"There's many a forward look in a backward glance." – Evan Esar
Sincere thanks for your interest in last month’s Scleral Lens Monthly. The joy of working with scleral lenses is the continual learning process. This month I queried more global scleral lens experts to share their words of wisdom and how their fitting strategies have changed over time.
Dr. Karen Carrasquillo summed up her expertise beautifully. "More than 'knowing' words of wisdom, I wish I had fully understood from the beginning that fitting scleral lenses is more than just an adaptation of a piece of plastic in someone’s sclera. It is amazing what these pieces of plastic can do to transform people's lives. Now I understand than when I’m fitting a patient, I first aim to fully understand the patient’s condition and potential risk factors. I strive to always look at the big picture before diving into the mechanics of the fit and troubleshooting process. As a consequence, my 'fitting' strategy has evolved over time to become a better listener and learning to always try to take a step back to consider all potential scenarios, which at times involves managing the case beyond the actual fit. I wholeheartedly believe that even when more advances in technology become available and even when technology continues to be at the forefront and at our fingertips, approaching each case as treating a condition, with everything that it entails (beyond just the fit), is the ultimate pathway for success with our patients."
Dr. Jeffrey Sonsino stressed the importance of good vision when fitting scleral lenses. "Our fitting strategy has evolved immensely over the past 12 years. If we cannot achieve at least 20/25 vision in complex cornea patients, there must be a reason, such as a corneal scar in the visual axis, lenticular or retinal changes. Otherwise, we are not trying hard enough."
Post-lens tear reservoir debris may be affecting the vision and comfort of a scleral lens fit, a hassle for both the patient and practitioner. Dr. Sonsino “wishes he knew the origin of debris in the post lens tear reservoir. Now that he knows it and can fix it, his patients are a lot happier.” Dr. Daddi Fadel reported that post-lens tear reservoir debris “may be transient and last a few months. It would be better to wait before searching for an option to manage it. The use of preservative free solutions may be beneficial." This is a good reminder to verify solutions at every aftercare visit to confirm that patients are using the correct solutions (and disposing of preservative free solutions after a single use).
Dr. Karen Deloss advises that "not everything is perfect" and "we are always our own worst critics." She approaches her fits in a stepwise fashion. "My primary goal is fit and comfort and I try to achieve this in a simple way if feasible, and keep additional tools such as toric peripheral curves as a backup. The second goal is vision. Once fit is achieved I aim to improve vision with front surface toric or aberration control. If you change too many things at one time, you don’t know what worked."
At times it is difficult to know when to stop altering a fit. Dr. Ryan McKinnis stated that "the enemy of good is better. We can spend mountains of time trying to perfect a fit on an eye that is otherwise showing no signs of complications." He also emphasized the importance of delegation and "to make sure your charges are appropriate since you are offering a highly specialized and complicated service. You deserve to be paid appropriately."
These are wonderful pearls to support your scleral lens practice. Many thanks to all of the scleral lens experts for their contributions to this edition of Scleral Lens Monthly.
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.