Contact Lens & Anterior Eye 29 (2006) 231–237

www.elsevier.com/locate/clae

Calculated tear oxygen tension under contact lenses offering

resistance in series: Piggyback and scleral lenses§
Barry A. Weissman *, Ping Ye
Jules Stein Eye Institute and Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles,
CA 90095-7003, United States

Abstract

Background: Models of oxygen delivery to the cornea with contact lens wear have considered the customary situation of one lens being
worn on the cornea. However, two lenses, such as a rigid lens piggybacked on a soft lens, may be worn by patients with special ocular and
visual needs. This paper extends existing single lens models to circumstances where two lenses offer resistance to oxygen in series.
Methods: Theoretical oxygen tensions are calculated for tear layers trapped beneath piggyback contact lens systems (and scleral lenses) and
the anterior corneal surface with a simple single chamber corneal model using a personal computer software spreadsheet.
Results: Acceptable values are anticipated for contact lens materials of modern oxygen permeability values of approximately 60–100 Fatt Dk
units under open eye conditions.
Conclusions: The results of this spreadsheet model of oxygen supply to the anterior corneal surface offer a useful guide to clinicians
concerned about providing their patients with physiologically acceptable piggyback lens systems.
# 2006 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.

Keywords: Piggyback; Contact lenses; Oxygen transmissibility; Oxygen permeability; Corneal physiology

1. Introduction ongoing concerns regarding hypoxia (hence this paper) of

two lenses on an eye.
Piggyback contact lenses commonly consist of rigid The list of complications of contact lens wear is quite
lenses fitted over soft lenses, although rarely other extensive. Since the initial appreciation of hypoxia as the
combinations are prescribed [1–3]. Piggyback lenses have etiology of many of these problems by Goodlaw [4] and
been used as an unusual clinical technique when the Smelser and Ozanics [5] more than 50 years ago, much effort
condition of an eye is such that the optics of rigid lenses are has been expended at first defining human corneal oxygen
required for visual rehabilitation yet rigid lens tolerance, requirements and then devising contact lenses that will
either physiological and/or physical, fails (e.g. during allow their clinical satisfaction. Unfortunately, piggyback
treatment of keratoconus or other corneal irregularity). lenses result in a double barrier to oxygen supply over the
Piggyback lenses require more care on the part of the patient corneal surface. The current work explores some theoretical
(two separate contact lenses per eye), have increased costs calculations to predict corneal oxygen supply under piggy-
in both solutions and lenses, and there have been some back lenses. Scleral lenses will also be considered as another
case of two layers resisting oxygen flow in series.

§
Dr. Ye was supported in part by an education grant from Vistakon, a
division of Johnson & Johnson Vision Care, Inc. Dr. Weissman’s participa- 2. Theory
tion was supported in part by a research grant from Dr. Marvin Smotrich.
* Corresponding author at: Jules Stein Eye Institute, 100 Stein Plaza,
David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-7003, Oxygen permeability (termed Dk where D is the oxygen
United States. Tel.: +1 310 206 6351; fax: +1 310 206 0595. diffusion coefficient and k is oxygen solubility) is an
E-mail address: [email protected] (B.A. Weissman). intrinsic material property. Dk is directly dependant on a

1367-0484/$ – see front matter # 2006 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.clae.2006.09.001
232 B.A. Weissman, P. Ye / Contact Lens & Anterior Eye 29 (2006) 231–237

material’s oxygen permeable moieties for both rigid and is an oxygen flux into the cornea sufficient to sustain its
hydrogel plastics, usually silicone and/or water [6,7]. metabolism (about 5–10 ml O2/cm2 h) [27,28]. In vivo
Oxygen transmissibility is termed Dk/t in the contact lens oxygen flux was considered a potentially useful metric
literature where t is sample (e.g. lens) thickness [6–10]. Both when lens Dk/t values were low, but flux changes minimally
Dk and Dk/t are laboratory ‘‘in vitro’’ measurements, most with modern lenses (values 50–100 Fatt Dk units) [29].
commonly determined by the polarographic method of Fatt Polse and Mandell originally used tear layer oxygen tension
[6,12]. In the contact lens literature, Dk is measured in units (tear pO2 or P2) as a marker for oxygen supply adequacy and
of 1011 (cm2/s) (ml O2/ml mmHg). Oxygen transmissi- found a ‘‘critical value’’ of 11–19 mmHg; others have since
bility (Dk/t), where t is in cm, is measured in 109 (cm/s) raised this value to 70 mmHg or greater [30–33]. Brennan
(ml O2/ml mmHg). Benjamin has proposed ‘‘Fatt Dk units’’ alternately proposed percent of normal corneal oxygen
as alternate units for Dk for simplicity [11] and this will be consumption as another possible measure, but this has yet to
used below. Dk/t is then measured in Fatt Dk/t units. be widely accepted [29].
Dk/t measurement is complicated. First there is varia- Fatt and Ruben introduced the concept of ‘‘biological
bility in thickness, both between different lenses and from oxygen apparent transmissibility’’ (BOAT) to be a measure
point to point on any optically powered lens. Because of in vivo contact lens oxygen performance: BOAT = (Dk/
contact lenses are usually quite thin compared to their areas, t)cl(P1  P2/P1) [34]. They used matrix algebra on a modern
some authors have simply assumed that the lenses are made personal computer spread-sheet with a simple single layer
of a uniform thickness. Optically powered lenses, however, corneal model to calculate theoretical oxygen tensions under
only really have uniform thickness at low minus (about contact lenses (P2); P1 is the oxygen tension on the front
0.75 D) optical powers [13]. Morris and Fatt suggested surface of the contact lens, either 155 mmHg with the eye
that the central value of thickness was close enough to open and exposed to a sea-level atmosphere or 55 mmHg if
average thickness for lenses of optical powers between the eye is closed [34–37] when the lens anterior surface is
1.50 D that this value could be used [14]. Fatt and others covered by the underside of the upper lid. This is a
proposed several mathematical techniques to provide an simplification of the previous method of Fatt and his
average thickness, especially for optical powers greater than colleagues [35–37] that relied on a mainframe computer to
1.50 D [15–17]. Holden and Mertz [18] and Tomlinson solve several simultaneous equations and unknowns. Fatt
and Bibby [19] suggested that thickness should only be and Ruben applied their model to the then current range of
averaged over a central zone about 6 mm in diameter (rather hydrogel contact lens parameters, predicting P2 values
than the entire diameter) of each lens. Fatt and Neumann ranging from 10 to 100 mmHg for lenses of water content of
alternatively argued, however, that average thickness is not 38–70% (Dk ranging from about 10 to 40 Fatt Dk units) [34].
appropriate for predicting lens physiological (in vivo) BOAT unfortunately is confusing and has not been used
performance in the absence of tear exchange or mixing, such much.
as in the case of hydrogel lens wear [20]. They suggested Huang et al. [38] extended the Fatt and Ruben [34]
that the thickest portion of the lens is most important as it is technique to silicone hydrogel lenses of 60–150 Fatt Dk units
the Dk/t at that site which will produce the greatest hypoxic using the same simple single chamber corneal model. They
stress to the underlying corneal tissues. concluded that clinical variability in contact lens t no longer
As theory evolved, to improve accuracy of polarographic affects tear layer pO2 with lens materials 100 Fatt Dk units –
measurements of Dk/t necessitated by increased lens’ Dk at least under open-eye conditions. Brennan developed a more
values, corrections for both the effects of boundary layers of complex (8-chamber) model that plots corneal/contact lens
fluid on the lens surfaces (which leads to under-estimations oxygen tension profiles [29]. The Brennan model continues a
of Dk and Dk/t) and the ‘‘edge effect’’ caused by the multilayer revision of Fatt’s model cornea by Harvitt and
polarographic sensor collecting oxygen from an area greater Bonanno [25]. Harvitt and Bonanno [25] corrected for altered
than its own diameter (leading to over-estimations of Dk and oxygen consumption with corneal acidosis and provided
Dk/t) were introduced [21–24]. newer boundary conditions for both closed eye (60 mmHg)
What is the best criteria by which to judge corneal oxygen [39,40] and aqueous humor (24 mmHg) pO2 [41]. The
supply? Both Holden and Mertz [18] and Harvitt and Brennan model includes several theoretically important
Bonanno [25] proposed critical Dk/t values below which improvements: Brennan corrects for spurious oxygen con-
corneal physiology might be compromised, but Fatt stated sumption when the oxygen tension falls to zero within the
that Dk/t was an in vitro measurement and a ‘‘disappoint- cornea, and he improves several thickness values using more
ment’’ as a measure of in vivo performance [26]. First, modern estimates.
oxygen tension under a contact lens on an electric sensor (in We herein extend the Huang et al. [38] model to
vitro) is always zero at the steady-state. It is both undesirable piggyback contact lens systems, where two layers of
as well as unlikely to reach zero under a lens on a living eye. resistance to oxygen diffusion are in front of the corneal
Secondly, the flux of oxygen across a lens on a polarographic surface. As tear pO2 seems as good a surrogate as any, we
sensor tends to infinity as the lens t decreases to zero – but will use this value as our outcome measure in this
the in vivo limiting case (e.g. without contact lens on an eye) manuscript. We use several of the Brennan improvements
 B.A. Weissman, P. Ye / Contact Lens & Anterior Eye 29 (2006) 231–237 233

in boundary conditions but not his more complex model (as inherent group of living cells. Consideration of these layer-
will be discussed below). Fatt suggested that piggyback by-layer individual parameters would lead to a much more
lenses (Dk/tpb) could be considered ‘‘resistance in series’’ complex model of corneal oxygenation with several
[42]. Mathematically, unknowns and equations to be solved simultaneously as
has been done by Fatt and colleagues, Harvitt and Bonnano,
Dk 1 and then Brennan [27,29,35–37].
¼ ; (1)
tpb ðt1 =Dk1 þ t2 =Dk2 Þ But for the sake of this simple calculation, where we seek
to calculate only the oxygen tension in the tears (P2), it may
considering piggyback lens systems of lens #1 (Dk1/t1) and be reasonable to only use a simpler single chamber model
lens #2 (Dk2/t2). (If contact lens Dk is high, approaching the and a whole corneal value for Q. This was first measured at
Dk of water or tears (e.g. over 50 Fatt Dk units), any fluid 9.54 ml O2/cm2 h (or 6.58  105 ml O2/ml s) by Freeman
layers should also be considered as additional resistance in with rabbit cornea [44] and his value was used by Fatt and
series; see below.) Scleral lenses are very large overall colleagues [35–38]. Bonanno et al. recently estimated
diameter (15–24 mm) rigid lenses that usually trap fluid human Q at (5–6)  105 ml O2/ml s, not much different
reservoirs over the corneal surface. The entrapped fluid layer than a previous estimate of about 4  105 ml O2/ml s
and contact lens should also act as resistance in series (with [45,46]. Considering the variations in this value reported
the scleral contact lens as lens #1 and the entrapped tear over the years, we will use 5  105 ml O2/ml s (or
layer as lens #2), and this will also be discussed below. 9.7 ml O2/cm2 h) here as a fair estimate.
Whole corneal Q may not be independent of either
oxygen tension or pH. Forty years ago Fatt suggested that Q
3. Methods should be fairly stable at oxygen tensions greater than
20 mmHg [47]. As others have found stability in Q at
Various constants (corneal thickness or tcor; anterior perhaps only a few mmHg [33,48], changes in corneal Q
cornea oxygen tension (P1) for the open- or closed-eye; related to low oxygen tension will not be considered further
whole corneal oxygen consumption or Q; aqueous humor here. Brennan [29] accepted the Harvitt and Bonanno
oxygen tension or Paq; and corneal oxygen transmissibility finding that Q increases with acidosis [49] and this was
or Dkcor) (see Table 1 for constants used here) were placed incorporated into his model but is not used in our simple
into a Microsoft ExcelTM spread-sheet developed by Huang model.
et al. [38] after the spread-sheet previously discussed by Fatt To see if it is reasonable to use our simple model,
and Ruben [34] to allow theoretical calculation of tear layer particularly considering all the complications involved with
oxygen tension (P2) under contact lens systems. Q described above, we compared results for tear pO2
We use the value for closed eye palpebral oxygen tension calculated under single contact lenses for sample values of
accepted by Brennan [29] and Harvitt and Bonanno [25] of 60 Dk/t ranging from 10 to 150 Fatt Dk/t units using the original
mmHg rather than Fatt’s earlier [35–37] value of 55 mmHg. A Fatt et al. [34–37]/Huang et al. [38] model, Brennan’s more
value for a human corneal thickness of 540 mm (after the complex model [29], and our current version of the Fatt
meta-analysis of Doughty and Zaman [43]) is used here rather model (with the changes in boundary conditions: pO2
than the earlier values of 500 mm used by Fatt and Ruben [34] aqueous, lid pO2, corneal thickness, and the value for whole
or 560 mm used by Huang et al. [38]. We use 30 mmHg here cornea Q noted above). As the reader can see from Fig. 1
for Paq as a compromise between the value of 55 mmHg used (showing the results of such calculations) there are minimal
by Fatt and colleagues [30–34] and the 24 mmHg used by differences in predicted tear layer oxygen tensions under
Brennan [29] and Harvitt and Bonanno [25]. open eye conditions and slight differences under closed eye
It is necessary at this point to consider the role of corneal conditions for all three models. We therefore present
oxygen consumption (Q). Each layer of the cornea has piggyback lens results from our model below.
separate values for Q (as well as for thickness, Dk, etc.), Note in Fig. 1 that predicted tear pO2 initially increases
based on the individual metabolism and volume of each rapidly with increasing Dk/t (regardless of open or closed

Table 1
Corneal parameters and boundary conditions used in the calculations
tcor (mm) Q (ml O2/cm2 h) P1closed (mmHg) P1open (mmHg) Paq (mmHg) Dkcor (Fatt Dk units)
Fatt and Ruben [34] 500 9.54 55 155 55 24.7
Harvitt and Bonanno [25] 495 Various (by layer) 61.4 155 24 Various (by layer)
Huang et al. [38] 560 9.54 55 155 55 24.7
Brennan [29] 532 Various (by layer) 61.5 155 24 Various (by layer)
Current study 540 9.7 60 155 30 24.7
Note: tcor: corneal thickness; Q: corneal oxygen consumption; P1closed: eyelid oxygen tension; P1open: open eye oxygen tension; Paq: aqueous humor oxygen
tension; Dkcor: corneal oxygen permeability.
234 B.A. Weissman, P. Ye / Contact Lens & Anterior Eye 29 (2006) 231–237

Fig. 1. Tear layer oxygen tension (in mmHg) predicted by the original Fatt/Huang, Brennan, and the current models for various contact lenses from 10 to
150 Fatt Dk/t units (or 109 cm/s ml/ml mmHg) is graphed. The upper curves are all open eye predictions and the lower curves are all closed eye predictions.
Benchmarks of the Polse and Mandell [30], Mandell and Farrell [31], Holden et al. [32] critical corneal oxygen tensions (COT) (11–19, 23, 75 mmHg,
respectively) and the Holden and Mertz [18] and Harvitt and Bonanno [25] (this particular value has been supported by the later work of both Pappas [53] and
Sweeney et al. [54] but contested by Brennan and Efron [33]) suggested critical Dk/t values (24, 87, 125 Fatt Dk/t units, respectively) (dashed lines) are shown
for historical reasons.

eye conditions) to slow down and asymptote after a Dk/t a sub-calculation. Thicknesses were chosen to be uniformly
value of about 70–100 Fatt Dk/t units. Our model suggests 0.01 cm for all sample lenses for the sake of these examples
that tear pO2 eventually stabilizes at about 150 mmHg under but these values could be easily changed as appropriate in
open and 50–60 mmHg under closed eye conditions. These the spread-sheet and new specific results developed for any
are the expected boundary conditions without any contact specific lens situation.
lenses on the eye. Although various previously proposed Excel (Microsoft Office 2000 Standard, Microsoft
‘‘benchmarks’’ for critical tear pO2 and lens Dk/t are shown Corporation, Redmond, WA) does the mathematical work.
for comparison in Fig. 1, the reader should note the The entries/values were entered into a newly opened Excel
limitations of these values discussed above. Inspection of spreadsheet on a Pavilion a767c desktop computer (Hewlett
Fig. 1 also fails to indicate a clear-cut boundary between Packard, Palo Alton CA), into cells A1–A3, B1–B3, C1–C3,
what should be physiologically questionable versus what and D1–D3. Cells A1–A3, B1–B3, and C1–C3 form a 3  3
should be tolerable. The answer of the question posed matrix. By use of provided built-in Excel mathematics
several paragraphs above, ‘‘what should be the ‘‘critical’’ functions, the matrix A1–A3, B1–B3, C1–C3 was inverted
oxygen value?’’ therefore remains elusive. If one had to and placed into cells A6–A8, B6–B8, and C6–C8.
estimate, however, from the literature it is clear that This new matrix was then multiplied with the 3  1
maintaining an open eye tear pO2 of about 100 mmHg would matrix D1–D3. The resulting 3  1 matrix was placed in
likely be physiologically tolerable for most corneas. cells D6–D8. Because Excel cannot directly multiply a
Values for Dk/tpb and P2 were developed from Eq. (1) for 3  3 matrix with a 3  1 matrix, we used sub-steps. The
various reasonable piggyback combinations of contact 3  3 matrix was divided into three sub-matrices, each
lenses ranging from 10 to 150 Fatt Dk units (Table 2) as with the dimensions of 1  3. This allowed for a simpler
 B.A. Weissman, P. Ye / Contact Lens & Anterior Eye 29 (2006) 231–237 235

Table 2 (see discussion above regarding contact lens thickness). For

Predicted tear layer oxygen tension under piggyback contact lenses of example, if the clinician uses an underlying lens of 100 Fatt
several Dk/t values (all sample contact lenses of 0.01 cm thickness for
simplicity) Dk/t units (e.g. Bausch & Lomb PureVisionTM Acuvue
OaysisTM) and a top lens of 60 Fatt Dk/t units (e.g.
RGP SCL Dk/t Open eye pO2 Closed eye pO2
(Fatt Dk/t units) (Fatt Dk/t units) (mmHg) (mmHg) FluoropermTM 60), the predicted tear pO2 values would be
either 109 mmHg (open eye conditions) or 25 mmHg
15 10 0 0
15 20 9 0 (closed eye conditions).
15 60 39 0 Scleral lenses form another special case of resistance in
15 100 46 0 series. Scleral GP lenses have thicknesses about 400–500 mm,
15 140 50 0 about 0.04–0.05 cm. They usually entrap tear layers of
60 10 9 0 substantial thicknesses, about 200 mm or more. If we assume
60 20 57 0 we have a scleral lens of 100 Fatt Dk units, 0.04 cm thick,
60 60 99 17 overlying a tear layer (about 80 Fatt Dk units [6]) 0.02 cm
60 100 109 25
60 140 114 28
thick, our model predicts an open eye pO2 at the corneal
surface about 60 mmHg (assuming no tear mixing in the tear
150 10 17 0
layer; mixing would probably increase this value) under open
150 20 69 0
150 60 114 29 eye conditions. Closed eye conditions yield a tear pO2 of 0.
150 100 125 37
150 140 130 41
5. Discussion

matrix multiplication where [1  3]  [3  1] = [1  1]. The resistance in series model for piggyback lens oxygen
Multiplying each of the three sub-matrices by the [3  1] transmissibility discussed above is probably the simplest
matrix gave 3 number values viewed as a 3  1 matrix in model for such a contact lens system situation. Tear layers of
D6–D8. any substantial thicknesses between or under the lenses would
The mathematics described above placed a value for B in decrease the whole system Dk/t (by increasing resistance by
D6, B0 in D7 and C0 in D8 (see Fatt and Ruben [34] and Fatt one or two additional layers of their own Dk/t values). Any
and Weissman [35] for definitions of B, B0 and C0 ) for each tear exchange secondary to a relatively ‘‘loose’’ fitting top GP
lens at each thickness and boundary conditions. These values lens would however increase the pO2 at the corneal surface by
were used to calculate tear pO2 (P2) values by increasing the pO2 in between two lenses [42].
It is also important to note that our model is based on
P ¼ xB0 þ C0 : (2) oxygen consumption of normal corneas. Diseased corneas,
such as may often need to wear piggyback contact lens
Where x is tcor, the thickness of the cornea, P will be P2, systems, may have greater or lesser oxygen requirements, or
predicted oxygen tension at the corneal surface. possibly a greater or lesser response to hypoxia; no data is
Oxygen flux (j) through the piggyback contact lens found in the literature.
system could be calculated by: j = (Dkpb/tpb)(P1  P2). Previous literature provides some support for our results.
Oxygen flux can also be calculated into the cornea by This literature is unfortunately complicated in most cases by
jcor = Qtcor + BDkcor [34]. These values should be identical. incomplete descriptions of the lenses used. Giasson et al.
Oxygen flux will not be calculated here, however. [50] describe piggyback lens systems of estimated Dk/tpb
between 8 and 24 Fatt Dk/t units, and provide values for
measured oxygen percent of 4.5–10.1% (translating into tear
4. Results pO2 values: 34–80 mmHg). Inspection of these results by
use of our Fig. 1 suggests some consistency. Similarly,
Our results for predicted tear pO2 with piggyback lens estimating the Dk and ts of Tsubota et al.’s piggyback lenses
systems under open and closed eye conditions are shown in [51] with reasonable values suggests calculated tear pO2
Table 2. With the exceptions of only the lowest Dk/t lenses, values of 55–85 mmHg by our model, not much different
most combinations result in open eye tear pO2 values of than their measurement of about 90 mmHg.
100 mmHg or greater, which should be reasonably well Smith et al. [52] found that GP scleral lenses generated
tolerated physiologically for most patients. Closed eye corneal swelling of 5–17% with extended wear, consistent
results did not generate tear pO2 values greater than about with our calculation of minimal resultant tear pO2 for closed
41 mmHg from any combination of lenses. Extended wear eye conditions.
of piggyback systems appears physiologically questionable. In summary, we here present an extension of our
Specific contact lens combinations could be individually previously published single chamber corneal spreadsheet
investigated using the described model, provided that model of oxygen supply to the anterior corneal surface. Our
contact lens thickness could be adequately approximated predictions appear reasonable, and should prove to be a
236 B.A. Weissman, P. Ye / Contact Lens & Anterior Eye 29 (2006) 231–237

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