What Are Scleral Contact Lenses?

In the beginning…of contact lenses…there were scleral lenses…only.

In the year 1887 a great gift was given to the world of sufferers of distorted vision resulting from corneal tissue that was irregular in shape from disease or trauma.

The contact lens was invented nearly simultaneously by physicians working separately in Germany and in France. Working from drawings of Leonardo da Vinci (1508) and ideas of the British astronomer Sir John Herschel (1828), August Müller and separately Adolph Fick and Eugene Kalt blew glass shells to fit the outer eye and to some extent remedy their visual difficulties. These lenses rested on the conjunctiva of the eye above the sclera or white of the eye and were thus the first scleral contact lenses — the first contact lenses of any sort.

What are Scleral Contact Lenses?

The design and manufacture of scleral lenses has been a story of technological development significant for improvement in comfort, material, and affinity for the ocular surface.

For many years the lenses were partially molded and partially ground from the material of which hard contact lenses are made: PMMA (poly-methyl methacrylate) known as Plexiglas or Perspex. To form these lenses, like tooth implants, a plaster cast is made from a negative mold prepared from dental impression putty. The plastic would be heated and given the shape of the fitting surface of the lens from the plaster cast and then the power and edge curves would be ground onto the outside surface of the lens. Later came preformed trial sets not unfamiliar to those which we use today.

The current generation of scleral lens fitting began sometime in the last fifteen years with the mating of advanced corneal topography measurements, computer driven lathes and the observations of some very clever contact lens scientists. Proprietary designs of scleral lenses offering a variety of diameters, fitting philosophies, and multiple parameters are filling the gaps contact lens specialists have been wrestling with using smaller corneal contact lens designs for decades with less than optimal results. Most recently a firm has begun manufacturing lenses with a 3-D printer from an image generated from the eye. One eye…one lens, the lens is meant to fit like a fingerprint.

When discussing contact lens treatment, experts are experts because they agree that, any sort, size, or design of lens will have both positive and negative effects on the eyes and the tissues surrounding them. While it is true that many of the fitting and comfort issues confronted with corneal lenses of any size and design can be managed well with scleral designs, the scleral lens can also be difficult for some patients; for some eyes; for some conditions.

From the outset the larger size of the today’s scleral lens provides comfort on par with soft contact lenses for exactly the same reason: their size. Also, like soft contact lenses the scleral will not move around on the surface of the eye allowing the wearer a much more relaxed contact lens experience — there is no necessity to balance small corneal lenses between tense eyelids – vision can be enjoyed in any direction of gaze. The lenses will not fall off the eye and the increased size is a clear plus in finding a dropped contact lens.

On the other hand the quality of vision gained with scleral lenses specifically in cases of distorted corneae is far more comparable to that achievable with corneal GP lenses than with soft contact lenses in most cases.

Over the years my keratoconus patients have benefited from a series of contact lens breakthroughs that have variously improved the quality of their vision, their comfort with contact lenses, or in some other way the health of their eyes. Some years ago I “re-invented” the piggy-back system of contact lens wear which I summarized in 2008 in an article published in the Contact Lens Spectrum. Piggy-backers would place their vision restoring firm contact lens on top of a disposable daily wear lens of minimal focusing power. The soft lens would reduce the sensation of the firm lens while in many cases preventing the contact lens from abrading the cornea. More recently I have been successfully moving patients to scleral lenses because there is certainly less bother (only one lens per eye) and far less worry over corneal abrasions as the lens rests on the conjunctiva over the sclera and maintains a fluid cushion over the cornea itself.

Scleral lenses are finding their place in the world of contact lens fitting primarily to remedy vision problems from very irregular or otherwise damaged corneae both those caused by developing disease and trauma through injury or surgery. More and more, these lenses are requested by patients with normal eyes who want to enjoy the benefits provided by these lenses while participating in sports or other activities.

Scleral lenses are renowned for their greater comfort. In many cases a correctly fitted lens can be worn for many waking hours. Many patients have found that they benefit from exchanging the fluid from the reservoir from time to time throughout the day. The fluid that fills the lens-cornea space is sterile, non-preserved normal saline or in some cases saline with a non-preserved tear substitute added when needed for improved comfort.

A proper care regimen for scleral lenses is not different from that for any other contact lens manufactured from a firm oxygen permeable material. The lenses require cleaning upon removal, soaking in a recommended solution appropriate to the material of the lens and a periodic treatment to remove protein deposits. Of course, the exact care specifications will vary from patient to patient according to the evaluation of their contact lens specialist.

Just like any lens modality, the fitting requires expertise. Many who fit and dispense contact lenses rely on boxed soft lenses for their patients. When corneae become distorted those lenses will hardly fill the need. Greater expertise is required to fit rigid corneal lenses needed for these more problematic surfaces. The decision of the corneal lens expert to move on to the world of larger lenses is not of the same magnitude as that from boxes to corneal GP lenses. The investment is more a matter of time spent in discussion with the manufacturer’s fitting consultants, some reading, a webinar or two and keeping up to date with the lens designs that are available.

I was not among the first to use the current generation of scleral lenses, but when the opportunity knocked some years ago, I realized the importance of this form of contact lens and I believe I have positively influenced the quality of life of many of my patients.

5/28/15

Bezalel Schendowich, OD
Medical Advisory Board of the National Keratoconus Foundation
Fellow of the International Association of Contact Lens Educators
Clinical Supervisor & Specialty Contact Lens Fitter, Sha’are Zedek Medical Center, Jerusalem, Israel

Coping With Retinitis Pigmentosa

Tribulations, Travels and Tennis Balls

Linda Becker stopped playing tennis at night because she couldn’t see the balls coming at her. “Coincidentally, I saw something about night blindness on TV, so I went to my optometrist,” Becker says. He confirmed she had night blindness and sent her for more testing. An ophthalmologist told her: “I’m sorry, but you have retinis pigmentosa, and you’ll be blind some day.”

“As a young mother, I couldn’t wrap my head around that,” Becker says. So she entered a decade of denial until she started to sideswipe other cars while driving. “I drove into my development one day, and there was a thump over the hood of my car. I thought, ‘Oh my god, what did I do? Did I kill somebody?’ I pulled over, and a police officer who happened to be driving behind me came over to my window. I was devastated. I said, ‘What have I done?’ He told me a jogger who wasn’t paying attention had tripped over the hood of my car. But I knew if I could have seen better, I would have stopped. That was the day I put my car keys down.”

Coping with Retinitis Pigmentosa

Encouraged by her kids to get a guide dog, Becker called Guide Dogs for the Blind (GDB). She learned she needed orientation and mobility (O&M) skills, including knowing how to walk with a white cane, before she could be considered for a dog.

“I called the Braille Institute, and it was daunting, to say the least: Thinking about walking with a white cane, having people know I’m blind and feeling disabled. Going through that whole transition — I didn’t want to even face it,” she recalls. “But I went, and I took classes, until I knew it was time for me to have a guide dog. I’ve always been a dog person, and I’d rather use my dog as a mobility tool than a cane. Plus, I wanted the companionship.”

She successfully completed the GDB requirement of walking one mile to and from her home with the cane. She then completed two weeks of on-site training at GDB’s campus in Oregon, where she was paired with Lyla, a yellow English Lab.

Becker started teaching classes at the Braille Institute and helping others navigate their vision-loss transition. She teaches a 14-week sensory-awareness class. “It helps develop and educate your other senses when you start losing your sight,” she says. “It humbles me. I have no sight now. My transition of going to the Braille Institute, learning to use a white cane, then learning to have a guide dog, taught me a whole lot about myself and feeling very independent. I was able to speak about guide dogs and speak about blindness — and be a teacher.”

She became an outreach ambassador for the Braille Institute, facilitating low-vision support groups throughout Orange County, Calif. She also went to work for GDB as an alumni-outreach representative, putting together workshops and helping people learn about the “guide-dog lifestyle.”

Now 66 years old, Becker finds the most enjoyment in traveling. “Being with a guide dog and in the blindness community took me places,” she says. “I was asked to be a keynote speaker here or an ambassador there. I’d never done that type of thing before, and I’d never traveled much. I just kept hopping on airplanes with my guide dog and going to hotels and trying to figure things out. I ask questions and collect tips, so I can share with others how easy it can be to travel with or without usable sight. It is really exciting, and I’m really driven to go different places.”

Since Lyla’s retirement, Becker travels regularly with her guide dog, Anchorage, a yellow lab. “He gives me courage,” she says. The pair is currently planning a trip to Australia and New Zealand. Becker is no longer daunted by learning new skills, exploring new places or even flying tennis balls — Anchorage is quite happy to deal with those when he is off-duty.

For more on traveling with guide dogs, including Becker’s adventures with Lyla and Anchorage, read “Traveling Tails”.

5/26/15

Lauren Hauptman
Lauren Hauptman INK

Living Well With Low Vision Online Courses

As of May 5th, 10 new audio lessons offering tips and techniques for living well with low vision are now available as part of the newly-launched Low Vision Focus @ Hadley (LVF). These low vision online courses offer practical knowledge to make life easier.

Low vision is defined by having significant difficulty seeing even after one’s vision is corrected with eyeglasses, contact lenses, surgery or medicine. Some typical symptoms of low vision include dimness, haziness, and having difficulty recognizing faces, reading labels and safely moving around. Low vision can make everyday tasks like reading the mail, shopping, cooking and paying the bills difficult. According to 2010 research by the National Eye Institute, the number of Americans with low vision will continue to grow dramatically, from 2.9 million in 2010, to 5 million in 2030, to 8.9 million in 2050, as our population ages. One out of every six older adults will experience age-related vision loss due to conditions such as macular degeneration, glaucoma or diabetes.

As the largest provider of distance education for people who are blind and visually impaired worldwide, The Hadley School for the Blind (www.hadley.edu) is building on its history and expertise with this new program. The LVF is designed to help those living with low vision maintain their independence by sharing practical ways to address daily living skills made difficult by vision loss. Most low vision assistance focuses on a device that is meant to correct the vision problem. The LVF, however, offers ways for older adults to educate themselves on their condition as well as learn adaptive techniques to continue the tasks of daily living. The LVF is unique in that it offers those living with low vision the opportunity to learn and take advantage of our resources from the comfort of their own homes, at a time that is convenient for them, with the benefit of one-on-one counseling and support, at no cost to them.

A newly-revised series of 10 audio lessons is the core component of the LVF. Each lesson is approximately 30 minutes long and is available on a CD that is mailed to the client. The CDs are free for the client to keep. When a new client comes to the LVF, he or she speaks with an intake coordinator to determine which lesson(s) best meet their needs based on their challenges with low vision. Clients will be limited in their requests to two lessons initially. Additional titles may be requested once the client has had the opportunity to listen to these initial lessons and determine future need. The audio lessons include:

Making the Kitchen User Friendly	Getting Around in the House
Basic Tactile Marking	Going Out with a Friend
Doing Simple Kitchen Tasks	Keeping Prescriptions in Order
Low Vision Cooking	Looking Your Best
Going Out for a Meal	Simple Home Modifications

While the LVF is geared primarily toward seniors, adult children of seniors living with low vision are encouraged to take advantage of the resources offered by the LVF to aid their parents in the adjustment process. Additionally, while many of the people who are living with low vision are seniors, the program is open to any individual who is experiencing sight loss. Clients and professionals also are encouraged to utilize the programming of the LVF in either the development of new low vision support groups in local communities or to sustain existing support group networks.

In the future, Hadley will provide free, educational videos and webinars as part of the Low Vision Focus and the program will soon reference popular Hadley courses that may be of interest to individuals with low vision.

“We are so excited to offer the Low Vision Focus @ Hadley and enable this growing population to retain their independence and live with confidence,” says the dean of Educational Programs and Instruction and interim Director of the Low Vision Focus @ Hadley Doug Anzlovar.
For more information or to begin taking advantage of the LVF, please visit www.lowvisionfocus.org or call toll-free at 1-855-830-5355.

5/21/15

Kate Streit
Media and Marketing Specialist
The Hadley School for the Blind

Must Love Dogs

Traveling with Guide Dogs

Adam Lawrence was diagnosed with retinitis pigmentosa (RP) when he was 17, but the disease did not have a profound effect on his life until his early 40s. “I sometimes had trouble with bright sunlight during the day, but I dealt with it by wearing dark sunglasses. Then one morning, I woke up, and it was like I was staring through a haze of pepper,” he says.

Lawrence gave up his job in the banking industry, as he could no longer see the contracts he needed to review. “I had to stop working and driving, and I had to figure out how to adapt,” he recalls. “I was great at organization, so my job became running the house, while my wife went to work. I got a scanner and a JAWS (Job Access With Speech) screen-reader for my computer, and I learned to read Braille.”

Lawrence is now legally blind, and his RP had another profound affect on his life about seven years ago, when he and his wife encountered Guide Dogs of America (GDA) at a fundraising event.

“I didn’t plan to get a guide dog, but they had a chocolate Lab puppy on the table” he says with a smile. “They put my hand on the puppy, and there was no turning back.”

Lawrence went through an interview and then an intensive 28-day on-site orientation program at GDA’s school in Sylmar, Calif. He was paired with a black and tan Labrador named Escort — also known as “the greatest dog in the world.”

With Escort, Lawrence feels a sureness and freedom he never experienced with other mobility tools. “When I walk with a cane, I don’t feel as confident, and I’m much slower. He gives me confidence, mobility and ability.”

Now in their sixth year as a team, Lawrence and Escort are virtually inseparable. They even shop together: “A person in the market takes our list, then Escort and I follow them around the store.”

They also travel extensively and have been everywhere from Mexico to New England to Colorado, where they went rock-climbing. “On the way down, Escort chose the more difficult path for himself, and left the easier path for me. He’s amazing,” Lawrence says.

Lawrence is quick to point out that “Escort is not a GPS. I have to plan and know where we are going. He’s there to keep me safe; he’s not there to figure out where to go — that’s my job.”

For more on traveling with guide dogs, including Lawrence’s adventures with Escort, read “Traveling Tails”, an article from our most recent e-newsletter.

5/19/15

Lauren Hauptman
Lauren Hauptman INK

Traveling With Low Or No Vision

What Good is Sitting Alone in Your Room?

Traveling with low or no vision

There is a whole world out there to discover — regardless of whether you can see it all with your eyes. No one will tell you traveling with low or no vision does not present challenges, but there are precious few that cannot be overcome with planning, creativity and patience.

A plethora of for-profit and nonprofit companies exist to help you navigate the complexities of traveling with a vision disability — from technology and websites, to travel agents and tour operators. And don’t overlook helpful — and free! — resources such as your friends and family, assistance pets and even complete strangers.

Travel Tools
Everyday tools become even more essential when you are traveling in unfamiliar surroundings. A mobility cane (consider a small travel version) will let you find your way more easily — and notify others of your vision issues. This is especially helpful for two reasons: Strangers are less likely to get in your way and more likely to help if you ask for it. In a recent DEF blog post (“Visual Aids and Techniques When Traveling”

Linda Becker, who has retinitis pigmentosa (RP) and travels primarily with her guide dog, is planning her next trip to Australia and New Zealand with Mind’s Eye Travel, a company that specializes in creating tours especially for people who are blind or visually impaired, as well as providing sighted guides. There are many such companies that will assist you with all facets of travel, from immigration documents to reservations to tour guides. Traveleyes offers discounts to sighted travelers in exchange for helping guide non-sighted travelers during group vacations around the world. DisabledTravelers.com is a good resource for companies that specialize in travel for people with accessibility issues. It includes reviews and recommendations on everything from airlines and cruises, to travel agents and hotels.

Plan, Prep, Pack
Ask any experienced low-vision traveler, and they will tell you planning, planning and more planning is the key to successful travel. Not only will it make your trip go more smoothly, it will give you peace of mind, as well as the ability to relax and enjoy yourself. The fewer surprises, the more confident and comfortable you will feel. And if something does goes awry, it is easier “go with the flow,” because everything else has been planned.

Right at the top of the list with planning is, well, making a list. Prepare a list of all the items you will need, then double it. That means if you wear contact lenses, pack at least one extra pair, as well as cleaning solutions. Same goes for glasses and sunglasses. Make sure you have plenty of the medications and other supplies you use on a day-to-day basis. Most seasoned travelers suggest you have multiples of all these stashed in different bags: your carry-on, your suitcase and a handbag of some kind that never leaves your side. This way, if one bag gets lost, you still have another one or two. Sample sizes may become your best friend!

Carolyn Hammett, an accomplished photographer and world traveler who has keratoconus (KC), advises: “Be prepared; having backups makes you more comfortable. Be ready to change contact lenses in public restroom if you need to. Have one of everything you need, vision-wise, with you at all times.” To learn more about Hammett and see what she packs for a two-week trip, see “Through a Lens with One Eye Blind,” a story from our recent e-newsletter focused on travel experiences and tips.

“Leave extra time, notify airlines or others in advance that you may need assistance, and don’t be afraid to ask for help,” says Adam Lawrence, who also has RP and travels regularly with his guide dog. (Read more about traveling with guide dogs in “Traveling Tails”, from an article in our recent e-newsletter.

Speaking of help, don’t forget the helper sitting next to you right now, whether it’s a spouse, a friend or a guide dog. Traveling alone can be vexing for people with full vision, so it’s natural for those with low vision to feel even more anxiety.

Dame Judi Dench, who has age-related macular degeneration (AMD), recently told Radio Times she no longer travels alone. “I need someone to say, ‘Look out, there’s a step here!’ or else I fall all over the place like a mad, drunk lady,” she said.

“Don’t travel by yourself the first time — go with someone you trust, and let them know how much help you want,” Hammett says. “I’ve gotten to the point where I tell my husband, ‘Don’t tell me anything until I screw up.’”

With planning, preparation and practice, you may get to a point where you feel comfortable traveling alone. You will only know your limitations if you try to stretch them.

“Just try,” Hammett says. “Do it once to find out if you can.”

Additional Resources

Access-Able Travel Source’s “Travel Tips for People Who are Blind or Visually Impaired”

Society for Accessible Travel & Hospitality

Transportation Security Administration’s “Passengers Who Are Blind or Have Low Vision”

5/14/15

Lauren Hauptman
Lauren Hauptman INK

Eyeglasses Timeline

Eyeglasses are something we all take for granted, but they haven’t always existed. More than 700 year ago you had to learn to live with poor vision. Now more than 6 in 10 people in the US wear either glasses or contact lenses, with 60% of them being far-sighted. Here is an eyeglasses timeline to see how eyeglasses have evolved.

5/12/15

Susan DeRemer, CFRE
Vice President of Development
Discovery Eye Foundation

Itchy Eyes? It Must Be Allergy Season

Spring is in the air, which also means it’s the season for allergies (i.e. Itchy, watery, red and generally unhappy eyes). People with keratoconus need to be particularly careful around allergy season, because rubbing your eyes can exacerbate both your allergies and keratoconus. Among the general keratoconus population, we see a significant incidence of allergic eye disease, which causes itchy eyes. In addition to this, there is a high correlation of keratoconus patients who rub their eyes. If you are one of these, STOP. When you rub your itchy eyes, it damages the mast cells within the eye tissue, causing histamine to release from these cells. More histamine around your eyes will increase itching and your urge to rub, which in turn can cause keratoconus to get worse. So even if rubbing makes your itchy eyes feel good, stop: the potential long term damage outweighs the short-term relief.

Whether your eyes are watery, itchy, or red around this time, you’ll find the best relief beyond your neighborhood drug store’s allergy aisle. While there are over-the-counter medications that help allergies, they may not be the best option for you. Oral medications for allergies tend to dry out the body in general (which is why they make a runny nose stop running), which includes the eyes. When it comes to eye drop options for allergy relief, the results are often unpredictable and short-lived.

Some surprisingly simple changes to your home can help. Keeping the windows and doors closed to keep the allergens out is helpful. Take your shoes off before coming into the house, consider taking a shower before bedtime, or frequently wash your pillowcases, which may remove enough of the allergen to improve your symptoms. If you have a pet that goes outside, consider bathing them twice a week to remove allergens they track in. For direct, immediate relief, place a cold wash cloth on the surface of your eyes to calm the symptoms.

The next step to relief includes personalized recommendations from your eye care provider (ECP). A common medication your ECP may prescribe is an antihistamine-mast cell stabilizer, such as Pataday or Lastacaft. These combination drugs use an antihistamine for immediate comfort and a mast cell stabilizer to carry out the benefits long term. Often these medications are so effective that they may be the only ones you need. When your allergies are severe and this combination drug is not enough, your ECP may add a topical steroid ointment to complete your treatment.

Be extremely diligent in rubbing and rinsing your lenses with fresh solution prior to storing them overnight. This will help to remove the allergens that have accumulated on them during the day.

Even if your annual eye exam doesn’t happen around allergy season, remember to visit your eye care provider if you have allergy symptoms. It may require a combination of prescription medications and environmental changes tailored to your specific symptoms to prepare your eyes now and for allergy seasons to come.

5/7/15

David L. Kading OD, FAAO
Specialty Eyecare Group
Offices in Kirkland, WA and Seatte, WA

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Charissa Young
Optometric Extern
Eye Care Group of Southern Oregon, PC

May Is Healthy Vision Month

It’s Healthy Vision Month! Make Your Vision Last a Lifetime.

When it comes to our health, we often visit our doctor or nurse regularly to make sure our bodies are healthy. But what about our eyes? They’re not always top of mind, but they’re just as important.

During Healthy Vision Month, held each May, the National Eye Institute (NEI) reminds you to make your eye health a priority and encourages you to take important steps to protect your sight.

Get a dilated eye exam. Getting a dilated eye exam is the only way to detect eye diseases early, because with many, there are no warning signs. Talk to your eye care professional about how often you should have one. If you want to see what your eye care professional sees during a dilated eye exam, check out NEI’s new eye exam animation!

Live a healthy lifestyle. Eating healthy foods, maintaining a healthy weight, managing chronic conditions, and not smoking can lower your risk of eye disease.

Know your family history. Talk to your family members about their eye health history. It’s important to know if anyone has been diagnosed with an eye disease, since many are hereditary. This will help to determine if you are at higher risk for developing an eye disease yourself.

Use protective eyewear. Protect your eyes when doing chores around the house, playing sports, or on the job to prevent eye injuries from happening. This includes wearing safety glasses, goggles, safety shields, and eye guards that are made of polycarbonate.

Wear sunglasses. When purchasing sunglasses, look for ones that block out 99 to 100% of both UVA and UVB radiation, so you can keep your eyes healthy. Prolonged exposure to sunlight can increase your risk for getting an eye disease. A wide-brimmed hat offers great protection, too!

These steps can help you keep your eyes healthy and prevent vision loss and blindness from eye disease.

To learn more about Healthy Vision Month and find additional eye health information, visit www.nei.nih.gov/hvm.

5/5/15

National Eye Institute
National Institute of Health

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Month: May 2015