What got you interested in hard to fit lenses and kind of getting into scleral fittings?
The reward. That's very rewarding to put somebody with a lens that that has no other way of seeing. So it's nice to put a lens on somebody and have them seen the best they've seen in years and just see their reaction and how much it improves their lives.
Do you have a story of a patient who was fitted with scleral lenses that come to mind?
One guy had a really bad Corneal scar in one eye from keratoconus and couldn't see out of that eye. And, then he had a corneal transplant in the other eye and just had struggled to see - period - out of glasses or anything. I got him fit up in a contact lens, and he was just visibly emotional about how well he could see. He was one of my first fits here. I remember I kind of got started with the process sooner because of him because I knew I had this guy who needed some help. So, I started sooner than I normally would have. But it was well worth it. He was very happy.
You mentioned keratoconus and corneal scarring which definitely is part of people who are candidates for scleral lenses. Would you say there are other signs?
Yes. Any type of corneal disorder, irregular astigmatism. I fit high astigmats as well. For a lot of those it's harder to fit a soft lens on a high astigmat, and while it's getting to be easier, it's still not great. The scleral lenses mask a lot of the corneal cylinder so it usually ends up with a lot more stable clear vision than a soft lens for people, who even just that have high amounts of astigmatism that aren't related to a corneal condition. Dry eyes is a big one. People who suffer from dry eye tend to benefit from scleral lenses especially if it's a severe dry. They can wear their lenses longer and they're more comfortable. A big one that I've been doing lately is multifocal scales. For people who have been unsuccessful wearing soft contact lens multifocal. I've successfully changed a couple of those over to the scleral lens multifocal. I think it's the same kind of principle how scleral lenses masking small amounts of astigmatism and irregularities on the front of the eye. Getting rid of those higher-order aberrations and altogether helps improve the success rate interesting.
Makes a lot of sense because people over 40 have a harder time wearing standard multifocal lenses because of dryness, improper fit, or discomfort.
Especially with the stigmatism. Anybody that has over three-quarters of astigmatism tend to do a lot better with a sclera multifocal than you can do with like a toric soft multifocal lens.
Some practices push purchasing contact lenses like dailies, especially for bifocal multifocal because of their convenience. But of course, with these kinds of things, there's no insurance to cover them, typically. Are scleral lenses different? Or do they kind of have the same price points like soft lens multifocals? Or is it still a little more expensive for the higher quality?
It's still a little more expensive. Although, I don't know. If you were to compare apples to apples. If somebody were in a soft toric multifocal, I think the prices would actually come out more similar than you'd expect.
So, while the expense is higher for sclerals, but they don’t they provide vision similar to LASIK?
Yes, that’s true.
Some say the insertion of scleral lenses are trickier because they’re much better lenses. Are your lenses custom designed? If so, how do you go about the fitting? Maybe provide a basic outline.
Well, it depends. If it's more regular or a mild care keratoconic fit, then they're not technically custom designed, but we've got a fitting set that I'll try on their eyes. From there, I'll order a lens based on the parameters of what I would I see on their eye, and what I'm measuring in there over refraction. I call the company and order based on that information. The more advanced keratoconus require a more of a customized customizable lens. This way, I can change all kinds of things on them. I still have a fitting set for that, but there's more room for adjustments.
Do you use a certain technology to get those measurements?
We have a topographer, A corneal topographer that helps quite a bit to see the lay of the cornea and sclera. That's big for these.
Do you find that scleral lens are basically the main thing you'll prescribe for keratoconus, or do you have other methods as well?
There are other methods if it's mild keratoconus. You can a lot of time to get by with a small RGP lens. There are hybrid lenses. We do some of those and some of our patients are doing well with the hybrid lenses. But, I think in the long run or from what I've seen, scleral lenses are much healthier. Now that we've been fitting scleral lenses for almost two years now, I tend to go to the scleral lenses a lot sooner than I normally would.
My last question is more for just a basic one. How do you think the process is to get started with scleral lenses for a patient? Do you think they find it rather straightforward? Difficult? Varies?
It varies. Depends on the patient. If they’re a long time soft contact lens and they're not really squirmish about putting things in their eyes, they tend to pick it up pretty quickly. There are a couple more steps in the process of taking them in and out, but most of them that have been successfully fit are very happy with the process. Once I get used to it, it's fine, and like I said, people that have had contact lens experience in the past, tend to do pick it up a lot quicker. I've had a couple of patients who had never really worn contacts before, so it was a little tough at first. But, most of those have really taken to it and done really well. When they're seeing so well, and their eyes are so much more comfortable than what they tried in the past, they tend to fight through it & do well.
Is it one of those things you start and never go back?
Yes, that's been my experience so far. They start, and they're successful. Especially keratoconics. I think when you have the smaller RGPs on the keratoconus patients. they can see well a lot of times, if it's not too bad of keratoconus. But, in the long-term, there could be scarring on the cornea. The same with the hybrid lenses. I feel like I see a lot more corneal neovascularization with them in the long run.
Right. Some practices like to try techniques like piggybacking and other methods before they start sclerals to get results. But, sounds like scleral lenses are certainly one of the better options. Well, this was great! Thank you so much!
My pleasure. I appreciate it.