Tuesday Tips for ECPs is a blog for optometrists fitting scleral lenses - but written from the patient's perspective. Today's post relates to the training and instructions new scleral lens users need for success and safety in lens adaptation.
Mistake #1. Failure to use appropriate application and removal techniques
Application and removal is not always a slam dunk. In a survey of 358 patients we ran in November 2018 about scleral lens application, half of the patients reported mastering the application technique in two weeks or fewer, but 39% required 4 weeks or more and 18% required 8 weeks or more or were still struggling after more than 8 weeks. Online complaints by patients about inadequate training are common. Patients are showing up in droves on Facebook for coaching from peers, some with stories of spending up to 2 hours at a time, with pictures and descriptions indicative of unsafe practices. While peer suggestions are unquestionably helpful, patient safety requires physician oversight of the training process.
- Dedicate sufficient clinic time and trained staff for training needs, recognizing that some patients will require much more assistance than others.
- Offer a variety of application and removal tools and techniques (ring, stand, light, etc as well as conventional scleral cups; manual and plunger removal)
- Provide a video of the specific technique + tool that you have recommended for the patient.
- Do not dispense lenses until the patient has mastered safe application and removal techniques.
- Review application and removal technique at follow-up appointments.
Mistake #2: Failure to fill the lens with the appropriate solution
New patients who are given product samples in a starter kit will often switch to a different product (a) if they one they were given is unavailable due to an industry shortage (a frequent problem in the past 4 years) or (b) if they do not know where to purchase the one they were given. Pharmacists are unfamiliar with the preservative-free salines (which aren't sold in drugstores) and equally unfamiliar with requirements specific to scleral lenses and thus are unable to recommend appropriate substitutes. As a result, patients may end up purchasing a preserved product such as Sensitive Eyes, BioTrue etc. and using them for long periods.
- Provide clear written instructions.
- Provide the names of at least two acceptable preservative-free options (perhaps "Preferred" and "OK in an emergency").
- Inform patients that these products are not sold in drugstores. If possible, suggest a reliable source to purchase from.
- Verify all solutions during every follow-up appointment.
Mistake #3: Failure to properly clean and disinfect lenses
Some patients get confused about what each of their various solutions is for and which steps to follow when. Labels and instructions on off-label products are confusing and inappropriate for scleral lens use. Many patients do not know the difference between cleaning and disinfection and may be failing to do one or the other. Some patients end up storing lenses unsafely in preservative-free saline, thinking that "saline" is the same as a multi-purpose solution, while others may think that a multi-purpose solution can be used in the bowl of their lenses.
- Provide detailed verbal and written instructions for all cleaning and disinfection steps.
- Ensure that cleaning and disinfection protocols are reviewed at each follow-up appointment.
- Always provide a back-up product name in case patients cannot obtain your preferred product.
Mistake #4: Failure to keep plungers and cases clean
Many patients never or rarely clean their plungers and case, or never air-dry them. Plungers come in airtight containers, leading to bacterial buildup or mold if replaced in the container while still wet.
- Provide written instructions for cleaning all equipment.
- Reinforce verbally.
Mistake #5: Failure to report experiences that have implications for lens safety and success
New scleral lens patients do not know what they do not know, and as a result, they may not be reporting issues that need further investigation or indicate further instruction is required. They may spend two hours trying to put a lens in and get abrasions in the process, or may be exerting too much force on a tightly sealed lens while attempting removal. They may be experiencing adverse effects upon lens removal that are never detected or talked about as they only happen at night. They may experience significant discomfort, redness, etc. from a solution they are using, or persistent fogging or mucous issues that may lead to discontinuing use of the lenses.
Provide patients with a "threshold" of what is acceptable during and after wear. "If-then" scenarios are particularly helpful, with examples of experiences that should prompt a phone call or an early follow-up appointment.