Contact lens technology is moving fast. On the immediate horizon are contact lenses embedded with augmented reality, contact lenses that slowly release medications, and telescopic contact lenses for people with low vision.
For optometrist David Foresto, owner of Advanced Optometry in Brisbane, this is incredibly exciting, however the main game remains to help everyday people see better.
It has to be said that David Foresto appears to be unflappable.
He works on some extremely delicate cases, speaks on stage at conferences and lectures – all with ease. So, when he told me that he was floored by a 10-year-old girl who announced that she’d like to grow up to be an optometrist, I wanted to hear all about it.
The little girl came to Mr Foresto as a patient when she was just three. Having had her crystalline lenses surgically removed due to damage caused by Marfans syndrome, she needed to be fitted with contact lenses.
Katie was the most difficult patient I’ve ever had to fit with contact lenses. She would scream whenever I got within a few metres of her. She did everything she could to stop me or her parents from being able to get a lens into her eye
Marfan syndrome affects the connective tissue that holds the body’s organs together and provides support to many structures. This inherited disorder affects one in 10,000 to 20,000 people,1 and when it comes to the eyes, can cause changes in shape, myopia, and the lens to break up and free float in the vitreous.
To say Katie* was a difficult patient in those early days was an understatement, yet given everything she’d been through, her behaviour was entirely reasonable.
“I’d fit a four-week-old baby with contact lenses any day over a three-year-old,” Mr Foresto said when recounting the story. “Katie was the most difficult patient I’ve ever had to fit with contact lenses. She would scream whenever I got within a few metres of her. She did everything she could to stop me or her parents from being able to get a lens into her eye.”
It took ingenuity and a lot of patience to win her over.
Realising that there was no way Katie’s parents would be able to change her lenses every day, Mr Foresto quickly changed strategy.
“Visual gain was super important but not at the risk of damaging Katie’s sense of security or trust in her parents. So, I made the call that we would swap her from a rigid daily into a weekly lens. When that was still too much, we went to a Bausch & Lomb 90-day custom made silicone lens with daily drops to reduce the risk of any infection.”
The decision meant Katie and her parents would visit Mr Foresto’s practice every three months to have her lenses changed.
“Between the three of us, we could get the lenses changed over quickly and she’d be on her way, but I was always perceived to be the bad guy. That was fine by me – it protected her trust in her parents, which in the end, was most important,” Mr Foresto explained.
Bad guy maybe, but the long-term benefits of this strategy were quickly realised. Within about two years Katie was able to change her own contact lenses. Today she wears soft daily contacts with glasses on top… and she plans to be an optometrist.
“I couldn’t believe it when she told me. I said, ‘what, are you telling me that after everything I’ve put you through, you want to do the same?’”
Like any young patient who expresses an interest in optometry, Mr Foresto advised Katie that while he believes contact lens practice is the best aspect of optometry – and while the opportunities to practise in this area are growing exponentially – it’s not for everyone.
“I think it’s great when any kid tells me they want to practise optometry. I always encourage them, but I suggest they look at all aspects of the profession, they get some work experience with a more mainstream practice, and seek out a spectrum of opinions.”
Three-year-old patients like Katie aren’t typical of those who come in through Mr Foresto’s doors for complex contact lens solutions. It’s mostly keratoconic adults, patients with corneal grafts, myopia control, and babies who’ve had eye surgery for cataract and trauma.
Mr Foresto describes providing each of these patients with vision as a “Fred Hollows” moment.
“I feel particularly fortunate. There are many eye health professionals working to maintain sight for people with diseases like glaucoma and macular degeneration. I have the great fortune of being able to return clear vision – to enable people to read again, to drive again, to see their grandchildren’s faces… and in the case of young children, to learn and grow with ease alongside other children their age.”
Surgery for babies with cataract typically occurs at around four-weeks-of-age, and contact lenses are required until the child is at least eight-years-old, at which point their eyeballs have grown enough to have intraocular lens implants.
“Once a baby has had their lenses removed, they have light perception only. When they are referred to see me, their eyes constantly flicker because they can’t see so there’s nothing to fixate on. After all these years, I can usually fit a contact lens pretty quickly and then I hand the baby back to the parents. Suddenly the baby can see. They stop crying and (sorry dads), they see their mother’s face and they stop looking around. Their vision locks on.
“Well before COVID I realised the importance of this moment and I started wearing a face mask. While it’s best for the health of the baby (since we work in such close proximity), the main thing I want to ensure is that my face is not the first face a baby sees.”
The gift of giving clear vision is one that could easily lead a person to develop an inflated sense of self, however in the university lectures he gives, Mr Foresto reminds optometry students that this is never appropriate.
Insisting that optometrists are simply the vector for clear vision he says, “We always need to remember that this is not about us. It’s the parents and the patient who are on this journey – and it can be long and highly stressful for them. I have patients who travel by road, plane, and train to be fitted with custom contact lenses and then they do it all again to return home. It’s nice to be part of making a difference to their lives.”
With fellow optometrists and ophthalmologists referring patients to Mr Foresto for custom contact lenses, he says compliance with followup appointments, and contact lens hygiene measures including daily lens replacement, is usually high.
“Patients who come via referral trust me from the start and, if they’re parents of babies or small children, they have a strong desire to do everything possible to care for the child’s vision. However, it can be difficult for some families – babies in foster care who are moved from home to home, and families with shared care arrangements can be more complex to manage. We do as much as we can to ensure the patient’s needs are taken care of.”
COLLABORATIVE CARE
While providing patients with clear vision is his greatest professional joy, Mr Foresto says the opportunity to work collaboratively with ophthalmologists is another source of professional satisfaction.
“Treating paediatric cataract patients necessitates a partnership between ophthalmologist and optometrist. They remove the cataract, and, because contact lenses aren’t an area they typically specialise in, it’s up to us to restore visual development.
“Sometimes I’ll be in the operating room to fit a contact lens, working alongside an ophthalmologist who is checking for glaucoma pressures – it’s a real team environment with mutual respect.”
These days Mr Foresto lectures on contact lenses to ophthalmology registrars. Initiated by registrars within the Royal Australian and New Zealand College of Ophthalmology (RANZCO), he says these lectures are an important opportunity to communicate the benefits of contact lens wear, provide information about contact lens hygiene, and reassure them about the extremely low risks of wear.
“Ophthalmologists can be risk averse to contact lenses, especially for children, and that’s partly because they see the tiny fraction of patients who have experienced problems. In reality, the superior outcomes of contact lens wear – in terms of clear vision, quality of life and the ability to participate in the community as a student or worker – in many cases far outweigh the risks.”
With major contact lens companies investing in extensive research and development, the numbers of people whose vision and quality of life can be improved by contact lenses is only going to grow. For Mr Foresto, this makes it increasingly important for ophthalmologists in training to gain an objective understanding of this technology early in their careers.
THE FUTURE
Mr Foresto says the most exciting aspect of contact lens research remains in vision correction – as our understanding of optics improves, it will be possible to squeeze better and better vision from these tiny pieces of plastic.
“Of all areas of contact lens development, I believe scleral lenses for keratoconus and patients who’ve undergone a corneal transplant remain the standout; continued material improvements that allow these patients to comfortably wear their contact lenses for 24 hours a day is the holy grail.
“But a huge step for all of humanity will be the evolution of augmented reality in contact lenses. This is a step that will merge biology with technology, and it will be society changing.”
Mr Foresto believes scleral lenses are the most likely vector for augmented reality – being highly customisable with a rigid structure, able to be used repeatedly, and thick enough to embed the technology.
“The concept of augmented reality contact lenses remains unfathomable for many; however, the advent of smart glasses and virtual reality goggles is providing us with an initial taste of the benefits it will provide.
“Much like driving a car with a heads-up display, once you get used to it, you can’t imagine being without the assistance and information that’s presented, and if you do drive a regular vehicle, you feel like you’ve gone backwards,” he commented.
But most importantly, for people with low vision, augmented reality contact lenses will enable optometrists to return usable sight to people with low vision by projecting images onto the remaining, functioning part of their retina – and, according to Mr Foresto, “that’s what we’re here to do”.
He believes optometrists will be perfectly positioned to grow their practices with this technology.
“I’m not sure whether they will be commercially available within my time as a practising optometrist, however they are coming, as are many fascinating contact lens technologies that will help our patients see better.”
Having first been drawn into contact lens practise by circumstance and now having fitted thousands of custom lenses, it’s easy to understand why Mr Foresto continues to draw the greatest satisfaction from this area of optometry.
*Patient name changed for anonymity.
Reference
- https://my.clevelandclinic.org/health/diseases/17209- marfan-syndrome
