The popularity of scleral lenses has grown exponentially over the past 5 years. You can’t go to a major meeting without seeing at least 50% of the contact lens education dominated by talks about this modality. Interestingly, their utilization does not match this overall growth in education. By and large, soft contact lenses still dominate the market.

My theory to explain this disconnect is that many eye care practitioners are wary of the difficulties that can come with fitting scleral lenses, including increased chair time, and they worry that they may lose revenue. This article lists five ways to troubleshoot issues you may run into when fitting scleral contact lenses.

1. BEFRIEND YOUR LAB

I am talking first-name basis. Get to know who is responsible for what. Learn about the warranty program so that you can, in turn, educate your patients about it as well. Labs want you to be successful. When troubleshooting a problem, your lab should be your first stop. Most often, it will also be your last.

2. BE A SLIT-LAMPER EXTRAORDINAIRE

In the lectures and workshops that I have run, I have found that many docs rely on OCT imaging to help guide their fitting decisions. This is like getting an MRI to determine if a shoe fits. Although OCT can be beneficial in supporting what you see at the slit lamp, it can sometimes overcomplicate the process. Instead, practice your slit-lamp assessment of vault, impingement, and compression. This allows the patient’s symptoms to be equally important as your slit-lamp evaluation. Do not create problems where problems do not exist. Allow the eye to help fit the lens.

3. MINIMIZE (BUT MAINTAIN) VAULT

My first cohort of scleral lens patients has now been wearing lenses for going on 6 years. The single most important change I have made in my fitting during that time is to respect vault maximums. You hear a lot about vault minimums (ie, don’t touch the cornea or limbus) but not as much about maximums. Too much vault induces hypoxia and results in neovascularization.

Early on, I was definitely more liberal in my vault maximums. Theoretical models over the past 10 years have shown that minimizing the vault while maintaining it is healthiest. My personal experience includes a patient with worsened neovascularization who may have been lost to follow-up for a couple of years. That patient had more vault (ie, 400-600 µm) than patients with 100 µm to 200 µm or even those with mild touch.

4. FLUORESCEIN ON TOP

Filling the bowl of a scleral lens with fluorescein is a no-brainer. We all do it, and we know why it’s important to do it. Putting fluorescein on top of the lens, however, allows observance of unwanted tear-film communication, edge lift, vault analysis, and imaging of any lens markings that may be present.

5. CONJUNCTIVAL LENSES: LIVING ON THE EDGE

The only interaction that a scleral lens should have with the eye is near the edge in the peripheral curves resting on the conjunctiva. If there is a problem with comfort, vision, or appearance of the eye, understand the peripheral curves of the lens you are working with and how to alter them and strive for perfection here. Study the lens design you are using. Ask your lab for a visual to help you better understand how each change affects the fit.

YOU CAN DO IT

Scleral lenses have been the subject of increased attention, and for good reason. They work well for patients with hard-to-fit eyes and with many ocular conditions. Sure, they can be challenging to fit at times, but they can be equally rewarding. If you run into a problem, review these troubleshooting tips and see if you don’t find yourself back on course.