TOP 30 Q&A
BACK AND THE FUTURE
The experts weigh in on the most significant developments that have occurred in contact lenses and what will be momentous going forward.
JASON J. NICHOLS, OD, MPH, PHD, FAAO, & DEBORAH FISHER
While developing an understanding of the most significant events in the contact lens industry, it seems obvious that there were none better to ask about the past and the future of the contact lens industry than those voted as the 30 Most Influential in Contact Lenses.
To start, Contact Lens Spectrum asked each of the 30 most influential awardees: “What was the single most important development in the contact lens industry over the past 30 years?” And, while there have been numerous developments since 1986 in terms of technologies, materials, modalities, and, quite frankly, too many other things to mention, a few items topped a majority of the respondents’ lists.
Overwhelmingly, slightly more than one-third of the respondents (37%) said that the number one development over the past 30 years was the introduction of frequent replacement contact lenses and, in particular, the daily disposable modality. While this modality took many years to take off in the U.S. market, today this news probably isn’t very shocking considering the continuous growth in the daily disposable segment over the last 10 years. In fact, daily disposables now account for 28% of fits and refits in the United States, up from only 11% in 2009 (Nichols, 2016). Some estimates suggest that this number is even higher, with daily disposables comprising up to one-third of the U.S. soft lens market (Nichols, 2016).
Not surprisingly, the second most popular development noted by the 30 most influential was the development of silicone hydrogel materials for contact lenses (30% of responses). According to Contact Lens Spectrum data, silicone hydrogel materials made up about 68% of fits in the United States in 2015 (Nichols, 2016). Additionally, Morgan et al (2016) noted that of the 84% of new fits and 87% of refits for soft contact lenses internationally, silicone hydrogels were the most widely prescribed.
About 24% of the 30 most influential list cited soft lenses, sclerals, the availability of high-Dk/t materials, and contact lens manufacturing advancements as their number one picks (6% per category). The remaining responses were split evenly among various miscellaneous categories, including imaging and the lens surface.
Here is how our Top 30 responded.
FREQUENT REPLACEMENT AND DAILY DISPOSABLE CONTACT LENSES
Dr. Joe Barr: Daily disposable contact lenses that provide enhanced all-day comfort, whether spherical, for astigmatism, for presbyopia, and even possibly for myopia control, with the ultimate in contact lens comfort and safety.
Dr. Edward S. Bennett: For the first two-thirds of this time period, the single most important development was the introduction of frequent replacement (and later daily disposable) lenses.
Dr. Noel Brennan: The most important development in contact lenses over the past three decades is mass-produced, frequent replacement, soft lenses. A survey by Dr. Gary Orsborn and Steve Zantos (1989) around the time of the introduction of those lenses showed that the most common problems with contact lens wear included deposits, discomfort, and papillary conjunctivitis. Frequent, planned lens replacement positively impacted all of these. Daily lens replacement offered the additional advantage of eliminating ocular exposure to care solution chemicals.
Unfortunately, frequent replacement lenses failed to achieve the expected reduction in microbial keratitis when worn on an extended wear basis. The introduction of silicone hydrogels runs a distant second, having failed to significantly impact ocular adverse events or discontinuation rates.
Dr. H. Dwight Cavanagh: The most important developments have been safe extended wear and low-cost daily disposable lenses.
Dr. Robin L. Chalmers: The development and wide availability of daily disposable contact lenses have resulted in soft lenses that are associated with fewer adverse events and are easier to use at the same time. Eyecare practitioners should be actively prescribing daily disposable lenses for many of their patients who are in risk groups that make them more likely to experience inflammatory events.
Dr. Michel Guillon: Thirty years ago, the contact lens industry was in its infancy, producing contact lenses that were expensive to manufacture and, therefore, had a high unit cost and required complex maintenance. As a consequence, only a minority of potential wearers achieved successful contact lens wear. Today, the industry is the second largest medical device industry in terms of units, producing high-precision, low-cost, easy-to-use contact lenses and providing vision correction to one in six ametropes in the Western world.
This has been achieved as a result of major improvements in the understanding of contact lens physiology along with significant developments in materials, designs, and manufacturing technology. In my view, the most beneficial advancement for patients today has been the advent of the daily disposable modality both with materials that were in use 30 years ago and with newer generations of materials.
Craig W. Norman: The introduction of frequent replacement soft lenses—in particular, daily disposables. The contact lens industry as a whole continues to drive growth by decreasing patient dropouts. Daily disposable lenses, which are now employing novel materials, combined with removing potentially irritating lens care solutions, appear to be the best option to achieve this goal.
Dr. Eric Papas: From a clinical perspective, the ready availability of affordable daily disposable lenses has had the greatest impact in terms of reducing complications, improving comfort, and enhancing convenience.
Dr. Loretta Szczotka-Flynn: The mainstream fitting and use of daily disposable lenses. This is well documented to be the safest form of soft lens wear. Having daily disposable options in torics, multifocals, silicone hydrogels, and cosmetic tints opens up the availability to most soft lens candidates. I encourage all practitioners to embrace fitting them and the industry to continue making them affordable options for all.
Dr. Jeffrey J. Walline: Daily disposable contact lenses were the most important development in the contact lens industry over the past 30 years. This modality has consistently proven to be a safe and convenient modality.
Importantly, daily disposable contact lenses removed much of the care responsibility from contact lens wear, thereby encouraging practitioners to fit children with contact lenses at earlier ages. Although children have proven to be capable of frequent replacement contact lens care, many practitioners would not have fit children with contact lenses unless the care regimen was considerably simplified, as it was with daily disposable contact lenses.
Dr. Mark Willcox: The manufacture of soft lenses that can be used on a daily disposable basis. This is likely to be the safest mode of wear at least in terms of corneal inflammatory events. However, they are not a panacea.
Research suggests that some wearers are not compliant with the daily disposable mode and may wear lenses for longer or not dispose of them after wear and wear them again (Dumbleton et al, 2013). This poses challenges to ocular health, as wearers may not have the full armament of disinfection systems or the knowledge to disinfect lenses when not being worn. If patients choose to sleep in lenses, this greatly increases their risk of having corneal inflammation.
Dr. Jan Bergmanson: The development and clinical refining of the silicone hydrogel material.
Professor Nathan Efron: It has to be the development of the silicone hydrogel family of contact lens materials, for the simple reason that, in a single stroke, we solved hypoxia! Lack of oxygen to the anterior ocular structure was a major limiting factor in the development of contact lenses in the 20th century. Previous problems that took up so much problem-solving chair time—such as corneal edema, epithelial microcysts, corneal neovascularization, and endothelial polymegethism—are now relegated to textbooks on the history of contact lenses. These materials are not perfect, but they have certainly heralded a new era of contact lens development.
Dr. Desmond Fonn: The development of silicone hydrogel contact lenses and the learning that followed about hypoxia, inflammation, infection, and comfort. Silicone hydrogels were the springboard that led to an increase in the number of wearers to 140 million worldwide.
Professor Brien Holden: Professor Holden’s co-development of a silicone hydrogel lens design, which was the first to be approved for 30 days of continuous wear, had a major impact on the industry. This coincided with a significant increase in the uptake of contact lens wear globally.
Dr. Lyndon Jones: Development of silicone hydrogel materials.
Professor Fiona Stapleton: Undoubtedly, the development of silicone hydrogel contact lenses. While this development wasn’t a panacea for all contact lens-related complications or discomfort, solving metabolic consequences of long-term lens wear was vital for the industry and wearers.
Having highly oxygen-permeable contact lenses also stimulated a huge body of research to understand and model lens interaction with the ocular surface, which has moved the field on considerably.
Dr. Ralph Stone: In the overall contact lens business, the most important step forward has been the development of silicone hydrogel lenses. Initially, they were touted to solve the issues of corneal hypoxia and infections, paving the way for continuous wear. While this objective has not been fully achieved, these materials provide a new generation of advantages, but not without their own set of new challenges.
Dr. Helen Swarbrick: The development of silicone hydrogel lens technology has revolutionized the field and will continue to dominate contact lens practice. The initial promises of reduced infection rates and widespread use of continuous wear have not eventuated.
Nevertheless, the benefits of these lenses compared to hydrogel lenses in terms of reduced hypoxic effects and enhanced comfort from improved surfaces and deposit control mean that they have become the dominant contact lens type in today’s market. Further developments of this technology are continuing to enhance contact lens wear for many patients worldwide.
Dr. Barry A. Weissman: Undoubtedly, the development of silicone hydrogel contact lens materials—which freed us all, at least considering daily wear conditions, from the constellation of physiological corneal complications of hypoxia—was the most important development during the past three decades.
SOFT CONTACT LENSES
Mark P. André: I started my career about the time that soft contact lenses were being introduced to the world, and I’ve been witness to the evolution of this product. Innovation in manufacturing stands out to me as something that has not only made contact lenses affordable to the masses, but has provided us with a higher quality lens that is disposable.
In 30 years, we have nearly eliminated all of the soft lens complications related to poor lens design, hypoxia, lens deposits, and solution sensitivities. There are very few industries that can claim a product that has improved so dramatically, yet costs a fraction of its original price.
Patrick Caroline: Since 1986, the most important developments in our contact lens industry might include the continued refinement of soft contact lens designs (spherical and toric) and soft contact lens materials, predominantly the silicone hydrogel family of materials.
Dr. Bennett: In the past decade, the introduction of modern mini-scleral lenses has greatly improved the lives of thousands of individuals who have pathological dry eyes and highly irregular corneas, while likely reducing referrals for some form of corneal transplant surgery.
Patrick Caroline: The birth of the modern scleral contact lens.
Dr. Richard Hill: The development of high-Dk/t materials having surfaces compatible with the tears.
Dr. Perry Rosenthal: I believe the most important developments in the contact lens field during the past 30 years have been the recognition of, and response to, the importance of oxygen transmissibility sufficient to avoid corneal hypoxia and the development of hydrophilic contact lenses.
CONTACT LENS MANUFACTURING
Dr. Philip Morgan: Among a list of strong contenders for the claim of “most important development” in the field, and perhaps the key development in recent times, has been the remarkable manufacturing innovation that has led to the ability to make daily, two-week, and monthly replaced contact lenses affordable to millions of wearers. These improvements led to an unprecedented growth across the industry and brought the benefits of contact lenses to millions of people worldwide.
Dr. Christine Sindt: Computer-driven lathing technology and the associated hardware, which can mill with extreme accuracy.
Patrick Caroline: The continued refinement of corneal and scleral imaging instruments.
LENS SURFACE IMPROVEMENT
Dr. Donald Korb: The understanding that the surfaces of the contact lens must better mimic that of the cornea has been the most important development, implemented by: 1) The advent of one-day lenses, since the lens cannot self-clean as can the cornea; and 2) the advances in contact lens surface properties to minimize the rate of evaporation and provide better lubricity to minimize dryness, lid wiper epitheliopathy, and sensation and to improve comfort, since the rate of evaporation from the contact lens is greater than that from the cornea.
Next, Contact Lens Spectrum asked: “What do you predict will be the most important development in the contact lens industry in the next 30 years?” Once again, there were some definite trends that formed from the responses.
According to a study by Holden et al (2016), half of the world’s population will by myopic by 2050. This, combined with the fact that myopia is becoming the leading cause of permanent blindness worldwide, explains why 38% of Contact Lens Spectrum’s 30 Most Influential said that myopia control is the wave of the future.
In the past few years, companies have either produced or proposed contact lenses that can deliver medications, help measure intraocular pressure (IOP), monitor glucose levels for those who have diabetes, or that will even be able to take photographs or stream video. So, it really wasn’t surprising that 28% of the respondents expect smart contact lenses to lead the way.
Another 14% are looking to continued material and design advancements in the future, and 7% think more comfortable lenses are going to make a difference in the years to come. The remaining 13% of respondents predict that we should look out for various other categories going forward, such as better eye care, compliance, and regulatory changes, among others.
Here is what our Top 30 predict.
Mark André: There is little doubt that contact lenses designed for controlling myopia will play a significant role in providing much needed help for future generations of myopes. Considering the health and financial consequences that we face if the worldwide epidemic of myopia isn’t properly managed, a treatment for minimizing or even preventing the development of myopia in children should be worthy of a Nobel Prize.
As our understanding of myopia progression improves, new and improved lens designs will be developed to provide our patients with a treatment option that guarantees them positive results.
Dr. Bennett: Contact lenses for myopia control will be the greatest development in the next 30 years, although accommodative lenses and lenses for drug delivery will also be exciting developments.
Dr. Brennan: Of all the great expectations for the future of contact lenses, the most important will surely be the U.S. regulatory approval of a soft myopia control contact lens. Shifting the focus from correcting to controlling refractive error will cause a massive evolution in eyecare practice. It will also serve to some extent to mitigate the impending public health disaster associated with the currently increasing amounts and prevalence of myopia.
Patrick Caroline: No doubt, the most important future development in our industry will be the effective delivery of myopia control optics through contact lenses. Myopia control has enormous potential for the eye-care industry. Today, we have only taken our first steps in what is sure to be a long and rewarding journey.
Dr. Fonn: Myopia control soft lenses.
Professor Holden: The burden of myopia loomed large in Prof. Holden’s activities in the last few years. With his colleagues and collaborators, he had been aiming to develop a contact lens that would control the progression of myopia to a degree that would prevent the majority of myopes from reaching high levels of the condition. I think it’s safe to say he believed this was the greatest challenge facing optometry, and that the contact lens industry could play a significant role in meeting it.
Dr. Jones: Development of contact lenses that will slow (or maybe even eliminate) myopia progression. This will turn optometry into a profession that prevents, rather than manages, ocular health issues.
Professor Stapleton: Comfortable and safe myopia contact lenses for children or new ways to modulate the visual environment to limit the development of myopia.
Dr. Stone: The most important objective for the next 30 years is myopia control. Whether this comes from use of a contact lens, a drug, the release of a drug from a contact lens, or some other combination of therapies, the importance of keeping the progression of myopia at low levels cannot be overemphasized given the ocular problems later in life.
Dr. Swarbrick: The use of contact lenses in various forms (orthokeratology, soft multifocals, and extended depth-of-focus lenses) to control axial eye growth in progressive myopic children will become increasingly important over the next few years. Significant increases in the prevalence of myopia, and particularly high myopia, are predicted worldwide, with the associated risks of glaucoma, maculopathy, and impaired vision.
We are only beginning to understand and refine contact lens approaches to slow or potentially stop eye growth in myopic children. This area of research and development holds the promise of great rewards in terms of protecting the ocular health of future generations.
Dr. Walline: Contact lenses that reverse myopic refractive error will be the most important development in the contact lens industry over the next 30 years. Someday, we will control eye growth so stringently through contact lens optics that we will slow axial elongation while maintaining normal growth of the other ocular components. This will reverse myopia onset, then maintain emmetropic eye growth until the eye reaches maturity.
SMART CONTACT LENSES
Dr. Barr: Smart contact lenses to improve eye care, health care, and vision function.
Dr. Bergmanson: The smart contact lens that monitors IOP or blood sugar levels, delivers therapeutics, and/or facilitates computer applications.
Dr. Brennan: Other exciting advances may be 3D printing of contact lenses, smart (electronic) lenses, combination (drug-eluting) lenses, or a breakthrough transformation in lens comfort that reduces discontinuation rates.
Dr. Guillon: The major contact lens challenges that remain unmet today are: 1) comfortable all-day wear for all lens wearers; 2) safe extended wear (the ultimate modality for convenience) for all lens wearers; and 3) correction of presbyopia without visual compromise. Currently, concepts are being proposed using contact lenses as heads-up display devices, and this may well happen. However, in my view, the major advancement that will benefit society will be continuous wear, autofocusing contact lenses incorporating electronic components that will replace accommodation. In addition, that same technology will likely be used to control myopia.
Dr. Hill: Contact lenses for the diagnosis and monitoring of ocular and systemic conditions.
Dr. Morgan: Over the next 30 years, I see the incorporation of miniature electronics into contact lenses as the main future development. Such advances will see the transformation of contact lenses from a simple fixed-focus vision correction modality to a lifestyle device. Such changes will allow for lenses that can change power for an enhanced correction of presbyopia (and perhaps other applications), for the sensing of ophthalmic and systemic diseases, and for a new form of information delivery, including day-to-day data, instant messages, and rich media.
Craig Norman: Hopefully, we will finally have an answer to solving the visual issues of presbyopic contact lens wearers. Maybe this will be with extended depth of focus (EDOF) optics or some new, but yet to be determined, optical design incorporated into traditional hydrogel, GP, or hybrid lens materials. My belief is that it will most likely be solved with some type of “smart lens” technology that incorporates digital components that mimic the accommodative process seen in younger, non-presbyopic patients.
Dr. Willcox: The development of electronic bionic lenses. These will be used for many applications, such as to overcome presbyopia, to project images in front of the wearer, or to form augmented reality. The development of these will require multidisciplinary research with engineers, material scientists, chemists, biologists, and clinicians—much like what occurred for the development of silicone hydrogel lenses in the 1990s.
MATERIAL AND DESIGN ADVANCES
Dr. Korb: Continuing material property advances to further decrease evaporation and provide increased lubricity are mandatory. However, for optimal contact lens wear, the tear film, because of evaporation, must exceed those qualities of an uncompromised “normal” tear film. The understanding that the desiccating stress induced by all contact lenses upregulates and then atrophies the meibomian glands, resulting in dry eye, is a call to arms for the industry to improve the tear film; this will be the most important development. This task requires routine treatment of the meibomian glands in a dental model culture, but is essential if contact lenses are to remain viable rather than harmful in this electronic viewing age.
Dr. Rosenthal: I predict that the most important development in the contact lens field over the next 30 years will be the evolution of a self-sterilizing, non-rotating, and non-adherent hybrid device incorporating a rigid center and soft periphery.
Dr. Sindt: Higher-order optics.
Dr. Szczotka-Flynn: Antimicrobial and biodeposit-resistant materials in a daily disposable modality. Eliminating the attachment of organisms, antigens, and other biodeposits to lens surfaces is still the rate-limiting step to truly benign contact lens wear. Achieving this would surely promote infection-free and inflammation-free lens use.
Dr. Papas: Broadly speaking, the future of contact lenses, including realizing the potential of some of the exciting new applications that are appearing, will not be secure unless we can fix the problems that currently exist—particularly with respect to discomfort and infection. So my prediction is that there will be significant and substantial investment by the industry in research that will produce solutions for these issues that have persistently dogged all of our lives. I would really like it to be a contact lens that can be worn with comfort and delivers great vision at any distance for the vast majority of presbyopes, but I would have said the same thing 25 years ago!
Dr. Stone: An important objective is the reduction of dropouts related to discomfort. New approaches to lens technology and enhanced care systems will take out many of the causes for discomfort, especially at the end of the day.
BETTER EYE CARE
Dr. Weissman: I would like to see an enhanced appreciation on the part of our patients of the challenges involved in providing proper professional care for their eyes, whether wearing contact lenses or not. I suspect I am overly optimistic in this regard. Many patients appreciate proper care; but too many, unfortunately, remain unconvinced that care is important to their safety and their outcomes until or unless they personally experience some tragic occurrence.
Dr. Cavanagh: During the next 30 years, we will see the development of an economic strategy to improve patient compliance with post-fitting care (incentives). For example, we should lower the cost of daily disposables as low as possible to increase compliance (i.e., take the cost out of complying).
Dr. Chalmers: There are many promising new technologies that will offer breakthrough advantages (i.e., retardation of myopia, drug delivery, treatment of dry eye), but they will succeed only if the worldwide regulatory agencies provide an environment in which the technologies can be fully tested in the field without undue burden. With use of better post-market surveillance methods, this should be the way forward to provide these products to patients who need them.
SINGLE-USE CONTACT LENSES
Professor Efron: I believe that the most important development in the next 30 years will be the inevitable move toward “single-use” contact lenses, which will primarily be daily disposable lenses, but also some extended wear. I envisage a discussion among two elderly contact lens practitioners in 2050 going something like this:
“Do you remember the days when contact lens wearers used to remove their lenses, clean them with special solutions, store them overnight in a disinfecting solution, and put the same lenses back on their eyes the next day. Not only that, but they repeated this ritual for up to a month! What a palaver!” CLS
For references, please visit www.clspectrum.com/references and click on document #250.
Dr. Nichols is an assistant vice president for industry research development and professor at the University of Alabama-Birmingham as well as editor-in-chief of Contact Lens Spectrum and editor of the weekly email newsletter Contact Lenses Today. He has received research funding from Johnson & Johnson Vision Care.
Deborah Fisher is associate editor of Contact Lens Spectrum.