Peer-reviewed Articles

Please use the year list below to look at past peer-reviewed articles.


Blackie,C. A., Coleman,C. A., Nichols,K. K., Jones,L., Chen,P. Q., Melton,R., Kading,D. L., O’Dell,L. E., Srinivasan,S. A single vectored thermal pulsation treatment for meibomian gland dysfunction increases mean comfortable contact lens wearing time by approximately 4 hours per day Clinical Ophthalmology 2018;12:169-183 [ Show Abstract ]

Purpose: To evaluate the effect of a single vectored thermal pulsation (VTP) treatment in contact lens wearers with meibomian gland dysfunction (MGD) and dry eye symptoms. Methods: The prospective, nonsignificant risk, open-label, randomized, multi-center clinical trial included 55 soft contact lens (SCL) wearers with MGD and evaporative dry eye. Subjects were randomized to the single VTP treatment group or an untreated control. The controls received a crossover VTP treatment at 3 months (crossover treatment group). Primary effectiveness measures were meibomian gland secretion (MGS) score and Standard Patient Evaluation of Eye Dryness (SPEED) that were evaluated at baseline, at 1 and 3 months post-VTP treatment, and at 1 month post-VTP treatment in the crossover treatment group. Exploratory variables included fluorescein tear break-up time (TBUT), lid wiper epitheliopathy (LWE), lid parallel conjunctival folds (LIPCOF), ocular surface staining, frequency of over-the-counter (OTC) drop use, and hours of comfortable contact lens wear. Results: At 3 months, the treatment group showed significantly greater mean change from baseline in MGS (12.4±9.1 vs 1.4±6.4, p˂0.0001), SPEED (−8.4±4.7 vs −0.7±4.4, p˂0.0001) and significantly greater improvement in exploratory variables (TBUT, LWE, and frequency of OTC drop use) relative to the controls. Mean comfortable contact lens wearing time increased by 4.0±3.9 hours at 1 month. This was sustained for 3 months with no change in the control group. The crossover treatment group demonstrated similar results to the treatment group at 1 month post-VTP. Conclusion: In SCL wearers with MGD, a single VTP treatment significantly improved mean meibomian gland function and significantly reduced dry eye signs and symptoms compared to an untreated control. The treatment increased mean comfortable lens wearing time by 4 hours (approximately doubling the pretreatment findings). This was sustained for up to 3 months post-treatment on average.

Chen,P. Z., Pollit,L., Jones,L., Gu,F. X. Functional Two- and Three-Dimensional Architectures of Immobilized Metal Nanoparticles Chem 2018;4(10):2301-2328 [ Show Abstract ]

Recent methodological advances have led to unprecedented precision in the immobilization of metal nanoparticles. These methodologies come from a broad range of disciplines and organize nanoparticle building blocks into a diverse selection of distinct architectures—from small arrays to ordered superstructures. Because properties can be dictated by assembly, architectures can present enhanced properties of the constituent nanoparticles or generate emergent properties of the collective architecture that are unavailable to their constituent nanoparticles. Functional architectures use these properties to further tailor and optimize performance in myriad applications. This review discusses the methodological advances that enable the immobilization of metal nanoparticles in distinct two- and three-dimensional architectures. Discussion will include their distinctions, properties associated with the assemblies and their applications, and the key challenges and future directions in this growing field. The integration of nanomaterials has transformed key applications in a multitude of scientific fields, such as in energy, environmental technologies, water, medicine, and chemical processing. Metal nanoparticles, the predominant type of nanomaterial, are at the center of many of these applications. Conventionally, the physical properties of metal nanoparticles, such as size and shape, are engineered to alter properties and enhance performance. Recent work has developed a new approach: immobilizing metal nanoparticles in architectures. These structures generate enhanced or emergent properties, which can be used to further improve performance in applications, and promise the next generation of applications of metal nanoparticles in science and society. This review discusses the methods (from a wide range of disciplines) that immobilize nanoparticles in precise two- and three-dimensional architectures. Also discussed are the properties that arise from and the utility of the architectures. Metal nanoparticles present enhanced, or emergent, properties when immobilized in precisely configured two- and three-dimensional architectures. Recent methodological advances in a broad range of fields enable the construction of a diverse selection of such architectures. This review discusses these methodologies, their constructed products, and the properties exhibited by the architectures. It also discusses the distinctions, sometimes subtle, between methodologies that often dictate the types of architectures that they can construct and thus the resultant properties that can be presented.

Delaveris,A., Stahl,U., Madigan,M., Jalbert,I. Comparative performance of lissamine green stains Contact Lens and Anterior Eye 2018;41(1):23-27 [ Show Abstract ]

Purpose To investigate the performance of lissamine green strips from different manufacturers. Additionally, the repeatability, need for sequential dye instillation and impact of repeated lid evertion on lid wiper staining were assessed. Methods Study 1 was a prospective, randomised cross-over study where controlled volumes of lissamine green solution prepared from strips (Biotech, Lissaver, GreenGlo, OPGreen) were instilled (right eye: single; left eye: double instillation) on five different days, with OPGreen being tested twice. Lids were everted and digital photographs taken, which were later assessed by a masked observer. Study 2 was an investigator-masked, randomised, controlled study testing the impact of single versus repeated lid evertion. Lid wiper staining was graded (0 to 3 in 0.5 steps). Results Lid wiper staining differed significantly between lissamine green solutions, with GreenGlo showing the highest amount of staining, and Lissaver the least (all p > 0.009). There were no differences in lid wiper staining over two days, using the OPGreen solution (all p > 0.05). The number of drops instilled (single versus double) did not significantly affect lid wiper staining (all p > 0.05). Repeated lid evertion increased lid wiper staining (p = 0.007 when combined with double drop instillation). Light absorbance patterns and measured concentrations aligned with clinical findings. Conclusion There were significant differences in performance between lissamine green solutions. Lid wiper staining was impacted by repeated lid evertion but sequential instillation and use of the Korb grading scale provided little advantage over simpler methods Clinicians must consider this when investigating lid wipers, especially when interpreting a negative finding. © 2017 British Contact Lens Association

Fonn,D., Jones,L. Hand hygiene is linked to microbial keratitis and corneal inflammatory events Contact Lens and Anterior Eye 2018;Epub ahead of print [ Show Abstract ]

Lack of or inadequate hand washing is a risk factor in the development of contact lens related microbial keratitis and corneal inflammatory events. In the public health domain there is compelling evidence that proper hand washing with soap can save lives. The purpose of this review is to draw attention to some of the public health literature in support of hand washing and how education can influence patients’ hand hygiene behavior. Contact lens wearers are also guilty of poor hand washing behavior but there is scant evidence that education of hand washing procedures of lens wearers alters patient non-compliance. It is well known that pathogenic microbial contamination of contact lenses, lens cases, care solutions and anterior ocular components have been found with contact lens wear. However while the originating source may be hands or water, it is most likely both of these. Besides proper hand washing this paper will include mitigating strategies for avoiding microbial contamination.

Korogiannaki,M., Jones,L. W., Sheardown,H. The impact of a hyaluronic acid-grafted layer on the surface properties of model silicone hydrogel contact lenses Langmuir 2018;Epub ahead of print [ Show Abstract ]

The introduction of high oxygen transmissibility silicone hydrogel lenses ameliorated hypoxia-related complications, making them the most prescribed type of contact lens. Despite the progress made over the last two decades to improve their clinical performance, symptoms of ocular dryness and discomfort and a variety of adverse clinical events are still reported. Consequently, the rate of contact lens wear discontinuation has not been appreciably diminished by their introduction. Aiming to improve the interfacial interactions of silicone hydrogel contact lenses with the ocular surface, a biomimetic layer of the hydrophilic glycosaminoglycan hyaluronic acid (HA) (100 kDa), was covalently attached to the surface of model poly(2-hydroxyethyl methacrylate-co-3-methacryloxypropyl-tris-(trimethylsiloxy)silane) (pHEMA-co-TRIS) silicone hydrogel materials via UV-induced thiol-ene "click" chemistry. The surface structural changes after each modification step were studied by FTIR-ATR and XPS. Successful grafting of a homogenous HA layer to the surface of the model silicone hydrogels was confirmed by the consistent appearance of N (1s) and the significant decrease of the Si (2p) peaks, as determined by the low-resolution angle-resolved XPS. The HA-grafted surfaces demonstrated reduced contact angles, dehydration rate and nonspecific deposition of lysozyme and albumin, while maintaining their optical transparency (>90%). In vitro studies demonstrated that the HA-grafted pHEMA-co-TRIS materials did not show any toxicity to human corneal epithelial cells. These results suggest that surface immobilization of HA via thiol-ene "click" chemistry can be used as a promising surface treatment for silicone hydrogel contact lenses.

Luensmann,D., Schaeffer,J. L., Rumney,N. J., Stanberry,A., Walsh,K., Jones,L. Spectacle prescriptions review to determine prevalence of ametropia and coverage of frequent replacement soft toric contact lenses Contact Lens and Anterior Eye 2018;41(5):412-420 [ Show Abstract ]

Purpose: To determine the prevalence of ametropia and astigmatism in a clinic population and to estimate the coverage of frequent replacement soft toric lenses. Methods: A review of patient files was conducted at three clinical sites. Prescription data collected between January 2014 and March 2017 in a patient cohort 14 to 70 years of age inclusive were analyzed to determine prevalence of ametropia and astigmatism. The percent coverage of frequent replacement soft toric contact lenses has further been estimated using different ranges for sphere, cylinder and axis availability. Results: In total 101,973 patients were included in the analysis of which 69.5% were considered myopic, 26.9% hyperopic and 3.5% emmetropic as determined by the eye with the larger absolute value of the spherical equivalent refraction. Astigmatism in at least one eye was found in 87.2% of the population, with 37.0% of the patients exhibiting astigmatism of at least −1.00DC in at least one eye. With-the-rule astigmatism was most prevalent in the 14 to 20 year-olds (53.0%), while against-the-rule astigmatism was most prevalent in the 41 to 70 year-olds (50.7%). For astigmatic eyes with a cylinder of at least −0.75DC (n = 83,540; 41% of all eyes), the coverage with toric soft lenses varied greatly depending on parameter availability and ranged between 30.7% (sphere: Plano to −3.00D, cylinder: up to −1.75DC, axes: 90 ± 10° and 180 ± 10°) and 96.4% (sphere: + 6.00D to −10.00D, cylinders: up to −2.75DC, 18 axes). Conclusion: Currently available frequent replacement soft toric contact lenses provide coverage for up to 96.4% of potential patients.

McCanna,D. J., Oh,S., Seo,J., Coles-Brennan,C., Fadli,Z., Subbaraman,L. N., Jones,L. W. The effect of denatured lysozyme on human corneal epithelial cells Investigative Ophthalmology and Visual Science 2018;59(5):2006-2014 [ Show Abstract ]

PURPOSE. During contact lens wear, the amount of lysozyme deposited on contact lenses varies depending on the lens material. The binding of lysozyme to some contact lens materials may result in a conformational change that denatures the protein to an inactive form. This investigation evaluated the effect that denatured lysozyme has on human corneal epithelial cells (HCECs) by measuring cell viability and the release of inflammatory cytokines. METHODS. HCECs were exposed to lysozyme that was denatured to various activity levels. After 24-hour exposure to the lysozyme (1.9 mg/mL) in growth media, the cells were evaluated for cell viability using confocal microscopy. The metabolic activity of the cells was determined using an alamarBlue assay. Cell supernatants were analyzed for inflammatory cytokines. RESULTS. Using confocal microscopy, there was no detectable change in the viability of the HCECs after exposure to the denatured lysozyme. However, using alamarBlue, a decrease in the metabolic activity of the HCECs exposed to denatured lysozyme was detected. HCECs exposed to lysozyme that was 67%, 47%, and 22% active showed a reduction in metabolic activity when compared with native (100% active) lysozyme and the media controls (P < 0.05). Exposure to the denatured lysozyme also caused an increase in the release of inflammatory cytokines (P < 0.05) from the HCECs. CONCLUSIONS. The results of this study show that denatured lysozyme can have a detrimental effect on HCECs. Both a reduction in metabolic activity and an increase in the release of inflammatory cytokines occurred after HCEC exposure to denatured lysozyme. © 2018 The Authors.

Moezzi,A., Hutchings,N., Fonn,D., Simpson,T. L. Mixed Model Analysis of Between-Subject Variability in Overnight Corneal Swelling and Deswelling With Silicone Hydrogel Lenses Invest Ophthalmol Vis Sci 2018;59(6):2576-85 [ Show Abstract ]

PURPOSE: To model between subject variability of corneal swelling (CS) and deswelling after overnight wear of silicone hydrogel (SiHy) contact lenses.

METHODS: A total of 29 neophyte subjects wore 12 SiHy lenses with central transmissibility range of 31 to 211 Dk/t units on separate nights, in random order, and on one eye only. The contralateral eye served as the control. Central corneal thickness was measured using digital optical pachymetry before lens insertion, immediately after lens removal on waking, then 20, 40 minutes, 1, 2, and 3 hours later. Mixed modelling was conducted for simultaneous analysis of group and between-subject effects of CS and deswelling.

RESULTS: The best model for overnight CS versus Dk/t was linear with a random intercept showing constant between-subject differences in CS for different Dk/t values. The best fit for corneal deswelling versus time was a curvilinear random intercept and random slope model. About 90% of the total between-subject deswelling variance in either lens or control eyes was due to the intercept variability with much less (∼10%) being due to the variability of the individual deswelling rate (slope). Subject age, sex, and ametropia were not predictors of individual corneal swelling in the swelling versus Dk/t analysis. Age, however, was a significant (inverse) predictor of the rate of corneal deswelling, only in lens-wearing eyes.

CONCLUSIONS: A large proportion of variability in corneal swelling is because of subject-specific differences in corneal response to hypoxia. This shows that "low swellers" and "high swellers" actually do exist.

Ng,A. Y., Keech,A., Jones,L. Tear osmolarity changes after use of hydroxypropyl-guar-based lubricating eye drops Clinical Ophthalmology 2018;12:695-700 [ Show Abstract ]

Purpose: To evaluate tear osmolarity after using a hydroxypropyl-guar (HP-guar)-based lubricating eye drop four times daily (QID) for 3 weeks. Methods: Thirty-one participants with dry eye disease (Ocular Surface Disease Index [OSDI] score ≥20 and tear osmolarity ≥300 mOsm/L in at least one eye) were enrolled in this prospective, dispensing, non-randomized study involving a baseline visit and 3‑week follow-up. Tear osmolarity, non-invasive tear break up time (NITBUT), conjunctival hyperemia, corneal and conjunctival staining were determined at baseline. Participants were instructed to instill one drop of a HP-guar-based drop QID in each eye for 3 weeks. At the follow-up visit, the symptoms and ocular surface parameters were reassessed. At this visit, one HP-guar drop was instilled into each eye and osmolarity was measured after 15 minutes, to examine short-term changes in osmolarity. Results: Twenty-eight participants completed the study (5M, 23F; median age 54 yrs, range 25-83 yrs). At baseline, mean OSDI score was 44.9±15.2 and mean osmolarities were 314.63±11.9/306.6±10.1 mOsm/L (worst eye [WE]/better eye [BE]). After 3 weeks, mean osmolarity reduced to 307.7±15.7/303.9±11.3 mOsm/L (WE/BE; p<0.05 and p=0.228, respectively) and mean OSDI scores reduced to 28.3±17.0 (p<0.01). A significant reduction in osmolarity was observed 15 minutes after instilling the lubricating drop (p<0.05 WE, p=0.09 BE). Significant improvements in central corneal staining (p<0.05 OU) and NITBUT (p<0.05 WE only) were observed. Reductions in conjunctival staining and hyperemia were observed, but were not significant (p>0.05). Conclusions: A significant reduction in tear osmolarity and improvements in dry eye symptoms, corneal staining, and NITBUT were observed after 3 weeks of QID use of a HP-guar-based lubricant drop. A decrease in osmolarity was also demonstrated 15 minutes after drop instillation.

Ngo,W., Jones, L., Bitton, E. Short-Term Comfort Responses Associated With the Use of Eyelid Cleansing Products to Manage Demodex folliculorum Eye and Contact Lens 2018;44(Suppl 2):S87-S92 [ Show Abstract ]

PURPOSE: To quantify the discomfort over time of various eyelid cleansers against Demodex.
METHODS: This was a prospective, randomized, controlled, crossover, open-label study that enrolled 26 participants. The cleansers used in this study were Biotissue Cliradex (CD), OCuSOFT Lid Scrubs Plus (OP), OCuSOFT OUST Demodex Swabstix (ODS), TheraTears Theralid (TT), NovaBay Avenova (NA). Bausch+Lomb Sensitive Eyes Plus saline was used as a control. Participants were asked to close their eyes as the product was gently rubbed (10 cycles of gentle lateral motion) into the eyelashes. Participants verbally rated their discomfort (0 = no discomfort, 10 = maximum tolerable discomfort) every 15 sec for the first 5 min, and every 30 sec for 5 min after, for a total of 10 min. The order of products used was randomized, and washout period between cleansing was 48 hr.
RESULTS: Twenty-five participants completed the study (mean age=26±6). There was no significant difference in discomfort scores at pre-application. The discomfort levels of saline, OP, and NA over the 10-min period were not significantly different than their pre-application discomfort at all time points (all P≥0.99). The discomfort of CD was significantly higher than pre-application levels between t=15 sec and t=180 sec (all P≤0.01), with maximum median (interquartile range [IQR]) discomfort of 3.0 (5.0) occurring at t=45 sec. The discomfort of TT was significantly higher than pre-application levels between t=45 and t=90 (all P<0.02), with maximum median (IQR) discomfort of 1.0 (1.5) occurring at t=75 sec. The discomfort of ODS was significantly higher than pre-application levels starting from t=60 sec and onward, with maximum median (IQR) discomfort of 6.0 (5.0) occurring at t=300 sec.
CONCLUSION: Of the cleansers used in this study, the ones that induced significant discomfort were CD, TT, and ODS. The results from this study may help clinicians educate patients about what to expect when approaching the topic of eyelid Demodex treatment.

Ngo,W., Srinivasan,S., Jones, L., A comparison of dry eye diagnostic tests between symptomatic and asymptomatic age-matched females Eye and Contact Lens 2018;44(Suppl 1):S110-S114 [ Show Abstract ]

PURPOSE: To quantify the strength of association of dry eye (DE) symptoms to DE diagnostic tests in age-matched females.
METHODS: Twenty females with DE symptoms (Ocular Surface Disease Index, OSDI, ≥13) were age-matched with 20 females without DE symptoms (OSDI<13) in this cross-sectional study. Noninvasive tear breakup time (NIBUT), ocular staining, meibum quality, number of obstructed meibomian glands (MGs), lid wiper epitheliopathy, Marx line placement, eyelid margin score, Schirmer test, meibography, and visual acuity were assessed in both groups.
RESULTS: Twenty participant pairs completed the study. The age (median/interquartile range [IQR]) of the symptomatic group was 60/15 and the asymptomatic group was 62/15. The tests (median/IQR, P value) that were significantly different between the symptomatic group and the asymptomatic group were OSDI (35.4/35.4 vs. 3.1/6.7, P<0.01), NIBUT (2.1/0.7 sec vs. 3.0/3.0 sec, P=0.01), meibum quality (3.0/0.0 grade units vs. 2.0/1.0 grade units, P<0.01), number of obstructed MGs (7.0/2.0 glands vs. 5.0/4.8 glands, P<0.01), and ocular staining (5.5/3.8 grade units vs. 0.5/1.0 grade units, P<0.01). The tests (area under curve, [AUC], odds ratio [OR]) that were most strongly associated with DE symptoms were ocular staining (0.93, 5.0), number of obstructed MGs (0.79, 2.6), meibum quality (0.76, 2.4), and NIBUT (0.74, 3.2) (all P<0.05). There was no significant difference between the two groups for the other DE tests (all P>0.05), and similarly, no significant association to DE symptoms (all P>0.05).
CONCLUSION: The diagnostic tests most strongly associated with DE symptoms in older women were ocular staining, meibum quality, number of obstructed MGs, and tear film stability.

Ngo,W., Srinivasan,S., Jones,L. An Eyelid Warming Device for the Management of Meibomian Gland Dysfunction J Optom 2018;Epub ahead of print [ Show Abstract ]

PURPOSE: To determine the effectiveness of the MGDRx EyeBag in managing meibomian gland dysfunction.

METHODS: This was a prospective, randomized, controlled, observer-masked, bilateral eye study that enrolled 29 participants. Participants were randomized into either the EyeBag group or the control group. The EyeBag group used the EyeBag 10minutes 2x/day, and the control group remained on their own dry eye treatment regimen (if applicable). All participants were observed at baseline, 2 weeks (2wk) and 4 weeks (4wk). At 4wk, participants in the EyeBag group were asked to stop using the EyeBag. All participants were seen again at 8 weeks (8wk). Primary outcomes were the Ocular Surface Disease Index (OSDI), Current Symptoms Questionnaire (CSQ), meibomian gland score (MG score), and non-invasive tear breakup time (NIBUT).

RESULTS: Twenty-five participants completed the study (mean age 38±15 years, 7 male). There was a significant change in OSDI over time for the EyeBag group (mean[lower 95% CI, upper 95% CI], baseline: 39.1[31.1,47.0], 2wk: 26.8[19.7,33.9], 4wk: 26.6[16.5,36.7], 8wk: 27.7[18.4,37.0]; p=0.01), but not in the control group (p=0.22), but no significant difference between groups at all time points (all p>0.27). Symptoms immediately improved after conducting the EyeBag based on at-home CSQ scores (Δ=-5.0 points, p<0.01), but not in the control group. For both groups, there was no significant change (p-value EyeBag,p-value control) in MG score (0.21,0.17) and NIBUT (0.49,0.06) over time.

CONCLUSIONS: The EyeBag may relieve symptoms of dry eye, but the effect on meibomian gland function and tear stability when used for only 4 weeks was undetectable.

Oh,S., McCanna,D., Subbaraman,L.N., Jones,L. Cytotoxic and inflammatory effects of contact lens solutions on human corneal epithelial cells in vitro Contact Lens and Anterior Eye 2018;41(3):282-289 [ Show Abstract ]

Purpose: To ascertain the effect that four contact lens (CL) multipurpose solutions (MPS) have on the viability and release of pro-inflammatory cytokines from human corneal epithelial cells (HCEC). Methods: HCEC were exposed to four different MPS at various concentrations for 18 hours. The cells were also exposed to phosphate buffer, borate buffer, and PHMB. The cell viability was evaluated using the alamarBlue assay. The release of pro-inflammatory cytokines was measured using a Multiplex electrochemiluminescent assay. Results: MPS-A, MPS-B and MPS-C all reduced cell metabolic activity p < 0.05 from control with MPS-A showing the greatest cytotoxic effect (maximum reduction, 90.6%). In contrast, MPS-D showed no significant reductions in cytotoxicity except at the highest concentration tested (19% reduction at 20% MPS concentration). Of the four cytokines evaluated MPS-C showed a substantial increase in the release of IL-1β, IL-6, IL-8, and TNF-α at higher concentrations when compared to control p < 0.05. At the 20% concentration of MPS-A and MPS-B the release of IL-1 β increased p < 0.05 but the release of IL-6, IL-8, and TNF-α decreased. MPS-D did not cause a change in the release of cytokines IL-1β, IL-6, IL-8 and TNF-α p > 0.05. Exposing the cells to borate buffer and PHMB caused an increase in the release of TNF-α p < 0.05. Conclusions: This investigation demonstrates that at different concentration levels, several of the MPS tested showed a decrease in viability and an increase in the release of inflammatory cytokines from HCEC. The borate buffer component as well as PHMB appears to contribute to this pro-inflammatory reaction.

Omali,N.B., Subbaraman,L.N., Heynen,M., Ng,A. Y., Coles-Brennan,C., Fadli,Z., Jones,L. Surface versus bulk activity of lysozyme deposited on hydrogel contact lens materials in vitro Contact Lens and Anterior Eye 2018;41(4):329-334 [ Show Abstract ]

Purpose: To determine and compare the levels of surface versus bulk active lysozyme deposited on several commercially available hydrogel contact lens materials. Methods: Hydrogel contact lens materials [polymacon, omafilcon A, nelfilcon A, nesofilcon A, ocufilcon and etafilcon A with polyvinylpyrrolidone (PVP)] were incubated in an artificial tear solution for 16 h. Total activity was determined using a standard turbidity assay. The surface activity of the deposited lysozyme was determined using a modified turbidity assay. The amount of active lysozyme present within the bulk of the lens material was calculated by determining the difference between the total and surface active lysozyme. Results: The etafilcon A materials showed the highest amount of total lysozyme activity (519 ± 8 μg/lens, average of Moist and Define), followed by the ocufilcon material (200 ± 5 μg/lens) and these two were significantly different from each other (p < 0.05). The amount of surface active lysozyme on etafilcon and ocufilcon lens materials was significantly higher than that found on all other lenses (p < 0.05). There was no active lysozyme quantified in the bulk of the nelfilcon material, as all of the active lysozyme was found on the surface (1.7 ± 0.3 μg/lens). In contrast, no active lysozyme was quantified on the surface of polymacon, with all of the active lysozyme found in the bulk of the lens material (0.6 ± 0.6 μg/lens). Conclusions: The surface and bulk activity of lysozyme deposited on contact lenses is material dependent. Lysozyme deposited on ionic, high water content lens materials such as etafilcon A show significantly higher surface and bulk activity than many other hydrogel lens materials.

Otchere,H., Jones,L., Sorbara,L. The Impact of Scleral Contact Lens Vault on Visual Acuity and Comfort. Eye and Contact Lens 2018;44(Suppl 2):S54-S59 [ Show Abstract ]

PURPOSE: To assess how varying degrees of corneal clearance of scleral contact lenses (ScCL) impact visual acuity (VA) and comfort in patients with corneal ectasia.
METHOD: Three ScCL were fitted to 20 subjects with previous diagnosis of either keratoconus (n=18) or pellucid marginal degeneration (n=2). Fitting of ScCL was based on corneal sagittal height (CSH) measured with Visante OCT at a 15-mm chord on the horizontal meridian. To select the ScCL from the diagnostic lens set, values of 325, 375, and 425 μm were randomly added in sequence to CSH. Subjects wore ScCL for 1 hr. Central corneal clearance (CCC) and topographic corneal clearance (TCC) along the vertical meridian were assessed using an ultralong optical coherence tomographer. High-contrast VA (HCVA) and low-contrast VA (LCVA) were measured using a logarithm of the minimum angle of resolution VA chart, and comfort ratings were obtained with a standard comfort scale (0-100).
RESULTS: Mean CSH in the horizontal meridian was 3.78±0.53 (range: 3.33-4.17) mm at a 15-mm chord. Mean CCC was 190±100 μm (TCC: 160±94 μm at +3 mm and 180±94 μm at -3 mm), 360±120 μm (TCC: 260±100 μm at +3 mm and 330±110 μm at -3 mm), and 450±170 μm (TCC: 320±120 μm at +3 mm and 400±120 μm at -3 mm) for each lens (P=0.001). Mean HCVA for lenses 1, 2, and 3 were 0.05±0.12, 0.07±0.11, and 0.11±0.08 respectively, which were significantly different (P=0.02). Tukey post hoc analysis showed that this difference was only significant between lenses 1 and 3 (P=0.01). Similar findings were found for LCVA. Comfort ratings for lenses 1, 2, and 3 were 74.9±9.2, 79.7±11.6, and 78.6±10.8, respectively (P=0.24).
CONCLUSION: The CSH is an effective method of determining the appropriate lens/cornea relationship. Lens 2 (+375 μm) gave the best combination of acuity and comfort ratings. Evaluation of the fluorescein pattern must be balanced with VA and comfort ratings for successful fitting in a clinical setting.

Phan,C. -M, Walther,H., Riederer,D., Lau,C., Lorenz,K. O., Subbaraman,L. N., Jones L. Analysis of polyvinyl alcohol release from commercially available daily disposable contact lenses using an in vitro eye model J Biomed Mater Res B Appl Biomater 2018;Epub ahead of print [ Show Abstract ]

The purpose of this work was to determine the release of polyvinyl alcohol (PVA) from etafilcon A, omafilcon A, and nelfilcon A daily disposable hydrogel contact lenses using a novel in vitro model. PVA is an ocular lubricant that can be found in multiple formulations of artificial tears. Nelfilcon A innately contains PVA, so only the release of PVA from this lens was evaluated. Etafilcon A and omafilcon A lenses were incubated in a PBS solution containing PVA. The release of PVA was evaluated using a novel in vitro blink platform with Milli-Q water and PBS under various blink conditions and flow rates. Nelfilcon A lenses significantly released more PVA than other lenses at 0.5 and 1.5 h in both PBS and Milli-Q water (p < 0.001). For nelfilcon A, there was no statistical significance between the release profiles of PVA between the blink and no-blink conditions, or for the various flow rates (p > 0.05). All tested groups and lenses showed a burst release within the first 4.5 h and rapidly plateaued thereafter. The current study demonstrates that releasable PVA (whether through uptake or through being inherently available from the material) is loosely bound on hydrogel lenses, and the majority is released within 4.5 h.

Phan,C. -M, Walther,H., Smith,R. W., Riederer,D., Lau,C., Lorenz,K. O., Subbaraman,L. N., Jones L. Determination of the release of PEG and HPMC from nelfilcon A daily disposable contact lenses using a novel in vitro eye model. J Biomater Sci Polym Ed 2018;Epub ahead of print [ Show Abstract ]

The traditional method to measure release of components from CLs is a vial containing a static volume of PBS (phosphate buffered saline). However, this model does not simulate physiologically relevant tear volume and natural tear flow, air exposure, and mechanical rubbing. These factors can significantly impact release kinetics. We have developed an in vitro eye model (OcuFlow) that simulates these parameters. The aim of the study was to measure the release of PEG (polyethylene glycol), and HPMC (hydroxypropyl methylcellulose) from a daily disposable hydrogel contact lens material (nelfilcon A; Dailies AquaComfort PLUS; DACP;) over 24 hrs using the OcuFlow platform. The elution of PEG and HPMC from DACP lenses was analyzed using LCMS (liquid chromatography mass spectrometry). The release of all wetting agents from the lenses followed a burst release pattern, which occurred within the first 1.5 hrs (P < 0.05). The release of PEG was greater than that of HPMC (P < 0.05). The amount of PEG and HPMC released at any given time was less than 1% of the amount in the blister pack solution. Our results suggest that HPMC and PEG are rapidly released from the CL.

Phan,C. -M, Weber,S., Mueller,J., Yee,A., Jones,L. A rapid extraction method to quantify drug uptake in contact lenses Translational Vision Science and Technology 2018;7(2):11 [ Show Abstract ]

Purpose: To develop a simple extraction procedure to quantify the uptake of four topical ocular pharmaceutical drugs into contact lenses (CLs). Methods: Four silicone hydrogel (SH) CLs (balafilcon A, senofilcon A, lotrafilcon B, comfilcon B) and four conventional hydrogel (CH) CLs (nesofilcon A, hilafilcon B, nelfilcon A, etafilcon A) were evaluated. The drugs studied were natamycin, moxifloxacin, timolol maleate, and ketotifen fumarate. For drug incubation, three CLs of each type were placed in 1 mL of 1 mg/mL drug-loading solution for 24 hours. The lenses were then extracted in 2 mL methanol for 2 hours. This process was repeated to obtain a total of three extraction cycles. Detection of natamycin, moxifloxacin, ketotifen fumarate, and timolol maleate were measured by absorbance at 305, 287, 297, and 295 nm, respectively. Results: The majority of the drugs were extracted after the first extraction cycle (P 0.05). Conclusions: This study provides a simple approach to determine drug uptake into CLs. This method can also be modified, such as changing the extraction time, extraction cycles, or extraction solvent to better suit other drugs and CL combinations. Translational Relevance: There is considerable interest in using CLs for ocular drug delivery. Accurately quantifying drug uptake on CLs has been a challenge. Hence, this study provides a simple method to quantify drug uptake in CLs. © 2018 The Authors.

Pucker,A. D., Jones-Jordan,L. A., Marx,S., Powell,D. R., Kwan,J. T., Srinivasan,S., Sickenberger,W., Jones,L., Contact Lens Assessment of Symptomatic Subjects (CLASS) Study Group Clinical factors associated with contact lens dropout Contact Lens and Anterior Eye 2018;Epub ahead of print [ Show Abstract ]

PURPOSE: Contact lens (CL) dropout is estimated to be approximately equal to the number of new wearers per year, resulting in virtually no growth in the global CL market. The purpose of this study was to determine ocular and CL factors associated with CL dropout.

METHODS: This five-site study recruited subjects 18-45 years of age who had ceased CL wear within the past 6-12 months due to discomfort. Dropout subjects were compared to age- and sex-matched currently successful CL wearers. Each subject was administered a symptoms survey and a study-specific survey that queried general CL history and compliance. Clinical testing included non-invasive tear break-up time, tear meniscus height, blepharitis assessment, meibum quality and expression, and meibography.

RESULTS: A total of 56 matched-pairs were recruited. Dry eye was found to significantly increase a subject's odds of dropping out of CLs. The odds of dropping out of CLs was also significantly increased with each worsening grade of upper or lower eyelid meibomian gland (MG) plugging, upper eyelid meibum quality, and upper eyelid MG tortuosity. No other factors analyzed increased a subject's odds of dropping out of CLs.

CONCLUSIONS: CL dropout may be precipitated by underlying dry eye symptoms, though most dry eye signs, with the exception of MG structure and function, had minimal predictive value for CL dropout. Nevertheless, evidence suggests that practitioners should screen for and educate CL patients about the importance of maintaining healthy MGs, which may potentially allow them to maintain comfortable CL use and increase their CL longevity.

Qiao,H., Phan,C. -M., Walther,H., Subbaraman,L. N., Jones,L. Depth Profile Assessment of the Early Phase Deposition of Lysozyme on Soft Contact Lens Materials Using a Novel In Vitro Eye Model 2018;44(Suppl 2):S11-S18 [ Show Abstract ]

OBJECTIVE: To characterize the location of fluorescently labeled lysozyme on commercial contact lenses (CLs) using an in vitro eye model that simulates tear volume, tear flow, air exposure, and mechanical wear.
METHODS: One commercially available conventional hydrogel CL material (etafilcon A) and three silicone hydrogel CL materials (balafilcon A, lotrafilcon B, and senofilcon A) were evaluated in this study. The CLs were mounted on the in vitro eye model and exposed to artificial tear fluid containing fluorescein isothiocyanate (FITC)-labeled lysozyme for 2 and 10 hrs. After these short incubation periods, circular discs were punched from the CLs at the center and periphery and were prepared for confocal laser scanning microscopy (CLSM). The CLSM captured a series of consecutive images spaced 5 μm apart, and the resulting images were rendered into two dimensional cross-sectional views of the CL. The mean fluorescence at each 5 μm slice was used to generate a histogram depicting the penetration of FITC-lysozyme into CLs.
RESULTS: For both incubation periods, the CLSM images and histogram of etafilcon A showed that FITC-lysozyme is more concentrated at the lens surface, with a moderate amount of deposition in the lens matrix. For balafilcon A, FITC-lysozyme was evenly distributed throughout the lens. For lotrafilcon B, there was a greater amount of FITC-lysozyme deposition on the surfaces of the lens versus the matrix. Senofilcon A had differential FITC-lysozyme distribution profiles depending on the location of the lens. At the lens periphery, FITC-lysozyme primarily deposited on the surface, whereas FITC-lysozyme was uniformly distributed at the center of the lens.
CONCLUSIONS: With the use of a sophisticated in vitro eye model, the study revealed a complex deposition pattern of FITC-labeled lysozyme on various CL materials after short periods of exposure. An understanding of the early deposition pattern of lysozyme on different CL material may elucidate new insights into the processes behind CL discomfort.

Stahl,U., Jalbert,I. Exploring the links between contact lens comfort, osmolarity and lid wiper staining Contact Lens and Anterior Eye 2018;41(1):110-116 [ Show Abstract ]

Purpose Contact lens discomfort remains poorly understood, not least due to lack of associations between clinical signs and symptoms. This study aimed to explore the relationships between osmolarity, comfort and lid wiper epitheliopathy in contact lens wear. Methods Twenty subjects participated in a randomized, cross-over study where comfilcon A and lotrafilcon A lenses were each worn for 10 days separated by a 7 days washout period. Tear and contact lens osmolarity, ocular symptoms including comfort, tear stability and production, and lid wiper epitheliopathy were measured. Results Comfort and tear stability decreased and upper lid wiper staining and foreign body sensation increased with lens wear. These were not affected by lens type. A reduction in tear production was seen after 10 days of comfilcon A lens wear. High proportions of lid wiper epitheliopathy were observed at the upper (range 65%–85%) and lower (range 90%–100%) lid margins. Tear and contact lens osmolarity were unaffected by lens wear or type. Contact lens osmolarity was associated with comfort (r = 0.45, p = 0.009). Tear osmolarity moderately correlated with tear stability (r = -0.53, p = 0.014) and tear production (r = -0.44, p = 0.012) but not with lid wiper staining. Conclusions A relationship between comfort and contact lens osmolarity and between tear osmolarity and tear stability and production were found, however, this study was unable to demonstrate an association between comfort and tear osmolarity or lid wiper epitheliopathy. Further studies using contact lenses with a wider range of comfort responses are warranted to investigate these associations further. © 2017 British Contact Lens Association

Wallerstein,A., Jackson,W.B., Chambers,J., Moezzi,A., Lin,H., Simmons,P.A Management of post-LASIK dry eye: a multicenter randomized comparison of a new multi-ingredient artificial tear to carboxymethylcellulose Clinical Ophthalmology 2018;12:839-848 [ Show Abstract ]

Purpose: To compare the efficacy and safety of a preservative-free, multi-ingredient formulation of carboxymethylcellulose 0.5%, hyaluronic acid 0.1%, and organic osmolytes (CMC-HA), to preservative-free carboxymethylcellulose 0.5% (CMC) in the management of postoperative signs and symptoms of dry eye following laser-assisted in situ keratomileusis (LASIK).
Methods: This was a double-masked, randomized, parallel-group study conducted in 14 clinical centers in Canada and Australia. Subjects with no more than mild dry eye instilled CMC-HA or CMC for 90 days post-LASIK. Ocular Surface Disease Index© (OSDI; primary efficacy measure), corneal staining, tear break-up time (TBUT), Schirmer’s test, acceptability/tolerability surveys, and visual acuity were assessed at screening and days 2, 10, 30, 60, and 90 post-surgery. Safety analyses included all enrolled.
Results: A total of 148 subjects (CMC-HA, n=75; CMC, n=73) were enrolled and assigned to receive treatment, and 126 subjects completed the study without any protocol violations. Post-LASIK, dry eye signs/symptoms peaked at 10 days. OSDI scores for both groups returned to normal with no differences between treatment groups at day 90 (P=0.775). Corneal staining, Schirmer’s test, TBUT, and survey results were comparable. Higher mean improvements in uncorrected visual acuity were observed in the CMC-HA group at all study visits, reaching statistical significance at day 30 (P=0.013). Both treatments were well tolerated.
Conclusion: CMC-HA-containing artificial tears relieved post-LASIK ocular dryness as well as CMC alone, and demonstrated incremental benefit in uncorrected vision, with a favorable safety profile. Results support use of CMC-HA eye drops to reduce signs and symptoms of ocular dryness post-LASIK.

Walther,H., Phan,C. -M., Subbaraman,L. N., Jones,L. Differential deposition of fluorescently tagged cholesterol on commercial contact lenses using a novel in vitro eye model Translational Vision Science and Technology 2018;7(2):18 [ Show Abstract ]

Purpose: We evaluate the differences in lipid uptake and penetration in daily disposable (DD) contact lenses (CL) using a conventional “in-vial” method compared to a novel in vitro eye model. Methods: The penetration of fluorescently labelled 22-(N-(7-Nitrobenz-2-Oxa-1,3- Diazol-4-yl)Amino)-23,24-Bisnor-5-Cholen-3beta-Ol (NBD)–cholesterol on three silicone hydrogel (SH) and four conventional hydrogel (CH) DD CLs were investigated. CLs were incubated for 4 and 12 hours in a vial, containing 3.5 mL artificial tear solution (ATS), or were mounted on an in vitro eye-blink platform designed to simulate physiologic tear flow (2 mL/24 hours), tear volume and “simulated” blinking. Subsequently, CLs were analyzed using laser scanning confocal microscopy and ImageJ. Results: Penetration depth and fluorescence intensities of NBD-cholesterol varied between the incubation methods as well as lens materials. Using the traditional vial incubation method, NBD-cholesterol uptake occurred equally on both sides of all lens materials. However, using our eye-blink model, cholesterol penetration was observed primarily on the anterior surface of the CLs. In general, SH lenses showed higher intensities of NBD-cholesterol than CH materials. Conclusions: The traditional “in-vial” incubation method exposes the CLs to an excessively high amount of ATS, which results in an overestimation for cholesterol deposition. Our model, which incorporates important ocular factors, such as intermittent air exposure, small tear volume, and physiological tear flow between blinks, provides a more natural environment for in vitro lens incubation. Translational Relevance: In vitro measurements of CLs are a common approach to predict their interactions and performance on the eye. Traditional methods, however, are rudimentary. Therefore, this study presents a novel in vitro model to evaluate CLs, which consequently will enhance elucidations of the interactions between CLs and the eye.

Walther,H., Subbaraman,L. N., Jones,L. Efficacy of Contact Lens Care Solutions in Removing Cholesterol Deposits From Silicone Hydrogel Contact Lenses. Eye & Contact Lens 2018;Epub ahead of print [ Show Abstract ]

PURPOSE: To determine the efficacy of multipurpose solutions (MPSs) on the removal of cholesterol deposits from silicone hydrogel (SH) contact lens materials using an in vitro model.
MATERIALS AND METHODS: Five SH lens materials: senofilcon A, comfilcon A, balafilcon A, lotrafilcon A, and lotrafilcon B were removed from the blister pack (n=4 for each lens type), incubated for 7 days at 37°C in an artificial tear solution containing C radiolabeled cholesterol. Thereafter, lenses were stored in a preserved saline solution control (Sensitive Eyes Saline Plus) or cleaned with 1 of the 5 MPSs incorporating different preservatives (POLYQUAD/ALDOX, polyquaternium-1/alexidine, polyquaternium-1/PHMB, and 2 based on PHMB alone) using a rub and rinse technique, according to the manufacturer's recommendations, and stored in the MPS for a minimum of 6 hr. Lenses were then extracted with 2:1 chloroform:methanol, analyzed in a beta counter, and μg/lens of cholesterol was determined.
RESULTS: Balafilcon A and senofilcon A lens materials showed the highest amounts of accumulated cholesterol (0.93±0.02 μg/lens; 0.95±0.01 μg/lens, respectively), whereas lotrafilcon A and lotrafilcon B deposited the lowest amounts (0.37±0.03 μg/lens; 0.47±0.12 μg/lens, respectively). For all lens materials, the MPS preserved with POLYQUAD/ALDOX removed more deposited cholesterol than any other test solution; however, the amount of removed cholesterol contamination from the individual contact lenses was only statistically significant for balafilcon A and senofilcon A (P=0.006 and P=0.042, respectively). Sensitive eyes and the other evaluated MPSs showed no significant effect on cholesterol removal (P>0.05).
CONCLUSION: Cholesterol-removal efficacy varies depending on the combination of lens material and solution. Only 1 MPS showed a statistically significant reduction of cholesterol deposit for only 2 of the 5 tested lens materials.

Walther,H., Subbaraman,L. N., Jones,L. Novel in vitro method to determine pre-lens tear break-up time of hydrogel and silicone hydrogel contact lenses 2018;Epub ahead of print [ Show Abstract ]

To develop an in vitro model to determine pre-lens non-invasive break-up time (NIBUT) and to subsequently use this method to compare the NIBUT over contemporary daily disposable (DD) contact lenses (CL).
Three silicone hydrogel (SH) and two conventional hydrogel (CH) DD CLs were incubated in an artificial tear solution (ATS). A model blink cell (MBC) was utilised to mimic intermittent air exposure. CLs were repeatedly submerged for 3 seconds (s) and exposed to air for 10 s over periods of 2, 6, 12, and 16 hours (h). NIBUTs (n = 4) were determined out of the blister pack (T0) and at the end of each incubation period.
Overall, nesofilcon A showed the longest NIBUTs (p < 0.001). At T0, CHs revealed significantly longer NIBUTs (p ≤ 0.001) than SHs. After 2 h, nesofilcon A showed the longest NIBUT, however, this was only statistically significant compared with delefilcon A (p ≤ 0.001). After 6 h, nesofilcon A NIBUT was significantly longer than all other CLs (p ≤ 0.001). Etafilcon A showed a significantly longer NIBUT (p ≤ 0.001) after 12 h and delefilcon A had the longest NIBUT (p ≤ 0.001) after 16 h. Statistically significant (p ≤ 0.05) changes of NIBUT within the lens materials varied between time points. After 16 h, all CLs showed significant reductions in NIBUTs (p ≤ 0.001) in comparison to T0.
NIBUT values reduced gradually over time and varying levels of deposition impacted measured pre-lens NIBUTs. While NIBUT of CH materials are longer immediately out of the blister pack, after tear film exposure, the NIBUTs obtained using this methodology became very similar.

Wong,S., Murphy,P.J., Jones,L. Tear evaporation rates: What does the literature tell us? Contact Lens and Anterior Eye 2018;41(3):297-306 [ Show Abstract ]

Purpose: A previous literature review reported tear evaporation rates (TERs) from studies conducted on rabbits and humans between 1941 and 2003. Closer examination of the presented data revealed inaccuracies in the reporting of some values. This paper presents updated tables of TERs using values from the original papers cited in the review, in addition to incorporating new studies published between 2003 and 2016. Methods: A copy of each paper cited in the literature review was obtained and checked against the evaporation rate reported in the review. If the expected value could not be found in the cited paper, other papers by the same author were consulted to see if the value had been reported elsewhere. A PubMed and Scopus database search was conducted to find papers published on tear evaporimetry since 2003. Results: Two new tables of TERs were created, based on the values reported by the original author. To aid in interpretation, the majority of results are expressed in units of x 10−7 g/cm2/sec. Where it was not possible to convert these values, some values are expressed as x 10−7 g/sec, x 10−7 g/sec/eye or W/min. Conclusions: Two new tables of TERs have been compiled to provide an accurate representation of the values reported in the original papers. These tables can be used as a point of reference for other researchers to compare their results.

Wong,S., Srinivasan,S., Murphy,P.J., Jones,L. Comparison of meibomian gland dropout using two infrared imaging devices Cont Lens Anterior Eye 2018;Epub ahead of print [ Show Abstract ]

Purpose: To measure the degree of meibomian gland (MG) dropout in the lower eyelid determined by analysis of images obtained from the LipiView II (LVII) and the Keratograph 5M (K5M).

Methods: The inferior eyelid of each participant was imaged in a random order using both devices. All images were subjectively assessed by a single-masked investigator to determine the extent of MG loss using the Arita 4-point meiboscore grading scale. The images were also semi-objectively analyzed with ImageJ to calculate the percentage of MG dropout, by tracing around the non-glandular area and the total exposed area of the lower lid.

Results: Twenty participants (mean age 37 years, range 23–60, 60% female) completed the study. A significant difference in meiboscore (mean ± SD) was obtained between the LVII and the K5M (1.43 ± 0.78 vs. 1.90 ± 0.81, Z = 3.25, p = 0.001). The meiboscore 95% limit of agreement (LOA) ranged from −1.88 to +0.93. A significant difference was found with mean ImageJ percentage dropout between the LVII and the K5M (31.5% vs 43.4%, t = −4.8, p = 0.00003). The percentage dropout 95% LOA ranged from −42.79% to +19.06%.

Conclusions: LVII images had significantly lower meiboscores and less percentage MG dropout. Varying amounts of dropout were observed between the devices due the amount of eyelid that was typically everted and because of differences in image quality. These results indicate that these devices should not be used interchangeably to evaluate MG dropout.

Woods,J., Varikooty,J., Fonn,D., Jones,L. A novel scale for describing corneal staining Clinical Ophthalmology 2018;12:2369-2375 [ Show Abstract ]

The assessment of corneal staining is a commonly conducted procedure in both clinical practice and as part of various research studies. Different grading scales are employed by many clinicians and researchers to undertake this procedure for corneal staining comparisons between eyes, products and over time. This paper describes the development and use of a grading scale for corneal staining undertaken at an academic research site. The scale involves assessment of three factors across five corneal zones: type, area and depth. Staining type and area are graded on a 0–100 scale, and depth is graded on a 0–4 scale. These factors can be combined to create a three- or two-factor staining grade, or the factors may be reported individually. An additional benefit of this scale is that the staining scores may be reported by zone as “zone staining scores” or the scores of zones may be combined to provide an overall corneal “global staining score”.

Yang,M., Luensmann,D., Fonn,D., Woods,J., Jones,D., Gordon,K., Jones,L. Myopia prevalence in Canadian school children: A pilot study Eye 2018;32(6):1042-1047 [ Show Abstract ]

Purpose: A pilot study to determine the prevalence of myopia, proportion of uncorrected myopia and pertinent environmental factors among children in a suburban region in Canada. Methods: Refraction with cycloplegia and ocular biometry were measured in children of two age groups. Myopia was considered at a spherical equivalent refraction (SER) ≤-0.50 D in at least one eye. Parents completed a questionnaire that captured the child's daily activities. Results: A total of 166 children completed the study (83 aged 6-8 and 83 aged 11-13). Myopia prevalence was 17.5% among the overall group, 6.0% among ages 6-8 and 28.9% among ages 11-13. Mean subjective SER in myopic children was -1.10 D (95% confidence interval (CI), -0.34 to -1.86 D) at ages 6-8 and -2.44 D (95% CI, -1.71 to -3.18 D) at ages 11-13. In this study, 34.5% of the myopic children were uncorrected, which represented 6.0% of the entire group of children. Mean axial length (AL) increased by 1.03 mm from ages 6-8 (mean 22.62 mm; 95% CI, 22.45 to 22.79 mm) to ages 11-13 (mean 23.65 mm; 95% CI, 23.45 to 23.84 mm; p < 0.01). The correlation coefficient between AL and SER was -0.618 (p < 0.01). Binary logistic regression between outdoor time and the prevalence of myopia showed that one additional hour of outdoor time per week lowered the odds of a child having myopia by 14.3% (p = 0.007). Conclusion: Myopia prevalence increased from 6% at ages 6-8 to 29% at ages 11-13. Thirty-five per cent of the myopes in this study were uncorrected. More time outdoors may be beneficial to protect against myopia onset.