Eyeworld

66 | EYEWORLD | WINTER 2026 C ORNEA Relevant disclosures Jacobs: None Louie: None Contact Jacobs: Deborah_Jacobs@meei.harvard.edu Louie: louied@ohsu.edu they get CXL to hopefully stop/reduce change, I'm happy to tell patients that scleral lenses or any therapeutic/medically necessary lenses aren't necessary. What role do specialty lenses play in manag- ing post-refractive surgery complications? Dr. Jacobs: Scleral lenses and other specialty lenses continue to play a role here. The challenge is that patients are typically not receptive to lens wear, since the reason they sought refractive surgery in the first place was to eliminate the need for spectacles or contact lenses. Generally, there has been less need for scleral lenses after LASIK now that ectasia risk is better understood and modern ablation patterns and protocols make problems with islands and decentration less likely. RK patients sometimes develop diurnal fluctuation in refractive error that worsens with time; they continue to be excellent candidates for scleral lenses for visual rehabilitation. Dr. Louie: We know that ectasia/irregu- larity is a risk for anyone who has undergone refractive surgery even many years after a great outcome. Similarly, we know that ocular surface problems are more likely in patients who have undergone refractive laser surgery. Scleral lens- es would be the main recommendation for both of those problems. How do you integrate specialty contact lens care into your practice? Dr. Jacobs: I am at an academic institution with an optometry and contact lens department separate from my cornea and refractive surgery department. I refer patients to them if I think custom soft lenses, hybrid lenses, or rigid corne- al lenses might be most appropriate. If I think a scleral lens is likely to be the best option, I make use of their scleral lens trial sets to conduct a scleral lens trial. This is time consuming and generally scheduled at the end of my clinic session so as not to slow down the care of other patients. I bill these visits according to medical billing criteria based on the documentation in my notes. If the patient and I decide that they are a candidate for a scleral lens, I refer to one of several optometrists in our contact lens department with experience and interest in specialty lens fitting. Dr. Louie: My practice was started at Casey Eye Institute with an aim to provide these spe- cialty/medically necessary contact lens services, so I don't necessarily think about integrating specialty contact lens care into anything. It's the opposite for me, I integrate "routine care" and other medical eye care/management in between the specialty contact lens cases. When should ophthalmologists refer patients for specialty contact lens fitting? Dr. Jacobs: It is my firm belief that every patient with keratoconus, other ectasia, or irreg- ular astigmatism/scarring should have scleral lens trial before the decision for keratoplasty. Dr. Louie: I think as soon as possible once basic treatment options have been attempt- ed. I don't know of any ophthalmologist who uses specialty lenses in their own practice. It is always going to be referred to an optometrist whose practice focuses on this. The challenging part of any specialty lens practice is creating a workflow and staff who are comfortable navi- gating medical insurance to optimize coverage. Most medical insurance don't cover "medically necessary" contact lenses for any diagnosis. Some vision plans do, but there is a high degree of variability—these services are time inten- sive, and materials are costly as well. Referring providers and patients need to be aware of this when any referral is made. Where do you see the role of therapeutic lenses evolving over the next 5–10 years? Dr. Jacobs: It is my hope that as the avail- ability and experience with scleral lens increas- es, more cornea specialists and optometrists will work in tandem to offer this option to patients with persistent epithelial defects and severe oc- ular surface disease. Advances in wavefront-op- timized and wavefront-guided optics will allow for even better vision correction for patients with more advanced keratoconus. Image-guided fitting and free-form lenses may streamline the fitting process and offer better fit. Dr. Louie: I hope they will be more accessi- ble from both a general eyecare and insurance perspective. There is some evolution of how lenses are fit; currently we use a diagnostic fitting process, but there are more instruments out there that could give us a more accurate assessment of scleral/conjunctival shape to help optimize the process. Similarly, the optical prop- erties of these lenses continue to improve, as higher order aberration correction is becoming more available, but this also requires specialized instrumentation. continued from page 65

• Cover