Skip to main content
Home » What are Scleral Lenses and How Can They Help Me?

What are Scleral Lenses and How Can They Help Me?

Full narration from our webinar for patients about scleral contact lenses (February 26, 2021:

Dr. Woo :

Hi, everybody, thank you so much for joining us today. We’re super excited to be here with you and chat a little bit about scleral lenses. And I’m just going to get my screen up here.

Okay. Well, thank you so much, everybody for joining us. We’re so excited to be here with you guys to talk about scleral lenses and how they can help you. I’m Dr. Woo, and I’m super excited to be here with my good friend and colleague, Dr. Morrison. And we’re just going to kick off the webinar just by talking a little bit about how we got interested in scleral lenses. And so Dr. Morrison, will just explained to us kind of, ‘how did you get involved in scleral lenses? And why did that become a passion for you?’

Dr. Morrison:

Yeah. Hey everyone, super excited to have you on the call today. Scleral lenses are definitely a passion of mine. Both of our practices deal with a lot of scleral lens patients. I got into scleral lenses, kind of just because I tried everything else for myself. So I had really, really dry eyes, I had something called GPC as a middle scholar. And I was actually told that I would never be able to wear contacts ever. I tried GP lenses, I tried orthokeratology, I tried scleral lenses about 10 years ago or so and they weren’t as advanced as they are now so the fitting process just wasn’t as good. So I wasn’t able to wear them then. And then eventually, with all the technology, I ended up getting into scleral lenses. With the newer technologies, I’ve been able to wear them successfully, for the last like seven years, I’ve had the same pair for like five years so it’s been really awesome for me and I can wear these lenses all day every day and I feel great and no dryness issues. So that’s how I got into scleral lenses. And I wanted to have that option to give it to my and treat patients who might have the same issues as me where they’ve gone down this really long road of wanting to get into contact lenses and not being able to see well not being able to function well. And there’s always new things coming on the horizon. So that’s why I got into this specialty.

Dr. Woo:

Wow, that’s awesome.

Well, I didn’t realize that you wore a specialty lenses. So that’s very cool. My story’s a little bit different. I got interested in specialty lenses when I was actually in optometry school. So, when I was in school, I really thought I was going to go into macular disease, which is a lot of back of the eye stuff that was something that I really thought I was going to do a residency in. But what happened is during third year in our contact lens clinic, there was a patient. He had keratoconus and he really could not see anything at all. And he was there, you know, he didn’t have a job because it couldn’t work because he couldn’t see. And he was just really affected. And he just seemed really almost depressed, and of course, you know, you would have those feelings if you can’t see very well. And then we ended up fitting him with a corneal GP. And he was able to suddenly see I think it was like 20/30 or 20/40. And his face was just he was so excited that he could see again, and I was like oh my gosh, this is such an incredible part of optometry that I really want to look more into. And then that’s when I got interested in the residency and both Dr. Morrison and I are both residency trained in these special contacts. And then during the residency, we got lots of exposure to scleral lenses. So that’s kind of how we both got into it. So first we just want to talk about what are scleral lenses and you can see in this picture, Dr. Morrison is holding a scleral lens and you can see kind of the shape and the size of it. Scleral lenses are so cool. It’s something that we’re both incredibly passionate about. We’ve helped lots and lots of people. Something unique about scleral lenses compared to other lenses is that they’re very large, 14 millimeters to it could be over 21 millimeters depending on what the what the problem is. Just For comparison, soft contact lenses that maybe you wear or maybe you or your friends your family wear are about 14 millimeters or 14.5 millimeters. So it’s about that size or larger. They’re made out of a gas permeable lens material. So it is a hard lens material. But it’s not like a gas permeable lens. They don’t touch the cornea at all, which makes them very, very comfortable. And something else that’s great is that they don’t pop out of the eye. And that’s why a lot of my patients go into scleral lenses because they’re frustrated that their corneal gas permeable lenses pop out. Something else really important is that you have to fill the lens with preservative-free sailing before you insert the lenses. So Dr. Morrison, can you tell us a little bit more about scleral lenses?

Dr. Morrison:

Yeah, definitely. So I would say unique features of sclerals is mostly the fact that it doesn’t sit on the cornea, that it touches the white portion of your eye, which is called the sclera. The sclera has relatively little nerve innervation. So they don’t have a lot of nerves to make you uncomfortable if it moves around, which it doesn’t, the scleral lens doesn’t move around on eye with your blinks. And, you know, you do fill it with this sterile sailing. So you’ll see on the next slide that there, because you fill it with the sterile saline, you can actually heal the eye and heal different kinds of diseases. And you can see here, on the left hand side, this is the scleral lens, us filling it with saline prior to insertion. The second one is putting the lens on the eye kind of have to tilt your head down and bring the lens up to the eye. And then the third one is looking at the lens on the eye. And you can see how large it is, it’s a little bit larger, but when you’re wearing it, nobody, really notices that it’s any different than a regular contact lens. And I just wanted to say if anybody has, as a patient a specific question about sclerals, just pop it on the chat now and then we’ll get to it at the end of the presentation. But just so we don’t miss anything, just make sure that you have that on there.

Dr. Woo:

Yeah, and I think it’s really important, this slide is very important for patients. Because some patients, they don’t know that they have to use a special type of solution to fill the bowl of the lens. And I think it’s a really good opportunity for us to kind of educate patients that it’s very, very important to fill the bowl of the lens with something that does not have preservatives. A lot of times what I’ve seen in my career is patients will come in, and they’re filling the bowl of the lens with saline, but it’s not preservative free. And that is an issue because what happens is that it can become toxic to the eye. So if you’re watching this now and you’re like, what’s that pink thing? That is a little vial that you can use to fill the bowl of the lens. And there’s other options. So currently, there’s scleral fill, there’s lacquer pure, there’s neutrophil. And then the pink vials are either Addy pack or you they’re non preserved saline. It’s an inhalation solution. But I think the key is, whatever you’re using, make sure it’s in these little vials. If it’s not in a vial, if you’re using something that’s in a bottle of any type that is not preservative free. So even if you look at it, you said well, it says that it’s preservative free, the problem with the big bottles is that after 48 hours, the bottle is contaminated. And that’s because of all the bacteria, fungus viruses that are in the air. And have you seen that in your practice Dr. Morrison?

Dr. Morrison:

Definitely Yeah, in my practice, we’re pretty strict per se on what you actually use in the eyes. So we have a care sheet that every patient goes home with. And it tells you what exactly you clean it with to rinse everything off before inserting. So I would say even if you’re using a multipurpose solution to clean the lenses and you don’t use I think Dr. Woo you also prefer clear care the hydrogen peroxide solution to clean them overnight. If you’re not using the clear care and some patients who come in to me are not using that from other doctors which is totally fine. It’s just that when you take it out of a viscous solution, that solution does have preservatives in it. And so you’re going to need to take your saline and completely rinse the lens off before you fill it up and insert it. If you have a little bit of that solution with the preservatives in the bowl lens. When you put on the eye after maybe like three hours or so you’ll be like my eyes are kind of red, they’re irritated and when we take the lens off we can see that the front of the eye has been just damaged a little bit from the chemicals in those preservatives. So yeah, this is very important. And I will add that I’ve been having a lot of success recently with neutrophils not and we’re not plugging anything. In particular, I’m cool with my patients using whatever they want. But the neutrophil is, it’s a buffered solution with added electrolytes. And so a lot of patients with really severe dryness, they actually do a lot better with that, because it’s closer to the pH and composition of their tears. I think you’ve had the same experience. Dr. Woo, correct.

Dr. Woo:

Oh, absolutely.

And we have an interesting question that I think kind of fits in with kind of what we’ve been talking about. So I would I would love to get this question answered right now. So Cynthia asks, “hi, I wear RGPs and when I wear makeup, if any particle goes in between my lens and the eye, it gives me a lot of pain, and I have to remove my lenses a lot. Can small particles go inside the scleral lens, like they do with an RGP? Even when it’s a windy day, it’s really difficult.” And Cynthia, I am so happy that you asked this question, because this is one of the main reasons that people go into scleral lenses, because you don’t get that foreign body entrapment. If there’s a piece of dust or a piece of makeup that gets into the eye, and you’re wearing a corneal GP, yeah, that thing feels like glass in your eye, and you’ve got to take it out, rinse it off, put it back in your eyes already irritated. That’s the beauty of sclera lenses is that you don’t get that because of how large it is, and how much it covers your eye. And, Dr. Morrison, do you have any patients that you have found that you have switched them to a scleral lens because of this problem?

Dr. Morrison:

Absolutely. And I would say that I like my patients to use whatever works best for them in terms of contact lenses. And I will always offer all of the options. But most people who are or who have a scleral lens versus a GP lens are much happier in the scleral because of the comfort and because of that reason. So I’m really glad you brought that up because I used to wear GPS in high school. And yeah, if you got something in there, you’d have to pop it out, rerelease it put it back in you do that like I would do it multiple times a day. And the sclerals you just don’t have that it’s actually a protective factor too. I have a couple of patients who are ranchers. And so they’re out in dusty environments all day and with their scleral lenses, they don’t have to worry about it because nothing is get if something gets in their eye, they just flush it out and it doesn’t actually touch their cornea. So great question.

Dr. Woo:

That is awesome. Okay. Oh, go ahead.

Dr. Morrison:

Yeah, what makes them so special. Um, so as we were kind of talking about before, if you have an extreme irregularity to your cornea, or maybe you’ve had a corneal transplant, you have really bad keratoconus, anything kind of bizarre, you don’t have to touch it with a contact lens, you can actually evolve over that. And we learned a long time ago in what’s called the CLEK Study was a study of corneal lenses. And if the cornea lens touches your eye too much, maybe you won’t feel it, but it actually could cause scarring. And so back in the day, when people had very severe disease, we used to fit them with these GP lenses, it would be too, you know, you’d fit them with the best lens that you could, but it would be still too flat and touching the cornea and create scarring. And then you’d have to undergo a corneal transplant to remove the scarring. So with scleral lenses, we can avoid a lot of the corneal transplants that we did in the past, because they’re not touching the cornea and they don’t induce scarring. So that’s the best thing about them, I think, especially really severe disease, they can treat that. And they can treat dry eyes. So I tell my patients, because they always ask me am I going to feel dry with these lenses on because when you first put them on there, they’re bigger. So you’re like, Oh, I’m aware of them being on the eye. But they’re actually because you fill them up with that saline and it sits on your eye all day. It’s actually a treatment for dry eyes. So if you have a really severe dry eye, you have maybe a Sjogren’s syndrome, you have something like Stevens Johnson syndrome, they can actually go over and heal your cornea. And in in cases that Dr. Woo and I have seen they also heal if you have a scratch on the cornea and it’s not healing. A lot of herpes simplex has these types of damaged corneas. And because of the nerve innervation they don’t ever heal up and so when you put the scleral lens on because the lids aren’t rubbing on your cornea all day, you actually get the chance to heal. And they’re more comfortable, like we said before than previous lens options because they’re not sitting on your really strongly innervated cornea. They’re sitting on the white portion of your eyelids doesn’t have a lot of feeling. And I will say, for the healing damaged corneas, we’re going to try this out with a patient I just saw yesterday, she has a lot of post LASIK dryness, she’s gone through like every single treatment for dry eye available, nothing’s really working that well. And so she does do serum tears, which is like a healing drop. And sometimes, if you want to heal up the cornea a little bit faster, you can put a serum teardrop in the bowl of your lens, fill it with the saline, put it on, and then leave that for a little bit. It makes your vision a little cloudy, but we’re gonna try that for her and just see if that helps her out during her process of healing that cornea.

Dr. Woo:

Well, that’s really great, Dr. Morrison, because a lot of people maybe don’t know that scleral lens is not only do they help vision issues, but they also have healing properties. So like you said, we sometimes use these lenses, not even for the vision part, we’re using it as the for the protection. So I’ve got tons of patients that have dry eyes, and no matter what kind of dry eye treatments they’re doing, their eyes still will not heal up. And sometimes when they get referred to me, we fit them with a custom scleral lens. And that actually forms a barrier between the outside environment and their eyeballs. So it’s been such an incredible thing that we can do that we really didn’t have this option. You know, 15-20 years ago, it was scleral lenses were not really popular back then or. And so we’ve just come such a long way with these incredible technologies. And I think another thing that is a common misconception is that, wow, this lens is so much bigger than my current contact lens, isn’t that going to be more uncomfortable. And that’s what I thought too. I remember when I was really young, and I was wearing soft lenses. And then my eye doctor wanted to switch me into the corneal gas permeable lenses or the or the hard lenses. And I was like, wow, this thing is so small, it’s gonna feel great. And then I put it on my eye. And I was like, Oh my gosh, this like is way more uncomfortable than my soft contact lens. So I can see why patients would think the smaller you go, the more comfortable it would be. But with scleral lenses, it’s actually completely the opposite. The larger you go, the more comfortable. That is. And Dr. Morrison, why are scleral lenses more comfortable compared to the small corneal gas permeable lenses?

Dr. Morrison:

Yeah, mostly, it’s just because of where it touches on the eye. So both lenses are going to go under your upper eyelids, so you will feel them a little bit at first. But the GP lens has more of a surface where when you’re blinking, you’re blinking over and the GP is moving. And so the edge of it actually a butts up against the underside of your lid. Whereas the scleral lens, because it kind of mirrors the shape of your of your eye. And so it comes down like this and settles into the squishy part of the white portion of your eye. So you’re not blinking over as much and again, it just doesn’t have as much innervation on those white portions of the eyewear. The cornea, the front surface of your eye is has the most nerve endings of anywhere in your body. That’s why it hurts so bad when you scratch it. And we did have a question from Katherine about how often do sclera lenses need to be replaced, scleral lenses only needs to be replaced when either your vision changes significantly, or your cornea changes where the cornea is getting a little bit close to the lens and we need to make a change. So other than that, if you take good care of them, and your vision is still the same and the fit looks good. You can keep them for as long as the last.

Dr. Woo:

Yeah, and that’s one of the beauties of gas permeable lens material or scleral lens material is that lasts so much longer than a soft contact lens. So if you’re used to wearing soft lenses, these are completely different than the type of lenses that maybe your friends and family wear. These are totally custom contact lenses. They’re made out of material that’s totally different than a soft lens. So it lasts a lot longer. I usually tell patients for the most part, they’ll probably last one to three years in my clinic. That’s what I usually recommend. But it also depends on Yeah, how well they take care of the lenses. You know, like you were saying, Dr. Morrison, some of my patients are our farmers. And they’re just really rough on their lenses. And they’ve got these very calloused hands and they work in these really dirty environments and they get stuff in their eye all the time and it scratches up the lens. And so those people may have to replace it more than somebody that maybe is not in that type of environment. Another issue that could come up is deposits or things like that, where the actual material of the lens starts to degrade. And in those cases, even if your prescription doesn’t change, or the shape of your eyes not changing, sometimes the material can warp and change shape itself, or get scratched or get these deposits that will not come off, then though in those cases, you may need to replace them. But like Dr. Morrison said, if you take really good care of them, I mean, she’s had hers for five years, that’s amazing. But I also have some patients that they take such good care of their lenses, they handle them really well. And they don’t work in these environments. Or you know that where there’s lots and lots of issues that degrades the material. Another issue is the ocular surface. So if you have like, very, very extreme dry eye, or your eyes are very sick, or you know with some of these other conditions, sometimes those will require more frequent replacement. And that’s just because the surface of the eye kind of changes the shape of the lens and in the material.

Dr. Morrison:

They do come with certain coating as well. So certain coatings are great for dry eye, which we put on the lenses when we order them. Something called Hydra peg is a newer material that are newer coating that really helps with people with very severe dry eye and, and that does wear off with time. So you will generally have to replace your lenses, probably like every year, I would say.

Dr. Woo:

Yeah, absolutely. So just want to kind of give a breakdown of how scleral lenses compared to other types of contacts that you may currently be wearing, maybe you wore in the past, or maybe you’ve never even heard of any of these. So the first is called a rigid gas permeable lens. It’s also known as an RGP lens, a GP lens, a hard lens, it has a lot of different names for this type of lens. But like Dr. Morrison said, because you put the lens on and the cornea has so many nerves, it can, you might need to build up wearing time with that type of lens. It’s still a very, very good lens, and we use it a lot in our clinics. And it’s it has its place for sure. And I love gas permeable lenses, there’s tons of safety studies and research showing how it can help lots of patients. But when it comes to some of these really, really, really irregular eye conditions, it makes it very hard to fit. And that’s where scleral lenses really started to shine, you know, 10 years ago, the only reason they were using them for the most part was because they could not get the lenses to fit on some of these incredibly advanced keratoconus patients, or patients that have very irregular corneal transplants, things like that. And so the doctors, when they discovered this type of lens, or it kind of came back around, they realized, oh my gosh, we can correct like a huge amount of irregularity that we haven’t been able to before. So that’s given us a lot better options for some of these very complicated cases, you may have also heard of a hybrid contact lens. And that’s where the middle of the contact lens is a hard or a gas permeable center. And then it’s surrounded by a soft contact lens skirt. So ideally, you have the best of both worlds, you’ve got the vision of a gas permeable lens, and you’ve got the comfort of a soft lens. And these are also great options for patients. It just really depends on the condition. What’s going on with that patient. I, we Dr. Morrison and I fit hybrid lenses on a lot of our patients as well. And I had a question for you, Dr. Morrison, um, a lot of patients will come into the office, and they’ll ask me, you know, would I be a better candidate for a hybrid lens? Or a scleral lens? And how are you making that decision?

Dr. Morrison:

Yeah, so there was a study that came out that used some data that we take off of our corneal mapping technology, and it was able to tell us whether you’d be good with a corneal lens or whether you would need to move into or whether you’d be more successful moving into something like a scleral lens. And this all kind of dependent on the front surface of the eye and how elevated it was. So the difference between elevation here and here, maybe that one you need to evolve over it with a scleral lens, but maybe you just have a very mildly irregular cornea, and you could do very well with a GP or hybrid contact lens. And I also a lot of times in my practice, if people are going between one and the other. I will try both of them on the eye and then just let them decide feel the comfort, see the vision and kind of go from there. I would say the main thing about these other lenses as compared to scleral is that they have more limited parameters, in terms of making them more customized to your eyes, so they have all these different curves. And we can create different designs based on the curves. But with the scleral lens, the curves are much larger, and you can make them more elevated or depressed in different areas a little bit easier and more effectively than the GP lens just have more options, especially with the customization tools that we have. Now you don’t even have to have a spherical lens.

Dr. Woo:

Yeah. And lastly, we want to talk about soft contact lenses and Dr. Morrison, who are the best candidates for a soft lens compared to a hybrid or corneal GP or scleral lens, who would you put in a soft contact lens?

Dr. Morrison:

I would put anybody in a soft contact lens, if your vision is still good with glasses. So you’re still very happy with your vision with your glasses, a soft lens very similar, because it doesn’t correct anything on the front of your eye. And if you’re seeing good and glasses, you will see almost the same in soft contact lenses, but you won’t see necessarily any better. And we do have some soft contact lenses for people like with keratoconus, where they’re just thicker. And so sometimes the thickness of the material can minimize some of the abnormalities. Again, you would have to have a pretty mild condition and see decently well out of glasses to be able to be very successful in that, but I have seen it be successful on different patients. It just kind of depends and, and if some and mostly I keep somebody in a soft lens if they’re completely intolerant of any other lens, or if they don’t want to try something new or like a scleral and they’re kind of married to the idea of a soft lens. We can try it but it just won’t give you as good a vision generally.

Dr. Woo:

Great. And then Cathy asked another question, what’s the best way to store an extra pair of scleral lenses not in use? And that’s a great question, Kathy. The best way is to actually store the lenses completely dry, and in a dry case, and put it somewhere kind of in a cold dark environment. So just in like a cupboard or a drawer or something that you’ll find. If you store it in solution, the problem with that is you have to remember to replace the solution. Especially let’s say you’re putting it in a multipurpose solution. And you’re supposed to replace that every 30 days. And I don’t know about you Dr. Morrison, but for me, I would never remember to do that every month. So I think storing them dry and they’ll last a really long time doing it that way.

Dr. Morrison:

That’s a really good question. Agreed. So who can benefit from these lenses? So if you’re interested in sclerla lenses, and you think like, would this make my vision any better? I would say it is good for so many so many conditions, as you can see listed. One of the things that people don’t really think of with sclera lenses is a patient who’s 20/20 unhappy. So this is a patient who with the glasses or soft contact lenses, or their current prescription can see pretty well could see 20/20 but they still don’t feel like they have that crispness to the vision that they were hoping for. They still feel like it’s fuzzy, maybe they have some starbursts and they’re just not getting the vision that they would want. And that’s when we generally move into a rigid material contact lens because you have a little tear layer under the rigid material, it does correct a lot of irregularities on the front surface of the eye, even if the irregularity is just from dryness. Maybe you’ve worn your contact lenses for 45 years and your cornea is a little bit a little bit warped. You have a little bit irregular astigmatism. Maybe even you’ve had like a minor surgery, like you had a cataract surgery, and they do still go into the cornea. And so maybe after that, you’re like, Oh, it’s good vision, but it’s just not what I had hoped for. And so these patients are great candidates for scleral lenses because you’re correcting any irregularities on the front surface of the eye, you can achieve better and clearer vision. And so I’ll tell story, I had a patient who came in totally healthy and normal they were wearing soft, multifocal contact lenses and they were just unhappy. They were just unhappy with their vision. They were like I just don’t feel like I have the crispness that I desire at work. And so we talked about all the different options. We ended up fitting her with a scleral lens. And she’s seeing 2020 distance and near and she’s doing extremely well. She’s like this is the best that I’ve ever seen. And I’m actually doing the exact same thing with my mother. Now I’m having her get a special kind of special scleral lens and we’re going to do the multi-focal and just see if that will sharpen up our vision because just the clarity of the rigid material is so much better. And you fix a lot of the dryness issues. So if you’re blinking a lot and your visions getting better and worse, a lot of times it’s you’re very dry. And so if you can fix a lot of that dryness with the scleral lens, you don’t have those fluctuations in vision. And you can also see there’s a ton of conditions that you may have that would be beneficial for sclera lenses. keratoconus transplants, radial keratotomy, which is a surgery popularized in the 80s and early 90s, where they used to take a blade and Make incisions on the eye It was like the pre LASIK to correct your vision. Corneal scarring you got scratched in the corner in the eye, you have a scar, the scar creates this irregularity on the front surface where when light hits the irregularity, it spreads out. And so when it hits your retina, the image isn’t the same as you’re seeing is what’s on your retina because the cornea splits the image. And a lot of these conditions can do that. Stevens Johnson syndrome graft versus host disease tend to have extremely dry eyes. And so they will get actual damage from the dryness where you get vessel growth and different things like that. And post LASIK. You can have LASIK surgery, generally people are pretty happy. But a lot of people are not happy afterwards with the quality of their vision because again, you’re reshaping the cornea to look like this to this. And so the light does split. And so a lot of these patients are very happy in in scleral lenses and it fixes a lot of their post LASIK dryness.

Dr. Woo:

Yeah, and that’s a good point with the post LASIK patients because back, you know, 20 years ago, 30 years ago, when LASIK was becoming more popular, they didn’t necessarily have the diagnostic equipment to rule out bad candidates. So a lot of times, the patients that Dr. Morrison and I are seeing is our patients that they had LASIK, but their with their shape of their cornea was not really appropriate to begin with. But it’s no fault of the doctor or you know, the surgeon or anything that that did that did the procedure. We just didn’t have the technology that we do now. But as some of those people have gone throughout the last few years, sometimes we start to see some of these problems where now they have something called post LASIK ectasia, where the front surface of the eye the cornea starts to kind of bulge forward. And in that case, the vision becomes incredibly irregular. And we can help solve that with sclera lenses as well. Radial keratotomy back in my hometown in Arizona, it was so common, I think I would see probably five patients that had our K surgery a day, it was just a very common thing. And like you said, Dr. Morrison, some of them are real happy, they don’t need any glasses. But most of them are getting to that point now where the surgery has kind of degraded and the structure of their cornea has kind of changed shape. And things are a little bit different. And one of the main reasons I would fit scleral lenses was for these patients because they would complain that their quality of vision was poor, their vision was fluctuating. So they’d have five different pairs of glasses, you know, one in the morning, one for two hours after they wake up one at noon, they’d have these glasses that depending on what time of the day, they’d have to put them on, because their vision fluctuated so much. And that’s one of the other benefits of scleral lenses is that it can really help with our K patients that have fluctuating vision. So lots and lots of arcade patients that are very, very happy. So thanks doctor Morrison for explaining all these. Yeah, definitely. And this is such a great photo and I don’t know Dr. Morrison, if you designed this or whatever. Oh my gosh, it’s so cute. Can you explain what’s going on here?

Dr. Morrison:

So basically, people ask why do these lenses work and glasses and soft contact lenses do not work. And that’s because if you see on the left hand side this is an eye with keratoconus, which is a condition where the cornea bulges out, but this can be any corneal irregularity. Even if severe dryness, basically we see an image, the light in the image comes it passes through our glasses, the glasses, correct it, but once it hits that cornea that’s very irregular, the light rays bend again. And so the bending of the light rays actually creates an image on the cornea that’s distorted. So if you can see if you have a soft contact lens that just drapes around the cornea, you’re still going to have the same issue because you’re just mimicking the exact shape of your cornea. You need a lens that’s going to be rigid, where it can maintain its shape. And it can fill in all the gaps with the tear film so you can see better again, and so you can see on the right this is a person who this is a regular cornea. That’s why I drew it that way but you can kind of see potential That that regular cornea is actually a scleral lens over the cornea, you can see that this patient has a regular image coming through the glasses. And then once it hits their, their scleral, lens or cornea, it just creates the same type of image on the retina so you can see clearly again, and I will add that from the other side. corneal scars are a huge thing that I found in my practice where you could have a central scar and you don’t think you’re going to get any better than you are right now. I have had people go from 2400 to 2020. With the scleral lens, it is the even though they have the scarring, it’s like the most miraculous thing. So even small things on the cornea, that’s really degrading your vision, these, these can completely change that.

Dr. Woo:

Yeah, that’s a good point. Because sometimes if we don’t know, as doctors, if it’s going to work, what we will do is if we’re not sure, maybe we look at the cornea and we say, ‘Wow, that’s a really big scar,’ or it’s right in the center of their eye, not sure where we’re going to get something that’s great what Dr. Morrison and I do is we can actually put a diagnostic lens on your eye, and check to see what the vision potential is. So, which is great, because a lot of patients they have concerned that they don’t know if the vision is going to be any different, you know, how is it going to feel on my eye. So it’s kind of cool, because if you’re listening now and you’re like, gee, that sounds like something that I would like to try. Ask your doctor if they do have a scleral lens fitting set, because they can put one on your eyes so you can kind of see how it feels. And then they can just quickly just do a check to see what your vision potential is. And a lot of times, my patients will put we’ll put the lens on, and we’ll check through the machine, you know, the witches better one or two machine, and they’ll look and they’ll notice that the quality of the letters on the chart is so much better. Or like Dr. Dr. Morrison said, they go from seeing the biggie. And now they can see the really small letters on the chart that they haven’t seen in years. So that just kind of shows the patient and the doctor, hey, this is something that can really can really help. So if you do have a doctor that has a scleral lens fitting set, they can always try that on you. Here’s an example with a patient what we’re looking at is the in the center of the cornea, you see these little rings, and that’s something called arcus, which are these small little plastic rings that some of the keratoconus patients have, it’s not used as much anymore. There are some surgeons that that do prefer to use it or there’s some patients that are good candidates. But it’s not as popular as it was, you know, 20 years ago. And then there’s a scleral lens on top of this patient’s eye. So the problem with this patient is that with the keratoconus that’s already changing the shape of their eye to be very, very irregular. So the vision is very, very blurry. In tax, the purpose of them was to kind of center the keratoconus, so it wasn’t so far so far down and they thought it would also help with the progression of the keratoconus. But it ended up that it kind of made our lives a little bit more challenging refitting these contact lenses on patients, especially before we had scleral lenses, so those, I’m not seeing it nearly as much anymore. But just like Dr. Morrison’s picture on the last slide, instead of you know, on the left hand side, this patient, if they just wore glasses, they would see this kind of distorted funny image in their eye, but by putting them into a scleral lens that can reshape and read bend the light rays that are entering in the eye to make the vision very, very clear.

Dr. Morrison:

Yeah, and this is an example of a patient that I had, who had an extreme dryness from eyelid surgeries. This patient said that I could share their pictures so this patient had multiple surgeries because they had skin cancer, and so they had most surgeries which removes a lot of tissue. Because of this removal of tissue they were unable to close their eyes fully. You can see on both of these eyes, that the lids are very inflamed, that they have a space between when she closes her eyes There’s still a space for air to get through. And this created a really blurry vision. severely dry ocular surface all day discomfort. And so we fit this patient with a scleral lens for a therapeutic effect. Where we would fill the lens was saline, it would sit on her eye all day it would protect the eye, it would allow this eye to heal up to so when I first saw her vision was with the scleral lens, probably 2030 I said just wait a little bit, let’s see if it if it heals up your ocular surface. If you start healing, you might achieve better vision and she actually did. So she ended up achieving a slightly crisper and clearer vision a little longer that she wore these lenses because it was correcting her, her vision and her underlying problem and it was protective. I used to work in a huge ophthalmology clinic and hospital. And a lot of times patients who had this kind of issue where their lids wouldn’t close completely, you can get it from Bell’s palsy, different things like that. Sometimes ocular plastic surgeons will go in and actually they’ll suture your eyelid half closed, it’s called a tar sore fee. And, you know, no, person wants to go around with their eyelids shown sewn shot. It’s not the prettiest thing it happens, but it’s definitely not cosmetically what everyone would want. And so scleral lenses offer that option, where if you just wear your scleral lens all day, and then at night time, you’re able to like take the lid shut without the scleral lens in, then you can be healed and protecting your ocular surface. But you don’t have to go through that surgery of sewing your eyelid shut. So that’s, that’s really great for just a cosmetic thing with the patients.

Dr. Woo:

And so yeah. That’s really cool that you brought that up Dr. Morrison, because there’s actually a study that show that patients that are fit with scleral lenses are much happier compared to the ones that got the tar sore fee where their eyelid is sewn shut. You know, just like you said, No patient wants half of their eyelids sewn shut and walking around like this all day. But if the eye will not heal, sometimes there’s limited options. And a lot of times the tar sore fee was really the only thing. So what Dr. Morrison and I have been doing is we’ve been educating some of the eyelid surgeons about some of these other options that can provide something different for the patient. And I think like with this patient, Dr. Morrison, I mean, that’s amazing that you were able to help her with a scleral lens, so she doesn’t have to get her eyelid sewn shut. I mean, that is a lot of problems in itself. And when they go to reopen it, sometimes the lid can be deformed and things like that. So that’s a really cool case. But thanks for sharing that.

Dr. Morrison:

Yeah, it was great. Um, Cathy says, with the scleral lens resting on the white part of the eye, is there any concern making sure the cornea stays healthy? Um, I would say just like Dr. Woo talked about before, as long as you’re filling it with the correct solutions and not solutions that have preservatives in them, then the cornea does stay healthy. And there’s this thought for keratoconus patients, and it’s an old and it’s an old thought that if I wear lenses that touch my cornea, then that will stop my progression of keratoconus because it holds in the cornea. And this was something that I think was espoused for many years, but it’s not true at all. If anything, if your lens is touching your cornea very harshly, you actually get scarring and then you will have to go through a transplant later in life for the scarring. So you don’t have to have that it’s great. So the lens resting on the white portion of your eye is much healthier for the cornea and the lens resting on the cornea.

Dr. Woo:

That’s a good point because that was something that was thought and I think a lot of patients think that too that if they get fit with a contact lens that pushes on their keratoconus that it can help prevent it from getting worse. But the analogy that I like to give patients is pretend that you’re three years old and you have a shoe and you keep that same shoe and your foot keeps getting bigger and bigger and bigger. If you keep it in that shoe, it is not going to prevent your foot from growing and changing shape, it’s just going to distort your foot even more. So that was something that I think a lot of eye doctors thought as well that it was kind of keeping the keratoconus at bay and helping prevent it from getting worse. But now we know wow, you know if that happens, you can really do a lot of damage and it can actually lead to scarring, which can ultimately lead to a transplant. So now we know that that is that is absolutely not true. And we don’t fit that way anymore. So this is a question that I think is really important that the patients on this on this call probably want to know is how are they How do they know if sclera lenses are going to work for them? And if you’re listening right now and you’re thinking Gee, this sounds great, or I don’t know how would I find out the best thing to do is talk to your doctor and ask them, Hey, I heard about these lenses. Or if you already have a condition that you see that you might be a good candidate, you know, just kind of Ask your doctor about that. They will do a thorough history. So they will ask you a lot of questions about whatever the diseases that you have. Or maybe you’re just unhappy with your vision, like Dr. Morrison said, you might be just somebody that’s not happy with their soft contact lenses, and you’ve tried a lot of different options. So just kind of letting the doctor know what your what the issues are, and what your vision goals are, that’s really, really important for us to know, kind of what would make you happy, you know, if sometimes we have patients that say, my night driving is absolutely terrible. If I could just improve that I’d be happy. Or, you know, my soft contact lenses fluctuate a ton through the day, they’re always rotating. And I’m losing vision, if I could just get a little bit clearer vision that’s more stable, I’d be happy. So just think of things that would make you happy as a patient as far as vision and comfort wise. And then we’ll do a lot of images with some specialized equipment. And you can see in this picture Dr. Morrison’s office, she’s got a special instrument that scans the very front part of the eye, it’s called a typographer, that tells her what shape the eye is. And that kind of helps to also rule in or out certain candidates depending on your condition, we will put lenses on your eyes. So we will see kind of how you respond to the comfort. And we’ll also be able to determine your best vision. And lastly, just kind of figure out everything as a whole and talking about things together. So if you if you’re interested in scleral lenses, and you want to know if it’s going to work for you, you know, just simply ask your eye doctor and if they have this type of equipment, they’ll be able to also help rule out if you are a good or poor candidate.

Dr. Morrison:

Yeah, and I think I have we have a quick question. We have some patients, this is probably coming from a doctor who constantly get blurriness under the scleral lens, they have to remove it, clean it and replace it, could the problem be from the fit or from the tear film. So I would say probably a little bit of both. The general consensus over the years with fogging is that it’s coming from different proteins in the tear film, it’s coming from the where the lens is resting on the eye, it’s resting on the white portion, because it’s resting on the white portion of your eye for the non doctors on the call. Because it’s resting on that white portion of your eyes, it does touch some cells that create mucus. So sometimes we can create some of that, and that can get up under the under the lens and get foggy throughout the day. And then you’ll take it, remove it and replace it. And with a lot of our newer technology that we’re going to speak about in just a second. This has been decreased dramatically when I started fitting these lenses, fogginess was a real huge issue. With this newer technology and better designs and doctors who know the designs better scan, you know scan based mold based designs, you can really avoid a lot of this because it fits around your eyes so much better. There’s not one area that’s pushing down on the side, there’s not one area that’s poking up like this, you can get the fit of the lens a lot better, and that does decrease fogging. But there are some patients where even the best fit lens in the entire world is not going to make it’s going to definitely help but it’s not going to completely fix the issue a lot of these patients, radial keratotomy patients, severe dry eye patients graft versus host disease, different things like that you still create with your eye, more of that debris particles. You shed more epithelium throughout the day. And so that will get up under your lens and it’s just a simple removal and replaced but yeah, great question. I think the majority of it can be fixed with the fit of the lens. But some of it you do have to talk to patients about their expectations and say if you do have these conditions, you will maybe notice some fogging and I found that the longer you have the patient wear the lens the more used to the lens the eye gets. And so with time the fogginess will kind of decrease a little bit on its own because the eye is just really used to the lens.

Dr. Woo:

Yeah, and it’s always important to look at the patient when they come in for their follow up because you can find out is the fogging because of either the tear film or deposits on the front surface of the lens or is it actually behind the lens in that tear chambers. Those are two different problems. So I always like to look at the patient that their follow up and if they are complaining that they’re getting some fogging, take a look and see where the fogging is happening. And like you said, Dr. Morrison. A lot of times when it’s behind in that tear chamber between the scleral lens and the cornea, it can be from the fit. And I have seen a dramatic reduction in tear chamber fogging, by going to some of these more custom designs where the lens is fitting the white part of the eye basically perfectly. But like you said, sometimes you could have the absolute best, most perfect fit in the world. But if the eyeball is very dry, or there’s other underlying issues, it you may never completely resolve it. So I think it’s just important to have that conversation you know, with a patient in the beginning. And if they are having issues, just trying to troubleshoot it as best you can with different solutions, different billing solutions, different eye drops other different therapies you can you can manage their dry with.

But I do agree that sometimes when you have the patient wear the lens for a few months, you notice that the fogging actually decreases for whatever reason, and I don’t know exactly why that is, I feel like it’s like the eye just kind of gets used to that device and says, okay, this is a part of my body now, and just doesn’t produce as much mucus. That’s just my own thought. But yeah, I think it’s a great segue into some of these new designs.

Dr. Morrison:

Yeah, so these newer designs and sclera lenses, you might be in scleral lenses, right now I have a lot of patients come to my office and say, I’m in a scleral lens right now, I’m not super happy with it and making my eye a little bit red, etc. Or I have patients say I’m relatively happy, but I feel like it could be better. So the design technology of sclera lenses has increased dramatically in the last few years. So we basically have a couple different things, we have your conventional scleral lenses that most of us were fitting for the last, you know, 6-10 years. Now we have scan based designs, we have mold based designs, and we have higher order aberration correction. And so if you go to the next slide, Stephanie, we can talk about the scan based designs themselves. So this stuff, Dr. Woo and I both have some technology, which actually takes a scan of not just the cornea, but it scans the sclera the white portion of your eye, which is where the lens settles. So having that technology is really great to see how different that eye is, if you can see this picture down on the right, the bottom right hand side, all those different colors, that’s all different elevations of the eye. So every point that you see a different color, that’s a different shape on the side of the of the of the eye. So if you can see, if you fit a perfectly spherical lens around this eye, you’re going to have areas where the sphere is closer and the where the sphere is farther away from your actual eyeball. And sometimes this can result in some areas, it’s red, and then this area I can feel with my lid or again, like Doctor had mentioned, I’m getting some debris under the under the eye because the lens is just not fitting. And so it’s kind of like moving around a little bit.

And with the scan based we actually make it we take scans, we make it based on CAD software. And so you can see the software on the left is this person had a growth on their eye, it’s called pterygium. And so this lens actually got to move around the growth and it cut, it just fits much more perfectly, because we’re not bound by those spherical design properties that we were with older lenses.

Dr. Woo:

And something else that that we’ve been doing, I’ve been doing this for the last, gosh, seven years, I think whenever I print was invented. But it’s a really cool technology that Dr. Morrison and I have in our offices now. And you have to be certified in this. So not every eye doctor will have this type of technology, you have to get specially trained. But basically what you’re seeing in this photo is we actually take a mold of the eyeball. And the blue goo that you see there is really similar to kind of dental mold material. So if you ever have been to the dentist, and you have to put that tray in your mouth that has this kind of putty that kind of maps the entire surface of your teeth. We have something very similar but it’s very, very safe for the eye. So we’re actually taking a mold of the eye only takes a couple minutes in office, it’s painless, it does not hurt, It’s not uncomfortable. It just feels like kind of cold and gooey. But what that does is we’re able to map the eye perfectly. We send this mold to the laboratory in Colorado and they use a 3d scanner to map over 3 million data points. And the end result is what you see on the right here is this incredible custom unique scleral lens that is fit perfectly for you. This is like a fingerprint; nobody else will ever be able to wear this lens besides you. And in whatever this came from. It is that unique. It is incredible technology that we didn’t have before. And it’s become a huge problem solver for us, especially like with Dr. Morrison said, some of these people that have maybe a strange growth on their eye, and it’s going to be really hard to fit them into a traditional lens, or maybe they have a corneal transplant that is very, very severe or irregular in shape, that’s going to be much more challenging to fit in a traditional lens. So and in some cases, with my patients, I’ll just tell them that, you know, this lens will get us to the final result faster. Dr. Morrison had has an incredible analogy, and I’ve been using it ever since she told me is with a regular scleral lens, it’s like we put a suit on you with you know, just a regular suit. And we’re trying to tailor the suit to your body. So you’re coming in, we’re making adjustments you leaving in, you come back in, we make a few adjustments. And it’s still never going to be perfect, because that’s when there’s limited changes we can make. Whereas with this technology, we are taking the measurements and making a suit custom for you based off of all of these measurements. So when you get your first suit, it fits perfectly. And so a lot of times if patients are wanting to get to the end result faster, or if they want something that is very, very custom to their eye. This is this is definitely one of the best options for them.

Dr. Morrison:

Definitely, and you can talk about this doctor Woo, because you have more experience with the higher order aberration correction.

I just we’ll also mention about the about the other two lenses, they kind of go in order. Conventional scleral lenses can offer great results, scan base can offer a little bit better results, the mold base can offer even a little bit better results. And that’s in terms of comfort for sure. Fogging, definitely. And somewhat the vision as well, Dr. Woo, I have seen patients who with a conventional lens or 2025, with the mold based or scan based their 2020. And the reason is, because the optics are able to be decentered a little bit differently. And so you get just more of that precision, instead of you know, buying a suit and tailoring it to your body. So..

Dr. Woo:

Yeah, that’s a good point about the decentered optics, because some of the patients we have are, they’ve got disfigured eyes, maybe they had a trauma, one of our most recent patients, he had a trauma to his eye, he was building a house and he hit with a hammer and the nail went into his eyeball, and he had to have surgery. But what happened is during the surgery, the pupil the black part of the eye got displaced. And so now instead of being in the center of his eye, now it’s off to the side. And so any traditional contact lens was not really getting him any vision, because the optics of the lens was in the center of his eye, but his pupil is now over here. So the beauty of this type of lens is because it’s so custom, we can actually tell the laboratory, hey, we need to move the optics over to where his pupil is so much better vision than we would have gotten with any other type of lens. Higher order aberration correction is another new technology that not a lot of doctors have in the office. But this is good for patients that have some of these issues that no matter what we do with the traditional either gas permeable lens, soft lens, hybrid scleral, they’re just having issues. As far as maybe they’re seeing glare, still, maybe they’re seeing some halos. And maybe their vision is just not as crisp as they had hoped. So an example for this case, in particular, that you see on the left. The bar that you see that’s in red, tells us that there’s some problems with the light going into the eye, which is going to happen with people that have irregular surfaces like keratoconus, corneal transplants, really all of the patients we’ve been talking about today. But he has keratoconus and with the traditional scleral lens, he could only see about 2030 and that was with the best correction did as much as we could in that regular lens. But then we did the scan on him and we saw well there is an area that we can maybe try to improve. So we designed to this higher order aberration lens, and now he can see 20/20. So it’s a pretty amazing technology, we’re still figuring out who’s a good candidate who’s a poor candidate, we don’t really know yet because it’s so new. So a lot of doctors are still kind of testing out this technology. But you know, I tell patients that if they have exhausted all their options, and we’ve tried all these other lenses, and they’re still not happy with their vision, then this is something that we can try. It may not work, it may work, we don’t know. But sometimes patients are very, very motivated to at least try because they want to see if their vision can be corrected even more, so something really cool that we are doing now.

And if there are any last questions, we both have Facebook and Instagram accounts, so please follow us. We always are posting interesting cases and interesting little tidbits for patients. And please visit our websites if you have any other questions that you can get ahold of us either way. And I know Dr. Morrison, you’ve got to get to your patient. So I don’t think there’s any more questions at the moment.

Dr. Morrison:

Yeah, so thanks so much, everyone for joining us. Again, you can contact us if you have any questions. If you have anything lingering that you felt too nervous to ask on the chat, and we’re happy to help you. And we’re always here, there’s like lots of cool things coming down the pipeline. So if you, you know, have contact lenses that don’t fit you very well or you’re uncomfortable, you don’t have good vision. There are things out there for you, to help and new things are coming out every day. So don’t give up and just keep coming in and asking questions. And we’re, you know, we’re gonna help you out.

Dr. Woo:

Great. Well, thank you, everybody, for joining us. Thank you, Dr. Morrison, for spending your Saturday morning with me and hope to connect with you guys in the future.

Dr. Morrison:

All right. Thank you so much, guys.

Dr. Woo : Bye.