Handle with care
Proper application and removal of scleral lenses is crucial for long-term success
Lynette Johns OD FAAO FSLS
Fitting scleral devices combines science with art. The goals of fitting are to achieve an optimal vaulted reservoir over the cornea, minimize conjunctival compression, and avoid impingement of vessels and conjunctival tissue. The science involves protecting and maintaining the ocular physiology against compromise. The art of fitting is how we reach those goals. When treating a patient using scleral devices, proper application and removal training is crucial for long-term success.
A 55-year-old patient with a history of severe dry eye of unknown etiology who was recalcitrant to aggressive lubrication and punctal cautery was referred to our office for treatment. During the fitting process, she began application and removal training. We observed that she had a significant Bell’s reflex, and she was unable to desensitize the reflex to maintain fixation for application. We introduced a lighted plunger to provide a visual cue for her and to establish proper alignment of the device (see photo below). During one of the training episodes, she applied the device without proper alignment.
The photo shows an epithelial roll where the superior edge of the device burrowed into the epithelium, but it did not cause a break or defect. She reported a very painful moment during training and complained of extreme discomfort. We discontinued training for the day, and we advised her to use lubricating ointment. The following day, the corneal epithelium had remodeled and the roll was eliminated. She was significantly more comfortable and was ready to resume training.
A teenage patient with familial dysautonomia was referred for treatment to protect her neurotrophic corneas. She had successfully completed application and removal training, demonstrating for us proper technique during her sessions. We dispensed her devices to take home and return wearing the next day. She arrived early complaining of a red eye. Because her corneas were anesthetic, hyperemia is a significant finding that required immediate examination. We removed the device and found multiple foreign body tracking marks consistent with the edge of the device (see photo).
She admitted she’d had difficulty with application in the morning and had made multiple attempts. We decided to review application training and had her parents oversee her applications during the first few months after she was discharged from our care. She eventually was able to independently apply and remove her devices without further incident.
Fenestrated plunger with light
We typically discuss indications for using scleral devices and optimal fitting techniques. However, both of these cases demonstrate that proper education is just as important for successful patient outcomes. As clinicians and fitters, the last thing we would want to happen is for patients to keep the devices in a drawer because they cannot apply them. While scleral devices provide significant clinical benefit in protecting and supporting the corneal surface, they also can act as a weapon when improperly applied. It is our responsibility to assess our patients’ dexterity, reflexes, and social situation so that they can be confident and achieve the full value and benefit of what treatment with these devices provides.
Dr. Lynette Johns has been the senior optometrist at the Boston Foundation for Sight since 2005.
She is a graduate of the New England College of Optometry where she completed a residency in cornea and contact lenses. She is adjunct clinical faculty at the New England College of Optometry.
Dr. Johns is a fellow of the American Academy of Optometry and a fellow of the Scleral Lens Education Society.