Article

SCLERAL LENSES—A PRACTICE BUILDER

Adding scleral lenses can help distinguish a practice from its competitors.

Building a successful practice is both challenging and rewarding, especially because the healthcare landscape is constantly changing. Those who work in private practice are faced with growing competition from e-commerce and, more recently, apps that can perform online refractions.1 These issues are not going away, so to be successful in this competitive environment, practitioners must find a niche that attracts patients to their practices.

All practitioners share the goal of helping their patients. However, they differ in other goals and in how to achieve them. One way to compete is to offer something that is not available from every practice. The following facts are undeniable: 1) No two eyes are the same. 2) Each individual eye has its own unique shape and curvature, much like a fingerprint. 3) One size does not fit all.

Eye care and contact lenses, in particular, should be tailored to each patient’s needs, habits, and lifestyles. Therefore, the addition of scleral lens fitting and care to a practice offers a unique specialty niche and provides personalized and specialized eye care to a growing patient group. Physicians can use this model both to build their practices and to improve their patients’ lives.

INDICATIONS FOR USE OF SCLERAL LENSES

The literature lists 62 established indications for scleral lenses.2 As with early scleral shells, the primary indication for modern scleral lenses is corneal irregularity.3 Scleral lenses have also been beneficial in managing ocular surface dieases.4,5 Furthermore, scleral lenses can help protect and restore the ocular surface in lid or orbital disorders; can be used for refractive correction in otherwise normal, healthy eyes; and can be used as drug delivery devices.3,6,7 Scleral lenses can enhance visual quality and comfort4 and thereby improve quality of life.8 They can even reduce the necessity for penetrating keratoplasty in advanced keratoconus.9

Dry Eye Disease Dry eye disease is one of the most frequent reasons for visits to eyecare practitioners. Hundreds of millions of people in the world suffer from chronic dry eye disease; the reported prevalence with or without symptoms ranges from 5% to 50%.10 Based on signs alone, the prevalence is generally higher, reaching 75% in some populations.10 According to the Tear Film & Ocular Surface Society’s Dry Eye Workshop II (TFOS DEWS II), dry eye disease is characterized by tear film instability and hyperosmolarity, which leads to inflammation and eventual damage of the ocular surface (Figure 1).10 Consistent risk factors for dry eye disease include higher age, female sex, Asian race, meibomian gland dysfunction, connective tissue disease, Sjögren’s syndrome, computer use, contact lens wear, certain environmental conditions, and medication use.10

Figure 1. Severe diffuse superficial punctate keratitis resulting from dry eye disease.
Photos courtesy of Tom Arnold, OD

Dry eye disease can present in several different ways and also varies widely in severity. Dry eye can be caused by systemic conditions such as Sjögren’s syndrome, graft-versus-host disease, rosacea, lupus, or rheumatoid arthritis.10 According to recent research, scleral lenses are among the most effective ways of treating dry eye.11

Scleral lenses are custom-made for each patient and are fitted in a way to vault the cornea and maintain a constant reservoir of fluid between the lens and the cornea to ensure hydration. This protects the ocular surface from the environment and from the blinking friction induced by mechanical rubbing of the eyelids.

Ocular Surface Disease In eyes of patients who are suffering from extreme ocular surface disease, scleral lenses also have been successful in eliminating pain and light sensitivity.12 Sclerals are also considered an excellent option for those who are dealing with devastating dry eyes resulting from laser-assisted in situ keratomileusis (LASIK) surgery. Additionally post-LASIK corneas often have surgically-induced surface irregularities in addition to dry eye. Scleral lenses typically address both of these conditions extremely well. They improve the integrity of the corneal epithelium, vision-related quality of life, and visual acuity in patients who have ocular surface disease, especially in patients who could not tolerate corneal GP lenses.13,14

Irregular Corneas Patients who have irregular corneas and who have uncorrected vision or are wearing another type of lens are also excellent candidates for scleral lenses. A recent publication describes patients who are unable to tolerate or are not willing to wear corneal GP lenses; those patients reported major improvement in quality of life with scleral lenses.15 In fact, several other reports describe severe keratoconus patients who avoided corneal transplantation and obtained clear and comfortable vision—even 20/20—with scleral lenses.9,16

Because many patients need visual correction with scleral lenses following keratoplasty (Figure 2), a transplant can be delayed or completely avoided by determining whether scleral lenses alone can improve vision adequately.16 Patients who have secondary or acquired corneal ectasias, often following refractive surgery, may have mild-to-moderate corneal irregularities and/or ocular surface disease, such as dry eyes. Scleral lenses can also be considered in patients who have corneal scars and reduced visual acuity or other visual disturbances such as halos and glare. Other potential candidates include patients who have corneal degenerations or dystrophies.

Figure 2. A scleral lens on an eye following penetrating keratoplasty.
Photos courtesy of Tom Arnold, OD

Normal, Healthy Eyes There is also an emerging trend to use scleral lenses on patients who have normal and healthy eyes.3,7,17 They can even be used in the absence of ocular surface diseases, ectasias, or irregular corneas (Figure 3). These lenses can improve vision in patients who have normal, prolate corneas when compared to soft lenses. Because of their GP material, superior range of parameters, and stability, they can correct regular astigmatism better than other toric lenses can.18,19 Patients whose visual needs exceed soft lens parameters are particularly good candidates for this technology, which helps reduce visual distortions and higher-order aberrations.

Figure 3. A scleral lens on a normal cornea showing adequate central corneal clearance with fluorescein.
Photo courtesy of Tom Arnold, OD

Scleral lenses are designed to vault over the cornea and limbus, with minimal movement during blinks, making them more stable on the eye and ensuring exceptional comfort. When adequately stabilized, visual acuity also remains stable. Patients who have high refractive error, astigmatism, presbyopia, or any combination of these can do exceptionally well with scleral lenses.

Athletes are also good candidates for scleral lenses. The lenses maintain stability and do not dislodge like other lenses do. They also protect the eyes from debris and dust; one report even describes how scleral lenses protected against injury during a basketball game.20

If patients fall into any of these categories, sclerals may be right for them. An in-office demonstration can determine whether scleral lenses are the right fit, help first-time scleral lens wearers, and can correct any misconceptions.

Presbyopia Contact lens dropout is a phenomenon affecting all eyecare practices. Before the age of 40, the main culprit is comfort; after the age of 45, both comfort and vision play a role as presbyopia combined with tear film instability increase.21

Many innovative scleral lenses now offer the option to include multifocal optics in their design.22 The superior comfort and hydration that these lenses provide over both soft and corneal GP lenses can keep patients in contact lenses longer. Patients who have irregular or normal corneas can benefit from multifocal scleral lenses. Although fitting such lenses requires more time, laboratory consultants can be very helpful in achieving the best vision and comfort for patients.23

AN OPPORTUNITY

Scleral lenses are challenging to design and fit. But with online resources, webinars, workshops, and laboratory consultants, it is not difficult to become proficient in fitting scleral lenses. Once that proficiency is achieved, practitioners can specialize their practices around it. A variety of organizations offer resources for scleral lens education, including webinars, educational videos for both practitioners and patients, audio presentations, peer-reviewed research, frequently asked questions (FAQs), and practice tools for billing, coding, and insurance claims.

ATTRACTING SCLERAL LENS PATIENTS

Introducing scleral lenses to a practice can help attract new clients. Some of those clients who will wear scleral lenses are already established patients of the practice. Others will be referred by existing patients or will discover your practice through marketing material. Most, however, are referred by external practitioners. Scleral lenses can help build a practice, because they create strong networks and good relationships with other eyecare professionals, including cornea specialists,23 and thus create bridges between optometry and ophthalmology.24

In fact, some of the conditions treated by scleral lenses are so severe that some patients may already be followed by a specialist by the time that they arrive at your office.24 Although most eyecare practitioners are familiar with scleral lenses, many prefer to refer these cases to an experienced scleral lens practitioner, as they may not have the time, desire, or resources to fit them.24

Meeting these specialists and providing them with cards, referral folders, and other marketing materials can be a great way to demonstrate how the care of their patients can be optimized by establishing a collaborative relationship. Other providers whose patients may benefit from this collaboration include endocrinologists, oncologists, hematologists, rheumatologists, and otolaryngologists.

It is essential to communicate well with these collaborating eyecare providers by informing them about a patient’s visual acuity with scleral lenses, what type of follow-up care is recommended, and other relevant details.23 It is not uncommon for patients to see both their scleral lens practitioner and outside specialists multiple times. By working as a team, clinicians can provide better overall continued care and can generate new referrals.23 Collaborating practitioners who share their knowledge and expertise can benefit from and enjoy these partnerships and, more importantly, provide optimal care for their patients.24

A successful scleral lens practice often requires specialized equipment to provide corneal topography, corneal tomography, profilometry, anterior segment optical coherence tomography (OCT), anterior segment photography, specular microscopy, aberrometry, and lens/device monitoring with a radiuscope, loupe, and lensometer; these are all in addition to any basic primary care optometry equipment that is normally needed. Although many of the devices necessary for these services are costly, a successful scleral lens practice is often financially rewarding, as it can produce a strong interprofessional network and a loyal patient base.23

MARKETING THE PRACTICE

When building up a scleral lens clientele, advertising is important—especially outside of the practice. Asking grateful patients to provide testimonials is an easy and inexpensive form of advertising. These testimonials can have a powerful impact. If a patient agrees, photos or videos can be used to educate other patients in the office or can be posted online.23

Advertisements should target a specific demographic representing candidates for scleral lenses. Be sure to include keywords and content that is relevant to that demographic. Advertising can include print media (newspapers, journals, and magazines), television and radio, public displays on billboards or posters, websites, and social media (blogs, Facebook, Twitter, Instagram, and LinkedIn). Each avenue has its own associated costs.23

Published content can focus on scleral lens technology or new developments, ocular conditions, or a description of the practice, the practitioner, and staff. Sharing different topics can help increase a practice’s visibility online and help it grow its patient base; in turn, this can generate more scleral lens referrals.

It is important for a practice’s website to be esthetically pleasing, simple, easy to navigate, and, most importantly, discoverable. Both pay-per-click advertising and/or optimization on popular search engines can help increase a website’s visibility and attract potential patients to a practice’s website.23

Internal marketing or word-of-mouth is often the most effective form of advertising. Staff members can help identify good candidates for scleral lenses and initiate a discussion that complements the written or visual material found in the office. Office staff can also address questions or concerns raised by patients while they are in the office or through email and telephone inquiries.

CONCLUSION

Scleral lenses not only help build a practice but can also distinguish it from other practices. Fitting and designing scleral lenses is time-consuming but worthwhile. Many eyecare practitioners have no interest in pursuing this specialty. Others who are proficient in fitting corneal GP or hybrid lenses may have little or no experience in fitting scleral lenses.25 Specializing in scleral lenses can help those patients who have seen other practitioners but have not yet found an option that provides good comfort and vision.

Scleral lens expertise is a way to differentiate your practice from the thousands of others. Investing in networking and advertising can generate referrals and help your practice grow.

Scleral lens practitioners should continuously update their expertise in contact lens design and stay current on recent research so that they can provide their patients with optimal lens technology.

Be unique by helping people whom no one else can help, putting them first and showing passion and enthusiasm for scleral lenses. Your practice will thrive and grow. In his final column for Contact Lens Spectrum, Edward S. Bennett, OD, MSEd, said it best: “Patients deserve more than the simple option of receiving lenses from an available inventory.”26 CLS

REFERENCES

  1. Chirumbolo A. Opening a Private Optometry Practice — Everything You Need to Know. 2017 Jan 13. Available at https://newgradoptometry.com/opening-private-optometry-practice-everything . Accessed July 1, 2019.
  2. Fadel D, Kramer E. Potential Contraindications to Scleral Lens Wear. Cont Lens Anterior Eye. 2018 Feb;42:92-103.
  3. Tan DT, Pullum KW, Buckley RJ. Medical applications of scleral contact lenses: 1. A retrospective analysis of 343 cases. Cornea. 1995 Mar;14:121-129.
  4. Pullum KW, Whiting MA, Buckley RJ. Scleral contact lenses: the expanding role. Cornea. 2005 Apr;24:269-277.
  5. Pecego M, Barnett M, Mannis MJ, Durbin-Johnson B. Jupiter scleral lenses: the UC Davis eye center experience. Eye Contact Lens. 2012 May;38:179-182.
  6. Dubald M, Bourgeois S, Andrieu V, Fessi H. Ophthalmic Drug Delivery Systems for Antibiotherapy—A Review. Pharmaceutics. 2018 Mar;10:10.
  7. Nau CB, Harthan J, Shorter E, et al. Demographic characteristics and prescribing patterns of scleral lens fitters: the SCOPE study. Eye Contact Lens. 2018 Sep;44:S265-S272.
  8. Bhattacharya P, Mahadevan R. Quality of life and handling experience with the PROSE device: an Indian scenario. Clin Exp Optom. 2017 Nov;100:710-717.
  9. Koppen C, Kreps EO, Anthonissen L, Van Hoey M, Dhubhghaill SN, Vermeulen L. Scleral lenses reduce the need for corneal transplants in severe keratoconus. Am J Ophthalmol. 2018 Jan;185:43-47.
  10. Craig JP, Nelson JD, Azar DT, et al. TFOS DEWS II Report Executive Summary. Ocul Surf. 2017 Oct;15:802-812.
  11. Schornack MM. Scleral lenses: a literature review. Eye Contact Lens. 2015 Jan;41:3-11.
  12. Harthan JS, Shorter E. Therapeutic uses of scleral contact lenses for ocular surface disease: patient selection and special considerations. Clin Optom (Auck). 2018 Jul 11;10:65-74.
  13. Blackmore SJ. The use of contact lenses in the treatment of persistent epithelial defects. Cont Lens Anterior Eye. 2010 Oct;33:239-244.
  14. Bavinger JC, DeLoss K, Mian SI. Scleral lens use in dry eye syndrome. Curr Opin Ophthalmol. 2015 Jul;26:319-324.
  15. Picot C, Gauthier AS, Campolmi N, Delbosc B. Quality of life in patients wearing scleral lenses. J Fr Ophthlamol. 2015 Sep;38:615-619.
  16. Trattler B, Kramer E. Cross-Linking and Scleral Contact Lenses: First Steps in Treating Keratoconus. Ocular Surgery News. 2018 Oct 25. Available at www.healio.com/ophthalmology/cornea-external-disease/news/print/ocular-surgery-news/%7B0b01b5f0-ab7f-4730-8868-098fe3a05b28%7D/cross-linking-and-scleral-contact-lenses-first-steps-in-treating-keratoconus . Accessed July 1, 2019.
  17. van der Worp E, Bornman D, Ferreira DL, Faria-Ribeiro M, Garcia-Porta N, González-Meijome JM. Modern scleral contact lenses: A review. Cont Lens Anterior Eye. 2014 Aug;37:240-250.
  18. Michaud L, Bennett ES, Woo SL, et al. Clinical Evaluation of Large Diameter Rigid-Gas Permeable Versus Soft Toric Contact Lenses for the Correction of Refractive Astigmatism. A MultiCenter Study. Eye Contact Lens. 2018 May;44:164-169.
  19. Michaud L, Barriault C, Dionne A, Karwatsky P. Empirical fitting of soft or rigid gas-permeable contact lenses for the correction of moderate to severe refractive astigmatism: a comparative study. Optometry. 2009 Jul;80:375-383.
  20. Altman BA. Injury of a Mini-Scleral Contact Lens Wearer. Contact Lenses Today. 2013 Jan 20. Available at https://www.clspectrum.com/newsletters/contact-lenses-today/january-20,-2013 . Accessed July 1, 2019.
  21. Brujic M, Miller J. Minimizing Dropouts: What You Can Do. Rev Cornea Contact Lens. 2011 Mar 17. Available at https://www.reviewofcontactlenses.com/article/minimizing-dropouts-what-you-can-do . Accessed July 1, 2019.
  22. Barnett M. Multifocal scleral lenses. Contact Lens Spectrum. 2015 Dec;30:26-31. Available at https://www.clspectrum.com/issues/2015/december-2015/multifocal-scleral-lenses . Accessed July 1, 2019.
  23. Barnett M. Building a Scleral Lens Practice. Supplement to Contact Lens Spectrum. 2017 Oct. Available at http://www.clspectrum.com/supplements/2017/october-2017/scleral-lenses-advanced-fitting,-design,-and-trou/building-a-scleral-lens-practice . Accessed July 1, 2019.
  24. Arnold TP. Scleral Lenses Can Strengthen Bonds Between MDs and ODs. CollaborativeEYE. Available at https://collaborativeeye.com/articles/nov-dec-18/scleral-lenses-can-strengthen-bonds-between-mds-and-ods . Accessed July 1, 2019.
  25. Sorkin S. Comanagement of the Specialty Contact Lens Patient. CollaborativeEYE. Available at https://collaborativeeye.com/articles/nov-dec-18/comanagement-of-the-specialty-contact-lens-patient . Accessed July 1, 2019.
  26. Bennett ES. Building Your Practice with GP Lenses: The Final Word. Contact Lens Spectrum. 2018 Oct;33:15. Available at https://www.clspectrum.com/issues/2018/october-2018/gp-insights . Accessed July 1, 2019.