Lynette Johns OD FAAO FSLS
In the January I-Site case report, we discussed the importance of proper scleral lens application training to avoid harm to the cornea. Proper removal of the device is equally important. As practitioners, we focus on optimal scleral lens fitting to achieve our treatment goals of visual rehabilitation, ocular protection and comfort. But even with an optimal fit, patients may run into difficulties with removal of their devices. Inability to remove a scleral device may contribute to patient panic and anxiety, and also it may lead to an adverse effect.
A 48-year-old male monocular patient with a history of Stevens-Johnson syndrome and LASIK has been wearing a scleral lens for two years. At his routine follow-up, he complained that he had intermittent problems with removing the device, reporting that there would occasionally be a loud “pop” sound. He removed the device multiple times daily. The day of his follow-up visit, he complained that shortly after application he had tried to remove the device and experienced significant difficulty. He was uncomfortable until his appointment.
Figure 1 (above) shows his presentation during his examination and the bulla under his device.
Figure 2 (to right) demonstrates with fluorescein evaluation how the elevation of the bulla was. The neovascularization that was present created a subepithelial hemorrhage. Because he was functionally monocular, we chose not to lyse the bullae because we did not want to risk infection. He was monitored daily as the bullae resolved. When reviewing the proper removal technique, we determined that he was applying the plunger randomly to the surface and pulling the lens straight out. His intermittent experience of suction occurred when the plunger was applied to the center of the device, which creates the most suction. We reviewed with him to apply the plunger at the very edge of the device to provide a smooth removal.
A 52-year-old patient with a history of bilateral corneal transplants complained of a “red spot” on her iris that also was a subepithelial neovascular bleed associated with improper removal (see Figure 3 - to right).
The device she wore demonstrated ample fluorescein exchange similar to that shown in Figure 4 (bottom picture). Suction is unlikely a factor in the presence of fluid exchange. When discussing her removal technique, she stated that it felt like her “eye was going to pop out of her head with the lens.” In demonstrating her technique, she applied the plunger to the center of the device. We reviewed proper technique to achieve a smooth removal.
Improper scleral lens removal technique is very dangerous to ocular health. LASIK flaps and graft-host interfaces are particularly vulnerable areas. As part of our evaluation, we must ensure the best possible fit and assess removal suction after an extended wearing trial. Tear exchange suggests that the lens is not suctioned, but alternately, the absence of exchange does not necessarily mean that the device is suctioned. Feeling for resistance upon removal is a practical way to assess for suction.
Intermittent complaints of removal difficulty are a clue that it may be technique related. Scleral lenses are often easily removed shortly after application since they do not have time to settle. Suction shortly after application also suggests a technique issue. This highlights the importance of discussing removal issues as part of a routine assessment of the scleral lens fit. It is easy to overlook application and removal reviews with veteran scleral lens patients, but incorporating this discussion ensures the safety and compliance of the patient.
Dr. Lynette Johns is a cornea and contact lens residency trained optometrist and a member of the adjunct clinical faculty at New England College of Optometry.
She was recently the senior optometrist at the Boston Foundation for Sight where she exclusively fit scleral lenses and managed complex corneal disease.
She is a fellow of the American Academy of Optometry, a member of the Gas Permeable Lens Institute advisory board as well as a member of the BCLA. She is a clinical and educational consultant to the contact lens industry in specialty lenses.