Scleral lenses have experienced tremendous growth in the last few years. Ten years ago, only a handful of specialized practitioners were successfully fitting scleral lenses worldwide, and only a few laboratory manufacturers were producing them. Today, multiple manufacturers are developing new and innovative scleral lens designs, solutions, and technologies.
As the interest of practitioners and manufacturers continues to grow, scleral lenses are becoming far more “mainstream” in contact lens practices, particularly in specialty lens practices.
Once you become proficient in scleral lens fitting, you can focus on growing your scleral lens practice using the following strategies.
Tap All Available Resources
If you have any interest in scleral lenses, consider joining the Scleral Lens Education Society (SLS). Membership is free and offers many benefits.
Numerous resources can be found on the SLS website (sclerallens.org ). Topics include scleral lens indications, lens selection, scleral lens-induced complications, and lens care. The site also includes answers to frequently asked questions, audio presentations from the founding scleral lens visionaries, a lens application and removal video, and a living library of up-to-date, peer-reviewed research. Videos and webinars help practitioners master all aspects of scleral lens prescribing, from lens application to assessment, troubleshooting, and follow-up care.
SLS also provides COPE-approved lectures, webinars, and workshops at major meetings and in various regions around the United States.
The Gas Permeable Lens Institute (gpli.info ) is another excellent resource for scleral lens practitioners. The website includes a page of scleral lens FAQs that covers everything from basic to advanced techniques. The site also provides billing and coding information along with sample letters for medically necessary contact lenses.
Examine Your Current Patient Population
In general, three groups of patients can benefit from scleral lenses: those with ocular surface disease and dry eye, those with corneal irregularities that require visual rehabilitation, and those with normal corneas with refractive error. Scleral lens indications have most definitely evolved over time. Not only are scleral lenses fit on patients with irregular corneas or ocular surface disease, they are now used for a vast spectrum of indications. Offer this technology to existing patients who are good candidates for scleral lenses.
Immerse the Ocular Surface
Dry eye disease is a common and chronic condition, with prevalence estimates ranging from 7% to 34% of the population.1,2 Dry eye disease is characterized by insufficient or poor quality tears that cannot properly lubricate and nourish the eye.
Among the risk factors for dry eye disease are age and gender. The condition is more common in people 50 years old or older; hormonal changes, particularly in women, are associated with dry eye.3-6 Other conditions that may exacerbate dry eye symptoms include diabetes, glaucoma, Sjögren syndrome, lupus, and rheumatoid arthritis. Some medications may worsen dry eye symptoms, including antihistamines, hormone replacement therapy, and androgen therapy. Environmental factors, such as pollen or allergies, prolonged use of a computer or any digital device, an overhead ceiling fan, or contact lens wear can worsen dry eye.7 In advanced stages, severe dry eye may damage the surface of the eye and impair vision.
Dry eye may have multiple presentations and can range from mild to moderate to severe. For all forms of dry eye, but particularly severe ocular surface disease, including Sjögren syndrome, graft-versus-host disease, Stevens-Johnson syndrome, or limbal stem cell deficiencies, scleral lenses are an option to alleviate symptoms that may be debilitating.8
Scleral lenses are advantageous to protect and lubricate the ocular surface. The fluid layer between the posterior surface of the lens and the anterior surface of the cornea acts as a tear reservoir and constantly bathes the cornea. This tear reservoir can dramatically improve a patient’s comfort and symptoms of dry eye. The scleral lens also serves as a barrier between the ocular surface and the outside environment, which can help protect the eye.
Scleral lenses have been reported to improve corneal epithelial integrity, vision-related quality of life, and visual acuity in patients with ocular surface disease.9,10 In clinical practice, a significant improvement in quality of life was demonstrated for patients who had failed or were intolerant of conventional GP contact lenses.11 Scleral lenses can also be used for patients with mild to moderate dry eye to achieve excellent vision and comfort.
Correct Corneal Irregularities
Consider scleral lenses for your current patients who have irregular corneas and are not wearing contact lenses or are wearing a different contact lens modality. When fitted with scleral lenses, patients with keratoconus who were unsuccessful or intolerant of conventional GP lenses showed a significant improvement in quality of life.11 Scleral lenses may be an alternative to or a step prior to surgery in patients with keratoconus.11
Look beyond patients with primary corneal ectasias, such as keratoconus and pellucid marginal degeneration. Consider patients with secondary corneal ectasias, such as post-refractive surgery with mild to moderate corneal irregularities and ocular surface disease including dry eyes.
Patients with corneal scars and reduced visual acuities or visual alterations such as glare and halos are also excellent candidates for scleral lenses. Consider scleral lenses for corneal degenerations or dystrophies, including Salzmann’s nodular degeneration and Terrien’s marginal degeneration. Offer scleral lens technology including an in-office demonstration to determine if scleral lenses are the right fit for these patients. Often, perceived misconceptions are alleviated by an in-office demonstration.
Embrace Scleral Lenses for Healthy Eyes
Scleral lens indications are expanding to include normal, healthy eyes.12 These lenses can be used for corneas with a regular, normal, prolate shape without disease, ectasia, or irregularities. Scleral lenses help optimize visual acuity with crisp optics from GP materials.13 According to a recent study, in a population of asymptomatic contact lens wearers, large-diameter GP lenses can be a good alternative to soft toric lenses to correct refractive astigmatism.14
Scleral lenses can be customized to reduce higher-order aberrations, glare, and halos. Comfort is exceptional because the lenses do not touch the cornea or limbus and movement is minimal. I consider any patient wearing any type of contact lens, including soft, hybrid, and corneal GP lenses, who reports discomfort or experiences visual disturbance a candidate for scleral lenses.
Novel scleral lens designs and technology are available for patients with normal, healthy corneas and regular astigmatism. These patients are great candidates for scleral lenses, particularly when their visual needs exceed standard soft lens parameters. Specifically, patients with high astigmatism, refractive error, and presbyopia, including those with mild to moderate dry eye, are all candidates for scleral lenses.
When you offer scleral lens technology to patients with healthy corneas, not only are the patients thrilled with the vision and comfort, but offering this option also profoundly enhances practice growth.
Scleral lenses are also an excellent option whenever lens stability is essential, such as for patients with astigmatism. Visual acuity is maintained because the lenses do not rotate. Scleral lenses are also a good option for patients who play sports. Not only do the lenses remain stable without dislodging with quick movements, but they also protect the eyes from dust and dirt.
Incorporate Multifocal Optics
Shortly after patients reach age 40, the most significant contact lens dropout rate occurs. In patients under the age of 45 years, comfort issues are the main reason for contact lens dropout. After age 45, vision and comfort are almost equally stated as the reason for contact lens dropout.15
Many novel multifocal scleral lens designs have been introduced to the market in the last few years.16 Multifocal scleral lenses can be used for both irregular and normal, healthy corneas. There is massive potential market growth for multifocal scleral lenses.
To be successful, multifocal scleral lenses should be precisely centered on the cornea. With smaller diameter scleral lenses, spherical peripheries may be used. If a larger lens is needed, toric peripheral curves may aid with lens centration. If a lens is misaligned, the optics may be decentered to match the visual axis, enhancing the visual outcome. This process requires increased chair time and laboratory consultation. Your laboratory consultant can help determine the ideal multifocal design for each patient.
Establishing strong networks with colleagues is an important part of practice building. Meet with eyecare professionals to explain the indications and benefits of scleral lenses. Establishing good relationships with cornea specialists is particularly important. Network with other providers, including rheumatologists, oncologists, hematologists, and pain management specialists to help increase awareness of scleral lenses as an alternative to other medical and surgical interventions.
Open communication is essential when coordinating care. It is critical to communicate with the referring practitioner to explain the findings, including best corrected vision with scleral lenses, future recommendations, the time frame for follow-up appointments, as well as when the patient will return to the referring practitioner. Correspondence should be detailed, yet succinct and to the point.
Often, a patient will see both the scleral lens practitioner and the referring practitioner for multiple visits. Thus, status updates are pertinent to ensure that information is shared and care is optimized. This open communication can also help develop referrals.
Use Patient Testimonials
Patient testimonials are often the best and least expensive form of advertising. Testimonials are a long-standing marketing technique that can easily be employed in your practice. Ask patients if they will give a 30- to 60-second video testimonial in the practice. Inform them that they will not be identified by name or condition. Use relevant props, such as scleral lenses, imaging devices, or images if applicable. Patients’ positive emotions and expressions of overall satisfaction with scleral lenses are quite impactful. With permission, these video testimonials can be used in the examination room, played in the waiting area, posted to a website, or distributed via social media platforms.
Identify which demographic you wish to target for scleral lenses and create a message that is most relevant to them. For example, is the goal to attract patients with dry eye who are looking for other management solutions? Is the objective to recruit patients with keratoconus? The target group of interest may be more receptive to certain methods of advertising. There are multiple methods of advertising, including print (newspapers, magazines, and journals), electronic (radio and television), public (billboards and posters), and social media (websites, blogs, Facebook, Twitter, LinkedIn, among other platforms). There are different costs associated with these different methods; investment decisions need to be made in accordance with predicted returns.
The specific message and type of content may be more appropriate for one method of advertising compared to another. For example, a new or enhanced scleral lens product may be shared on your practice’s website or via a blog. The importance of an eye examination for children may be shared via Facebook, Twitter, or LinkedIn.
Topics shared may be diverse, including a new technology or innovation in contact lenses, topics relating to ocular health, or the expertise of practitioners and staff within the practice. Different topics will grow the practice, which, in turn, can generate more scleral lens referrals.
To grow your scleral lens practice via the Internet, create a list of keywords and claim your web pages. Use search engine optimization techniques to make your practice’s website straightforward for both patients and search engine robots to understand. Google is one of the largest search engines and hits can be obtained by typing in specific words. To draw potential patients to your site, it is critical to optimize certain keywords. For example, the words “scleral lens” or “keratoconus” could draw business to your scleral lens practice. Specific keywords of products, services, location, or practice details will enable the right audience to find your practice.
Internal marketing is often the best form of advertising. Trained staff can initiate a discussion about scleral lenses that complements point-of-purchase materials, such as brochures, videos, literature, or testimonials. Staff members can identity appropriate patients to whom they can enthusiastically recommend unique scleral lens technologies and the expertise of the practice.
Specialty contact lens meetings, such as the Global Specialty Lens Symposium, the International Congress of Scleral Contacts, the International Forum for Scleral Lens Research, the British Contact Lens Association and the Nederlands Contactlens Congres enable practitioners to stay informed about the latest developments in contact lens technology and network with like-minded practitioners.
Disease-specific organizations, such as the National Keratoconus Foundation (www.nkcf.org ) and the Sjögren’s Syndrome Foundation (www.sjogrens.org ) are also good resources. Some organizations, including scleral lens manufacturers, list practitioner and practice information on their websites, and some groups on Facebook and LinkedIn are dedicated to scleral lenses. Along with obtaining valuable information and exchanging ideas, these are good methods to obtain referrals.
Stay current with scleral lens designs, solutions, technologies, and instrumentation, and use manufacturers’ consultants. Each scleral lens design has its own unique features and specifications. Since manufacturers’ laboratory consultants are experts in their specific lens designs, it is important to develop a close relationship to succeed with scleral lenses.
Stay current with the literature and read publications related to contact lenses such as Contact Lens Spectrum. Search peer-reviewed literature for current scleral lens research. Incorporate new designs or technologies into your practice to enhance your scleral lens fitting success.
Your Efforts Rewarded
Establishing a scleral lens practice can be a time-consuming yet worthwhile effort. A scleral lens practice can be financially and personally rewarding, with the development of a loyal patient base. By putting patients first, always doing what is best for the patient and expressing compassion, empathy, passion, and enthusiasm for scleral lenses, your practice will thrive. An investment in advertising and networking can aid in referrals and practice growth. Staying current with scleral lens designs, research, and equipment technology can streamline the scleral lens fitting process and optimize success.
- Lin PY, Tsai SY, Cheng CY, Liu JH, Chou P, Hsu WM. Prevalence of dry eye among an elderly Chinese population in Taiwan: The Shihpai eye study. Ophthalmology. 2003;110(6):1096-1101.
- McCarty CA, Bansal AK, Livingston PM, Stanislavsky YL, Taylor HR. The epidemiology of dry eye in Melbourne, Australia. Ophthalmology. 1998;105(6):1114-1119.
- Schaumberg DA, Sullivan DA, Buring JE, Dana MR. Prevalence of dry eye syndrome among US women. Am J Ophthalmol. 2003;136(2):318-326.
- Chia EM, Mitchell P, Rochtchina E, Lee AJ, Maroun R, Wang JJ. Prevalence and associations of dry eye syndrome in an older population: the Blue Mountains Eye Study. Clin Exp Ophthalmol. 2003;31(3):229-232.
- Erdem U, Ozdegirmenci O, Sobaci E, Sobaci G, Göktolga U, Dagli S. Dry eye in post-menopausal women using hormone replacement therapy. Maturitas. 2007;56(3):257-262.
- Uncu G, Avci R, Uncu Y, Kaymaz C, Develiolu O. The effects of different hormone replacement therapy regimens on tear function, intraocular pressure and lens opacity. Gynecol Endocrinol. 2006;22(9):501-505.
- Kumar N, Feuer W, Lanza NL, Galor A. Seasonal variation in dry eye. Ophthalmology. 2015;122(8):1727-1729.
- Schornack MM. Scleral lenses: a literature review. Eye Contact Lens. 2015;41(1):3-11.
- Blackmore SJ. The use of contact lenses in the treatment of persistent epithelial defects. Cont Lens Anterior Eye. 2010;33(5):239-244.
- Bavinger JC, DeLoss K, Mian SI. Scleral lens use in dry eye syndrome. Curr Opin Ophthalmol. 2015;26(4):319-324.
- Picot C, Gauthier AS, Campolmi N, Delbosc B. Quality of life in patients wearing scleral lenses. J Fr Ophtalmol. 2015;38(7):615-619.
- 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;37(4):240-250.
- 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. Epub: Nov 24, 2016.
- 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;80(7):375-383.
- Brujic M, Miller J. Minimizing dropouts: what you can do. Review of Cornea & Contact Lenses; March 2011.
- Barnett M. Multifocal scleral lenses. A look at available lenses that can help our presbyopic patients. Contact Lens Spectrum; December 2015.