BostonSight says that practitioners can continue to tailor the lens with BostonSight Scleral’s suite of Smart features, including SmartChannel technology to vault anatomical obstacles and minimize suction and SmartSight technology to reduce higher-order aberrations.
Here, CLS shares the clinical experiences of two practitioners who are using BostonSight’s Smart360 in their practices.
Please tell us about your experience with BostonSight Smart360.
For Crystal Remington, OD, who practices in Kansas City, MO, the Smart360 and its image-guided fitting is one of the most important tools for scleral lens fitting. “Uploading, ordering, and modifying is completely seamless. The program is intuitive for all users with excellent results,” she notes. “I think it’s a great tool for the novice fitter, but also has a lot of value for those who are more experienced.”
Barry Leonard, OD, who practices in Los Angeles, believes that the Smart360 is the direction that all lenses are heading. “The whole concept of the Smart360 free-form lens is ultimately where every lens should be probably someday because every eye is unique,” he says.
Who are the best candidates for this product and why?
According to Dr. Leonard: “I started with round contact lenses and then we said, ‘Wow, we can make a toric one,’ and then we could say, ‘Wow, we can make quads,’ etc.”
Now, he says the task is to choose who could benefit from those customizations. “We’ve learned that a majority of scleras are toric, and, out of those, a huge majority are irregularly toric,” he says. “And that’s where the free-form [customization] comes in because you have more areas to manipulate and move around and really fit like a glove on a hand.
“I can look at the 3D image of the eye—of the sclera and the complete cornea—and we know which patients are irregularly shaped. Right away we use the calculators in the software and can then tell how much toricity is needed and where,” he adds. “We can determine that a conventional toric lens or a conventional quad lens is not really going to be advantageous for that.”
Dr. Leonard notes that eventually he would probably use this sort of lens on everybody regardless. “But, as it is now with the technology and the costs, you have to look at who could benefit the most.”
Tell us about the fitting process.
Dr. Remington notes that getting a good scan on the first go makes a huge difference in the quality of that first lens. ”Usually after that, it’s a small change or maybe just a refractive adjustment.”
She still applies a trial lens in office, even if it’s only to obtain an accurate refraction. “I also think this is an important step for prepping a novice patient on what to expect with scleral lenses. This builds excitement on the visual gains along with tempering hesitation for handling,” she says. “The patient can then prepare and be ready for questions at the dispense visit.”
She explains that since a lens is already in the eye, if that lens doesn’t look perfect, then she will go straight to the Smart360. “If the lens already looks perfect, I just order that! If not, then I base the order on the original lens and this gets me that much closer to the fit without trying on multiple lenses,” she says. “There is then less extensive manipulation to the design.”
Because his office is a referral center, Dr. Leonard notes that he sees a lot of patients who were previously unsuccessful and starts by trying to figure why. “You can see what they’re wearing and that it’s a pretty good lens, but now you can sort of tell why it’s not working,” he says.
Taking profilometry measurements and the patient’s history in consideration, Dr. Leonard can then recommend some lens choices. “But I would continue and say, ‘But in your case, because we see this or your history indicates that, we should just go right for the best and let’s go right for the most custom-made lens that we can get with the Smart 360.’”
Dr. Leonard notes that he can still use the other features that are available on BostonSight’s conventional scleral lenses such as front-surface eccentricity and channels.
How has the Smart360 technology helped troubleshooting with particular patients?
Dr. Remington notes that this technology is a fit saver for patients who have tricky pingueculas or postsurgical patients who have irregular shaped eyes as well as for patients whose previous scleral lenses or the fitting trial just don’t seem to center. “A Smart360 almost always centers better in these eyes. This helps with overall comfort for patients, gives more even corneal clearance and more stable vision,” she comments.
“Because the lens doesn’t rock or move, it eliminates debris troubleshooting issues,” she says. “This is a great option when refitting or changing a design for patients who may have already been wearing sclerals but need a change to improve physiological health of the eye. And because the lens centers better, the optics are much improved as well.”
Dr. Remington particularly likes using this design for patients who are retrying scleral lenses. “The Smart360 ensures a more perfect fit so there is a much higher success rate,” she says.
Overall, Dr. Leonard says that troubleshooting and determining the correct lens go hand in hand. “I have cases where I started with a conventional lens from a BostonSight fit kit or, more likely, some other manufacturer. We’ve done everything we can, and we’re still not getting what we want in terms of physiology or comfort or vision. So, we make the jump to the Smart360.”
Please tell us about a success story with Smart360.
Dr. Remington recently had success with a post-laser-assisted in situ keratomileusis (LASIK) dry eye patient. “We don’t expect these dry eye patients to be difficult to fit because, for all intents and purposes, they have normal scleral physiology. However, many times these are the most sensitive of cases and the least forgiving when it comes to comfort and vision,” she explains. “They want/need everything to be perfect. These are challenging patients in general and to make things seamless, Smart360 has a role in these situations as well.”
Dr. Leonard recalls a recent female patient who had been unsuccessful in the past. Due to previous corneal surgeries, she now had a “crazy-shaped” cornea. One eye has a graft and one eye had [radial keratotomy] surgery. “I said right away that we needed to go to this type of a lens because of the Smart360 technology and the free-form shape, and...I’m going to need these front-surface eccentricities and the channels on top of it,” he says. “We started off with the basic Smart360, and we fine-tuned that with a couple modifications.”
And then he observed what it did. “Is it going to settle more in one area than the other?” he asks. “In this case, she has a buckle that’s harder over here, and the sclera that is softer over there.”
He then determined that vision was not optimum. “And by changing the eccentricity values—which is one thing that they’re really unique about—we were able to really get her vision right. And she was just big smiles and really happy,” Dr. Leonard adds. CLS
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