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Patient switched into a custom scleral lens design after failing in a traditional scleral lens

We have been working with a 25 yo male with h/o keratoconus OS>>OD s/p CXL. He found us online looking to see if he can improve his vision with scleral lenses. His vision with his glasses was 20/30 in the right eye and 20/400 in the left eye. He was also having problems with night vision.

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Despite multiple changes, there was still excessive seepage into the 12:00 and 6:00 position, indicating a large amount of scleral toricity.

He was first fitted into the ZenLens and was able to achieve 20/20 vision in the right eye and 20/30 vision in the left eye with significant improvement in his night vision. Unfortunately, he was experiencing significant redness nasally and temporally. After several designs of increasing the haptics and vaulting over the pinguiculas, he continued to experience injection after an hour of wear. Due to the limitations of non-custom scleral lens designs, we recommended a custom Latitude lens in order to reduce the redness. When we have to make alterations to the lens design more than 2 times, we will often times switch designs completely.

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We refit him into a custom scleral lens, which fits his eye much better than the traditional scleral lens.

After imaging him with the sMap3D, we found that he had a scleral toricity of almost 400 in both eyes! The average scleral toricity is about 150-170 which can help explain the nasal and temporal redness he was experiencing with the previous scleral lens.
With the Latitude lens his redness significantly improved, only noticing a mild amount at the end of the night. In addition to the improved fit, he was able to achieve 20/15 vision in the right eye and 20/20 vision in the left! We are so thrilled that he is doing so well!

Live demonstration of an EyePrint Prosthetic

In this video, join Dr. Stephanie Woo for a live demonstration of the EyePrint Prosthetic on a real patient.

This patient suffers from poor vision as a result of prior eye surgery. She had radial keratotomy surgery (also known as RK surgery) in the early 1990’s. This surgery was a popular option for patients looking to eliminate their glasses or contact lenses.

Watch EyePrint Demo

RK surgery involved the surgeon making small cuts onto the cornea in a spoke-like pattern, hence the name “radial.” Making the incisions allowed the cornea to reshape and become flatter in the center. This changed the shape of the eye, which reduced the need for glasses or contact lenses.

Most RK patients saw well for many years, but as time has progressed, there have been many issues.

Bruce+potter+RK+scars+OS

RK scarring in the cornea

RK patients suffer from blurry vision, distorted vision, ghosted vision, shadow-y vision, double vision, and other visual complications.

This patient also has a corneal transplant. This was due to the enormous amount of scar tissue in the center of the cornea.

Due to her very irregular cornea, we decided to fit her into an EyePrint Prosthetic.

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The Eyeprint procedure is painless and take less than 3 minutes

Step-by-step instructions:

  • First, the tip is placed at the edge of the impression material and locked into place.

  • Next the trigger is squeezed, which allows 2 separate materials to combine in the chamber of the tip.

  • The mixed materials are placed into a small plastic tray.

  • We wait for 40 seconds for the material to set.

  • Then, the patient looks at their fixation target.

  • Quickly, the impression is inserted under the upper eyelid and then the lower eyelid. This is the most important part. You must get the lids out of the way.

  • Let go.

  • The patient continues to look at their fixation target for about 90 more seconds so the material can set.

  • Then, the impression is removed.

  • After, we proceed with a diagnostic scleral lens fitting to determine what power to add into the EyePrint.

Watch EyePrint Pro Demo

After several impressions are obtained, we send them to the EyePrint lab in Colorado. Next, the lab uses a 3-D scanner and captures over 3 million data points using information from the impression. This information is then used to design a perfectly custom scleral lens. The lens is then fabricated in the lab and then shipped to us for dispensing.

When the EyePrint arrives, we will call the patient and schedule her for a scleral lens dispense.

We were able to achieve 20/20 vision with the EyePrint with this patient. Looking forward to seeing how her next visits go!

Next: Does Insurance Cover Scleral Lenses?

How Do I Get Insurance to Pay for My Scleral Lenses?

How do I get insurance to pay for my scleral lenses?

If you have medical or vision insurance, they may contribute toward the cost of scleral lenses.

Some insurance companies such as VSP or Eyemed will reimburse eye doctors quite well for scleral lenses, and many offices accept this insurance for scleral lenses.

Other insurance plans reimburse eye doctors poorly for scleral lens fittings. Some of them reimburse less than the cost of the lenses! In this case, it is not feasible or realistic to expect your doctor to fit you into scleral lenses.

One way to get your insurance to cover scleral lenses is to have your doctor write you a letter of medical necessity.

This letter should include”

– Patient’s name

– Patient’s date of birth

– Date patient was seen

– Patient diagnosis

– Patient’s vision (uncorrected)

– Patient’s vision (corrected with glasses)

– Patient’s vision (corrected with scleral lenses)

– Abnormal findings

– Recommended treatment and plan

– ICD 10 codes

– CPT codes

– V codes

The letters we write for patients explain to the insurance company why the patient needs scleral lenses. Usually, our patients suffer from a medical eye condition such as keratoconus, corneal scarring, corneal transplants, RK scarring, post LASIK, etc so the reason they need scleral lenses is to improve their vision. Other patients have medical eye conditions such as extreme dry eye, graft-vs-host disease, sjogren’s, stevens-johnson and other disorders related to the ocular surface. Whatever the reason is, we will write a letter explaining to the insurance company the need for scleral lenses.

before+and+after+severe+dry+eye+with+scleral+lenses

Our patient who has extreme dry eye. Notice the major difference in her eyes before and after scleral lenses.

You can also have your doctor give you a list of diagnosis codes, ICD-10 codes, CPT codes, and V codes, along with the pricing for each service. This will allow the insurance company to see what is being requested, and the specific dollar amount needed.

Your insurance company may also request to speak with the doctor. In this case, your doctor will set up a meeting with the insurance company to explain your medical eye condition and explain why scleral lenses are necessary.

With some help from your doctor, you may be able to get a portion or the entire scleral lens fitting covered through your insurances.

What’s an alternative to Nutrifill?

Many of our patients use Nutrifill to fill the bowl of their scleral lenses.

However, there was a recall on the product in June 2021 and Contamac Solutions was recently made aware of a potential issue by its contract manufacturer in the production of Nutrifill Lot #FOE with a use by date of 09/30/2022. There have been no adverse events or complaints reported, and we do not believe any of the product shipped to consumers has been affected. However, out of an abundance of caution, we recommend that you discontinue use of any product from Lot# FOE while we work with our manufacturer to investigate further.

Nutrifill Saline Solution Single

Nutrifill was recalled in June 2021.

Many of our patients are asking, “What can I use instead of Nutrifill?”

Hear what Dr. Woo recommends as an alternative to nutrifill

Lacripure

One recommendation is Lacripure. Lacripure is available on Amazon or sometimes sold in your doctor’s eye clinic. It comes in 5mL vials, which is a smaller size compared to Nutrifill vials. It does not have the added electrolytes like Nutrifill does, though. We have many patients who love Lacripure. You can purchase them in a large box of 98 vials or if you want a smaller pack, they also sell them in 7 vial strips. The 7 vial strip is a good option if you want to make sure you like it before committing to 98 vials.


ScleralFil

Another option is ScleralFil. This product comes in 10mL vials, so it is the same size of the Nutrifill vials. Unfortunately, it does not come in other sizes. It also does not have added electrolytes. This is a great product and many patients like the large size. If you do not like the large size of 10mL vials, you might consider Lacripure or Addipak as options.


Vibrant Vue

A new option to market is called Vibrant Vue Saline. This is preservative free saline and comes in convenient 5mL vials, which is smaller than Nutrifill saline. If you find that the 10mL bottles of Nutrifill is too much, the 5mL size may suit you better.

vibrant+vue

Addipak

You can also purchase Addipak on Amazon, which is just non-preserved saline. This is a cost effective alternative to Nutrifill. You can find these in 3mL sizes and 5mL sizes. This is a very inexpensive option if cost is a concern. One thing you may want to be aware of though is that the plastic that Addipak comes in can come from different sources and different countries. There have been some concerns of chemicals in the plastic containers leaching into the solution. I don’t have any peer-reviewed data on this topic, but it is currently being studied.


Written Prescription

You can also have your doctor write you a prescription for non-preserved saline vials. The benefits of this is that you can take this Rx to your pharmacy. If you have good insurance benefits, the saline might be offered with just a small co-pay or in some cases, free! We always give our scleral lens patients written Rx for non-preserved saline, even if we have recommended a different filling solution. This is helpful especially if they run out of solution or need some when the are on vacation. Ask your doctor to write an Rx for you.

Next: What eye drops can scleral lens patients use?

Damage to Eye from a Burning Building

Super interesting case from Dr. Schorr from New Eyes!

We saw a 19 year old boy for a consultation today. He suffered a trauma from going into a burning building and when he opened the door, the door flew open and the padlock hit him in the right eye. According to the patient, he left the burning building but then his boss told him to go back in. When he went back in, he opened the door, and (probably due to backdraft), the door slammed into the right side of his face and the padlock went right into his eye. He was a child when this all happened.

Cornea+trauma+OD.+and+corneal+scar+jpg

Large, dense corneal scar which goes right through the center of his eye.

He had a globe perforation to his eye that had to be repaired quickly.

His crystalline lens could not be saved, so he is aphakic in that eye. He has severe corneal scarring. There is also a dense amount of scar tissue that attaches the posterior cornea to the anterior iris. You can see in the OCT image below that the back side of the cornea attaches to the front side of the iris.

He also has an artificial pupil and iris defect both nasally and inferior nasal.

His main goal of today’s visit was to see if a specialty lens could improve his vision. He sees count fingers at 4 feet and complains of diplopia in the right eye.

When I looked at his eye, I had little hope that any vision improvement would be possible, due to the severe scar tissue and lack of a normal entrance pupil.

We tried on a diagnostic Europa scleral lens to see if any vision improvement was possible and with a +8.00 over refraction, he could achieve 20/50 and he stated his double vision was gone.

Due to the ocular condition, he must be eccentrically viewing out of his artificial pupil inferiorly. We are going to attempt a scleral lens for him to see if it helps improve his vision, diplopia and balance. Stay tuned for updates!

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This image shows us that the back side of his cornea is attached to the iris

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The topography of the right eye shows irregularity

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We placed a diagnostic Europa scleral lens on his eye and he could see 20/50!

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Prosthetic Contact Lens

Prosthetic Contact Lens – A cool case sent over from Dr. Irene Voo!

A 73 year old white male was kindly referred to us for a prosthetic contact lens consultation.

He has a history of several retinal issues such as branch retinal vein occlusions and epiretinal membranes. He also has artificial lenses in each eye from cataract surgery.

His main complaint is that his vision is very blurry, distorted, double, and issues with glare on the right eye. His right eye is best correct to 20/200 and he complains of shadows, distortion and double vision. His left eye best corrected is 20/32.

Many times, patients that cannot see well out of one eye have a very hard time. This is because with both eyes open, the brain tries to overlay the image detected from each eye. This can result is visual confusion and other symptoms such as dizziness, nausea, feeling off balance, light sensitivity, issues with glare, blurred vision, double vision, visual discomfort and more.

He is so bothered by the distortion in the right eye that he wears a patch over his right eye to improve his visual comfort. He also wears a pair of glasses which were specially made by Dr. Quinton where the right lens is black and the left lens is clear. This also helps so that less light enters his eye.

We think he would be an excellent candidate for a prosthetic contact lens! We color matched his eye today using the Orion Fitting Set from ABB specialty lenses. The first photo was a good match but a bit too blue. The second photo was a different mix of colors and looks like a better match. We used Underprint #3, followed by CB3, and then #52-V to get this result.

prosthetic+contact+lens+orion

The first color match appeared a bit too blue.

With the Orion fitting set, you stack different colors until you get a good match.
We ordered the lens today to be completely blacked out on the underside of the contact lens so that no light will enter his eye. He should feel much more comfortable with the lens on his eye. We will post photos of his dispense soon!

prosthetic+contact+lens+orion+color+match

The second color match appears to be a better match.

Major thanks to Dr. Kramer for always helping us with prosthetic lenses and to Dede from ABB for your expert help.

Eye Drop For Droopy Eyelids

before+and+after+upneeq

*Posted with patient permission. Top photo is before Upneeq. Bottom photo is 10 minutes after.

Is there an eye drop for droopy eyelids?

Until recently, the only way to fix droopy eyelids was surgery. In order to qualify for medical insurance to cover the surgery, you have to fail a visual field test and the eyelid has to be drooping to a certain extent over the pupil. This was very frustrating to patients.

Many patients opted to pay out of pocket for eyelid surgery because they didn’t like the way their eyes looked or they felt like there was significant improvement in vision when they pulled their lids back.

We saw a patient today (a 61 year old female) and she has worn corneal gas permeable lenses for over 40 years. Sometimes patients who wear corneal GP lenses can develop a droopy eyelid (called a ptosis). This may be from the way that the lenses are removed. When corneal GP lenses are removed, often times patients use their upper and lower eyelids to pop the lens out of the eye. Over time, this is damage the muscle that’s responsible for lifting the upper eyelid.

For fun, we inserted an eye drop of Upneeq into both eyes and took a before and after photo. The after photo is about 10 minutes after inserting the drop. We showed the patient the difference and she was thrilled! She will use Upneeq every morning before she puts her contact lenses in. The eye drop will lift her upper eyelid and help with the droopy lid appearance.

The results will last 8-12 hours, so she will need a drop every day that she wishes to see an improvement in the droopy lid. Upneeq is not available over-the-counter, it must be prescribed by a doctor. The doctor will send your information into the pharmacy and they will contact you directly if you wish to order.

This is a great innovative eye drop to help patients who may want a surgery alternative to eyelid surgery.

FD: I have no financial interest in this product or company

Next: Learn more about dry eye

Summer 2021 Newsletter

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Can Corneal Transplant Patients Wear Scleral Lenses?

Can corneal transplant patients wear scleral lenses?

We had the pleasure of seeing a kindly referred patient for a specialty contact lens consultation yesterday.

This 78 year old white female has a positive ocular history of radial keratotomy (RK) surgery in both eyes in 1990, followed by a corneal transplant in the right eye in 1995, and then had LASIK on top of the right transplant in 1998. Radial keratotomy was a surgery performed in the late 1980’s and early 1990’s to help correct patient’s vision. It has now been replaced with safer options such as LASIK and permanent contact lenses.

Both eyes underwent cataract surgery in 2014.

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Right eye corneal transplant

She complains that her vision is blurry, distorted and double. This is very common for patients who’ve undergone RK surgery. Because of the scalpel cuts into the cornea, this creates an irregular shape, which distorts the image coming into your eye. This results in fuzzy, wavy, fluctuating, blurry vision. She was kindly referred by her corneal specialist, Dr. Casey at Nvision, to our clinic for an evaluation.

With glasses, she can see 20/200 “double” in the right eye and 20/50 “double” in the left eye. The corneal transplant looked clear centrally with minimal neovascularization inferiorly. RK scars were present on both eyes. When I assess a corneal transplant, I make sure that the center of the transplant is clear. If there is major scar tissue or haze within the transplant, there may not be an opportunity for vision improvement. Luckily, for this patient, her corneal transplant is very clear.

OS+rk+scarring+2

Left eye showing radial keratotomy (RK) scarring

When I am not sure if a patient will see better with a specialty lens, I always place a diagnostic lens on the eye. This will help us determine whether or not a specialty contact lens will improve your vision. If we put a diagnostic lens on and perform a few short tests, it will determine the best potential for vision improvement. For instance, let’s say you can only see the 20/400 line at the eye doctor (the big “E”). If we are not sure whether or not your vision will be helped with a contact lens, we will place a diagnostic lens on your eye and re-assess the vision. If your vision improves, it is certainly worth it to move forward with the fitting process.

Before that, we took sMap 3D images of each eye to map the shape of her sclera, the white part of the eye. Then, we placed diagnostic Europa scleral lenses onto the eyes to see what her best vision would be. There was superior touch with the diagnostic lenses on the right eye (see the OCT image), so we knew a traditional scleral lens may not be the best option for her. A more custom lens would be better suited for her unique eye shape.

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OCT imaging showing superior touch

With scleral lenses, she could achieve 20/50 in the right eye and 20/40 in the left eye. When a patient doesn’t see better on the visual acuity chart, I always ask them to rate the “quality” of their vision. She stated the letters were much sharper and less distorted. Since the vision improved the overall quality and clarity of her vision, we decided to order the Latitude custom scleral lenses.

We are really hoping to improve her vision with these special lenses!

Thank you Dr. Casey for your kind referral of your patient to our clinic!

 

Can you use scleral lenses for sports vision?

topo+OS (1)

Topography of keratoconus patient’s right eye

Thank you Dr. Jen Burke for your kind referral!

Dr. Burke sent a 17 year old patient to use for a corneal consultation. Even though the patient can see 20/20 with glasses, he reports seeing “lines” in his vision when he looks at a light source, especially at night.

topo+OS (2)

Topography of keratoconus patient’s left eye

A topography was taken of each eye, and you can see that both eyes exhibit irregular astigmatism. The left eye has more irregularity than the right eye. The steeper area on the left eye is also displaced nasally, so as the pupil gets bigger at night, it gets into the steeper shape, which can cause even more distortion.

As a hobby, he races formula drift, so his visual quality is very important.

With glasses, he can achieve 20/20 in the right eye and 20/30+2 in the left eye. He reports that the letters on the left eye appear more blurry and distorted.

OD+cornea

Photo of patient’s right eye

His pachymetry readings do not show a super thin cornea, which is great news.

We trialed the Europa scleral lens today, to see if it improved his visual quality. With an over-refraction, he could see 20/15 in the right eye and 20/15 in the left eye. He noticed the distortion was gone in the left eye, too.

We decided that the Latitude custom scleral lens would offer him the best vision and comfort, so we took 3D images of both eyes today. That information was sent to the lab and will be used to design custom fit lenses for each eye.

We are hoping that scleral lenses will help him see better and help with some of the visual disturbances. Looking forward to seeing him at his dispense appointment next week!

Thanks again Dr. Burke for thinking of us!