Where Do Specialty Contact Lenses Fit Into the Evolving Medical Optometry Practice?

Main Figure. A patient with history of thermal burns OS after a firecracker injury. BCVA hand movement.

The focus on medical optometry has increased over the past few decades, and most practitioners are aware of the benefits that it provides in driving your optometry practice down the medical track. So, the question becomes: How can you set yourself apart?

Introducing and/or offering specialty contact lenses in your practice carries several benefits to assisting in achieving this goal. It will set you apart from standard practices, improve your relationships with referring ophthalmology and optometric practices, increase gross revenue, and improve the patient experience.

In this article, I draw from my experience with scleral lenses at Bascom Palmer Eye Institute and explain how they have altered my management of patients with ectasia and ocular surface disease. I also illustrate how scleral lenses (Figure 1)—and specialty lenses in general—can transform your practice.

Singing the praises of SCLERAL LENSES

Scleral contact lenses are increasing in popularity, as they play a crucial role in the management of several corneal and ocular surface diseases.¹ Scleral lenses are rigid gas permeable (RGP) contact lenses that are shaped to the patient’s sclera, vault over the cornea, and deliver continuous hydration through a liquid bandage located between the cornea and the posterior surface of the lens. The combination of these details can help mask corneal irregularities and improve overall quality of vision as well as provide relief for patients with severe ocular surface disease (ie, Stevens-Johnson syndrome, ocular graft-versus-host disease, ocular cicatricial pemphigoid) and allow that disease to heal.

Because scleral lenses rest on the sclera and conjunctiva, which are substantially less innervated than the cornea, they are significantly more comfortable than corneal RGP lenses and, in some instances, can also deliver improved vision. This is likely due to lens stability and improved centration. With modern day material having a Dk of 200 and new modes of acquiring the corneoscleral profile to assist in complex fits with challenging anatomic limitations, the variety of patients that can be fit successfully has dramatically increased (Main Figure and Figure 2).

Fitting Tips

Several companies provide hardware and software that has the capability to create an initial scleral lens based on the profilometry of the patient’s sclera. At Bascom Palmer Eye Institute, we perform corneoscleral topography on all new scleral lens fits. Then, based on the scleral toricity, I know what kind of fitting approach is best. For example, if the patient has a spherical sclera, I will fit him or her with a standard fitting set, assuming he or she will likely require few fit changes.

If the patient displays a regular scleral astigmatism, I will fit with a standard fitting set but insert the toric trial lens to get a better idea of lens rotation expectations and gauge the degree of the amount of lens toricity that will need to be ordered. If there is a large amount of regular toricity, I will order a scleral lens with a toric haptic rather than an image-guided design unless the toricity is great (≥ 400 µm).

Once I have established that there is a large degree of scleral toricity or that there is an irregular surface, I use an image-guided lens design. If the irregularity of the sclera is severe, I adjust by changing to an impression-based scleral lens design (Figure 3). This allows for fewer remakes, shorter chair time, and increased lens cost due to the complexity of the fit.

If you don’t have access to one of these modalities to establish corneoscleral profilometry in your practice, you can use a more standard approach. This is completed by placing a trial scleral lens on the patient, evaluating the fit, and making appropriate adjustments to allow for proper alignment. It is very important that this initial lens has between 150 µm to 250 µm of central clearance. If not, continue to change your initial trial lens sagittal depth until this is achieved. Allow this trial lens to settle for at least 15 to 20 minutes, then overrefract and assess peripheral alignment for impingement and/or edge lift. Modern lens laboratories have several ways to align with different anatomic challenges (ie, pinguecula, pterygium, blebs) with notches, microvaults, and channels.

BENEFITS

Incorporating scleral lenses into the modern day medical optometry practice has several benefits for the practitioner, patient, and community ophthalmologists.

Increased Patient Acquisition

Specialty lens fitters are few and far between, and when community ophthalmologists get wind that a local practitioner fits these lenses, they will likely begin referring patients for a myriad of corneal diseases (if they are not already). This can drastically increase referrals and improve the overall relationship between optometry and ophthalmology.

Additionally, if you have a dry eye clinic or eye center incorporated into your practice, rather than referring patients who have not responded to conventional modes of treatment to an outside provider, you can keep them in-house.

Overall Gross Income

The national average cost for scleral lenses is about $500 to $8,000 per eye, and the average cost of a trial set is between $250 to $500. This is a large return on your investment and increased profit. This can also provide an opportunity to allow for a smaller daily patient load and reap increased net gain.

DRAWBACKS

In addition to there being benefits to offering scleral lenses, there are some drawbacks.

Investment in Time

To become a specialty lens fitter, it requires time to be properly trained. Training can come in several forms such as books, wet labs, conference lectures, webinars, virtual training, etc. Also, the fitting process is time-consuming, as the majority of these cases require several lengthy visits.

Cost

The cost of specialty lenses and lack of insurance coverage creates the problem of patients who would greatly benefit from the lenses not being able to afford them. There are companies and foundations that can help and offer scleral lenses at a reduced cost for patients in need of financial assistance.

Inconvenience

The inconvenience of specialty lenses can deter patients from their use. For example, debris collection within the reservoir and/or debris accumulation on the surface of the lens may require patients to remove the lens mid-day, clean it, and then reinsert it.

STAND APART WITH SPECIALTY OFFERINGS

Offering specialty contact lenses to patients is a rewarding experience. It can help build your patient base and be a great asset in setting yourself apart from the “standard” optometric practice. There are several ways to incorporate scleral lenses into your practice, whether it be through the traditional fitting strategy or with sophisticated technology. When looking for new ways to differentiate your medical optometry practice or gain more traction with patient acquisition, consider specialty contact lenses.