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SCLERAL LENS

Bilateral Corneal Transplants & Glaucoma Patient Success With Scleral Contacts

Our patient with bilateral corneal transplants and glaucoma arrived for his scleral contact lens dispense today.

As a refresher, he has corneal transplants in both eyes and cannot see well with glasses. He also has a decentered pupil for the right eye and a glaucoma tube in the right eye.

The left eye was so advanced, the Visionary Optics team had to carefully design his custom scleral lens to safely vault the transplant but also center well on his eye.

With his Latitude scleral lens, he achieved 20/30 in the right eye (the eye with the glaucoma tube and decentered pupil) and he is seeing 20/15 with the left eye!

The patient was so thrilled and said, "Wow I need to look in the mirror to see what I actually look like! I haven't seen this well in over 5 years!"

Thanks again to Dr. Saboori and Dr. Kostanyan for trusting us with this patient's care.

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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.

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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.

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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.

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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.

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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.

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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.

Does Insurance Cover Scleral Lenses

Does insurance pay for scleral lenses?

Yes. In many cases, insurance will cover the cost of scleral lenses. This is especially true if you have a medical eye condition, such as keratoconus. Both vision insurance and medical insurance may cover scleral lenses.

If you have a non-medical eye condition such as myopia, hyperopia or astigmatism, insurances will probably not cover scleral lenses. In this case, you would be responsible for all of the fees associated with the scleral lens process.

If you are identified as a good candidate for a scleral lens, your doctor will likely call both of your vision insurance and medical insurance plans. They will give them your diagnosis, along with the ICD 10 codes, and also some of the CPT codes and V codes to see if insurance will cover scleral lenses.

Then, their office will contact you to review what the insurance will and will not cover. From there, you can make a decision on whether or not scleral lenses are a good option for you.

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Your doctor’s office will review the total costs associated with scleral lenses prior to proceeding with the fitting.

Some insurances cover scleral lenses plus all of the costs associated with your fitting, dispense, insertion and removal training, and follow up care.

Some insurances will only pay for the scleral lenses, but none of the services. That means that you would be responsible for paying for the fitting, dispense and follow up care. Check with your doctor’s office to see how much you would be responsible for.

Other vision insurances cover medically necessary contact lenses, however the reimbursement is so low, that it cannot be used for scleral lenses. Scleral lenses are typically 10x higher in cost than a traditional gas permeable lens, and many insurance companies reimburse less than the cost of the lens! For instance, if the lens cost to your eye doctor is $500 and the insurance only reimburses $100, it would not make sense for that doctor to use the insurance to pay for scleral lenses. They would actually be fitting scleral lenses at a loss. In other words, it would cost your doctor money to fit you into scleral lenses!

This is why many doctors cannot accept vision or medical insurance plans for scleral lens fittings.

You can certainly check the provider network within your insurance company and call some of the eye doctors on the list who fit scleral lenses to see if that is a covered service within their practice.

At our clinic, we bundle the service and the lenses together into one lump sum. This fee covers the consultation, scleral lens fitting, dispense, insertion and removal training, follow up care plus the cost of lenses. We find this easier than charging patients every time they are seen.

Each doctor has their own way of figuring our their unique fees.

Bottom line: medical insurances and vision insurances can cover scleral lenses. Check with your eye doctor’s office to find out what your total cost (if any) would be.

Next: How Do I Get Insurance To Cover Scleral Lenses?

What Are Custom Scleral Lenses?

The sMap is such a cool instrument, and it tells us a lot of information.

Normal topographers map the corneal surface only, and give little (if any) data about the shape of the sclera. Since scleral lenses rest on the white part of the eye (the sclera), it makes sense that a scleral topographer could help improve our scleral lens fits. Scleral topographers are expensive, which is why most eye doctors do not offer this technology in their office. It would only make sense for clinics that are fitting scleral lenses at a high level to invest in this equipment.

This particular patient has severe keratoconus in the right eye (K max of over 70 diopters). He complains that a traditional scleral lens does not fit his eye perfectly and he has issues with redness and irritation. With the slit lamp, we observe a small area of elevation inferiorly and a slight area of increased elevation nasally. The nasal elevation is a result of a small pinguecula.

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Corneal topography showing a keratoconus patient

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A small pinguecula on the sclera can cause issues with a scleral lens fitting.

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A small area of elevation is seen on the sclera (white part of the eye) . This was easily detected with the sMap.

The sMap images take 3 D images of all areas of the eye, and the information is used to create a custom fit scleral lens. We instill a drop of sodium fluorescein and have the patient look up, down, and straight ahead. Then, the sMap software stitches the images together to give us a 3D image of the shape of the sclera.

Notice how the 3:00 and 6:00 position are slightly "warmer" colors compared the the rest of the sclera. This is due to the elevation of the pinguecula nasally and the small area of elevation inferiorly.

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sMap images of a patient looking up, down and straight ahead.

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Notice the 3:00 position and the 6:00 position have more of a teal and yellow color compared to the other colors on the map.

This information will be used to create a custom scleral lens, which should vault over those areas perfectly. This results in an extremely accurate scleral lens fit.

So grateful to have this special technology in our office!

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The end result is a beautiful scleral lens fit

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The scleral lens fit is perfect.

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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.

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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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