whereas blinking results in no significant improvement to corneal oxygenation.

The thickness of the tear film.

Measurements of the thickness of the pre-corneal tear film, pre-lens tear film, post-lens tear film, and the lipid layer on the surface of the tear film are summarized. Spatial and temporal variations in tear film thickness are described. Theoretical predictions of tear film thickness are discussed. Mechanisms involved in the upward drift of the tear film after a blink, and in the formation of dry spots, are considered.

Primary hemiarthroplasty for treatment of proximal humeral fractures.

BACKGROUND: Primary hemiarthroplasty of the shoulder is used to treat complex proximal humeral fractures, although the reported functional results following this method of treatment have varied widely. The aim of this study was to prospectively assess the prosthetic survival and functional outcomes in a large series of patients treated with shoulder hemiarthroplasty for a proximal humeral fracture. By determining the factors that affected the outcome, we also aimed to produce models that could be used clinically to estimate the functional outcome at one year following surgery. METHODS: A thirteen-year observational cohort study of 163 consecutive patients treated with hemiarthroplasty for a proximal humeral fracture was performed. Twenty-five patients died or were lost to follow-up in the first year after treatment, leaving 138 patients who had assessment of shoulder function with use of the modified Constant score at one year postinjury. RESULTS: The overall rate of prosthetic survival was 96.9% at one year, 95.3% at five years, and 93.9% at ten years. The overall median modified Constant score was 64 points at one year, with a typically good score for pain relief (median, 15 points) and poorer scores, with a greater scatter of values, for function (median, 12 points), range of motion (median, 24 points), and muscle power (median, 14 points). Of the factors that were assessed immediately after the injury, only patient age, the presence of a neurological deficit, tobacco usage, and alcohol consumption were significantly predictive of the one-year Constant score (p < 0.05). Of the factors that were assessed at six weeks postinjury, those that predicted the one-year Constant score included the age of the patient, the presence of a persistent neurological deficit, the need for an early reoperation, the degree of displacement of the prosthetic head from the central axis of the glenoid seen radiographically, and the degree of displacement of the tuberosities seen radiographically. CONCLUSIONS: Primary shoulder hemiarthroplasty performed for the treatment of a proximal humeral fracture in medically fit and cooperative adults is associated with satisfactory prosthetic survival at an average of 6.3 years. Although the shoulder is usually free of pain following this procedure, the overall functional result, in terms of range of motion, function, and power, at one year varies. A good functional outcome can be anticipated for a younger individual who has no preoperative neurological deficit, no postoperative complications, and a satisfactory radiographic appearance of the shoulder at six weeks. The results are poorer in the larger group of elderly patients who undergo this procedure, especially if they have a neurological deficit, a postoperative complication requiring a reoperation, or an eccentrically located prosthesis with retracted tuberosities.

Tear exchange and oxygen reservoir effects in silicone hydrogel systems.

PURPOSE: The effects of oxygen reservoir and tear exchange are known for conventional hydrogel contact lenses. This study attempted to (1) confirm their presence in lenses of a silicone hydrogel (SH) material and (2) evaluate their individual and combined contributions to hypoxic relief of the cornea. METHODS: Corneal oxygen uptake rates were measured polarographically for 10 OD corneas immediately after 300-sec periods (equivalent to 60+ blink cycles) of: (1) nonblink wear of a 0 Dk/L polymethylmethacrylate (PMMA) cap lens; (2) nonblink wear of that cap lens with a SH lens inserted between it and the cornea; (3) regular blinked wear of that same lens combination; (4) nonblinked wear of the SH lens alone; and (5) normal open-eye, non-lens wear. The rates for each eye had a ratio with its own baseline (no lens) rate, and the total sample mean was calculated for each condition from those individual eye means. RESULTS: (1) Under nonblink conditions, a 28% reduction in corneal oxygen demand was observed when a SH lens was inserted under the PMMA cap lens versus without. (2) When regular blinking was added to that lens combination, corneal oxygen demand decreased another 8%, for a total of 36%. The combination of SH insertion and blinking did achieve a statistically significant difference (P<0.05 by the Dunnett test) from the nonblink, 0 Dk/L, maximum deprivation condition. CONCLUSION: The statistically significant hypoxia reduction observed with the SH lens insertion and blinking indicates the additive presence of two factors: (1) a lens reservoir effect caused by the SH lens and (2) a bulk-flow tear exchange effect caused by blinking. Their respective contributions to the reduction of corneal oxygen demand over the period studied were found to be in the ratio of 3.4:1.

Adult distal humeral metaphyseal fractures: epidemiology and results of treatment.

OBJECTIVES: To examine the epidemiology and results of treatment of fractures of the distal humeral metaphysis. DESIGN: Observational cohort study. SETTING: An orthopaedic trauma unit, which provides all the fracture care for a well-defined catchment population. PATIENTS/PARTICIPANTS: A consecutive series of 320 patients with distal humeral fractures admitted to the unit between January 1988 and June 1997. INTERVENTION: We adopted a protocol of open reduction and fixation of all displaced fractures (greater than 5 mm of displacement in any plane) in patients who were medically fit for anesthesia. Postoperative immobilization was a cylinder cast for 6 weeks. Patients with undisplaced fractures or who were medically unfit were also treated nonoperatively in cylinder casts for 6 weeks. MAIN OUTCOME MEASUREMENTS: Epidemiological examination of patient subgroups and the incidence of complications of treatment. RESULTS: The overall incidence of distal humeral fractures in adults during this time was 5.7 cases per 100,000 in the population per year with an almost equal male to female ratio. There was a bimodal age distribution, simple falls were the most common overall cause of fracture, and the majority of the fractures were extra-articular (AO/OTA type A) or complete articular fractures (AO/OTA type C). The risk of complications during treatment was generally low in most patients, and the majority healed their fractures uneventfully. Overall, 90.6% of fractures united within 12 weeks and just under half of the remaining 9.4% patients with union complications healed without requiring further operative intervention by 24 weeks. The risk of union complications was higher following high-energy injuries, open fractures, and nonoperative treatment. Although the AO/OTA classification was not predictive of union complications, the "low" transcondylar (type A2.3 and A3) and simple intercondylar fracture (type C1.3) configuration had a greater risk of union complications than the "high" subtype. The rate of infection, myositis ossificans, and other implant-related complications were higher following operative treatment of type C fractures than type A and B fractures. CONCLUSIONS: The epidemiology of a consecutive unselected series of adult distal humeral fractures is defined in this study. The majority of these fractures are best treated surgically by rigid open reduction and internal fixation, except for "low" Type A and C fractures, which have a higher risk of union complications. The role of total elbow arthroplasty to treat these more complex injuries requires further evaluation.

Enhancing RGP contact lens performance: comparing back surface options.

BACKGROUND: In some cases, rigid gas-permeable (RGP) contact lenses may be the best--or only--means of refractive correction. High Dk RGP materials have markedly reduced hypoxia under those lenses. With aspheric lens back surface designs, post-lens circulation may be enhanced as well by maximizing the provision of nutrients and the clearance of metabolic by-products, toxins, and debris, while minimizing the risk of lens binding. METHODS: Performances of four aspheric back surface RGP designs were compared with a spherical optic zone and peripheral curve back surface reference design. Oxygen uptake rates were measured for each of 40 wearing combinations (five lens designs fitted to each of eight eyes) under non-blink and blink conditions for their effectiveness in reduction of post-lens hypoxia. Hypoxic reductions with blinking were scaled in exchange efficiency (EE) units, and used as relative indicators of post-lens tear exchange. RESULTS: Combined exchange efficiency index (EE) scores (averaged responses across all eight eyes) for each of the five lens back surface designs ranged from a best overall performance of +13.9 EE units down to only +2.5 EE units, with the spherical reference design averaging +8.9 EE units. Tear pump efficiency of each of the eight eyes (averaged responses across all five lens designs) ranged from a high of +12.3 EE units down to -9.8 EE units (i.e., worse than the non-blink condition of 0 EE units). Among the 40 eye-lens back surface design combinations studied here, the highest exchange efficiency score registered was +28.4 EE units, the lowest being -13.8 EE units. CONCLUSIONS: Aspheric lens back surface and/or peripheral curve designs were found to vary significantly in their post-lens exchange efficiency performances, but no "universal problem-solver" design was found among the five we investigated.