Putting the patient first when fitting scleral lenses
[This article was published on Menicon’s blog. Co-author = Esther-Simone Visser]
Modern scleral lenses are considered revolutionary by many. They can prevent the need for corneal transplants, offer desperately sought relief to patients who suffer from dry eyes or are unable to close their eyes completely, and can even save vision.
It is amazing how a small piece of technology can change patients’ lives. We often hear from wearers that they have regained their lives thanks to scleral lenses, which is hugely satisfying and a major motivator to continue pursuing new scientific discoveries and promoting innovation in this fascinating area of eye care.
The Visser effect
Scleral lenses offer an incredible design, correcting irregularities of the cornea without touching it. Scleral lenses rest on the surface of the sclera.
They have been around since the late 19th century and are considered one of the first types of contact lenses to be produced. However, it was not until almost 100 years later that they became popular with the general public.
Scleral lenses were first made of glass and then, around the time of World War II, of lightweight plastic. These early lenses often caused corneal edema in patients as a result of severe hypoxia, which, if left untreated, can lead to blurred vision.
It was not until the 1980s that Rients Visser, founder of Visser Contact Lenses in the Netherlands, paved the way for scleral lenses with his groundbreaking work in contact lens fitting. This came after he read a publication by fellow contact lens innovator Don Ezekiel, in which he described how he used gas-permeable materials for scleral lenses.
Rients Visser then focused on improving the design. In the 1990s, the introduction of a cylinder on the front surface was welcomed, as it improved vision. Visser then made a breakthrough by introducing the ‘back-toric’ scleral lens with the rear surface for his patients, which better matched the toric shape of the eye.
He continued to promote the improvement of scleral lenses. In 2010, researchers discovered new information about the shape of the sclera, which showed that it often has tangential surfaces rather than curved shapes. Rients Visser collaborated with Bart van der Linden of Menicon on the design and development of bi-tangential scleral lenses. The landing zones (where the lens rests on the sclera) were designed to follow the linear shape of the sclera rather than the curved shape, in order to better fit an irregular scleral profile.
These innovative scleral lenses, called Menicon Time XL, have had a huge impact on patient satisfaction and have increased the popularity of scleral lenses among patients and eye care professionals.
Four ways to put the patient first
Scleral lenses are an important frontline tool that should never be underestimated. It is crucial that we, as eye care professionals, understand the true potential of scleral lenses so that we can offer them to every patient who will benefit from them and provide the best possible care.
- Use scleral lenses as an early solution, if necessary.
We are often asked by eye care professionals how they can determine when to prescribe scleral lenses instead of other lenses. Our philosophy is that scleral lenses should not be seen as a last resort, especially when it comes to keratoconus. The diagram below shows the guidelines we have developed to help eye care professionals choose the right lens for each patient. - Inform the patient from the outset.
It is important to provide detailed information about how the lenses work and the fitting process, what it means to insert and remove them, and what to expect in terms of maintenance. This can contribute to the patient’s independence while strengthening the relationship between the eye care professional and the patient. Some patients may be hesitant to wear them, but with the right conversations and support, you will achieve successful treatment results. - Create an advanced aftercare plan.
Regular check-ups allow patients to ask questions and enable eye care professionals to monitor how the lenses are being worn. Follow-up visits (or telephone consultations and emails for remote patients) are crucial for quickly resolving any challenges and ensuring that patients continue to wear their lenses for successful treatment. - Involve your team.
Encourage your staff and colleagues to understand scleral lenses and keep them up to date with the latest information through internal training. Regularly discuss cases within the team to ensure that scleral lenses are always considered when appropriate.
The Visser contact lens selection algorithm
The Visser contact lens selection algorithm for selecting contact lenses for two important medical applications: irregular astigmatism and bandage. (Source: Visser E-S, Wisse PL, Soeters N, Imhof SM, Van der Lelij A. Objective and subjective evaluation of the performance of medical contact lenses fitted using a contact lens selection algorithm. Cont Lens Anterior Eye 2015)
- SiHy (silicone hydrogel) RGP (rigid gas permeable)
- Mild corneal irregularity: acceptable subjective visual quality with SiHy. Moderate corneal irregularity: unacceptable subjective visual quality with SiHy, acceptable lens fit with RGP. Advanced corneal irregularity: unacceptable subjective visual quality with SiHy, no acceptable lens fit with RGP.
- Note: The assessment of severe dry eyes included grades IV and V based on the Oxford Index for staining and tear film break-up time. SiHy or RGP corneal trial lenses were used to determine the degree of mild, moderate, or corneal irregularity.
Menicon Time XL
The Menicon Time XL contact lens is designed to simplify the fitting process for both the patient and the eye care professional, while delivering high performance and comfortable, custom-made scleral lenses for extended daily wear.
It is the first mini-sclera lens produced with a bi-tangential edge to address the toric shape of the scleral surface, which is observed in 95% of cases. This design optimizes the pressure distribution of the lens to improve comfort and enable long-term daily use. In addition, it makes Menicon Time XL lenses suitable for a range of indications, while the customizable elements ensure that it can provide a perfectly fitting scleral lens for patients.
We train our specialists in mastering the Visser fitting methodology at the Visser Academy, where we adhere to the philosophy of logical, predictable, and simple fitting. When eye care professionals are unfamiliar with scleral lenses, fitting them can seem complex, but with the right preparation and our structured fitting methodology, it can be a simple and satisfying process.
Additional fittings can be made based on the performance and adaptability of the diagnostic scleral lens. This method of scleral lens fitting is very transparent, with the scleral lens fitter managing the entire fitting process.
The first step is to identify the scleral profile. The advanced technology required to reliably quantify the scleral profile may not be accessible to all eye care professionals. However, the slit lamp is an excellent tool for this purpose. By using a narrow beam on the upper part of the sclera, the nature of the scleral shape (tangential or curved) can be easily identified.
Next, the lens diameter should be three to five millimeters larger than the horizontal visible iris diameter (the lens diameter in the diagnostic set is 16 mm, but lenses are available in a range of diameters from 14 to 17.5 mm).
The base curve radius can be adjusted to ensure a good fit for the lens. A limbus-free space can be used to create more peripheral space around the limbus area. In addition, aberration correction and frontal cylindrical correction can be added to the front surface to improve vision.
The Menicon Time XL lens is produced in both linear and toric versions, and the toric periphery of the lens can be precisely controlled to better align with the sclera for an easy and stable fit. The Menicon Time XL Fitting Guide provides detailed advice on how to fit these lenses in six steps.
Scleral lenses are an effective alternative for patients for whom other optical treatments have failed. Modern scleral lenses provide a fluid reservoir between the cornea and the lens, meaning they do not touch the cornea while retaining moisture on the eye. This makes them ideal for patients with eye surface disorders, as the lenses moisturize and protect the eye surface.
Who can wear scleral lenses?
Like soft, rigid, and other contact lenses, scleral lenses can correct myopia, hyperopia, astigmatism, and presbyopia. However, scleral lenses can also neutralize an irregular corneal surface and accommodate higher refractive powers, allowing them to be used in patients with stronger and more complex refractive disorders.
Scleral lenses have also proven effective in cases where the eyelid no longer functions properly. If a patient is unable to close their eyelids, scleral lenses can protect the surface of the eye, including the cornea, improve vision and quality of life, and reduce discomfort and pain. In cases of ptosis, the eyelid may droop so far that it covers the pupil and blocks normal vision. Scleral lenses can be used to hold the eyelid up and protect the eye.
From a practical point of view, scleral lenses can also be a good option for people who participate in contact sports or spend a lot of time in dry and dusty environments. Due to their design, scleral lenses stay securely in place in the eye and no dirt gets behind the lens.
We must guide patients
When patients are diagnosed with an eye condition, they are busy processing their potentially life-changing condition. It is our job as ECPs to help them find the best possible treatment.
Introducing scleral lenses to patients is the beginning of a lifelong journey and requires them to form new habits, which can take time and patience. But it is absolutely worth it. Scleral lenses not only open up new possibilities for the patient’s vision, but for their entire life.
About the authors
Esther-Simone Visser was educated at Utrecht University of Applied Sciences, the Netherlands, Moorfields in London, United Kingdom, and the College of Optometry at the University of Houston in Houston, Texas. In 2005, she obtained her Master of Science degree with distinction from City University in London, and in 2015, she completed her PhD at Utrecht University, Netherlands. Both research projects focused on scleral lenses. Her father is Rients Visser.
Henny Otten has been involved in the fitting and development of scleral lenses for more than two decades. He is passionate about sharing his knowledge and training new optometrists in the fitting of scleral lenses. He works in various hospitals, including two university hospitals, where he fits medical lenses. He is also a consultant for Menicon Netherlands.
Sources
Van der Worp E. A Guide to Scleral Lens Fitting. Pacific University Common Knowledge: Books and Monographs. 2010. Accessed April 2023.
Visser ES et al. Objective and subjective evaluation of the performance of medical contact lenses fitted using a contact lens selection algorithm. 2016. ContLens Anterior Eye
Visser, Medical Applications and Outcomes of Bi-tangential Scleral Lenses.
Optometry and Vision Science VOL. 90. No.10, October 2013.
Harthan Jennifer S et al. Therapeutic uses of scleral contact lenses for ocular surface disease: patient selection and special considerations, 2018, Clin Optom
Katsoulos Konstantinos et al. Scleral contact lenses for the management of complicated ptosis, 2018, Orbit
ReVision Optometry, 7 Benefits of Scleral Contact Lenses, 2020. Accessed April 2023
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