The refracting opticians of 1891—just then embarking on the journey to found the optometric profession—were likely unaware that, three years prior, another revolution had begun, one that would intertwine with their own decades later. While those early optical specialists were busy refining the art and science of spectacle lens prescribing in the United States, German ophthalmologist Adolf Fick had demonstrated a new method of refractive error correction: “contact glasses,” as he dubbed the modality we now call contact lenses.1
Making glass-blown lenses, some as large as 21mm in diameter, Fick put into practice a concept theorized by Leonardo da Vinci nearly four centuries earlier. Fick made plaster casts of cadaver eyes and fashioned scleral-fit contact lenses for keratoconic patients who couldn’t be corrected with spectacles. “In these circumstances, it is certainly not superfluous to look for another means for correction of various types of irregular astigmatism,” Fick wrote in an 1888 paper. “The most radical means would seem to replace the cornea with another regularly curved surface.”1 This he did—with limited success. His lenses were too large and heavy for practical use, and they offered no means of oxygen transmission.
Fick’s work was essentially what we might call a proof-of-concept study today, not a commercially viable design. Attempts at producing a working contact lens for the general public began with Fick’s German compatriot August Müller, who created glass lenses to correct his own -14D myopia. Soon after, the Carl Zeiss company began to produce the first commercially available contact lens trial sets and glass lenses in 1912.2 Other medical victories, including the development of anesthesia in 1884 and fluorescein in 1871, made the process of fitting lenses on patients easier, while technology such as the keratometer and lathes for the manufacturing of lenses continued to advance.2-4
However, limitations resulting from the use of glass—discomfort, irritation, swelling, poor adherence—remained.3 Also, glass contact lenses were considered dangerous to wear, further hindering adoption for simple vision correction.5 What might be better? “Next to plastic glass, or a jelly-like refractive substance that would be practical for optical purposes, might come a material that would be the equal of our own present glass, only more durable or less liable to crack or shatter. Lenses could then be made thinner, lighter in weight and more inconspicuous than those we now use,” noted a speculative but prescient 1897 paper on theoretical and applied optics.6
|Fig. 1. In the 1930s, contact lenses were advertised as a gee-whiz replacement for glasses. However, complications were common and fitting more complex. Click to enlarge.|
That wish would begin to come true by the 1930s as manufacturers turned to plastic materials, producing contact lenses that were thinner and easier to wear than their glass predecessors.7 Optometrist William Feinbloom, credited with the first use of a non-glass material, created a lens with a plastic resin outer segment and a glass optical center.5 Soon after, Teo Obrig and Ernest Mullen, among others pioneered the use of polymethyl methacrylate (PMMA)—the material used in Plexiglas—for contact lenses.2,8
With these advancements, optometrists started to embrace contact lens fitting as a viable option, and a rather futuristic one at that. Ads that ran in this magazine enticed Depression-era readers with the promise that contact lenses are “as modern as the world of tomorrow” (Figure 1).
Articles began to appear in The Optical Journal and Review of Optometry to help readers build up their knowledge base. Even then, patient compliance was paramount for success. “To the skilled practitioner there is little difficulty in fitting contact lenses, if he can secure the intelligent cooperation of the patient,” wrote an author in one of Review’s 1937 contact lens articles. “Three factors are of prime importance: the accuracy of fit, the ease with which tolerance can be established, and the physical and mental condition of the wearer.” All still ring true nearly 80 years later.
Dr. Feinbloom himself wrote for this publication in 1941 on the topic of correcting hyperopia with contact lenses. All throughout the evolution of contact lenses, other pioneers would share their theories and practical insights in these pages as well, including a notable early discussion of dry eye and contact lenses from 1960 that described the value of a brand new clinical tool: the Schirmer strip (Figure 2).
PMMA contact lenses improved upon glass, to be sure, but still lacked oxygen transmission, and the “hard” lenses caused much discomfort.
The first rigid gas permeable (RGP) lenses didn’t arrive until 1969, comprised of cellulose acetate butyrate, methacrylate-silicone combinations or simply pure silicone.3,7 These materials helped combat the oxygen deprivation that contributed to edema in PMMA wearers while still providing the clear, stable vision of rigid lenses.7 The corneal GP was invented when Kevin Tuohy accidentally cut down the size of a scleral lens during manufacturing and liked the ensuing size.5
In a separate undertaking, invention of a “water swellable gel” by Otto Wichterle and Drahoslav Lim in Prague in the late 1950s gave rise to the modern soft contact lens.2,9 The material, polyhydroxyethyl methacrylate (HEMA), was first designed for artificial mandible construction, but ultimately was repurposed by Wichterle when he found it could also be spin-cast into a contact lens.10
The first breakthrough occurred in 1971 when Bausch + Lomb launched the SofLens in the United States, using patents held by the National Patent Development Corp. that were granted to them by Wichterle.3,11 And with that, the modern contact lens industry was born.
|Fig. 2. Contact lens pioneers often debuted their latest thoughts in Review of Optometry. Click to enlarge.|
For a time, complications from and negative attitudes towards these new lenses abounded: Review published several articles in the mid-1970s on the subject. In “Why Patients and Doctors Resist Soft Lenses—The Four ‘Uns’,” influential contact lens expert Robert Koetting, OD, discussed why practitioners and patients were slow to adopt the new modality. “The doctor is uncertain. He wonders if he can fit the new lenses successfully and he wonders if they are here to stay. The patient wonders, too. The patient wonders if he can really wear the lenses and whether those scare stories he read are really true.”
Other problems our authors tackled in these pages included high-riding lenses, mucous build-up, lens coating (“The Most Serious Soft Lens Problem,” as Dr. Koetting called it) and numerous technical issues in fitting and design.12,13 Also, articles on orthokeratology and anisometropia gave doctors information on how to better handle patients with specialty needs.14,15
These were the formative years of the soft lens industry, and optometrists were instrumental in helping to realize its potential. Some, like Dr. Koetting, were among the first to develop specialty contact lens practices devoted to mastering this new and still largely unproven modality. Others, like Newton Wesley, OD, and George Jessen, OD, concentrated on research and development that went on to power the next wave of product innovation. The company they founded made key strides in specialty contact lens development. They may have been almost as significant as educators, however. “Wesley and Jessen taught all of us how to fit contact lenses,” said early contact lens proponent and educator Frank D. Fontana, OD, in a 2009 retrospective.5 “They almost single-handedly developed the market for contact lenses, just by traveling around the country educating people.”
Many other optometrists of the day played pivotal roles. A list of contact lens pioneers at the dawn of the soft lens era reads like a “Who’s Who” of mid-1970s optometry: in addition to Drs. Koetting, Fontana, Wesley and Jessen, notable thought leaders included optometrists Rex Ghormley, Neal Bailey, Don Korb, Paul Farkas, Ted Kassalow, Robert Morrison, Harold Davis, Mel Remba, Seymour Marco, Robert Kennedy, Jack Solomon, Rodger Kame, Robert Graham, Morton Sarver, Leonard Seidner, Wayne Cannon, Robert Mandel, Maurice Poster, David Ewell, Edward Goodlaw, Ted Bayshore and many others.5
These are the people who built the institutions and infrastructure of the contact lens field—and they had an “OD” after their names.
First Contact: An Annual Tradition DebutsIn 1977, this magazine launched an annual contact lens issue to recognize the importance of the modality and address the challenges of the day. Next month will see its 40th installment. Back in ’77, ODs wanted to hear about overnight rigid lens wear and orthokeratology; problems and complications, including the effects of soft lens flexure on lens power, micro dry spots on the cornea and lens wear intolerance due to allergies; the aspheric lens fitting process; contact lens practice management; and the prescription of eyeglasses for contact lens wearers. “Nearly four decades have passed since the AOA formally recognized contact lens fitting as an integral part of the optometric practice,” a contact lens panel article stated in April 1977. “That was in 1938. Even then, the interest of optometrists in this particular area of practice was intense. The fervor among practitioners to learn more about contact lenses was such that courses in fitting were being readily accredited by the AOA, despite the fact that contact lenses were still limited to experimental use. Much has changed [since then.] But the interest in contact lens practice has not diminished.”21
Throughout the 1970s and 1980s, optometrists led the way in developing new and better protocols of clinical care. Many were involved in research studies too—a rarity for optometry. Drs. Farkas and Kassalow in particular were instrumental in bringing to market extended wear soft lenses and several new GPs.
In perhaps the crowning achievement of the decade, in 1976 Brien Holden established the Cornea and Contact Lens Research Unit at the University of New South Wales, an institution that quickly became a hotbed of research—with optometrists in lead positions—and remains so today. Optometry has “owned” contact lens research ever since.
Despite optometric enthusiasm for contact lenses in the 1970s, the public was more dubious. An article in our June 1973 issue noted that of the 191,602 respondents to a 1971 US health survey, only 3,972 participants reported contact lens wear, while 92,716 continued to wear glasses.16 A second survey conducted by Seventeen magazine found that even by 1975, only one out of every four women needing corrective lenses ages 13 to 19 opted for contact lenses.17
Optometrists had plenty of challenges to work through if they wanted to broaden the appeal of contact lenses. “There are fewer problems with corneal insult and adaptation” with soft lenses, wrote one panelist in a July 1975 reader survey on prescribing habits. Another added there was “less irritation to patients and fewer problems for me with these lenses.”18 But others were more wary of soft lenses as an alternative to tried-and-true rigid lenses, with over half of respondents to the report noting they continued to fit first-time patients in RGPs in part for their higher visual clarity and ability to accommodate more ocular issues.16 One panelist from the same report called the development of the soft lens “merely a step in the right direction, and only a small step at that. Improvements are sorely needed in the areas of optics, manufacturing, measurability, hygiene, maintenance, public information and governmental control.”18
The latter topic was a contentious one. Government efforts to regulate the contact lens industry placed further stress on growth; a November 1975 report titled “Outlook for the Contact Lens Industry” noted the FDA’s recent release of regulations designating non-PMMA contact lenses as drugs requiring premarket clearance and investigation into whether material components of PMMA lenses should be similarly controlled. “What concerns our industry now,” then-president of the Contact Lens Manufacturing Association Charles W. Neefe said, “is why we should be required to prove that which has been proven so conclusively over so many years.”19 Questions about whether insurers would cover contact lens wear also began to arise—and confuse.20
Lens care back then was a chore. Heat disinfection was a fiddly business that patients disliked. A section in the October 1979 issue of Review of Optometry discussed the status of several cleaning and disinfection solutions—addressing challenges in wearers who are allergic to chemical preservatives and educating readers about new and emerging options.11,22 Other late-’70s articles, such as “How Effective Are Soft Lens Cleaners?” and “Putting Care Back into Contact Lenses,” considered whether these products were suited to the consumers to which they were marketed, and how to best educate wearers on options.23,24
All In the Family
By the beginning of the 21st century, contact lenses had become a booming success—but remained a continual source of educational need. So in January 2000, Review of Optometry launched a new magazine devoted to the field: Review of Contact Lenses (ultimately renamed Review of Cornea & Contact Lenses, or RCCL for short). Much of the routine contact lens coverage Review was known for migrated there, with an emphasis on addressing concerns of contact lens specialists in greater detail.RCCL’s debut issue covered topics still relevant today, including fitting the post-surgical patient, properly caring for lenses and use of topography for contact lens fits, complications associated with lens wear during allergy season or in the case of an irregular cornea. Advances in antibiotics were also covered, as was the debate over how to charge for contact lenses.
These were days of rapid evolution in contact lens products and protocols. An informal 1979 survey mailed to 200 Midwest contact lens practitioners asking what contact lens-related subjects they would most like to hear about in a lecture found that general interest in that period was predominantly focused on new contact lens materials coming to market, practice improvement techniques including how to train staff members, and what kinds of new devices were available to assist with lens fittings.11
Breakthroughs were indeed on the way. The dawn of the 1980s brought 30-day extended wear—a mixed blessing, to be sure, as the complications set off a backlash against contact lens wear—and “planned replacement” of lenses for greater convenience and safety. Once manufacturing capacity ramped up, daily disposables became a reality with Vistakon’s launch of Acuvue in 1987.
Nowadays, numerous journals, periodicals and even conferences have become dedicated entirely to the subject of contact lens research and development—a far cry from decades prior. “Looking at the 1946 volume of the American Journal of Optometry and Archives of American Academy of Optometry, I found that there were six original papers and six abstracts published relating to contact lenses,” wrote Henry A. Knoll in a letter to the Optometric Historical Society, published in its April 1976 newsletter. “These days, when you pick up a journal, there is a good chance that there will be a contact lens article between the covers. On the other hand, we still have a lot to learn.”
The continuing introduction of new contact lens materials, technology and accessories throughout the years has pushed contact lenses from a simple idea to one of the most popular forms of vision correction worldwide. Remaining issues like user noncompliance, dropout and the desire for contact lenses to work in increasingly complicated scenarios—for example, post-surgery, as a means to monitor systemic health or on highly irregular corneas—mean there’s still plenty of problems for optometrists to master.
1. Fick A. Contactbrille. Archiv für Augenheilkunde, March 1888:279-287.|
2. Antique Spectacles and Other Vision Aids. A Brief History of Contact Lenses. Available at: www.antiquespectacles.com/topics/contacts/contacts.html. Accessed June 7, 2016.
3. Princeton University. The Development of Contact Lenses. Available at: https://www.princeton.edu/~ota/disk3/1984/8409/840904.PDF. Accessed June 7, 2016.
4. Carlson JJ, Silbert M. THe technique of fitting ‘scleraorm’ contact lenses. Optical Journal Review. 1946 Oct;34-36.
5. Contact lens Pioneers. Supplement to Review of Optometry, 2009.
6. Hoffsetter HW. Visual science history. Newletter of the Optometric Historical Society. 1972 July;3(3):28.
7. Edward Hand Medical Heritage Foundation. A History of Contact Lenses. http://edwardhandmedicalheritage.org/images/History_of_Contact_Lenses.pdf. Accessed June 7, 2016.
8. Andrew Gasson. Contact Lens History. The Overseas Pioneers. Available at: www.andrewgasson.co.uk/opioneers_gyorffy.htm. Accessed: June 7, 2016.
9. University of Buffalo. Contact Lens Polymers. Available at: http://wwwcourses.sens.buffalo.edu/ce435/2001ZGu/Contact_Lens/ContactLensReport.htm. Accessed: June 7, 2016.
10. The AOA Foundation. How Soft Contact Lenses Came to the US. Available at: www.aoafoundation.org/ohs/hindsight/how-soft-contact-lenses-came-to-the-usa/. Accessed: June 8, 2016.
11. Pavlichko JL. News & Notes About Contact Lenses. Rev Optom. 1979 Oct;116(10):41.
12. Verma SB, Janoff LE. Determining back vertex dioptric power of a hydrophilic contact lens. Rev Optom. 1973 Oct;110(19):27-29.
13. Koetting RA. Why not use the radioscope to measure soft lenses? Rev Optom. 1973 Oct;110(20):34.
14. Paige N. The plus lens increment system for prognosis in orthokeratology. Rev Optom. 1975 Feb;111(4):7-8.
15. Warren GT. The single contact lens and anisometropic patients. Rev Optom. 1975 Jan;112(7):17-18.
16. Ed. Number and percent of population 3 years of age and over with corrective lenses, by age and sex: United States, 1971. Rev Optom. 1973 Jun;110(11):25.
17. Ed. Contact lens users begin young. Rev Optom. 1975 Aug;112(15):33.
18. Kelly C. Contact Lenses. Rev Optom. 1975 Jul;112(14):20-26.
19. Guerrein RL. Outlook for the contact lens industry. Rev Optom. 1975 Nov;112(22):38-41.
20. Heimann RA. Opticianry’s look at national health insurance. Rev Optom. 1975 Dec;112(24):36-37.
21. Acone P. The contact lens coup. Rev Optom. 1977 Apr:48-49.54.
22. Weiss SG. Delusions about contact lens fitting. Optical Journal Review. 1945 June:25-27.
23. Kleist FD, Thorston JC. How effective are soft lens cleaners? Rev Optom. 1978 April:43-49.24. Ed. Putting care back into contact lenses. Rev Optom. 1978 Apr;115(4)89-93.