"Loyal and efficient work in a great cause, even though it may not be immediately recognized, ultimately bears fruit." Jawaharlal Nehru
Many thanks for your overwhelming support of the last month’s Scleral Lens Monthly – Scleral Efficiencies. Based on your feedback, I asked additional scleral lenses experts for their words of wisdom.
Based on studies of scleral topography, rotationally asymmetric designs are frequently required to approximate the alignment of the landing zone with the sclera. At this time, many scleral lens designs are available with back surface toric designs. Dr. Jennifer Harthan recommends the use of toric haptics. "Toric haptics allow the lenses to land more precisely and evenly on the sclera, allowing for aligned fits, improved comfort and health, and reduced fogging." Dr. Edgar Davila-Garcia advises to customize a diagnostic fitting set to include multiple lenses with toric haptics. He suggests having a diagnostic fitting set with more lenses (for example 40 instead of 10 lenses) to improve the probability of getting the precise lens the first time. Dr. Pam Satjawatcharaphong, current Scleral Lens Society President, also recommends the use of back surface toricity. "While having a scleral mapping device can certainly make designing the haptic more accurate and efficient, not everyone has access to this technology. Since studies have shown most people have some scleral toricity, do not be afraid to use a toric lens right off the bat if you see edge alignment/misalignment issues during the diagnostic fitting and slit lamp evaluation."
The appropriate time needed for scleral lens settling is a hot topic. Dr. Heidi Miller recommends that once an ideal lens is found for both eyes, "I leave the patient in the room and go see another patient allowing more settling time before doing the over-refraction and final assessment of the fit." By doing this, she obtains a more accurate assessment lending to decreased future changes and fewer follow up appointments. Dr. Harthan recommends allowing lenses to settle for at least 30 minutes prior to performing an over-refraction. This will cut down on future re-makes. Dr. Davila-Garcia recommends to always have the patient wear the diagnostics lenses for a least 30 minutes or even one hour which is ideal. He states that it is "always better to have your patients stay a little longer than they would like at the fitting session to obtain good observations than having to bring them back multiple times because of indispensable lenses."
For new scleral lens wearers when patients are intimidated from a large lens and large plunger, Dr. Daddi Fadel, current Euro & Austral-Asian Scleral Lens Academy President, recommends to "use a smaller plunger for lens application," which is more approachable.
Credit for images, Dr. Daddi Fadel.
An expert scleral lens removal tip from Dr. Fadel: For more efficient scleral lens removal in cases of scleral toricity or irregularity, Dr. Fadel recommends identifying the meridian or quadrant where the lens is more lifted off and apply the removal plunger in that area to ease lens removal. For example, in with the rule toricity, place the plunger in the vertical meridian. In against the rule toricity, apply the plunger in the horizontal meridian.
Wise words from Dr. Harthan, "Regardless of what type of condition a patient is being fit for with a scleral lens, it is imperative to control their expectations, communicate with their co-managing providers, and have a solid grasp on their underlying systemic/ocular conditions. We should modulate scleral lens wear based on individual corneal characteristics and response to wear."
Dr. Barnett is a principal optometrist at the University of California Davis Eye Center in Sacramento, specializing in anterior segment disease and specialty contact lenses. She is the past president of the Scleral Lens Education Society. She is an advisor to and/or has received honoraria or travel expenses from AccuLens, Alcon, Alden Optical, Allergan, Bausch + Lomb, Bruder, Contamac, CooperVision, EveryDay Contacts, Johnson & Johnson Vision, Ocusoft, Paragon Bioteck, RaayonNova, ScienceBased Health, Shire, SynergEyes, and Visioneering Technologies.