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SCLERA LENS

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!

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.

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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.

Can I Use Eye Drops With Scleral Lenses?

Is it safe to use eye drops while wearing hard lenses or scleral lenses?

This is a question we get almost every single day.

In general, it is ok to use preservative free artificial tears while you are wearing contact lenses. In some cases, you can use eye drops that say “for contacts” on the label. The reason you can’t use regular eye drops is because most eye drops contact preservatives. This is normally not that much of an issue for the surface of the eye, because blinking and tearing will flush the preservatives off of your eye surface fairly quickly. However, when you wear contact lenses, the preservatives stick to the contact lens material and then that gets held onto the surface of your eye for many hours.

Your eye doctor will be able to recommend a safe eye drop specific to your unique eye and the type of contact lenses you wear. If you have a compromised ocular surface, it is very important to use preservative free products to limit the amount of BAK or other preservatives that make contact with your eye.

Keep in mind that 90% of eye drops that you see on the shelf of your locals stores are made to be used WITHOUT contacts.

If you have questions, talk to your eye doctor. Your eye doctor knows your eye the best and they are experts in eye drops!

Find out what eye drops Dr. Woo recommends here.

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.

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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?

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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.

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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.

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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!

Contact Lens Options for Corneal Transplant Patients

A very interesting corneal transplant patient arrived today for a consultation.

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You can see the double running suture for this corneal transplant patient

He had a herpes scar years ago, which led him to a corneal transplant in the left eye in 2018. After the transplant healed, he was fit into spectacles to improve his vision. He has always suffered with poor vision after the transplant, but claimed he didn’t know there were any other options.

I am always surprised when patients tell me that they’ve undergone a corneal transplant, but have not tried any contact lens options to correct their vision. When you get a corneal transplant, it creates a very irregular surface. This irregular surface usually requires a specialty contact lens such as a corneal gas permeable lens or a scleral lens to help smooth out the optical surface. By using a special type of contact lens to re-direct the light entering your eye, the result can be a remarkable improvement in vision.

He sought out another opinion from Dr. Wellish, and Dr. Wellish recommended a scleral lens to improve his vision.

He can see 20/200 “double” with best corrected glasses in his left eye. If you’ve been to the eye doctor, you know that the big “E” is the largest letter on the vision chart. The big “E” represents 20/400 vision, which is very poor vision. As the numbers on the vision chart get smaller, the better your vision is. Hence the term “20/20.” Someone with 20/20 vision has perfect vision. In this patient’s case, 20/200 is also very poor vision.

The transplant has a double running suture, which is what you see in the photo. This technique provides the benefits of a single continuous running suture with the added safety and security of a second continuous running suture. Corneal transplant patients run the risk of hypoxia, and not getting enough oxygen to their transplant. If this happens, patients will need to limit their wearing time with the scleral lens, or change to a different lens modality, such as a corneal gas permeable lens.

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The corneal topography for his left eye shows a high amount of irregularity

We placed a diagnostic Ampleye scleral lens: 4400 sag/ 8.04 BC/ -4.00 on his left eye to see what his vision potential could be, and he was able to achieve 20/20 vision with a +4.50 over-refraction! He was thrilled with the vision and comfort of the lens. When patients have an irregular corneal shape, I always place a diagnostic lens on top of their eye to see what their potential vision is. There have been times where the lens does not improve the vision, but it is better to find out now, instead of going through the whole fitting process.

Imagine barely seeing the big E on the vision chart and then improving the vision so that you can see the smallest line of letters! This is such a huge improvement in vision, and it will be life changing for this patient. It’s cases like these that put a huge smile on my face and warms my heart. I love helping patients see better!

We are excited to see him for his dispense in about 1 week.

Thank you Dr. Wellish for trusting us with this special patient!

Monovision scleral lenses

Monovision scleral lenses

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We saw a 66 year old male with a history of monovision LASIK OU 20 years ago. In the last few years, he began showing signs of ectasia OU and found about 9D of astigmatism. This is a very high amount of astigmatism! For reference, most soft contact lenses can only go up to -2.75D. His right eye (distance) was 20/30 far and left eye (near) was OS 20/ 20 at near but describes ghosting and shadowing. Both eyes, he was seeing 20/25 distance. He felt modest about his vision and was functioning well in his daily activities but wanted to see if he could see better.

With a diagnostic lens, he noticed a significant improvement in his vision and was eager to proceed. He was fit with the Latitude scleral lenses and kept in monovision. This goes to show that the number on the chart (ie 20/20) may not always correlate to the quality of vision. Even if a patient can see the letters on the chart, the letters may still have ghosting or appear doubled. This can be very debilitating for patients.

We saw him a week after his dispensing his new lenses and was thrilled to see how well he was doing with the new lenses! His vision was OD 20/ 20 far, OS 20/ 25+ near and OU 20/ 20 distance. Although he felt that his vision before the lenses were decent, he was most surprised at how much more he was able to see in his daily life. He described noticing the new details of the distant mountains during his daily drives to work.

Thank you Dr. Jenny Wong for your excellent care for this patient and for this update!

We love helping patients like these achieve vision that they haven’t seen in years!

Thank you Dr. Paul Casey for this fun case!

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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

Stevens-johnson treatment options

Steven’s-Johnson is a rare, but very serious disease. Stevens-Johnson Syndrome (also known as SJS) is unpredictable and can happen to anyone. It is caused by a reaction to a medication or infection. It starts off with flu like symptoms, but then spreads throughout the body in the form of a painful rash and blisters. Mucous membranes are affected, which is why eye doctors become involved.

SJS is a serious condition which requires hospitalization. After being released from the hospital, the patient usually works with a team of doctors to manage different parts of their body.

SJS patients usually have extremely dry eyes, inflamed eyes, and severe eye pain. Many patients wear very dark sunglasses indoors and outdooors. Often times, the pain is so bad, they keep their eyes closed the entire day and night. Their quality of life can be very poor.

We are fortunate to work with some of these special patients.

A 79 year old female arrived at the office last week for a consultation. She had SJS 30 years ago, and still suffers from a variety of issues. Regarding her eyes, she stated her eyes were incredibly painful all the time. She has to put preservative free artificial tears in her eyes every few minutes, around the clock! Her eyes are red, swollen, and highly sensitive to light.

You can see in the photo that her eyes are very swollen. She wears dark sunglasses all the time due to her severe light sensitivity. She keeps her eyes closed majority of the day because they hurt when she opens them.

For these types of patients, I highly recommend the EyePrint Prosthetic. This is due to the fact that we only have a very small eyelid fissure to work with. For SJS patients, they can’t keep their eyes open even for a few seconds, so it makes fitting their eyes very difficult.

By taking an impression of the surface of the entire eye, the lab is able to design a specialized custom lens. This is the best option for SJS patients, in our opinion.

We were able to take multiple impressions of each eye and send those to the lab to be fabricated.

She arrived to our office for the dispense and we inserted the lenses for her. She was thrilled with the vision and the comfort of her eyes. She wore them over the weekend and when we saw her for her follow up, she said, “You’ve given me a new lease on life!”

You can see in the photo that her eyes are much less swollen and much less red when she has the lenses in her eye. This is because the scleral lens is filled with a preservative free saline, that bathes her eye all day. This also forms a protective barrier between her delicate eye and the outside environment. Scleral lenses can be life changing for these patients. We are honored to work with these special patients – we love seeing their eyes heal and get another chance on life!

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Do Scleral Lenses Work for Everyone?

Do scleral lenses work for everyone?

Scleral lenses are becoming a very popular contact lens choice for a variety of patients. Scleral lenses have given us the ability to fit even the most complicated eyes. Scleral lenses are also very comfortable compared to other contact lens modalities. Corneal gas permeable lenses are notorious for their significant discomfort. While the vision is excellent in corneal GP lenses or hard contact lenses, the comfort can sometimes be unbearable, which leads many patients to discontinue wear.

Luckily, scleral contact lenses are much more comfortable, so many doctors select that as a first line approach. In the past, scleral lenses were used as a “last ditch effort.” Doctors would usually fit patients into corneal gas permeable lenses, hybrid lenses, and other lenses before reaching for a scleral lens.

While scleral lenses are a great option for many patients, not all patients can wear scleral lenses. Sometimes patients have a very difficult time inserting a scleral lens. They cannot hold their eyelids open far enough or perhaps their eye is too sensitive and blinks the lens right off of the eye. Also, some patients have eye conditions that will not support a scleral lens.

Corneal transplant patients often fall into this high risk category. Patients who’ve had corneal transplants are at greater risk for corneal edema and graft rejection. For this reason, many patients are unable to wear scleral lenses. Scleral lenses cover the entire cornea, which limits the amount of oxygen that gets to the transplant. The cornea requires oxygen to stay healthy. If the cornea cannot keep up with the oxygen demands, it can start to develop swelling, also known as edema. This swelling causes the transplant to become cloudy and then it causes the vision to become blurry.

Scleral lenses can also cause the corneal transplant to reject, which is very scary. This is why it is so important to follow up with your doctor. They need to assess the health of your eye and the cornea to ensure any contact lens is not causing any damage.

For many transplant patients, a corneal gas permeable lens is the best option. A corneal GP lens does not cover the entire cornea. Every time you blink, the contact lens moves and gets fresh tears underneath the lens to nourish the cornea. Patients who wear corneal GP lenses are at much less risk of corneal edema and transplant rejection compared to patients who wear scleral lenses.

If you have a corneal transplant, be sure to check with your eye doctor to find out what type of specialty contact lens is the best for your eye safety.

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Corneal transplant patient with glaucoma wearing a corneal gas permeable contact lens

CASE REPORT – CORNEAL TRANSPLANT PATIENT