Scleral lenses have revolutionized the way that we fit complex contact lens patients, particularly those who have irregular corneas. Arguably, one of the most challenging aspects of scleral lens fitting is the application process.

Patient Reassurance

Patients may get anxious over the idea of applying a large rigid lens for fear of discomfort. We can verbally reassure patients that initial comfort in sclerals is excellent. However, before launching into training, it may be helpful for practitioners to place the lenses on the patients’ eyes for them first. Allowing patients to become familiar with the feeling of saline touching their cornea and experiencing the lens comfort firsthand can improve confidence and reduce stress once their training proceeds.

Possible Challenges

Small Palpebral Apertures and Short Fornices When patients have small palpebral apertures or short fornices, it can be physically difficult to fit a larger scleral lens onto the eye. An obvious strategy to overcome this is to decrease the overall diameter of the lens. However, ensure that the lens is still fully vaulting over the cornea once the change is made. In cases of very steep or tall corneas, it may be required to maintain the requisite primary functional sagittal depth of the scleral lens (defined by where the lens first touches the ocular surface) while reducing the width of the landing zone (Figure 1).

Fixation and Manual Dexterity Difficulties One frequent cause of failed lens application or entrapped bubbles under a scleral lens is poor fixation. This can be improved using various techniques.

1. Place a mirror with a fixation target flat on the table. Patients can look down on it as a guide to properly align the lens over the cornea.
2. Instead of a traditional scleral lens plunger, try using a vented scleral plunger, which can be purchased already vented or modified by cutting the tip off of a traditional plunger. The vented plunger does not create suction, but the light visible through the hole at the bottom can aid in patient fixation. If patients are proficient at pinning their lids, this also removes the additional step of squeezing the plunger to release the suction once it is against the eye, which some patients find helpful.
3. There are several light-guided application tools and stands on the market that can be useful for patients who have difficulty maintaining fixation and/or have manual dexterity issues. These can be particularly helpful for patients who require both hands to hold their lids open, as the stand can hold the plunger in place while they guide their eye to the lens using the fixation light as a target.

Strong Blink Reflex When patients have a strong blink reflex, ensuring proper pinning of lids and desensitizing them to the feeling of saline touching their cornea is key. One common pitfall is not actually holding the lids open due to the patients’ fingers migrating to their eyebrow area or to their fingers slipping. Advise patients to dry their fingers and lids well to avoid slipping, and instruct them to position their fingers at the base of the lashes. When done properly, the lashes should be pinned underneath the fingers. Then, ask patients to try blinking. If they can easily close their eyes, they will need to practice pinning the lids more firmly. If patients are still struggling, have them practice holding their lids open while instilling refrigerated artificial tears at home so that they become more accustomed to the sensation prior to their next training session. CLS

For references, please visit www.clspectrum.com/references and click on document #316.