Are you tired of just “spinning the wheels?”

Don’t take this the wrong way, I do understand that spinning the phoropter dials is the foundation of optometric care – prescribing spectacle lenses is where it all started!1 We apply the art of refraction to improve quality of life for the public on a daily basis. This repetitive routine gave me a “blah” feeling about refractive disorders until I found my passion for specialty contact lenses.

I started offering specialty contact lens services about 3 years ago. Fitting custom contact lenses and orthokeratology lenses quickly became my favorite aspect of practice. If you want to talk about improving quality of life, then take the “Mount Everest” keratoconus patient that has failed with other forms of correction and fit them with scleral lenses! You just made a friend for life – AND you probably made a few more friends from the referrals. The skill set required to successfully fit scleral lenses can be challenging.

WAVE designed scleral lens

I use WAVE Contact Lens System® to design lenses for my patients.

WAVE is a bit different than the traditional fitting set method. With WAVE, I don’t have/use a fitting set! The lenses are designed using the patient’s corneal topography. I load a patient’s maps into the software and begin MY design process. The WAVE software uses the topography and tries to “match” the back surface of a lens to the shape of the cornea. As a WAVE Certified Designer, I can tackle just about any cornea that comes my way. I have successfully designed scleral lenses for: post-pk, pellucid, keratoconus, significantly scarred, high cyl, Sjogrens and a few other corneal disorders. I like using this method because it gives me more control over the fit instead of relying on the lab rep over the phone and a fitting set. I have complete control over the fit and can specify parameter changes to the micron. Yes, I said micron! If I want to get 1 micron more clearance or 100 microns more clearance – I can do that with WAVE.

WAVE Design Software

When designing scleral lenses the central corneal clearance is definitely taken into account. I like my central clearance to be about 270 microns. On average, scleral contact lenses tend to settle about 100 microns throughout the day2. So that leaves about 170 microns of clearance. I want to minimize any corneal edema that could be induced from the net oxygen permeability of [lacrimal lens + scleral lens]. My thoughts are the more clearance you have, the less oxygen permeability you will have. I like my limbal clearance to be about 80 microns. I have noticed that excessive limbal clearance can cause lens fogging and tear film debris. The landing zone of the scleral lens is also a very important design consideration. If the landing zone is too loose with edge lift it will be very uncomfortable for the patient and sometimes won’t even stay on the eye. If the landing zone is too tight you can get seal-off and conjunctival blanching. A tight lens also can be difficult to remove from the eye. Usually, my ideal edge angle is around 39 degrees on average via the WAVE software. I have had to adjust it to as high as 52 degrees on occasion. A properly fit scleral contact lens should be comfortable all day, easily removed, and provide excellent vision.

Now let’s move on to orthokeratology!

I am a big advocate for orthok. Orthokeratology is a great alternative to glasses, soft contact lenses, or refractive surgery. We have many choices when it comes to choosing orthok lenses for our patients. As I am a WAVE Certified Designer, NightLens™ is definitely my lens of choice. As the Hair Club for Men commercial goes, “Not only do I treat patients with NightLens™, I am a NightLens™ patient myself!” I can sleep in my NightLenses and see for about 3 days. On the third day, by the end of the day, I am about a 0.75 Diopter myope – my starting refraction is -2.25.

My Nightlens

OrthoK is also a great alternative for vision correction in the pediatric population. The youngest patient I have in NightLens™ is 8 years old – in contrast, the oldest patient I have in NightLens™ is 55 years old. Athletes can benefit by playing their sport(s) without spectacle lenses and soft contact lenses interfering with their performance. Young myopes can benefit from orthok for myopia control3. Myopia control is controversial for sure, but I am a believer as I have personally witnessed halt of myopic progression in my patients. If mom and/or dad are highly nearsighted and their child(ren) are following in their footsteps – then why not offer a way to possibly stop their eyes from progressing? To me, you are doing your patients a disservice if you don’t at least inform them of orthok as a treatment option. Now I know there are other schools of thought regarding myopia control treatment, but I chose orthokeratology for my patients. OrthoK is on the rise and I think it will soon become the treatment of choice for myopic children. Orthokeratology had its beginnings in the 1960’s and has changed a lot since then. As technology advanced, so did orthokeratology lenses. I can design my NightLenses™ to match the “fingerprint” of one’s eye utilizing topography based designs. I can adjust treatment zone diameter based on pupil size. I can fight back against the unsightly myopia epidemic! As an optometrist, I feel that we “own” refractive disorders. Heck, don’t you remember that thick, heavy book from school called Borish’s Clinical Refraction? This book is probably considered the refraction “bible” and look what professional title the author holds – you guessed it, “O.D.” So if you agree that we are the experts on refractive disorders, then why aren’t you on the myopia control bandwagon?

Specialty contact lenses have taken the “blah” out of refractive disorders in my practice. I enjoy “spinning my wheels” to help my patients see better. If you want to learn more about my personal story with NightLens, visit here.




2. Optom Vis Sci. 2014 Dec;91(12):1462-6. doi: 10.1097/OPX.0000000000000409.
A comparison of the short-term settling of three scleral lens designs.
Kauffman MJ1, Gilmartin CA, Bennett ES, Bassi CJ.

3. Robert L Davis1, S Barry Eiden, Edward S Bennett, Bruce Koffler, Lisa Wohl and Michael Lipson. (2015) Stabilizing Myopia by Accelerating Reshaping Technique (SMART)-Study Three Year Outcomes and Overview. (FULL pdf) Advances in Ophthalmology & Visual System VOL 2 Issue 3.