The role of comanagement in specialized scleral contact lens fitting
Comanagement optimizes outcomes for patients who wear scleral lenses.
Successful fitting ensures no contact is made between the posterior contact lens surface and the cornea—no matter how irregular the topography. (Adobe Stock / Andrey Popov)
Scleral contact lenses are becoming more popular because of their unique design. Unlike other contact lenses, scleral lenses vault over the cornea and rest on the conjunctiva overlying the sclera. This makes them more comfortable than other types of gas permeable contact lenses, and allows them to be used to correct a wider range of vision problems.
For patients who wear scleral lenses for therapeutic purposes, it is important to manage their relevant corneal disease, ocular surface disease, and refractive error.1 For these patients, comanagement of their underlying ocular and systemic conditions is often the key to success.
Scleral lens use and comanagement of patients
The most common reason patients wear scleral lenses is for Keratoconus, a progressive condition that causes the cornea to thin and bulge.2 Successful fitting ensures no contact is made between the posterior contact lens surface and the cornea—no matter how irregular the topography. There are a range of co-management indications for patients with Keratoconus. Younger patients may be candidates for corneal crosslinking, a procedure that can help to slow or halt the progression of the disease.3
In patients with advanced keratoconus and visually significant corneal scarring, corneal transplantation may be a recommended treatment option.4 This procedure can restore clarity and vision in patients who cannot be optimally corrected with contact lenses alone. Patients who are not candidates for corneal transplant or who do not wish to have surgery may be able to use scleral lenses as a non-surgical alternative. In these cases, technologically advanced, impression-based scleral lenses may be the best option.5
Another ocular comorbidity that can affect scleral lens wear includes glaucoma. The effect of scleral lens wear on intraocular pressure (IOP) remains a popular topic in the research; some studies show an increase in pressure, whereas others show a decrease in pressure.6,7 For patients who wear scleral lenses and have glaucoma, close monitoring is warranted. This includes patients who have undergone glaucoma surgery, including tube shunt surgery or trabeculectomy.
Newer scleral-mapping technology allows practitioners to avoid or vault over a tube or bleb to minimize the impact of a lens near or over this alternative pathway for aqueous humor.8 Impression-based lenses can be modified to provide a lens edge that very closely resembles the ocular surface. This can help to improve comfort and vision for patients because these lenses can be designed to avoid pressure on alternative drainage structures.9
In addition, patients who wear scleral lenses may suffer from binocular disorders, such as vertical heterophoria or accommodative dysfunction, which cause symptoms as double vision, eyestrain, and headaches. Many scleral lens manufacturers can add prism in both vertical and lateral directions, decenter optic zones, and apply multifocal optics to lessen any symptoms noted by the patient.10 Vision therapy specialists and strabismus surgeons are often consulted for their expertise on further combination treatment.
Lastly, scleral lenses can be a therapeutic benefit for patients with dry eye syndrome. The saline used to fill the bowl of the scleral lens provides continuous lubrication to the cornea and conjunctiva while also providing protection from foreign offenders.11 Scleral lenses are a good option for patients with severe dry eye syndrome who have not responded to other treatments, such as artificial tears.
The following case studies demonstrate the therapeutic benefit of scleral lenses for patients with multiple ocular conditions and complex histories. By working together with these patients’ ophthalmologists, both patients reaped the numerous benefits of successful scleral lens wear.
Case 1
A 74-year-old man with a history of surgical repair of a left ruptured globe from a tennis ball injury presented for a specialty contact lens fitting, complaining of photophobia and reduced vision OS. The patient presented to our clinic as a non–contact lens wearer but had trialed gas permeable lenses in the past. His entering vision was 20/20 OD and 20/300 OS (pinhole: 20/100 OS).
On slit lamp examination, the left eye was significant for a 3-mm upper eyelid ptosis, buried subconjunctival sutures superotemporally with temporal conjunctival prolapse, 1+ corneal neovascularization inferiorly and temporally, an iris defect superiorly, and an IOL implant. Corneal topography revealed high amounts of corneal astigmatism OS. The patient was diagnostically fit using a commercially available scleral lens in-office, yielding best-corrected visual acuity of 20/20 OS.
Figures 1 and 2. Case 1 - Image of scleral lens on-eye highlighting the location of the conjunctival sutures OS.
Figure 3. Case 2 - Final scleral lens fit therapeutically to address punctate epithelial erosions and central epitheliopathy with haze OD.
(Images courtesy of Thomas A. Wong, OD, FNAP.)
Based on the initial evaluation, a trial lens was ordered and dispensed with the appropriate modifications. However, at follow-up, removal of the scleral lens revealed scleral impingement overlying one of the conjunctival sutures (Figure 1).
To allow for adequate clearance of these sutures, a proprietary technology was incorporated to allow for a flute in the lens and was specified by location, height, and width.9 While the modified lens was being manufactured, the patient returned to their ophthalmologist reporting new-onset double vision in their left eye.
The ophthalmologist examined the patient’s eye and found that there was a previously buried suture that was no longer fully intact. The suture was removed, and the patient’s symptoms resolved. The patient returned for dispense of the new lens, and the final fit yielded appropriate central, mid-peripheral, and limbal vault, with adequate scleral alignment in all quadrants (Figure 2). Visual acuity remained stable, 20/20 OS.
The patient wears the lens comfortably during all waking hours without irritation. Comanagement with the patient’s surgeon was imperative, as the patient was able to promptly seek care for the new onset diplopia. The patient plans to undergo a future iridoplasty, which will likely require a refitting of the scleral lens.
Case 2
A 59-year-old woman presented for scleral lens evaluation. She had exposure keratopathy of the right eye secondary to surgical removal of a vestibular schwannoma. As a result of the surgery, she suffered damage to cranial nerve 7, leading to facial paresis of the right eye and inability to fully close her right eyelid. Her ocular history included: right canthoplasty with right lower eyelid ectropion repair, right upper eyelid/orbital exploration with foreign body removal, placement of a right upper eyelid gold weight, and temporary right lateral tarsorrhaphy.
The patient presented as a previous scleral lens wearer; however, she was referred for a refitting after adjustment of the lateral tarsorrhaphy OD. Entering acuities with spectacles were 20/50 OD and 20/20 OS. Corneal evaluation was significant for 2+ punctate epithelial erosions and central epitheliopathy with haze OD and clear OS.
The patient desired a scleral contact lens to address vision, lubrication, and the uneven eyelid appearance. The patient was diagnostically fit using a commercially-available scleral lens in office, yielding best-corrected visual acuity of 20/20 OD. An initial trial lens was ordered and dispensed with the appropriate modifications. However, at follow-up, the anterior surface of the lens was found to be wetting poorly and deposited from the continuous use of artificial tears during the day and gel overnight.
In consultation with the patient’s cornea specialist, the use of artificial tears over the scleral contact lens was slowly decreased and her wear time of the contact lens increased. The scleral lens was also coated with Tangible Hydra-PEG (Tangible Science) to address wettability and decrease surface deposits.12 The diameter and sagittal height of the right eyelid were increased incrementally to determine how to improve the cosmetic appearance of the eyelid.13 The final lens is pictured in Figure 3.
Conclusion
The two cases above highlight the importance of comanagement to optimize outcomes for patients who wear scleral lenses. Through partnership and timely communication, these patients were managed by many ocular specialists and ultimately saw 20/20 in their diseased eye despite their extensive ocular history. Scleral lenses were a successful treatment option for these patients, allowing us to avoid the need for additional surgeries and the associated risks. Building a professional network of collaborative colleagues can often lead to the most rewarding medically necessary contact lens fits.
References
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2. Ortiz-Toquero S, Martin R. Current optometric practices and attitudes in keratoconus patient management.Cont Lens Anterior Eye. 2017;40(4):253-259. doi:10.1016/j.clae.2017.03.005
3. Kankariya VP, Kymionis GD, Diakonis VF, Yoo SH. Management of pediatric keratoconus - evolving role of corneal collagen cross-linking: an update.Indian J Ophthalmol. 2013;61(8):435-440. doi:10.4103/0301-4738.116070
4. Şengör T, Aydın Kurna S. Update on contact lens treatment of keratoconus.Turk J Ophthalmol. 2020;50(4):234-244. doi:10.4274/tjo.galenos.2020.70481
5. Nau AC. Medical application of contact lens technology. Adv Ophthalmol Optom. 2019;4:1-12. doi:10.1016/j.yaoo.2019.04.001
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8. Zenlens scleral lenses. Bausch + Lomb. Accessed September 11, 2022. https://www.bauschsvp.com/lenses/zenlens/
9. Tanhehco T, Jacobs DS. Technological advances shaping scleral lenses: the Boston ocular surface prosthesis in patients with glaucoma tubes and trabeculectomies.Semin Ophthalmol. 2010;25(5-6):233-238. doi:10.3109/08820538.2010.518873
10. Vincent SJ, Fadel D. Optical considerations for scleral contact lenses: a review.Cont Lens Anterior Eye. 2019;42(6):598-613. doi:10.1016/j.clae.2019.04.012
11. Scanzera AC, Ahmad A, Shorter E. Adjunct use of therapeutic scleral lens for exposure keratopathy after severe chemical burn.Case Rep Ophthalmol. 2021;12(1):243-247. doi:10.1159/000511223
12. Bavinger JC, DeLoss K, Mian SI. Scleral lens use in dry eye syndrome.Curr Opin Ophthalmol. 2015;26(4):319-324. doi:10.1097/ICU.0000000000000171
13. Sindt CW. Tangible Hydra-PEG: a novel custom contact lens coating technology designed to improve patient comfort and satisfaction. Tangible Science. 2016. chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.eye-iq.com/uploads/Hydra-PEG-White-Paper.pdf
