Clinical Guide for Scleral Lens Success Melissa Barnett, Daddi Fadel 2 Cover Image: Credited to Melissa Barnett. Description: This manuscript is the result of a collaborative effort between the Scleral Lens Education Society (SLS) and the Accademia Italiana Lenti Sclerali (AILeS). Acknowledgements: The authors wish to thank the Scleral Lens Education Society and Accademia Italiana Lenti Sclerali Board members, Robert Ensley, Luigi Lupelli, and Gregg Russell for reviewing this manuscript. Publication date: 2018 Recommended Citation: Barnett M, Fadel D. Clinical Guide for Scleral Lens Success. SLS & AILeS. 2018 Available and published by 3 Melissa Barnett OD, FAAO, FSLS, FBCLA, is the principal optometrist at the UC Davis Eye Center in Sacramento, CA. She is an internationally recognized key opinion leader, who lectures and publishes extensively on anterior segment disease and specialty contact lenses. She is a Fellow of the American Academy of Optometry and the British Contact Lens Association, a Diplomate of the American Board of Certification in Medical Optometry, and serves on the board of the American Optometric Association Cornea and Contact Lens Council, Women in Optometry and Women of Vision, Gas Permeable Lens Institute, and Ocular Surface Society of Optometry. She is past president of the Scleral Lens Education Society. Dr. Barnett is a spokesperson for the California Optometric Association and a guest lecturer for the STAPLE program. Drs. Melissa Barnett and Lynette Johns edited the book Contemporary Scleral Lenses: Theory and Application with the unique perspectives and contributions of international experts. She is an advisor to and/or has received honoraria or travel expenses from AccuLens, Alcon, Alden Optical, Allergan, Bausch + Lomb, Contamac, Johnson & Johnson Vision, Novabay, Ocusoft, Paragon Biotek, Shire, the Sjögren’s Syndrome Foundation, the Scleral Lens Society, the STAPLE Program, SynergEyes, and Visioneering Technologies. Daddi Fadel Dip Optom, FSLS, is a lens designer and specialist in contact lenses for irregular cornea, scleral lenses and orthokeratology. She speaks five languages; Arabic, French, English, Italian and Greek. She studied optometry at Istituto Superiore di Scienze Optometriche (ISSO) in Rome (1998-2001), a four-year course achieved with honors. She started to lecture and publish in her first year of Optometry school. She has 20 years experience in optometry and specialty contact lenses. She runs an optometric practice specializing in contact lenses in Italy where she designs and fits special customized contact lenses. She lectures and publishes nationally and internationally, especially on contact lenses in irregular cornea, scleral lenses, and ortho-k. She is the Founder and President of Accademia Italiana Lenti Sclerali (AILeS), a board member of Accademia Italiana Lenti a Contatto (AILAC), and a Fellow of Scleral Lens Education Society (SLS). 4 Contents I. Introduction .......................................................6 II. Staff training .......................................................6 III. Patient and family communication .....................................6 IV. Scleral lens indications ..............................................7 V. Case history ......................................................10 VI. Eye examination ...................................................10 VII. Fitting scleral lenses ...............................................10 1. Diameter selection.................................................. 12 2. Central corneal clearance ............................................ 12 3. Peripheral corneal clearance .......................................... 17 4. Limbal clearance ................................................... 17 5. Landing zone design ................................................ 17 6. Lens edge ........................................................ 19 7. Over-refraction..................................................... 23 VIII. Number of visits ..................................................24 IX. Wearing schedule..................................................25 X. Patient education for correct application and removal techniques...........25 1. Scleral lens application .............................................. 25 2. Scleral lens removal ................................................ 26 XI. Devices for scleral lens application and removal .........................26 XII. Scleral lens care ...................................................27 XIII. Follow-up schedule ................................................27 XIV. Conclusion .......................................................28 Appendix A .......................................................29 Appendix B .......................................................30 References .......................................................34 5 I. Introduction would pertain to possible scleral lens wear prior to contact lens fitting. During the consultation, staff Fitting scleral lenses has expanded in the last members should present the benefits of scleral lenses decade, and scleral lenses are continuously gaining and properly educate the patient on other options, popularity amongst practitioners globally. The fitting including corneal rigid gas permeable contact lenses, approach differs from corneal rigid gas permeable custom soft contact lenses, hybrid lenses, glasses, and soft contact lenses; therefore practitioners, staff, and/or surgical procedures, and further explain and patients should be appropriately educated. the fees, insurance coverage, fitting process and The Clinical Guide for Scleral Lens Success is a follow-up schedules. It is appropriate to have a signed collaborative work between the Accademia Italiana document where the patient has acknowledged Lenti Sclerali (AILeS) and the Scleral Lens Education discussing this information with additional instructions Society (SLS) with the purpose of providing a protocol regarding refunds of lens materials and fees as well for scleral lens fitting. Each country has different as the office policy on lens changes or refits. This laws and regulations concerning the practice of eye information should be properly vetted and discussed. care. Therefore, these guidelines may be adapted Proper instruction and training on contact lens care accordingly. Furthermore, this guide will be constantly and handling is also crucial for fitting success. updated with new research in the scleral lens field. Proper staff training is the foundation for success in a Despite the fantastic advances in lens design and scleral lens practice. Patients who have experienced materials, there are many aspects of scleral lenses vision challenges prior to scleral lens fitting are that are still unknown. often frightened about their prognosis and are most concerned about their own future, so it is important to II. Staff training be professional, competent, and provide high quality customer service. It is helpful to have staff attend continuing education courses to learn and increase Scleral lenses are life changing because of the unique their awareness of scleral lenses. marriage of superior lens optics, large lens diameter, and a comfortable lens wearing experience. Patients who are interested in wearing scleral lenses have III. Patient and family communication often tried other modalities without success, and have possibly searched for information from websites, A positive approach that effectively communicates social media, or other practitioners. Unfortunately, and focuses on scleral lens benefits and their consistent information on scleral lenses is not always differences from other lens modalities will improve available, so patients may not be well informed patient and family expectations and overall despite their best efforts to learn about this modality. satisfaction. It is important to be realistic and To enhance fitting success and patient satisfaction, understand what information is pertinent for patients staff members should be trained to identify good to know. Patients are often anxious about their vision scleral lens candidates, provide accurate information, performance and ocular health or have had previous and educate, train, and support patients throughout experiences with practitioners that might not have the fitting process [1]. Practitioners and staff members been optimal. This may color their personal view may have personal experience with scleral lenses, of the situation and influence their expectations. which makes conveying their experiences much Understanding the psychological aspect of scleral lens easier. Having staff members try scleral lenses fitting and respecting the amount of information given themselves may improve empathy for those patients to a patient at one time may differ from one individual who may be trying scleral lenses for the first time and to another. Limits must be respected, and information increase conviction and confidence for this option. may need to be dispersed, or even repeated over multiple visits for simpler comprehension. It may also The first communication with the patient occurs be helpful to have a family member join the patient when they are speaking to staff at the office, either during instruction in order to assist the patient if they in person or on the phone. Staff should be able to are unsure or unable to handle an aspect of care or provide basic information about scleral lenses and handling on their own. be knowledgeable on good candidate selection in order to