DO YOU STRUGGLE with troubleshooting sectoral areas of impingement in scleral lens patients who have elevated areas of conjunctival abnormalities? Do patients complain of increasingly red eyes during scleral lens wear that they didn’t have when using other contact lens modalities? A great option to consider for these patients is a focally designed vault or ripple within the scleral lens’ peripheral landing zone to truly customize the scleral lens experience to fit your patient’s specific anatomy and align properly with the sclera.
Pingueculae are the most common conjunctival abnormalities that can affect a scleral lens fitting, impacting almost 48% of patients (Viso et al, 2011). When a scleral lens lands on these conjunctival abnormalities, it can cause hyperemia and irritation, as well as visual complaints due to tear reservoir fogging from scleral misalignment and possible flexure.
Instead of increasing the overall toricity of the lens or flattening the entire quadrant of the abnormality, scleral lens fitters can design a small, customizable vaulted area located within the peripheral curves of the lens. Many manufacturers offer this technology, which allows a more reproducible and precise design compared to hand notching a lens in office.
Designing an isolated area of focal vault can be performed in a number of ways. The most accessible and low-tech approach would be to measure the abnormality with your slit lamp beam while the lens is on the patient’s eye, along with lens rotation and location of the lesion to design the lens in consultation with your desired lab.
Another great option is to use an anterior segment camera with measuring features to precisely gauge the appropriate width and location of the lesion (Figure 1).
Lastly, if an office has access to a scleral profilometer, a completely customized contact lens can be designed that has the precise depth and location required to completely vault over the abnormality (Figure 2).
Recently, a patient presented who required a scleral lens due to severe dryness and corneal ectasia secondary to refractive surgery. At the first fitting and dispense, her nasal and temporal pingueculae did not appear to warrant much concern. However, at her two-week follow-up she complained of midday fogging (Figure 3, available online) as well as redness nasally and temporally in her left eye.
Even small pinguecula can appear to be non-problematic, but after hours of scleral lens wear, they often will become inflamed and bothersome. By designing a more customized scleral lens to vault over these areas, the problems with midday fogging and redness are eliminated and the patient is able to increase wear time throughout the day.
There are several options available today to improve comfort and wear time for patients with conjunctival abnormalities. Often, these scleral lens customizations appear daunting for novice fitters, but actually they are quite straightforward. Remember, lab consultants are always there to help you along the way to provide the best lenses for your patients.
References
1. Viso E, Gude F, Rodríguez-Ares MT. Prevalence of pinguecula and pterygium in a general population in Spain. Eye (Lond). 2011 Mar;25:350-357.
