12  Extended and Continuous
Wear Lenses
ERIC B. PAPAS, DEBORAH F. SWEENEY, DESMOND FONN and HELEN A. SWARBRICK
CHAPTER CONTENTS Introduction, 237
Historical Development,  237
Physiological Considerations in the Closed
Eye, 237
Soft Lens Materials for Extended Wear,  239
Wearer Selection, Lens Fitting and
Management, 240
Introduction
The concept of extended wear (up to 1 week) or continuous
wear (up to 1 month) holds considerable appeal for contact
lens wearers because it brings them close to the world of the
nonwearer. Being able to see clearly, all the time, without
glasses and not needing to worry about contact lens cleaning
and disinfection is a situation that would be attractive to
many of those with refractive errors. Nevertheless, the
numbers who currently adopt this modality are relatively
small. Across the globe in 2015, only around 8% of all soft
lens fits and 2% of RGP fits (excluding orthokeratology) were
for extended wear (Morgan et al. 2016). Although this figure
appears to have been reasonably stable for the last few years,
there are considerable regional variations. In Lithuania,
extended wear may account for as many as 25% of new fits,
whereas it is seldom used in countries such as Germany,
France or Japan.
The reasons for these contrasting behaviours are several
(Efron et al. 2012), but divergence in practitioner attitudes
and differing awareness of the potential risks are likely factors
(Keay & Stapleton 2008). Microbial keratitis (MK) is the
primary risk associated with lens wear, and sleeping whilst
wearing lenses is a major risk factor that has remained
unchanged despite the introduction of materials with suf-
ficient oxygen permeability (Dk) to eliminate the hypoxic
effects associated with hydrogel lenses (Stapleton et al. 2013).
Thus for overnight wear with soft lenses of any kind, around
1 in 500 users per year will suffer a corneal infection (Staple-
ton et al. 2008) – about the same risk as being robbed in
the USA (Szczotka-Flynn et al. 2009).
With this background, it is evident that practitioners
dealing with extended wear require an understanding of
the basic physiological processes contributing to the health
of the eye during eye closure, how these are modified by the
presence of a contact lens and the risks involved with over-
night wear. Before prescribing extended wear, key pieces of
information must be communicated to patients so that they
are fully aware of the risks involved and understand their
role in managing their ocular health.
This chapter aims to provide a summary of the current
status of extended wear so as to enable clinicians to
manage those who may be considering this contact lens
modality.
Complications, 242
Rigid Gas Permeable Lenses,  254
The Future for Extended and Continuous
Wear, 258
Fitting Rigid Lenses for Extended
Wear, 259
Dedication, 259
Historical Development (see
Section 8, History, available at:
https://expertconsult.inkling.com/)
Hydrogel lenses became available commercially in 1971, just
over a decade after the first report of the development of a
hydrophilic material suitable for contact lens applications
(Wichterle & Lim 1960). Initially used for daily wear, they
later were fitted as bandage lenses and worn continuously
to treat bullous keratopathy, recurrent corneal erosions,
corneal ulcers and perforation or dry eye syndromes (see
Chapter 26) (Gasset & Kaufman 1970, Dohlman et al. 1973,
Ruben 1976). At about the same time de Carle pioneered
development of high water content hydrogel lenses for con-
tinuous wear in non-therapeutic situations (de Carle 1972).
Weissman (1983) raised the issue of severe corneal com-
plications and in 1989 the FDA issued a recommendation
that extended wear should be for a maximum of six consecu-
tive nights. An understanding that extended-wear lenses
must transmit considerably more oxygen than daily wear
lenses in order to minimise disruption to corneal physiology
during eye closure led to more oxygen-permeable silicone
hydrogel lenses being developed in the late 1990s. These
gained approval for 30 nights of continuous wear in Australia
and Europe in 1999 and in the USA in 2001.
The global figure for extended-wear fits was around 8%
in 2016 (Morgan et al. 2016). About one-third of these
wearers were still using conventional hydrogel materials. In
2016, the FDA listed 6 RGP, 5 silicone hydrogel and over 25
hydrogel materials as approved for extended wear (FDA 2016).
Physiological Considerations in
the Closed Eye
OXYGEN AND CORNEAL SWELLING
When the eye is open, oxygen is supplied to the cornea
directly from the atmosphere (Smelser & Ozanics 1952, Hill
& Fatt 1964). At sea level, the concentration of oxygen in
the atmosphere is approximately 21%, corresponding to a
*kPa = kiloPascals, where 1 kPa = 7.5 mm Hg.
237