Diagnostics for the Right Fit

Scleral lens practitioners soon recognize the time required for managing complex cases. Increased complexity can demand more than the standard number of visits, increase chair time, require more lens exchanges than usual, and even necessitate a change in lens brands. To the practitioner, multiple visits and lens tweaking may demonstrate a commitment to superior care, but patients may become impatient with the process. They must be brought to understand that scleral lenses are serious medical devices and that follow-up care will become a regular part of their lives. Part 1 of this two-part series appeared in the May issue of Modern Optometry (bit.ly/Arnold0519) and covered the information-gathering stage of the scleral lens fitting process. This article explains how to identify and address difficulties in order to enable patients to wear scleral lenses successfully.

THE DISPENSING VISIT: 5 KEYS

The happy day arrives when your patient returns to pick up his or her scleral contact lenses. At this time, it is important for your scleral lens team to demonstrate correct lens care and handling and emphasize the patient’s need to adhere to these practices. Your team can foster successful lens wear with the following five strategies:

1. Present the new lenses to the patient and review the solutions necessary for lens insertion and care.

2. Provide a form listing the recommended solutions for the patient’s scleral lenses and an appropriate wear and return schedule.

3. Observe the patient as he or she attempts the correct procedure for lens insertion, and provide assistance as needed.

4. Check the overrefraction, lens position, and orientation of any reference marks generated on the lens.

5. Stress the need for a clean lens-handling environment.

PROGRESS VISITS

Communicating With Patients: 5 Tips

After the dispensing visit, it is common to have the patient return for progress visits. For example, a 90-day evaluation period is included with our global fee. It is our goal to maintain optimum ocular health for our scleral lens patients. A good case history and external examination of the patient at each visit is very important. We have found the following five guidelines helpful for assessing the fit of scleral lenses:

1. Instruct patients to insert their lenses at least 4 hours before the visit. At the visit ask them at what time they inserted the lenses.

2. Ask patients about their wearing experiences and whether they have any questions or concerns.

3. Confirm that they have been following the prescribed care regimen and using the specified solutions. Consider asking patients to describe their regimen as a way of confirming adherence.

4. Ask if their comfort level decreases as the day passes. If it does, try to determine whether the problem is related to reading or computer work, inside activities, or outside activities such as driving.

5. Ask patients if either of their eyes becomes red or extra white during lens wear and, if so, whether any redness affects the entire eye or only a particular sector. Recommend that they purchase a magnifying mirror with a light source (we sell the i-Chek Illuminated Eye Examination Mirror by i-Chek in our office) to view their eyes at the end of the day, and request that they provide a detailed report of any ocular redness or blanching they observe.

Elements of a Careful Examination

Before the patient sees the clinician, the scleral lens staff may elect to perform one or more tests (see Testing, Testing). Thereafter, the patient is escorted to the examination room. Before having him or her get behind the slit lamp, assess the patient’s overall ocular appearance. Check for signs of injection, especially in one area, and for obvious blanching of the conjunctiva underneath the landing zone (Figure 1). These signs may indicate that the lens landing zone is too tight. Also assess blink frequency and the fullness of each blink.

At the slit lamp, evaluate central corneal clearance with a bright optic section but without the use of fluorescein. Central corneal clearance is easily viewed with 16x magnification in a darkened room.

Look for signs of conjunctival prolapse. Although the long-term complications are unknown at this time, the incidence of prolapse can often be reduced by decreasing limbal clearance.¹

Look for shadows at the lens edge by shining an optic section obliquely across the lens surface from the middle of the lens outward toward the edge. A notable shadow may indicate excessive clearance in this area. A confirmatory test can be performed using lissamine green dye. When applied to the bulbar conjunctiva, the dye may be taken up under areas of the lens haptic that are too flat. A toric or even quadrant-specific haptic may be indicated.

Finally, remove the patient’s lenses yourself to gauge tightness and suction. When patients complain of difficulty removing their lenses, it is often the case that they are using excessive force when pushing the lens remover onto the lens and are thereby increasing suction. A lens can be readily removed by wetting the tip of the remover with rigid gas permeable lens solution and gently applying the remover to the scleral lens. Demonstrating this technique can be instructive for patients. After removing both of the patient’s lenses, look for excess staining, which may indicate a need for lens adjustments.

MEDICAL EVALUATION VISITS

After dispensing and fitting the patient’s lenses, remind him or her that scleral lenses are medical devices used to address vision issues caused by a medical condition and that periodic visits are therefore necessary to identify detrimental changes to the eye related to contact lens wear. Explain that these visits are medical visits and that he or she is responsible for the cost of tests that his or her insurance may not cover. Make sure the patient knows that lens replacement may be required at any time after the initial fitting period.

A careful history should be taken during these visits. Request a rundown of current medications. Take note of recent illnesses, current A1C levels (if the patient is diabetic), and drug-induced or medical conditions that could compromise the patient’s immune system. Repeat the five questions listed earlier under Progress Visits.

Next, have the patient remove his or her lenses so that anterior segment OCT imaging and wavefront analysis can be performed and keratometry measurements taken. Your goal is to collect enough quantifiable information to analyze and understand the patient’s eye and adnexa. This is also a good time to inspect the eye for signs of neovascularization (Figure 2), especially if the patient has a history of radial keratotomy or penetrating keratoplasty (Figure 3). Look for subtle corneal infiltrates, check the post-wear refraction, assess tear quality and tear breakup time, and evaluate staining of the cornea, the conjunctiva, and the lid margins. Be alert for giant papillary conjunctivitis. Confocal microscopy can help you to scan for polymegethism, edema, and endothelial blebs.

LOOK FOR LEARNING OPPORTUNITIES

The most rewarding part of fitting scleral lenses is that it provides learning opportunities. We know the effect reduced vision has on our patients. Our tendency is to focus on the cornea to assist our patients’ vision, but we should remember that the cornea does not exist in isolation. That compromised cornea is attached to its surrounding tissues and to a person—our patient—and each of these is dynamic, not static. We will never see the same ocular environment we saw on the day of the initial scleral lens fitting.