During these unprecedented times of the COVID-19 pandemic, we have been encouraged to evaluate best practices for specialty contact lens fitting. It is especially important to develop practices and procedures to ensure safety at all times. It is critical to reduce the length of time that patients are in the office and to decrease the number of in-office visits. Generally, scleral lens fitting and follow-up appointments can be time consuming. To limit the number of patients in the office while retaining excellent communication and empathy, certain protocols can be employed. This article will discuss the future of scleral lens fitting as it moves away from diagnostic and toward empirical fitting. It is time to embrace new methods of practicing, as the future is now.

NEW MEASURES AND SAFETY

A flood of misleading information was previously circulating globally regarding the use of contact lenses during the COVID-19 pandemic. Practitioners should emphasize that contact lens wear is safe as long as wearers adhere to proper wear and care instructions. Clinicians should take this opportunity to re-educate patients on proper hygiene (Figure 1) and the importance of compliance. Multiple health organizations have released recommendations and best practices for contact lens use and patient care.^1-4 Clinicians and their staff should observe rigorous protocols, including personal protective equipment (PPE), communication with patients, and proper sterilization of instrumentation, examination room, and reception areas after each patient.

In the context of eyecare practice and how it will be carried out in the future, this consists of maintaining proper distance between clinician and patient and avoiding conversations when in close proximity to patients, such as during slit lamp examination. Reducing examination time is also encouraged. An alternative to reduced examinations are telehealth visits prior to a physical examination. However, with this, there may be a higher risk of developing psychological distance with your patients. Investing time for conversation and patient education is crucial for contact lens success. The big dilemma then is: How can we maintain social distancing and empathy for our patients without reducing time spent with them or compromising the quality of the eye exam?

Incorporating telehealth, through regular video visits and/or chats, will allow patients to feel connected to their physician and to not feel left alone. Tell patients that we will only be physically distant but available to continue dialogue and to review education, using available technology in the best way. Telehealth will reduce the number of in-office visits and, as a result, will reduce the rate of contagious conditions, anxiety for patients (and clinicians), and time spent disinfecting and sanitizing the office and instruments.

WHAT’S ON THE HORIZON?

Options for Empirical Fitting Best practices for scleral lens fitting have been revised and altered during the current pandemic. Developing practices and procedures is crucial to reduce the risks of infection with prolonged exposure and to keep patients and staff safe. Empirical fitting may be the best option for safety. Various studies have compared empirical GP contact lens fitting to diagnostic lens fitting and have demonstrated that empirical fitting reduced chair time and increased first-fit success rate,⁵ improved initial patient satisfaction,⁶ ameliorated lens fitting,⁷ and was a reliable and practical method, especially in pediatric patients.⁸ Gemoules⁹ investigated empirical fitting of scleral lenses and found that this method presented a more accurate and efficient alternative compared to diagnostic fitting. Most importantly, empirical fitting represents a safer method of contact lens fitting, as diagnostic multipatient contact lenses are not used.¹⁰

Impression-based technique and eye profilometry are two methods used for empirical fitting of scleral lenses. With impression fitting, an impression of the eye is taken, then a 3D scan is performed to allow a lathe to create a highly customized scleral lens to match the precise curvature of the ocular surface. Profilometry is another method for scleral lens empirical fitting. Through fluorophotometry, some technology that is currently available can assess the ocular surface elevation out to 22mm, measure the ocular sagittal height, and determine the presence of scleral toricity or asymmetry as well as conjunctival irregularity. A different software measures the ocular surface up to a maximum of 18mm horizontally and 17mm vertically and incorporates scleral toricity or asymmetry to allow a better initial selection of scleral lens diameter and design. Two of the products measure the eye in primary gaze direction while a third takes images in three positions of gaze (primary, superior, and inferior) and stitches the images together. Additionally, each uses software slightly differently. One uses software for the best-fit lens selection from different scleral lens designs commercially available, a second uses software to design a customizable scleral lens, and a third uses an external software to design a customized lens. In addition, the scleral mapping data can be transferred to product-specific software for the design of a highly customized scleral lens.

The power of the lens may be calculated from the manifest spectacle refraction and keratometry values or by using keratometry readings and the prescription of the fellow eye. If a patient previously wore a lens, initial lens power may be determined from that lens. Otherwise, a rigid lens may be applied on the eye, and an initial lens prescription may be calculated using the lens power, base curve, and over-refraction.

Fitting Procedures It is important to reduce the length of time that patients are in the office and to reduce the number of patients who are in the practice and reception area at the same time. When fitting contact lenses, social distancing should be respected. It is recommended to avoid, or at least to reduce, the number of times that a patient is touched and to minimize the use of diagnostic sets. Switching to empirical fitting may be the best alternative and represents the future of specialty contact lens fitting. A transparent dialogue with patients is essential; one option is to let patients choose whether they prefer diagnostic or empirical fitting. Explain the benefits of empirical fitting to patients (e.g., they will receive highly customized, personal, and sterilized contact lenses that have never been applied before to any patient). When using lenses from diagnostic sets, a disinfected lens is applied to a patient’s eye; however, that lens was previously applied to other patients’ eyes. Practitioners may add an extra cost for the empirical fitting due to the increased time necessary to design a lens.

Additionally, the use of technology and empirical fitting can be helpful when designing fully customized contact lenses in the corneal, limbal, and scleral areas.

The procedure would consist of the following steps:

1. Do a telehealth appointment to obtain patient information, case history, and review of symptoms, medications, and other important information.
2. Complete an initial in-office examination for ocular assessment and measurements. After the evaluation, patients should leave the office.
3. Perform an empirical scleral lens fitting using the data collected during the initial visit. If patients are rigid contact lens wearers, the scleral lens power may be calculated based on their previous lenses. Otherwise, use plano lenses.
4. Order the lenses.

When the lenses are available to deliver, practitioners should follow this procedure:

1. Bring patients in for an in-office visit for a first lens assessment and over-refraction. During this visit, educate patients on lens application and removal techniques using their own lenses, personally designed for them and never applied before to any other patient. The first lenses may be delivered to patients, allowing them to learn application and removal techniques.
2. Order new lenses, including the power and making small design changes, if needed.
3. The second pair of lenses would be delivered directly to the patients.

For follow-up visits, practitioners can schedule remote evaluation at the delivery of the second pair of lenses; remote evaluation after one-to-two weeks; and in-office evaluations after three-to-four weeks. At this point, it is possible to make the final changes for a new order, if needed. If other lenses are ordered, the procedure is similar to the delivery of the second lenses.

IN-OFFICE LENS CARE AND STORAGE

Biohazard Waste of Scleral Lenses The diagnostic lenses applied to patients that are exposed to diseases such as COVID-19, hepatitis, human immunodeficiency virus, prion disease, herpes ocular infection, adenovirus, and Acanthamoeba keratitis should be thrown away after their use and need to be treated as biohazard waste.¹¹

Storage Container Used diagnostic lenses should not be directly placed into a storage container. After removal, place the lenses into a disposable case and disinfect them. In the meantime, the lens storage container should be disinfected also, before the diagnostic lenses are placed back into the well. Storage cases should be replaced when possible to avoid biofilm formation. Lens containers should also be treated as biohazard waste.

Expiration Contact lens solutions expire 28 days after opening the bottle regardless of the expiration date indicated on the package.¹¹ Thus, every time a new bottle is opened, it is necessary to write the date that it is opened and the expiration date on the bottle (Figure 2). Solutions should be thrown away after the expiration date. Staff and patients should adhere to the expiration dates of all solutions for contact lens care.

Cleaning For lens cleaning, practitioners should wear gloves and rub the lenses with surfactant cleaners or multipurpose solution (MPS). Rubbing the lenses removes microbes, parasites, and debris (lipids and protein) as well as cosmetics and creams that can adhere to the lens during daily wear. Removing debris increases the effectiveness of the disinfection process and helps to maintain lens surface treatments. After rubbing, lenses should be rinsed with saline or an MPS to remove the cleaner and all residue from their surface.

Disinfection After cleaning and rinsing lenses, it is important to disinfect them by soaking the lenses for at least three hours in a non-neutralized ophthalmic-grade 3% hydrogen peroxide. After three hours, practitioners, wearing gloves, should thoroughly rinse the lenses with saline or an MPS and then wipe and store them dry in a disinfected case.¹¹ It is also crucial to disinfect everything that comes in contact with the lenses—such as rubber stoppers, lids, and vials—in a non-neutralized 3% hydrogen peroxide for, at minimum, three hours. And, just like for the lenses, these items should be rinsed thoroughly with MPS or saline before reuse, or they can be replaced.¹¹

Storage Lens containers should be labelled with the last disinfection date. If stored wet, the lenses and containers should be re-disinfected and storage solution should be replaced every 28 days.¹⁰ Documentation should be maintained, including reference number for each lens, patient reference for each lens, dates of use, dates of disinfection, method of disinfection, person performing disinfection, and supporting competent personnel and training record.¹¹

REMOTE EVALUATION

Remote evaluations are an essential way to reduce in-office visits and chair time. They allow clinicians to achieve a gross evaluation for some changes in scleral lens haptics and the ocular surface. The downside of this assessment is that clinicians rely on the patients’ photographs, which should be clear and in focus. Instructions from the Cornea and Laser Eye Institute, P.A. CLEI Center for Keratoconus on how to capture images and video of the eye may be delivered to patients (https://sclerallens.org/for-patients-2/covid-19-updates/ ). A video illustrating how to correctly capture pictures may also be valuable for patients’ education (see https://www.youtube.com/watch?v=kzlnEp6_NQk ). The use of imaging software that enhances the presence of hyperemia, vessel compression, and ocular surface staining allows professionals to better evaluate the patients’ pictures (Figure 3).

A remote evaluation may be used for patient triage as well. Clinicians can analyze images and decide whether patients need to visit right away or whether it is possible to see them in two or three weeks, depending on the results and the practitioners’ judgment.

Remote evaluations would not replace in-office visits; they would only reduce the number of in-office visits. It would be interesting to explore whether patients would exhibit better compliance with this follow-up visit system. For remote evaluation, practitioners need to deliver to patients a kit that includes alcohol-based gel for their hands, fluorescein, lissamine green, a yellow filter, and cobalt blue light (Figure 4).

IMPACT OF COSTS

The sudden loss of steady income that everyone has experienced has heightened the need to be more efficient in our practices. In our opinion, the two largest factors in this are chair time and material costs. Controlling these two aspects of specialty lens practice is essential to bottom-line profitability.

Chair Time This is a fixed cost that every practice has. Rent, salaries, insurance, utilities, and taxes are all costs that are incurred whether the amount of patients evaluated is one or 50. The meter is running whenever patients sit in your examination chair. More patients evaluated while still delivering exemplary care will lead to a more profitable practice. In this regard, empirical fitting of specialty lenses may reduce examination time and eliminate the need for multiple diagnostic lenses. The latest guidelines from governing bodies regarding disinfection protocols are regarded by some as especially onerous, but they are necessary to ensure patient safety. Eliminating this step would save valuable chair time if the end product delivered to patients is superior to the guesswork that multiple diagnostic lenses may entail.

Material Costs Obtaining a comfortable lens with excellent optics is the desire of every patient and the goal of eyecare practitioners. Fewer lenses ordered and reducing the number of patient visits to dispense multiple iterations of those lenses will not only be more profitable, it will increase patient satisfaction and confidence. Purchasing multiple lenses for a patient is not only time-consuming, it is costly as well. Even with “free exchanges,” there are shipping costs that are incurred. In addition, those so-called “free exchanges” are not really free, as manufacturers price their products with the expectation that they will be creating more than one lens for many patients. It is not unheard of that many practitioners will order 1.5-to-three lenses per patient before the prescription is finalized.

Empirical fitting utilizing the currently available technologies that include scleral profilometry and corneal and ocular tomography will increase practitioners’ likelihood of “getting it right” the first time or certainly will minimize the number of patient encounters and lens orders to do so.

CONCLUSION

Nothing will be the same after the current pandemic, including scleral lens practice. We all need to utilize best practices and to protect ourselves, our staff, and our patients. Practitioners need to wear PPE and to maintain social distancing. To reduce exposure to infections, it is fundamental to reduce the length of time that patients are in the office and the number of patients in the practice and reception area. When fitting scleral lenses, we need to guarantee safety. Today, the advancements in technologies allow us to fit scleral lenses empirically, increasing the safety of lens fitting, decreasing chair time, and reducing the amount of diagnostic lens disinfection and documentation needed. If diagnostic sets are used, proper lens cleaning, disinfection, and storage are imperative.

COVID-19 has definitely altered what we would imagine for the future in scleral lens fitting. Safety—combined with highly customized scleral lenses for each eye—has brought the future to the present day. CLS

REFERENCES

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