Public awareness of scleral lenses is growing, and patients may soon be the ones initiating the conversation, especially those who are frustrated with their current experience in soft toric lenses. Clinical experience and early research supports the idea that new patient groups could benefit from wearing scleral lenses. So, let’s surge past some common causes for hesitation in fitting and prescribing scleral and mini-scleral lenses.
Why Not Give Them a Try?
Hesitation #1: They’re only for complicated corneas. While the majority of patients wearing scleral contact lenses are those who have irregular corneas, the Scleral Lenses in Current Ophthalmic Practice: an Evaluation (SCOPE) study reports that 10% of scleral lenses are being prescribed for patients who have uncomplicated refractive error (Nau et al, 2017). Those who have previously struggled with rotational stability in their soft toric lenses are great candidates for an upgrade into mini-scleral contact lenses. Mini-scleral lenses are similar in diameter to soft toric lenses, so they are less intimidating and easier to handle. The GP optics of scleral lenses will correct the majority, if not all, of their astigmatic error, and a front-surface toric scleral lens can be utilized to correct any remaining astigmatic error, if needed. The inherent stability of these large lenses provides a great base for toric optics, and the complaints of vision fluctuation due to a rotating lens will be long gone.
Hesitation #2: I don’t have time for them in my practice. Initially, the fitting of scleral and mini-scleral lenses was time consuming. Steps included trying on numerous diagnostic lenses until the most appropriate vault was determined, then waiting for the lens to settle to ensure complete corneal clearance. Thankfully, research and instrumentation allow us to select the most appropriate diagnostic lens within minutes and then predict lens settling to optimize chair time. Studies have shown average scleral lens settling ranges from 76 microns to 146 microns (Vincent et al, 2017; Caroline and André, 2012) and that over-refractions show minimal change after lens settling (Bray et al, 2017).
Prescribing mini-scleral lenses for high astigmatism does not have to take a lot of chair time. Many fitting sets have lenses with toric back surfaces as diagnostic lenses. This allows fitters to evaluate the alignment of the lens on the eye prior to ordering and to make any adjustments to over-refractive cylinder axis using the same LARS (left add, right subtract) rule as with soft toric lenses. Simply fit the lens to the eye, note the position of the toric lens markings, and order the lens with the desired sagittal depth and over-refraction.
Hesitation #3: They are too expensive. Practitioners are also hesitant to present the cost of scleral lenses to their patients. Explaining the customization options of the lens design will help patients understand their potential investment, like how smartphones can have preferred apps and settings while simple flip phones often have no ability for personal preferences. Patients who have a history of trying multiple toric lens brands may also be open to a lens design upgrade.
Some will be ready to commit to the best option immediately, others may need some additional resources to make their decision. It can be helpful to prepare your office with brochures, studies, or website recommendations. Those who elect to not go forward in the current year may make financial plans in the following year and present to your office ready to go at the next exam. Regardless of their decision, all patients who have acuity to gain deserve education about the latest contact lens technologies.
Mini-scleral lenses are a great option for patients looking to improve their lens-wearing experience. We should not let our previous hesitation regarding cost, chair time, and applicable patients discourage us from providing the best vision yet for our astigmatic patients. CLS
For references, please visit www.clspectrum.com/references and click on document #263.