Tips for Applying Scleral Lenses
By Gregory W. Denaeyer, OD, FAAO
One of the most challenging aspects of scleral contact lenses is successfully applying them. Their relatively large diameter and their need for a pre-application saline reservoir make these lens designs relatively more difficult to apply for patients and practitioners alike. The following tips will help with this process.
If you are considering fitting scleral lenses, first assess whether a patient will be able to successfully apply them. Small apertures, deep sockets, tight lids, and blepharospasm tendencies are all characteristics that make applying large-diameter contact lens designs more difficult.
If you have some concerns, attempt to apply a diagnostic lens. The ease or difficulty of applying the diagnostic lens will give you some indication of your patients' future success with applying the lens themselves.
Once you have determined that a patient is a good scleral lens candidate, the following suggestions can help with lens application. Make sure the patient's face is parallel to the surface of the contact lens table to maximize aperture space. If the patient's face is at an angle, the lower lid is more likely to get in the way during application. Instruct the patient to fill the lens with saline all the way to its rim. This will ensure that the amount of saline wasn't underestimated and allows for mild spillage during application. If the patient continuously gets bubbles under the lens secondary to fluid loss, consider prescribing off-label use of Refresh Celluvisc (Allergan) to fill the lens. The relatively increased viscosity of Celluvisc reduces the tendency for spillage.
Some patients can balance a fluid-filled scleral lens on a tripod made with their thumb, index, and middle fingers. Alternatively, many patients prefer to use a large scleral plunger to hold the lens. The DMV Vented Scleral Cup (DMV Corp.) eliminates a step in the application process. Once the scleral lens is pushed onto the eye, patients do not need to release suction because of the open bulb design.
Patients are taught to fixate on the center of the plunger to ensure that the lens is applied to the center of the eye. Dalsey Adaptives (dalseyadaptives.com) makes a lighted plunger that may help improve fixation. The company also manufactures a stand that holds the plunger in an upright position. With the lens positioned on top, patients have both hands free as they lower their eye onto the lens (Figure 1).
Figure 1. Scleral application using a plunger with stand.
The EZi (Q-Case, Inc., ezibyqcase.com) scleral lens ring has a plastic applicator that patients wear on their finger. The lens is then balanced on the platform for application.
Depending on the patient, learning to successfully apply a scleral lens could take between five to 30 minutes. Fatigue becomes a factor after 30 minutes for most patients. If a patient was unsuccessful, let him take the lens home to practice, as long as he has demonstrated that he can successfully remove the lens. Alternatively, you can schedule another training session on a subsequent day.
If the patient has a caretaker, make sure to actively involve the caretaker in the training session. He may be helping the patient at home, especially if the patient has a physical disability. CLS
|Dr. DeNaeyer is the clinical director for Arena Eye Surgeons in Columbus, Ohio, and a consultant to Visionary Optics, B+L, and Aciont. You can contact him at email@example.com.|