Best Practices for Incorporating Scleral Lenses Into Your Offerings

I own a private practice with my husband, Mark Coan, OD, in Ocoee, Florida, where we and one associate optometrist provide primary-care optometry. For more than 20 years, I have run our specialty contact lens practice. I have always loved contact lenses because I wear them myself for nearsightedness. I think contact lenses are phenomenal because of how beneficial they are for so many visual conditions.

Training

My optometric training began at the New England College of Optometry in Boston. Then, I completed my cornea and contact lens residency in 1999 at Pacific University College of Optometry in Oregon. I had already trained in fitting gas-permeable lenses and was frequently prescribing soft, toric, and multifocal contacts as part of our primary practice by the time scleral lenses emerged, so I had foundational knowledge about fitting specialty lenses. I began my scleral lens training by taking a few courses at professional meetings. Ten years later, I returned to Pacific University for a few weeks of further training.

Through my affiliation with Pacific University, I was included on scleral lens research projects. These research projects led me to writing about scleral lenses in optometric journals and trade publications, which then led me to lecturing on the topic. Now, I’ve become somewhat of a mentor to other optometrists on scleral lenses; colleagues will ask my opinion about their cases and often send me their patients.

Building a Scleral Lens Practice

I began building our scleral practice by visiting local optometrists as well as cataract and LASIK surgeons to inform them about my expertise. I showed them patient cases and explained my treatment approach (for example, what I would do for an irregular cornea). When a physician refers a patient to me, I send that patient back to their originating clinic for follow-up and any other prescriptions. This way, referring physicians can confirm that our mutual patients have been successfully fit (also, I don’t want colleagues to be reluctant to refer to me because I have an optical). A happy patient is the best way to get repeat referrals, and it is important to maintain a good reciprocal relationship with all referring physicians. My word-of-mouth referral network has grown over the years without any source of external marketing.

The Psychology of the Scleral Lens Patient

Scleral lens candidates often have endured more than one unsuccessful contact lens or scleral lens fit, they have spent time and money with zero results, and they are very frustrated and skeptical of these lenses. In addition to fitting expertise, you must be good at explaining why this treatment may not have worked for them in the past, why you think you can help them, and at setting these patients’ expectations. Scleral lenses should not hurt or be uncomfortable.

I approach these individuals with patience and understanding. I explain that I specialize in these lenses and that I see many patients with similar medical conditions who have had negative experiences in the past. To convert these skeptics, before discussing fees, I sometimes fit them first with diagnostic scleral lenses so they can get a sense of how the lenses will feel and the quality of vision they will impart. Making patients comfortable in scleral lenses helps remove their reluctance to try them again.

Scheduling and Practice Flow

My staff and I schedule an hour for a scleral patient’s first visit, including fitting the patient that day. I fit several specialty lenses every day of the week. I keep an open schedule in order to accommodate the longer follow-up time that specialty lens patients require.

I have two technicians who work alongside me. They obtain the patient’s medical history, list every treatment he or she has tried previously, and they tell me the patient’s motivation for coming to our office. These technicians also perform the pretesting, including corneal and scleral topographies, pachymetry, over-refractions, and optical coherence tomography (OCT), so I can devise a treatment plan.

Once I select a brand of scleral lens to prescribe for a patient, a technician will aid me in my examination by using the software within the Eaglet-Eye Surface Profiler (Eaglet Eye B.V., the Netherlands) to determine the first trial lens to fit. Next, the technician will place the lens in the patient’s eyes and evaluate the fitting. I have trained my technicians to look at a fluorescein pattern to ensure that the lens is vaulting over the entire cornea. Once they confirm the vaulting, they will perform the OCT measurements and auto-refraction.

I determine the best-fitting lenses by adjusting various parameters, and then I order the lenses from the lab while the technician discusses with the patient the fees for the lenses, the evaluation, and the care products that are needed for successfully using scleral lenses.

When the lenses arrive, my staff schedule a contact lens dispensing appointment, at which time they will educate the recipient about removing and cleaning the lenses.

Considering the Investment

For colleagues interested in adding specialty lenses to their practices, you need training and practice to be successful. I rounded out my education by completing a contact lens residency, reading journals, attending conferences, listening to webinars, and taking the time to do a scleral lens fellowship. Professional conferences are the best place to start; you can get a wealth of information by attending lectures, participating in workshops/wetlabs and meeting with vendors. The fellowship required me to research the medical literature on these lenses and their fitting skills. It would be challenging to become adept with these lenses with limited knowledge.

Succeeding with scleral lenses requires a commitment to be all-in, because they do have a learning curve and a significant investment in technology. For example, I would not fit these lenses without an OCT device, which enables me to measure the lens’ central clearance in microns and make micro-adjustments. I can also evaluate where and how the lens is landing on the sclera and any problems in the fit. A corneal topographer is necessary to diagnose any irregularities in the cornea. The scleral topographer is also useful for accurate fittings.

Additionally, I have anterior-segment cameras that I use to record each fitting, and these save me from human error when I am fitting multiple scleral lenses per day. I also like having a scribe in the room to help me remember refractions and catch mistakes. I believe that all these tools and best practices help me work smarter, not harder. Of course, you also need a scleral fit set (sometimes you can get loaner sets to use). Many scleral lens manufacturers will provide a consultant who will come to your clinic and show you how the lens works. Then, you can send this person pictures from your follow-up visits. This training can be helpful.

Summary

I love working with scleral lenses. Aside from being a good source of income, scleral lenses can be very rewarding; you can change somebody’s life for the better. Recently, I saw a patient who couldn’t pass a driver’s test without visual correction. I fitted her in scleral lenses, she passed her driver’s examination and got her license, and because she could drive, she was able to keep her job and support her family. There is great demand for these lenses and for providers who can fit them comfortably.