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SCLERAL LENS

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

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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.

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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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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!