"Besides the noble art of getting things done, there is the noble art of leaving things undone. The wisdom of life consists in the elimination of non-essentials." Liu Yutang
These words are so true regarding scleral lenses. What is essential? Adequate clearance without corneal touch, an even landing and acceptable vision. Then what is not essential? Is the half diopter of astigmatism correction worth the one letter of improvement? Is it necessary to change the toric haptic in a single meridian 50 microns? To help improve scleral efficiency, I asked scleral lens experts for their tips and tricks to optimize time when fitting scleral lenses.
Dr. Lynette Johns recommends that once a patient is proficient with application and removal, she dispenses the lens and evaluates the patient one week later after wearing the lens for 3-6 hours. If lens modifications are needed, another lens is ordered, mailed to the patient, and an evaluation is scheduled two weeks later with the patient wearing the lens for 3-6 hours. Dr. Stephanie Woo recommends scheduling scleral lens dispenses as the last appointment of the morning before lunch or the last patient in the afternoon in order to assess the lens fit and over-refract prior to passing the patient along to the technician for their application and removal training. This way you can head to lunch or head home! Dr. Edgar Davila-Garcia recommends the "viability test." The noun viability means the quality of being able to happen or having a reasonable chance of success. Prior to doing the actual scleral lens fitting, perform some application and removal training to verify if the patient is able to apply and remove the lens independently. He has had a few patients that could not wear their scleral lenses due to application and removal issues, even after a successful fitting.
Dr. Jeff Sonsino recommends training your technicians to the highest level. One of Steve Jobs’ captains came to him and said, "What if we train our team too well and they leave?" His reply: "What happens if we don’t, and they stay?" Technicians and staff are invaluable to a specialty lens practice with multiple responsibilities including obtaining prior authorizations, scheduling appointments, applying scleral lenses, performing imaging, application and removal training, answering questions and billing and coding. Dr. Mile Brujic recommends having a billing and coding leader in the office. Dr. Woo recommends selecting a starting lens for the technician to apply. They can clean, condition and prepare the lens and place it on the patient's eye in order for the practitioner to quickly come in, examine the lens and make adjustments from there.
The incorporation of OCT adds efficiency and accuracy, states Dr. Brujic. Imaging by technicians after lens settling can save valuable time. According to Dr. Karen Carrasquillo, the use of scleral topography has been reported to increase efficiencies as your lens is a one and done. Dr. Sheila Morrison relays that the fitting relationship between the ocular surface and a scleral lens determines fitting success. Scleral shape is usually asymmetrical and there may be differences between the shape of the right and left scleral shape where the lens lands.
Sodium fluorescein is routinely used for scleral lens fitting. Dr. Tom Arnold recommends adding lissamine green to the bulbar conjunctiva to identify flat areas under the haptic.
According to Dr. Morrison, compliance with solutions is an often-overlooked cause of complications with scleral lenses. She recommends to always inquire which solutions are used and how the solutions are being used. Dr. Daddi Fadel advises to use a smaller plunger for lens application if a patient is intimidated by the large scleral lens and large plunger.
Personally, these tips have helped me over the years. Hopefully they will aid with efficiency in your scleral lens practice. Many thanks to all of the scleral lens experts for their contributions to this edition of Scleral Lens Monthly.
Image credit Tom Arnold, OD.
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, Contamac, CooperVision, EveryDay Contacts, Johnson & Johnson Vision, Ocusoft, Paragon Bioteck, RaayonNova, ScienceBased Health, Shire, SynergEyes, and Visioneering Technologies.