Skip to main content
Home »

SCLERAL CONTACTS

Keratoconus Patient Referred To Us For Contact Lens Consultation

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

We had a very nice 48 year old patient referred to us for a contact lens consultation.

He was diagnosed with keratoconus in his 20’s, but his corneas remained stable throughout the years, and he was able to get by with spectacles.

Over the last 2 years, he noticed a huge decrease in the vision in both eyes. He was seen by Dr. Abrams, who inserted Intacs in the right eye, and then later Dr. Wellish performed corneal crosslinking on the left eye to stabilize the vision.

Intacs OD OS cornea

NaFL 1 od Nafl os 2 (2) NaFl OS 2

He complains that his vision is very poor and distorted and also his left eye suffers from extreme dry eye. He uses Oasis tears in both eyes, along with autologous serum in the left eye. He also uses Restasis in the right eye twice per day to help with dry eye syndrome.

With glasses, he can see 20/60 “double” in the right eye and 20/150 “distorted” in the left eye.

Due to his highly irregular corneal issues, we decided to proceed with the EyePrint Prosthetic with each eye.

pachy od intacs

topo od

topo os

We took an impression of the ocular surface in each eye and then fit him with a diagnostic scleral lens to check his vision potential. With an over-refraction, he could see 20/40 in the right eye and 20/30-2 in the left eye. He also noticed his left eye felt much less dry with the scleral lens on!

We send the impressions to the lab and we will see him in 1 week for his dispense and training. He will continue to use his Restasis drops as recommended, and he will fill the bowl of the scleral lens with autologous serum and Nutrifill. He will also use Tangible Clean MPS.

We are looking forward to helping him see better!

Scleral Lens Assessment Video by Dr. Stephanie Woo

How do I evaluate a scleral lens?

Often times I am asked to discuss scleral lens assessment. What do you look for? What equipment is needed? Any other advice?

Here is a short video of me assessing a scleral lens on a patient's eye.

First, I get an overall view of the lens to make sure there are no bubbles. I also evaluate the font surface for wettability issues or scratches or deposits.

Next, I have the patient look up, down, to the left, and to the right. This helps me evaluate the edges of the lens to see how the lens is interacting with the conjunctiva. After I take a look at the lens with the slit lamp, I will then check the central clearance and edges with an OCT machine.

Patient Referred To Us For Corneal Inflammatory Condition

Thank you Dr. Stafeeva for your kind referral to our office!

A 59 year old patient was kindly referred to us from her corneal specialist, Dr. Stafeeva.

This patient had a corneal inflammatory condition of unknown etiology and has been managed with many eye drops including antibiotics, steroids, and other eye drops.

Although the inflammation has resolved, she is left with a very large corneal scar with pannus and neovascularization.

You can see from the topography images, the K max is over 60 diopters in a small central island. The scleral topography images show some large amount of scleral toricity and irregularity.

Her habitual glasses are about a +4.50 in each eye and she can see 20/20 in the right eye and 20/200 in the left eye. When we don't know the vision potential of a patient, we always trial a diagnostic lens. With a diagnostic scleral lens and a +1.75 over-refraction, she was able to achieve 20/20 vision in the left eye! She was thrilled with the improvement in her vision.

Due to the large amount of irregularity, we highly recommended a custom scleral lens such as the Latitude scleral lens or the EyePrint lens. She is going to discuss with her husband and let us know which lens she wants to proceed with.

Also, we may need to fit her into a soft contact lens for the OD to account for the anisometropia, but we will determine that at the dispense.

She will continue her primary eye care with Dr. Ochiltree and any cornea care with Dr. Stafeeva.

OS cornea

OS pachy over scar

OS scar (3)

OS topo

sMap scleral elevation OS (1)

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.

OD 20210219 113937183.01

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.

Right+eye+new+latitude+lens+inf

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.

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.

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.

od+transplant

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.

oct+showing+superior+touch

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!

Contact Lens Options for Corneal Transplant Patients

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

pkp+os

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.

topo+os

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!

Heartwarming story about a keratoconus patient

Touching stories like these will NEVER get old!

heartwarming stories eye

We saw a 21 year old boy with keratoconus yesterday for a contact lens fitting. I had originally seen him at my office in Arizona a few months back for an initial consultation, and his father has worked very hard the past few months to save up money for the contact lens fitting.

He had corneal crosslinking in both eyes, and he also has intacs (plastic rings placed into the cornea) in the left eye. His best corrected visual acuity was 20/200 in the right eye and 20/400+2 in the left eye. He complained of very blurry and distorted vision, along with ghosting and issues with glare.

OS+intacs

We decided to fit him into the Ampleye scleral lens. With the 4200 sag on the right eye and 4400 sag on the left eye, we were able to achieve central clearance. Both lenses had excessive clearance, but instead of swapping out the lenses, I just consulted with the experts at Art Optical to adjust the vault.

With an over-refraction, he was able to achieve 20/20 vision in the right eye and 20/25 vision in the left eye! He was so amazed at how well he could see! His father was so happy that he started crying in the office. He told us “I just want my son to be able to see the stars.” What an amazing Dad!

Such an incredible and heartwarming case. We are so grateful and honored to help these patients achieve their best vision through specialty contact lenses.

Thanks again to the Art Optical team with your help designing the lenses.

We also recommended that his family members get screened for keratoconus by using a simple in-office test to find out genetic risk for keratoconus. If we discover a sibling’s genetic risk factor is very low, we might only need to see them for an eye exam yearly. If we discover a sibling’s genetic risk factor is very high, we may consider seeing them more than once a year. This is a great test to help doctors manage keratoconus risk at a very high level.

Learn more about keratoconus

Book an appointment