Highlights from the Scleral Consultative Institute

I graduated optometry school having never fit a scleral lens and only a handful of rigid gas permeable lenses. Shortly after opening Scott Eye Care from scratch in 2013, I learned that keratoconus and corneal disease is much more common than I realized—one study found a prevelance of one in 223 people!¹ Moreover, only about 6% of patients have a spherical sclera.² I also realized that many patients have corneal transplants not only from keratoconus, but also due to infection complications and trauma. High myopes, pellucid marginal degeneration, and dry eye patients can also benefit from a properly fit scleral lens. I first learned this skill at a workshop in New Orleans, and in 2017, I fit my first patient. I grew my patient base by asking for referrals, and I fit more than 70 patients last year. Fast-forward to August 2024, when I was invited to attend the Scleral Consultative Institute (SCI) Boot Camp, and here is what I learned.

BOOT CAMP

SCI takes place over a weekend at the practice of Jeffrey Sonsino, OD, in Nashville, Tennessee, and space is limited to eight or 10 attendees (Figure 1). Mile Brujic, OD, joined Dr. Sonsino as faculty, along with practice manager and scleral lens technician Randy Teller, COMT.

Day 1: Diagnostic Fitting

Drs. Sonsino and Brujic began the meeting with a presentation on their fool-proof method of fitting scleral lenses. They don’t even use fluorescein with their fitting method; their staff are trained to capture anterior-segment OCT (AS-OCT) images of each diagnostic fit at the initial fitting and once the prescription lens arrives (Figure 2).

Dr. Sonsino’s technician captures an AS-OCT over the central vault of the scleral lens, both horizontally and vertically. Using these images, he measures the clearance over the cornea, with about 300 µm being ideal at lens insertion (the lens will settle during the day). These central scans also help determine if the lens is decentered, as the vault from one side of the scan will be greater than the other side. Dr. Sonsino also has his staff capture several other AS-OCT scans, including the following:

• In the horizontal meridian to assess the lens fit over any pinguecula that may be present
• Over the toric markers to assess the steep meridian
• 90˚ away from the markers to assess the flat meridian of the lens (if you fit a toric haptic, which is best to start with, as more than 90% of the patients you fit will have a toric sclera)³

We ended the morning by learning how to troubleshoot a poorly fitting scleral lens, focusing on midday fogging, that nagging complication we all deal with when fitting scleral lenses. According to the speakers, most midday fogging is caused by an uneven fit when comparing the steep and flat meridians of a lens. When a patient blinks, the uneven fit causes microscopic movement of the lens, activating the mucosal cells of the conjunctiva and leaving the patient with midday fogging. Drs. Sonsino and Brujic also touched on other complications, such as fogging caused by ocular surface disease, blanching, or edge lift.

After lunch, we moved on to the business side of things: billing and coding. It’s crucial to bill properly because you deserve to be paid for providing this highly specialized care. Leave no penny on the table.

Day 2: Real-World Experiences

On the second day, Dr. Sonsino brought in some of his patients, whom we fit with scleral lenses and scanned with AS-OCT (Figure 2). One patient was a true follow-up visit—his lenses had just come in that week. He tried them on, and we spotted a couple of areas of inadequate fit using AS-OCT images, and Dr. Sonsino’s technician recorded this and started on the modification order.

TAKEAWAYS FROM BOOT CAMP

Since attending this meeting, I have significantly reduced the number of follow-ups by using scleral profilometry combined with AS-OCT imaging, and my fit process is much more streamlined. Training your staff to help will streamline your fitting process too, making your job much easier. Remember: Fitting scleral lenses is only lucrative if you finalize the fits! Involving your staff in the process will help you get to the finish line quicker and see more fits.

At the dispensing visit, my staff place the lenses on the patient’s eyes and then capture an AS-OCT at insertion. I can see right away if the fit is right or if adjustments are needed. It is easy to measure central clearance, look for displacement, and judge haptic alignment. I then perform an overrefraction, if necessary.