I probably don't need to wax poetic anymore about my love affair with scleral lenses, but click the link if you are interested in why I think they are such a great alternative for irregular cornea patients.  Since I first started fitting sclerals, there has been a major learning curve and the excellent reps at Essilor have really helped me triage difficulties.  My first few fits were a bit like walking in the dark -- no one seemed to be publishing information about sclerals!  Now you have Contact Lens Spectrum devoting almost entire issues to sclerals, and excellent resources at the Scleral Lens Education Society page.  But if anyone wants a cliff notes version of how I fit scleral lenses, here it is:

1) Flatter is Better

The concept of sclerals is that they don't interact at all with the cornea, so there should never be touch.  But a lens that is too steep causes a lot of vision, comfort, and fit problems. There is some debate about just how much vault you want centrally in your lens, but I have been ascribing to the around 250 micron rule with excellent results.  Apparently there may be some settling to the lens after a few hours or days of wear, so it is not a bad idea to check a patient back after dispensing lenses in a few days to see how they are doing (have them wear the contact lens in, and tell them to have had the lens on for at least 3-4 hours before coming).  Not sure what 250 microns looks like?  Don't worry, I don't have microscopic eyes either (or an anterior segment OCT).  The average cornea is around 540 microns, so just aim for a vault that is about half the thickness of the cornea in an optic section beam on your slit lamp.  Works like a charm!

2) Size Matters

When I first started reading about fitting sclerals the theory was that a larger lens is easier to fit.  Well that is true if you have a large cornea, but so many people out there have small/tight eyelids.  A large lens is going to be really difficult to fit in this case!  I like to measure corneal diameter (I never did this at first and it caused me a lot of headaches) with my slit lamp --just turn the beam horizontally and measure width.  If you have a small diameter cornea (anything around 10 mm) then a smaller diameter scleral is a better bet.  Maybe start between 14 to 16 mm in diameter on your lens.  In some cases, the cornea is too small and the lids are too tight to ever make a scleral fit appropriately, so if you are having no luck getting rid of bubbles in this type of fit, I have been advised to abort.  The new toric peripheral curve lenses may help in future.

3) You Do Need a Perfect Fit (or at least really close to perfect if you want optimal lens performance; this means no bubbles, no conjunctival entrapment, and no scleral blanching)

Blanching is Bad via

To me a perfect fit means a nice even tear film under the lens.  Scleral blanching is a huge no-no; check for this by letting the lens sit for 20 minutes in office.  If the lens is too tight, the sclera will be blanched white underneath and result is a ton of discomfort and suction when the person tries to remove their lens.  Small bubbles tend to not worry people much; they may be insertion related.  But I have found bubbles do matter - - even small ones cause poor comfort after a few hours of wear, and can really wreck havoc on vision, even if you think that it is just a little peripheral bubble.  Believe me, you want it gone.  A central bubble means the lens is too steep of course. A reverse geometry design is sometimes necessary to get rid of those pesky mid-peripheral bubbles. Conjunctival entrapment, where the conjunctiva folds over the limbal cornea under the lens, used to be no big deal in the literature.  Now there is evidence that this can cause neovascularization to form in the limbal tissue underneath, where the corneal tissue is being deprived of oxygen under the conj.  Flattening the lens tends to help solve this issue (read here for more details).

4) Poor Comfort?  Check the Edge
The peripheral edge is a major source of lens awareness in this lens.  We spend a lot of time with sclerals looking at the central and mid-peripheral fit, but you need the edge of the lens as flush as possible against the conjunctiva.  If the patient can feel the edge with blink, it is going to be exceedingly uncomfortable.  A great tool in knowing if you have achieved a good fit is by checking the suction when the patient removes their lens with a plunger.  Too steep centrally = a lot of suction.  Too much peripheral edge lift = a lot of suction.  Believe it or not, a properly fit lens will actually have very little suction when the patient removes it properly.  It is a really nice feed back tool for your fit if you don't have the luxury of having an anterior segment OCT.

Oh No!! Another non-wetting lens!  There goes another 2 weeks to order a new lens to check if vision is acceptable or we need another over refraction!  Via

5) Choose the Right Material
Nothing is more annoying than having that perfect fit lens, but the patient can't see out of it because the surface is non-wetting.  In my experience, Tyro 97 is your best material to prevent that non-wetting surface issue.  With that being said, Optimum Comfort is the material my Essilor rep tends to recommend for better comfort, but I have had too many wetting issues with Optimum Comfort to go that route anymore.  Especially if the patient has MGD issues.  Tyro 97 every time for me now.

If you are a regular here, you know I was very excited to speak as a panelist for Allergan this weekend at the North Carolina Optometry Fall Congress in Asheville, NC.  It was such an honor to sit beside some of the most recognized female optometry leaders in our state:  Dr. Ann Hoscheit and Dr. Sally Miller.  Both are published, private practice owners that have held numerous leadership positions both in state and national optometric organizations, and I was a bit out of my league as the "new doc perspective" on our panel.  It was an incredible experience, and I came away with a few new concepts that I thought more female and prospective ODs might benefit from:

• Create your own personal statement:  This is a common tool used in business management, but as a person, it is so important to know what you stand for too.  Just thinking about what you want to accomplish, what you want to prioritize, and what you want as your personal identity can help guide your decision making through the entire year.  Ask yourself who you want to be as a doctor, a wife, a mother, or any other responsibility you have in your life.  If you know your own identity, and what you want to be, it really helps you stay focused on what truly matters in the stresses of daily life.
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• Don't be afraid to negotiate--and learn how to speak the language of negotiation:  For me, this is a very challenging task.  As a new grad, I felt like I was just one more face in a sea of graduating optometrists looking for an opportunity to see patients.  The first time I spoke to students in optometry school, they asked me how I negotiated my contract and employment.  My helpful response?  It didn't really work like that.  For me, I was not in the position to buy in to partnership with an established OD, and I had just two job offers to choose between.  Not much negotiation.  Looking back, maybe if I had had more of a business background I would have understood that I had more room to negotiate my situation than I thought at the time.  Since my first signed contract, however, I have done a lot more negotiating than many would think.  As an OD you are constantly negotiating your hours, your number of patient exams in a given day, your exam time slots.  The helpful advice given at this Allergan panel meeting was that as women, we need to negotiate for ourselves like we are negotiating for a business.  Dr. Rachel Wruble advised to negotiate for the business of you -- less personal desire, and more how what you are requesting is an asset to the company or situation. For example, it feels natural to say, "I want a lunch break because I will get hungry if I work for that many hours without lunch."  I know I said something similar the first time I negotiated my hours.  But if you want to have a bigger impact in the business world, negotiating is less about you, and more about how you function within the business.  You need a lunch break because without a chance to refuel, you will be working less efficiently, and risking providing a lower level of care.  That turns the exact same concept less personal; creating a greater level of importance and impact for your request. 
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• The Future Is Bright:  I capitalized this because there was an overwhelming positive message to this meeting of the female minds.  We discussed the importance of public outreach in educating Americans about the importance of the eye exam, with programs like the AOA's Think About Your Eyes campaign and even the impact on a smaller level that school screenings or career days to educate young people about what we do.  Our profession is such a legislated career, and political action campaigns are the arena where optometry gains its rights for practice and to see patients on insurance plans that may try to cut us out.   We have to fight for new healthcare changes that will provide patients access to us with equal pay as our MD counterparts.  And there are so many new fights on the horizon, like the proposal for universal licensure that would make optometrists licensed nationally instead of filing for individual state licensure.  The important take away is that we need leaders in this industry with a voice, that are willing to fight for our profession.  I hope to become more and more involved in getting the word out about optometry (the driving force between the creation of this blog back in 2011!)

If you have been diagnosed with dry eye, which 48% of Americans experience according to this study, your doctor has probably tried to describe the underlying cause of your dryness.  You knew your eyes were feeling badly:  itching, watering, redness, burning, pain, dryness, or blurriness between blinks are all common symptoms of dry eye syndrome.  Now it is your doctor's job to find a way to make your eyes feel better and perform more optimally.  In order to do that, they have to know what is causing your dryness.  Current literature often breaks down dry eye syndrome as one of 2 categories:

• Aqueous Deficient Dry Eye:  Basically this means you aren't making enough tear film.  In many cases this is associated with conditions like Sjogrens Syndrome where inflammatory mediators are reducing both tear and saliva production
• Evaporative Dry Eye:  Basically the tears that you make just dry right up off the ocular surface.  This type of dry eye means you are producing tear film, but the tear film is missing the proper components to stay long enough on the eye. 

Inspissated Meibomian Gland

Posterior Blepharitis

Chronic Infammation -- classic for Ocular Rosacea

Long-standing Dry Eye

In just 10 days I have the pleasure of speaking as a panelist for Allergan's VIEW (Visionary Insights for Eye Care Women) luncheon at my state's optometric society meeting.  It was such a great honor to be chosen as a speaker, representing the changing face of the new generation of optometrists--a profession dominated by females. More students than ever are graduating with their doctorate in optometry (when I first enrolled there were 16 schools in the USA, now there are 21 with more scheduled to open in the coming years).  And more students than ever are females (there is a reported 60-65% female enrollment in optometry schools across there country).

Why are so many women pursuing optometry, especially when faced with the negativity of many optometrists in today's healthcare marketplace?  There are many reasons that would appeal to stereotypic gender norms:

•  optometry is a flexible career, with part-time work available for family-minded doctors
•  shorter lenght of time in school (a 4 year program instead of 4 plus 4 or more years of residency in an MD program)
•  no surgeries, so no blood / lower stress, no life or death discussions

But we all know that for many women, these perceived "female-friendly" points may not have had any influence on their career decision at all.  My personal opinion is that optometry is appealing as a career in general, not just to women.  More than ever, women are driven to pursue higher education, and as such they are finding careers in medicine, law, and other professional degrees.  But where optometry really separates itself from other professions is the ability to focus on one topic, and become an expert at that.  Optometry is a career that appeals to the detail-oriented (maybe there are more of females with this talent/curse than males??).  You spend the entire day looking at one body part, talking about one body part, measuring and calculating minuscule changes in that body parts length and curvature.  You talk about eyes all day long.   To me, as a woman, I love having that focus, the ability to pour my entire body of knowledge and study into the smallest of details about the human eye.  Thinking of being an expert on the entire body sounds just ludicrous to me -- I don't know how primary care doctors can manage so much at once.  As an optometrist, I am the doctor you see for all eye-related questions and concerns-- the eye specialist.  You can't get much more rewarding than that for someone that loves details.

With that being said, I am not immune to the pinch of negativity in my industry. I feel my eyes are more open than ever to the uncertainties of healthcare in today's world.  I have seen the profession of optometry struggle under the weight of reduced insurance reimbursements and general perception of the value of an eye exam.  Eye exams reimburse very little through most vision insurances (between $40-50 for a comprehensive exam on average).  In the past, doctors have offset those terrible margins by relying on product sales, but glasses and contact lens marketplaces have expanded (like all products) into the realm of the internet, and doctors are feeling the heat to see more and more patients every day.  In many cases this means compromised ability to focus on the details that made our profession so unique and rewarding -- the time to discuss all of the health benefits of the exam, to investigate dry eye, ocular allergies, and UV exposure changes that affect the eye and vision.  The eye is the only part of the body to assess the blood vessels with a live view, and most of my patients are surprised to learn that I am screening them for hypertension, cholesterol issues, and diabetes during their eye exam.

So why do so few people in the general population not know that your eye exam is an important health screening?  Most people are under the misconception that if you can see, your eyes are healthy.  If you read this website routinely, you know how many times I have debunked this myth.  In most cases, if your vision is affected by an ocular disease, it is too late to improve vision, even with glasses or contact lenses.  

My charge to all optometrists, new and old, female and male, is to embrace this profession for the specialist career that it is.  We need to educate at every chance we get what we are seeing when we look at our patient's eyes.  We need to take medical responsibility for the eye -- we are the primary EYE care provider after all.  We are who you need to see for a red eye, dry eye, burning eye, blurry eye, watery eye.  You name it; we are eyes.  Embrace the medical training we have and promote it!  This is the way to bring optometry into 2014, and the new wave of female optometrists are going to be the industry leaders to usher this change in patient perception.

If you are a female optometrist or optometry student, please comment and let me know what struggles you have faced or concerns that you have about our career and our role as female doctors in shaping its future.  I want to hear from you, so that I can bring these topics to my VIEW panel discussion, and the greater audience of online readers and industry leaders!

I may have been the only person on Friday to open my work email and do a little dance of excitement when I saw the good news -- Biofinity XR is launching on November 4th!  To most of us, wearing contact lenses seems like a normal part of our day.  We don't ever worry about what would happen if there were no contact lenses being made in our prescription.  But for some people, having a soft, disposable contact lens that is available in their power at their doctor's office is a luxury they have never experienced.  With Cooper's new launch, we will finally have a contact lens that offers the thin material and high oxygen benefits that lower prescription wearers have been enjoying for a decade!

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