By Dr. Nathan Schramm, OD, CNS, FSLS (in process)
Scleral lenses are the next big thing in optometry! Fitting sclerals can be very rewarding both emotionally and financially. We have had several patients come to our clinic with BCVA in glasses or contacts worse than 20/150 in one or two eyes and leave with scleral lenses that allow them to drive. You will become your cornea specialist’s best friend when you start fitting his or her patients. Think about it, he or she has done all the hard work of a cornea transplant, INTACS, and/or crosslinking and although the surgery was a clinical “success,” refractively the patient cannot see well with their glasses, and may not be able to tolerate soft contacts, small diameter RGP’s, or hybrid contacts. That’s when sclerals save the day and makes both the scleral fitter and the surgeon the hero!
This article will refer any size scleral as sclerals, official classification is above (Wilcox P, 2014)
Many eye doctors think of sclerals as a huge lens that is difficult and time consuming to fit and difficult for the patient to insert into their eyes. It can be a last resort as a non surgical refractive option when all else has failed. I challenge you to change your thinking because modern lathing technology has made scleral lenses much more customizable and can be made the same diameter as a soft contact lens or slightly larger. They could be used as a first line treatment for keratoconus, cornea transplants, and other corneal ectasias. According to an article in Contact Lens Anterior Eye, “Scleral lenses should be considered as lens of choice in eyes with complex corneal geometry, as besides visual rehabilitation, their use may delay or prevent further surgical involvement.” (Severinsky , 2014)
A 2009 study showed that scleral lenses have the same initial comfort as soft contact lenses and remain comfortable throughout the day with the benefit of superior optics and contrast of a small diameter RGP (Michaud, 2009).
Don’t have enough ectasia in your practice?
Almost everyone is a candidate. In the same 2009 study using a popular scleral lens design, young, healthy astigmatic soft contact lens wearers were fit into scleral lenses. At the end of the study they were given a forced choice and over 50% of the patients chose to continue scleral lens wear over soft contact lenses (Michaud, 2009). These were patients that did not need to wear sclerals therapeutically. One of our in-office studies for a single brand of sclerals showed only ten percent felt the scleral lenses to be uncomfortable. These results will be presented at the GSLS Las Vegas Conference in January 2015.
More than half of our scleral fits have dry eye disease. These patients get a huge benefit from having a moisture chamber on their eye the entire day. For severe dry eye, we order autologous serum tears and have the patient instill them into the scleral bowl.
Before photo of 62 year old with severe dry eye with history of ocular rosacea, meibomian gland probing, Lipiflow, multiple glaucoma meds, -2.50D of astigmatism, now he is 20/20 distance, J1+ for near x OU with multifocal sclerals and improved quality of life and vision.
About 75% of our scleral patients are presbyopic. Multifocal sclerals are a fantastic option. It is possible with a scleral multifocal lens design to have a 70% adaptation rate (Buffalo, 2014). We have successfully fit patients with up to 3.50 diopters of corneal astigmatism utilizing scleral mutifocal designs with good success.
Aphakia – Throw away those coke bottle glasses!
Let your local retina specialists know that sclerals are a wonderful option for those needing very strong corrections due to aphakia or highly myopic. Our oldest scleral patient at this time is 80 years old.
To build a thriving scleral lens practice you need a plan, education, and the proper support.
One of the most common scleral fits is for keratoconus. The lens is fit so that it does not touch the cornea.
According to a 2010 study, a protective way to reduce oxidative damage and potentially prevent Keratoconus development is to improve the contact lens fit to minimize corneal micro trauma. (Miguel Romero-Jiméneza, 2010)
With the help of Gary Gerber’s Power Practice and Franklin Covey’s “Wildly Important Goals” (WIG’s) we created a plan that combines a scoreboard and goals. In order to motivate your staff and yourself you need to know if you are winning. How long would you watch a basketball game if the scoreboard was broken?
Our first year’s goal was to have eight new scleral fits a month and our long term goal is to have eight new fits a week. At that level, the practice would gross about $1 million from sclerals alone.
1. We meet with one referral source every week, which include local cornea specialist, LASIK surgeons, ophthalmology clinics, and commercial optometry offices.
Once a week in the early morning, we buy a Starbucks coffee traveler (big box of coffee), staple our cards to the top of it (our cards have our headshot on them), and drop it off as a gift to a clinic that sends us patients. If you can win the staff, you can eventually win the doctor.
2. We have dinner or lunch with at least one cornea specialist a month.
3. Purchase or lease an OCT that has the capability of anterior segment imaging. This will speed your ability to fit scleral lenses and aid in trouble shooting more advanced fits such as post cornea transplants.
OCT image helped to create a notch on the scleral lens to improve comfort due to an area of heaped bulbar conjunctiva from an underlying scleral buckle.
If there is a scleral wet lab at an upcoming conference or at a local optometry school, start there first.
In addition another excellent option would be to contact Xcel’s Alison Penn (404-921-4467) or Cassandra Gordon of Visionary Optics (813) 507-8635 to have a trainer from their company come to your office to do a scleral wet lab on several of your patients.
Contact Blanchard’s Lee Buffalo (706) 299-9033 who will fly you to a weekend scleral workshop for an entire day of training and wet lab.
In order to get patients to come to your office wet lab, you can talk to your local cornea specialists and tell them you’ll be fitting a new type of scleral (you may not need to tell them it’s new to you).
Can you try to refer us some patients that are good candidates?, ie keratoconus, post refractive ectasia, dry eye on maximal therapy, post PK (is higher level and may want to wait for more experience)
You can tell them you’re offering a discount because it is a new lens and it is a workshop.
- Join www.sclerallens.org because they have a scleral lens message board and a fellowship program and once completed allows the practitioner to be listed on the website as a “Scleral Fitter.” Right now there are only about 40 fellowship trained scleral fitters in the world.
- Join the AAOMC and their Google Group
- Join Dr. Gary Gerber’s Power Practice and their specialty contact lens group
- Attend Dr. Nick Despotidis’ Supercharge your Practice on April 17th at Vision By Design(VBD). Many of his tips can be applied towards sclerals.
- Attend Vision by Design sponsored by AAOMC, next year it is April 16-19, 2015 Houston, TX.
Wilcox P, B. D. (2014). Scleral Lens Wrap Up. Vision by Design – Scleral Wet Lab, (p. 11). Chicago.
Severinsky , Behrmanb, Frucht-Perya, Solomonal. Cont Lens Anterior Eye. 2014 Jun;37(3):196-202. doi: 10.1016/j.clae.2013.11.001. Epub 2013 Dec 2.
L. Michaud, S. Woo, A. Dinardo-Lotoszky, J. Harthan, B. Morgan, E. Bennett and R. Reeder Clinical Evaluation of Large Diameter GP for the Correction of Refractive Astigmatism Optometry – Journal of the American Optometric Association, 2009; 80(7):375-83.
Buffalo, L. M. (2014, May). National Sales Director. (O. Nathan Schramm, Interviewer)
Abraham J, Schramm N, Retrospective Analysis of ten months of Atlantis Scleral Lens fits at Natural Eyes of Weston, to be presented at the Global Specialty Lens Symposium January 2015 (In submission).
Miguel Romero-Jiméneza, J. S.-R. (2010). Keratoconus: A review. Contact Lens & Anterior Eye , 157-166.
About the author: Dr. Nathan Schramm, OD, CNS is a leading authority on ocular nutrition and scleral contact lenses. Dr. Schramm graduated from Nova Southeastern University and completed his optometric rotations at Tianjin Eye Hospital in China as well as several optometry/ophthalmology clinics in Jacksonville, FL. He is completing a fellowship in scleral lenses in 2014.
Dr. Schramm is an accomplished writer, educator, lecturer, and radio personality. He previously was a contributing author and co-editor of journal and magazine articles. He has written for Healthy Living Magazine, VLIFE, and Natural Awakenings. Dr. Schramm has taught other doctors about nutrition and scleral lenses in China and throughout the United States at various optometry and ophthalmology conventions. He has been a frequent guest on Dr. Michael Lange’s radio show, Ask the Doctor, and has appeared on the television show, Leading Experts.