Skip to main content
Home »

DRY EYE

Keratoconus Patient Wore Gas Permeable Contacts For Many Years

Thank you Dr. Ochiltree for this kind referral!

73 yo female has worn gas permeable lenses for many years due to keratoconus.

Keratoconus patients are not able to wear traditional contact lenses or glasses due to the irregular shape of their eye. Many times, corneal gas permeable lenses, hybrid lenses, custom soft lenses or scleral lenses are needed to improve their vision.

Over the past 8 years, we have successfully managed her with corneal gas permeable lenses.

In the last few months, she reported that the lenses were starting to slip and move around with increase in discomfort. She reported a long history of dry eyes with excessive mucous strands and her primary care optometrist (Dr. Ochiltree) told her that her gas permeable lenses had protein and deposits building up on the lens surface.

Upon our examination, she had several areas of dellen, SPK with staining, corneal neovascularization and pannus. We also found that her gas permeable lenses had heavy protein and lipid deposits and scratches.

At this point, we reviewed some of the options. The first option is we could keep her into the same corneal gas permeable lens type of lens. We also discussed some of the pros and cons of other lens designs such as hybrid lenses and scleral lenses. After discussing all designs, she chose the custom scleral lens.

Due her dry eye syndrome, corneal neovascularization and high scleral toricity, we felt that she would be most successful in a custom scleral lens.

Patients with dry eye may benefit from scleral lenses. This is due to the fact that there is a layer of liquid that bathes the eye all day. Gas permeable lenses rest directly on the cornea, so they can rub and irritate the eye surface. Scleral lenses do not touch the cornea at all, and rest on the white part of the eye, which has significantly less nerve endings. This results in a very comfortable lens for many dry eye patients.

With the help of Visionary Optics, we were able to design custom scleral lenses using 3D technology.

Switching between GP lens wear and scleral lenses can take some time to get used to. The patient was surprised at the stability of her vision when she looked toward her right and left. She could see 20/20 at distance out of each eye and she was happy with the comfort! Overall, she has been very happy with the change! We are excited to see how she progresses over the next few weeks.

OD corneaOS cornea

OD pannus at 800OS cornea and temporal conj irregularity

cornea OD

cornea OS

Latitude® Custom Scleral Lenses

OD OCT central clearance 152

OD OCT nasal edge

OD OCT temp edge

OS OCT central clearance 165

OS OCT nasal edge

OS OCT temp edge

How to Deal with Contact Lens Discomfort

Do your eyes itch or burn when wearing contact lenses? There are several reasons why you may be experiencing contact lens discomfort. Discover the possible causes behind the problem and see what you can do to relieve your discomfort.

What Causes Contact Lens Discomfort?

Some of the top causes of uncomfortable contacts are:

Dry eyes

Dry eye syndrome is a common condition that arises when your tears can’t keep your eyes sufficiently lubricated due to an imbalance in the tear film. Certain diseases, medications and environmental factors, like high levels of dryness and wind, can cause or contribute to red, itchy or irritated eyes, especially when wearing contacts.

Allergies

Allergens are typically harmless substances that induce an allergic response in certain people. Pollen, mold, dust and pet dander are some of the most common airborne allergens that trigger eye allergies. Cosmetics and certain eye drops, such as artificial tears with preservatives, can also induce eye allergies, which can make contact lens wear uncomfortable.

Corneal irregularities

The cornea at the front of the eye may be irregularly shaped due to astigmatism, keratoconus, eye surgeries (i.e. LASIK or cataract surgery), eye injuries or burns, scarring, corneal ulcers and/or severe dry eye. Irregular corneas often prevent traditional contact lenses from fitting correctly and comfortably.

Symptoms of Contact Lens Discomfort 

  • Burning, itchy, stinging eyes
  • Sensation of something being stuck is in the eye
  • Excessive watering or tearing of the eyes
  • Unusual eye secretions
  • Redness of the eyes
  • Reduced sharpness of vision
  • Blurred vision, rainbows, or halos around objects
  • Sensitivity to light

How to Relieve Contact Lens Discomfort

Try Different Contact Lenses

Nowadays, there are many types of contact lenses on the market, including specialty contacts for dry eyes and astigmatism. Meet with our optometrist for a personalized eye exam for contacts.

With the variety of contact lens brands available, switching to a different contact lens may be the simplest answer if you’re experiencing discomfort that isn’t connected to improper fitting or issues with tear production. If your existing lenses fit well but still irritate and dry out your eyes, speak to us about trying a different design or brand of contact lenses, or changing your lens-wearing schedule. 

Artificial Tears or Eye Drops

Over-the-counter artificial tears or eye drops are a common way to temporarily relieve contact lens discomfort. However, it’s important to keep in mind that unless prescribed by an eye doctor, they may not be treating the root of the problem. 

Moreover, certain eye drops are incompatible with contact lenses, and may damage your contacts or harm your eyes. We also recommend staying away from products that claim to remove redness from your eyes, which temporarily reduce the size of blood vessels to lessen redness, but do not address the underlying cause of the condition, and can actually worsen it over time.  

Take Good Care of Your Lenses

Inadequate contact lens care leaves residue on your lenses, which can discomfort, harmful eye infections and inflammation. Below are a few important contact lens hygiene guidelines to follow:

  • Before handling your contact lenses, thoroughly wash and dry your hands.
  • Remove your lenses before showering, bathing or swimming to prevent infection. 
  • Do not sleep in your contact lenses (unless they are approved for sleeping). 
  • Replace your contact lenses according to the manufacturer’s instructions (e.g., don’t reuse daily wear lenses).
  • Regularly clean your contact lens case and ask your eye doctor when to replace it.
  • Only use a contact lens solution that is appropriate for your lenses. 
  • Never reuse or mix contact lens solutions.
  • Schedule regular appointments with your eye doctor.

If you are experiencing discomfort with your contact lenses, get in touch with The Contact Lens Institute of Nevada in Las Vegas today. We’ll get to the bottom of the problem and provide effective solutions for all-day comfort.

Q&A

What kinds of contacts are available?

Contact lenses are available in a wide range of materials and replacement schedules. Disposable contact lenses and extended wear contacts are the most convenient for many users.

I’ve already been fitted for contact lenses, so why did my optometrist ask me to come back?

If you’re asked to return a week later, it’s because your optometrist wants to rule out any issues, such as contact lens-related dry eye or irritation.

If it’s been around a year since your last eye checkup, you’ve likely been contacted to check whether your prescription has changed and to evaluate your eye health. The sooner problems are detected and treated, the better the outcome. 

Dry Eye Patient Fit Into Custom Scleral Lens

Thank you Dr. Wellish for this kind referral.

66 year old Male was referred to us for a scleral lens consultation for dry eyes. This patient had a h/o of PRK (corneal transplants) in both eyes in the 1990’s and had recently undergone cataract surgery in the right eye

He opted for the Multifocal PC IOL for the right eye (so he could see distance and near without glasses) and was interested in doing the same for his left eye. Unfortunately, his signs of dry eyes were too severe to proceed. Dr. Wellish kindly referred him to us to help heal his left eye with a scleral lens. Our goal was to fit him into a scleral lens to help hydrate and protect the cornea, allowing it to heal for possible cataract surgery.

With a diagnostic lens, his vision improved significantly and was suspected that it could be good enough to delay cataract surgery. Due to his high scleral toricity, we recommended a custom scleral lens to maximize the fit and comfort of the lens.

After wearing the Latitude lens for about 3 weeks, he was able to achieve 20/20 in the distance! The Latitude scleral lens is a custom scleral lens that uses 3D imaging to create a custom fit scleral lens. At this point, we incorporated multifocal optics into the left scleral lens to match the multifocal IOL in the right eye. He has been very happy with his vision near and far in both eyes, and sometimes feels that his left eye is more comfortable throughout the day than his right eye! The plan is to continue monitoring his cataract and managing the signs and symptoms of his dry eyes.

OS Scleral Elevation

OS cornea with NaFl 3

OS cornea with NaFl 2

OS cornea

OD topo axial crop

OS topo axial crop

OS inf edge Medmont

OS latitude Medmont

OCT OS temporal

OCT OS nasal

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.

Dr. Woos’ Top 10 Eye Drop Recommendations For Contact Lens Wearers

Many of our patients ask about eye drop recommendations. Some of the key things that I consider:

  • Eye Condition(s)
  • Contact Lens Wearer?
    • What type? soft? hard? hybrid?
  • Age
  • What problems are you having and how often?
  • What have you used before (if anything)?

If a patient has a medical eye condition such as sjogren’s syndrome, graft-vs-host disease, Stevens-Johnson, extreme dry eye, etc., I will always recommend a non-preserved eye drop. This is because the surface of the eye is compromised and I don’t want any unnecessary preservatives sticking around on the ocular surface. Over time, too much exposure to preservatives can lead to a toxic response on the ocular surface.

If a patient wears contact lenses, I also recommend preservative free drops. This is because the preservatives within the eye drops can stick to the contact lens material. Then, those preservatives can stay on the contact lens surface, making contact with the eye for many hours. This continued exposure can cause a sensitivity to the preservative, making your eye red, dry, and irritated. There are some eye drops that are labeled “for contacts” which might be safe for the type of contact lens that you wear. If you have any questions, ask your eye doctor for their recommendations.

Here are my top eye drops, in no particular order (I have no financial interest in any of these eye drops):

oasis

Oasis Tears. I like these because they are individual vials and preservative-free. Many of my patients use they on a routine basis every day. If you have scleral lenses, and suffer from scleral lens fogging, this can be incredibly helpful. Simply fill the bowl of your scleral lens with 1 or 2 drops of Oasis tears, and then fill the rest of the bowl with non-preserved saline. Many of our scleral lens patients who suffer from fogging find that if they use Oasis tears to fill the bowl of their lens, they can wear their lenses for a longer period of time without them fogging up.

blink

Blink for Contacts. This eye drop is made for contact lenses (soft and hard lenses). It is in one large bottle instead of vials, so it is NOT preservative free. This is important because if your eye doctor recommends a preservative-free artificial tear, this would not be a good option for you. You can find this eye drop at most local drugstores and grocery stores.

retaine

Retaine MGD. This eye drop is great for anyone who needs to replace the lipid layer of their tears. There are 3 layers of tears. The bottom layer is a mucous layer, which is closest to your eyeball. The middle layer is the aqueous layer, which is made of mostly water. The top layer is a lipid layer. Think of this top layer as an oil layer. It helps to prevent tears from evaporating off the surface of your eye. This is a great option if you have meibomian gland dysfunction.

celluvisc

Celluvisc. This is another more viscous preservative-free tear. It is similar to Oasis tears, but more readily found in local stores. Sometimes it is out of stock, so it can be frustrating for patients who rely on this product. This is another troubleshooting eye drop that I use for scleral lens patients when they have issues with fogging. Simply add 1 or 2 drops of Celluvisc to the bowl of your scleral lens and then fill the remainder of the bowl with your non-preserved saline. If you like this drop, stock up because stores quickly run out of it and it may take weeks or months for you to get it.

systane

Systane Preservative-Free. This is another product that is easy to find at most any store that you already shop. I have seen them at local drugstores and grocery stores. Be careful with this brand (Systane) because they have so many eye drop options, it can be hard to remember which one to use. They have many different eye drops that are very good to use without contacts (such as Systane Balance, Systane Ultra, etc), but if you are using the eye drops in conjunction with contact lenses, please choose the preservative free vials.

zaditor

Zaditor. This is another eye drop you can find over-the-counter at most stores. However, sometimes you have to ask the pharmacist because they keep it behind the counter or they keep it locked up. This is not because you need a prescription to purchase it. This is easily purchased at a store or online. This is a GREAT eye drop for anyone suffering from eye allergies. If you have itchy, runny, irritated eyes, this is a great product to try. This does have preservatives, so please use one eye drop in the morning when you wake up, then wait five minutes and then insert your contact lenses. At night, remove your contact lenses, and then place another drop of Zaditor. This is a great over-the-counter eye drop for eye allergies.

refresh

Refresh Relieva for Contacts. We give a sample of this to all of our patients during their contact lens training. Our Allergan rep gives us samples of these to pass onto patients. Again, this is one that you can easily find at most stores. The larger bottle indicates that it is not preservative free, however, many of our contact lens patients find this eye drop provides relief from dry eye during the day. There is also a preservative-free version which I have never actually seen at a store, but can be found online.

blink1

Blink Preservative-Free. This is another preservative-free product that I like recommending to patients. However, I have never found it at an actual store - all of my patients have to order this online. It is similar to Systane Preservative Free.

regen

Regener-Eyes. This is the first eye drop of its kind. It is a biologic eye drop, meaning that it is made of stem cells. Many of my patients find this eye drop soothing. If you suffer from dry eye, this is a wonderful product to try, especially if you experience minimal effects from traditional eye drops. I recommend this to any of my extreme dry eye patients. Sometimes the stem cells are very powerful and can heal the damage from an impaired ocular surface. You can’t order this online or find it at a store, it must be prescribed through an eye care professional. Please ask your eye doctor if this is something you want to try.

gel

Systane Gel. This is a great option for patients who suffer from extreme dry eye. You can’t use this during the day (because it is so thick that it will make your vision blurry). After your contacts are removed, you can squeeze a small amount into the lower eyelid cul-de-sac right before bed. This will coat your entire eye with a very thick layer of liquigel. It is much thicker than a traditional eye drop. This is great to use right before you go to bed. It is pretty expensive for such a small tube, but if it significantly helps with your dry eye, it is worth it.

I hope this list of eye drops was helpful to you! Wearing contact lenses can limit the type of eye drops you can use, but hopefully one of these on the list will work for you. As always, it is best to consult with your eye doctor if you don’t know which eye drop to select. They know your eyes the best, and they are true experts when it comes to eye drops.

Lupus patient with extreme dry eye

Thank you Dr. Mallinger for this kind referral.

We have 77 yo F with a h/o of lupus erythematosus and severe dry eyes was referred to us for a scleral lens consult. Her current regime for managing her dry eye symptoms included topical steroids, constant instillation of various artificial tears, and taping her eyelids at night when she sleeps. She has tried punctal plugs, ectropion repair, medicated dry eye drops and stem cell procedures with no improvement. She reports spending most of her time sitting in the dark with her eyes closed due to her severe discomfort and light sensitivity.

When we saw her, she was very light sensitive and was wearing sunglasses inside. She had 2+ inflammation and 4+ diffuse SPK OU. She had a lot of difficulty keeping her eyes open due to her discomfort and pain from the dryness. Her VA was 20/60 right eye and 20/200 left eye with no correction.

With all that she had been through, we felt that it was worth trying a scleral lens to protect her corneas from the outside environment and allow them to bask in continuous moisture to allow them to heal. We recommended the EyePrint Prothesthic due to her highly irregular corneal surface.

It was night and day after the first time we inserted her lenses. She was able to hold her eyes open and reported significant comfort compared to her naked eye. Unexpectedly, she was able to achieve 20/25 vision! Due to the severity of her condition when we assessed her, we plan on having her wear the lenses continuously with close monitoring for the next few weeks.

We will keep you posted

Is There Hope For Severe Dry Eye Patients?

Such gratitude helping complex patients!

Our 62 year old female returned to clinic for a second EyePrint Prosthetic dispense. She suffers from severe glaucoma in both eyes, and only has vision out of the right eye. She also suffers from autoimmune issues and recurrent uveitis in both eyes.

Dr. Saboori performed glaucoma surgery on her right eye and saved her vision and she has done well over the past year. She has been able to see about 20/50 out of the right eye. Unfortunately, over the past few months, she has developed severe ocular surface disease, and her eyes are extremely dry. Dr. Lin did an excellent job managing her with all sorts of dry eye treatments such as Restasis, Xiidra, artificial tears, gels, amniotic membranes, and serum tears.

Despite all of these treatments, her eye remains very dry, which is debilitating for her. She complains that her eyes are in constant pain. She also complains her eyes are so dry, she has to constantly use artificial tears to lubricate the surface. She is also very sensitive to light. She walks around indoors and outdoors with dark sunglasses due to her light sensitivity.

She was kindly referred to us for a specialty contact lens evaluation. When we saw her, she had declined and was seeing 20/200. She explained that her eyes were in constant pain and she was miserable all the time.

At this point, we recommended something called the EyePrint Prosthetic. Because she has a very large tube shunt, it is important to fit the lens exactly to the contours of her eye. We performed the eyeprint fitting in office and designed a custom lens based on that impression.

She arrived for the EyePrint dispense when the lens arrived, and with a small prescription added to the lens, she could see about 20/50. She was thrilled that she had functional vision and her eye was no longer in pain. She felt immediate relief with the lens. We checked on the lens about 1 week later to confirm that the lens was resting on the tube shunt properly. After we confirmed the fit to be ideal, we re-ordered the lens with a new prescription.

We saw her for a dispense today with the new Rx and upon insertion, she achieved 20/30 vision! She was so incredibly happy with how well she could see and her eye felt so much better.

The lens was finalized and she will return to Dr. Lin and Dr. Saboori for dry eye management, glaucoma management, and all other eye care needs. It is such an honor to help these types of patients.

Find out what Toni has to say about her experience at our office:

Are there treatment options after LASIK?

We had a very lovely young lady kindly referred to us from Dr. Wellish!

This patient suffers from extreme dry eye syndrome. She had LASIK eye surgery performed years ago, and she did quite well until having children. She explained to me that her eyes became very dry, painful and uncomfortable after having kids. This could be due to a fluctuation in hormone levels.

Patients who undergo LASIK eye surgery can also be at risk for neurotrophic keratitis, a condition in which the corneal nerves become desensitized and thus causes more corneal issues such as severe dry eye and non-healing defects.

Despite multiple treatments including prescription eye drops, lacrisert, punctal plugs, artificial tears, gels, and Lipiflow, she still remains uncomfortable. Currently, she uses Cequa twice per day, refresh tears every hour or two hours, Celluvisc every 3-4 hours, autologous serum tears twice per day, Lacrisert every week, and gel at night.

She complains that her eyes are very dry and uncomfortable, especially when reading or looking at the computer.

After reviewing all options, we decided to perform sMap 3D imaging to take a 3D scan of her eyes. This information will be used to create a custom scleral lens called the Latitude. Hopefully, the lens will provide a barrier for her eye and the outside environment to provide her some relief. The bowl of the scleral lens is also filled with non-preserved saline, which should also help improve her eye comfort and staining.

I also added Regener-Eyes and Eyesuvis to her current eye care regimen to see if those eye drops can offer any additional relief.

Looking forward to her dispense!

treatment after lasik 1

treatment after lasik 2

treatment after lasik 3

treatment after lasik 4

treatment after lasik 5

Sjogren’s patient fit into scleral lenses

A 47 year old female was referred for contact lens evaluation. She was diagnosed with ocular cicatricial pemphigoid and Sjogren’s. These two conditions cause the eyes to be incredible red, irritated and dry. She suffers frm extreme dry eye.Her habitual scleral lenses are several years old and feel that they are getting dirty and fogging. She reports poor night vision with glare and halos. She reports only using preservative free sodium chloride solution to rewet her eyes throughout the day. Her lenses are about 2 years old, per patient.

She was 20/40 right eye and left eye with her current lenses. The front surface of the lenses had poor non-wetting surface and protein deposits. You can see in some of the images how deposited the surface of her lenses were. Both eyes exhibited poor tear film stability, inflamed bulbar conjunctiva, and formation of symblepharon. Symblepharon is a condition in which the under part of the eyelid starts to fuse with the white part of the eye. This can happen with patients that suffer from extreme dry eye. Due to her signs and symptoms, we felt that a custom Latitude lens would provide her the best comfort and vision.

The Latitude is a custom scleral lens that uses 3D imaging technology. The patient looks straight ahead, then up, then down, and the machine captures 3 D images in each gaze. Then, the software stitches the images together. This give the laboratory an incredible amount of information, so that a custom scleral lens can be designed and fabricated.

We worked with the lab to help design her new scleral lenses.

We dispensed her new lenses and she reported noticing immediate improvement in comfort and vision. You can see how well the new lenses fit her eye in the images below. Due to the instability of her tear film, we started her on Cequa as well as recommending preservative free artificial tears to replace the sodium chloride solution for the additional lubricating agents. Cequa is an eye drop intended to help with dry eye syndrome. We are very happy with how the new scleral lenses look and feel on this patient’s eyes!

Financial disclosures: I have no financial interest in any of the companies or products mentioned in this case report.

Severe Dry Eye and Scleral Lenses

One of our favorite patients came in for her annual exam for her custom contact lenses.

This patient suffers from severe dry eye syndrome. She has had multiple treatments and used multiple eye drops without much relief. Dr. Wellish kindly referred her to me for a specialty contact lens evaluation last year to see if anything could be done to help with the dry spots on her eye.

We fit her into Latitude custom scleral lenses and here is her current regimen: In the morning she cleans her eyelids and inserts her Restasis eye drops. Next, she rinses off her scleral lens with preservative free saline, and fills the bowl of the lens with autologous serum tears and preservative free saline. During the day, if her eyes feel dry, she uses Refresh Optive throughout the day. At night, she removes her scleral lens, cleans her eyelids, then applies her Restasis drops. She uses her Bruder mask every night to keep her meibomian glands healthy.

On days that she does not wear her scleral lenses, she uses her autologous serum tears three times per day, along with Celluvisc and other preservative free eye drops to help manage her dry eye.

I am happy to report her eyes are much healthier now, and all of the dry spots on her cornea are resolved. She is doing great, and we will see her again in 3 months to check on the contact lenses and her dry eye. We are also having her try Regener-Eyes stem cell drops because of how great she responded to the autologous serum. I also recommended Tangible Boost so that she can re-coat her scleral lenses every month to help with dryness. Lastly, she is going to try mascara from Eyes are the Story, to see if her eyes respond better to a makeup that’s created for dry eye patients.

She will also continue to see Dr. Wellish as directed for her dry eye management and annual exams.

Helping dry eye patients is so fun!

Financial disclosure: I have no financial interest in any of the companies mentioned in this case report