Empirical Fitting & Scleral Lens Practice Post COVID-19 Conversations with Tom Arnold
Hello again and welcome to another Contactts with Conway. Today's guest is Dr
Tom Arnold from Sugarland in Texas. Tom has practiced there since he opened his first practice in
1992 and has specialized in the fitting of scleral contact lenses for the past 10 years.
He co-chairs the International Congress of Scleral Contacts - the ICSC - which was the first meeting of its
type internationally, devoted solely for the fitting of scleral contact lenses.
I began our conversation by asking Tom
what first sparked his interest in fitting scleral contacts?
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When did you start working with scleral lenses?
Tom: Well, I was kind of pushed into it actually.
I’d been in practice 36 years, I’ve had my own private practice now for 28 and always focussed on contacts,
I enjoyed contacts and always made them a big part of my practice.
I was doing conventional lenses like we all did, I mean I was trained in the days of PMMA gas permeables.
So I was very familiar with corneal lenses
and of course soft lenses became popular. But in any case, I was going along in a 3-doctor practice
– quite busy, and like most big practices, I saw keratoconus patients
and fit them with the conventional cone-type lenses, sometimes hybrids.
I knew about scleral lenses; I became aware of scleral designs about 2005-2008.
But I was a busy practice and that seemed quite specialised and so I wasn’t keen on it.
However, I have a very close relationship with a corneal specialist
– we graduated at the same time - and he’s been my main cornea guy, and he’s sent me a lot of patients.
And what happened was, I had a pretty severe cone that I thought was time for a graft,
and so I sent him to my cornea doctor and my cornea doctor sends him back
and said “no, fit him in a scleral”.
And I knew what a scleral was and I said “I don’t have time for this” you know, and I’m not set up for it.
So, his suggestion was send him to the University of Houston, to actually, one of my professors.
So, I did, I said “that’s fine, go to UofH”.
Then this happened a second time, where I sent a patient.
So, when I had my third keratoconus,
I had a few like most people, and of course we have a lot of post-RK ectasia because RK is very popular,
there’s a lot of ophthalmologists in the Houston area, we have a very big medical community.
So, on the third one I thought,
well I’ll just have to man up and go for this. So, I took it upon myself to become educated,
I went to a seminar, a full day seminar, where there was a wet lab, and I bought a kit.
The next cone that came in, I thought “well, let me try it”. And I was very lucky,
not knowing really anything, I just kind of followed the fitting guide,
and stuck a lens on – this was a patient who had worn RGPs for keratoconus.
And I put it on and I was just lucky. Beginners luck. It fit great, centred well,
and the patient just had this wide-eyed look and said “This is amazing,
this is really comfortable”.
So, I thought, dang, I’m on to something.
I have made it a focus over the last 7 years.
I’ve pretty much focussed on scleral lenses, and I’ve been very excited to do so.
Martin: So, you’ve really followed the curve as they’ve developed in interest, particularly in the United States.
I mean the development path in the United States has been much steeper than it has elsewhere in the world.
Where do you see practice going now?
Tom: Well as you know Martin, there’s been a big interest in the last few years on scleral profilometry.
And there’s been a number of very good studies now that have taught us a lot about scleral architecture,
if you will.
We all remember our ocular anatomy and the Spiral of Tillaux
and the distance of the extraocular muscles shooting out from the limbus.
But, when you start fitting sclerals and you start struggling with centering the lenses,
it really becomes evident how toric and asymmetric and of course there’s some studies that indicate
as many as two thirds of our patients have a highly irregular sclera that we’re trying to fit.
Martin: Yeah, we spoke to Greg DeNaeyer earlier, and Pat Caroline,
who were also part of this study that’s come up.
Tom: I reference them a lot. The study that Greg, Sanders and Jason Jedlicka and some other people did
in 2017, it was landmark. And that’s where I got the two thirds figure.
Greg DeNaeyer, pioneer.
Martin: I know I was at the GSLS you were at this year,
and there was a lot of talk about the use of diagnostic sets.
Here in the UK, we went through a phase I think it was the 90s,
it seems an age ago.
Where we had mad cow disease, CJD, and we weren’t allowed to use fitting sets.
Now, that more or less killed off the GP business in the UK for many, many practitioners
who had grown up with using the fitting set.
And I’ve head now that similar moves are occurring, for different reasons,
within the United States. Perhaps you’d like to explain to the rest of us what’s occurring?
Tom: Exactly, yeah, continuing on the theme of being able to map the sclera with some new instrumentation,
the movement, and I think this has been coming – you referenced GSLS,
the American Optometric Association released some guidelines on disinfection,
there’s an article that will be published next month in Optometry and Vision Science by Melissa Barnett.
And it’s got guidelines for handling and disinfecting
multi-use diagnostic lenses in the US. And their quite onerous, quite frankly,
in terms of what we really need to do. This was in January before COVID.
And I think what COVID is going to do is, I think this is our equivalent of mad cow disease.
Patients are going to be reluctant – you know “where’s this lens been? Who was it on?”
And as we ramp up in America, I’m sure as you will in the UK,
we’re going to slowly increase the number of patient visits, we’re going to spread them out in time.
So, we’re not going to see as many people, and time is going to be even more of a premium.
So, I think where this is heading is empirical fitting.
Where, if we can take a patient,
take a scan of them, maybe take an auto-refraction and say “right, good, I’m going to order you a lens,
just for you, a virgin lens so to speak, and then you come back and you get that lens.
There are ways that you can come up with the prescription through your spectacle refraction case,
of course we do this with corneal lenses all the time.
Some manufacturers are even going the extra mile and saying
“ok, we’ll make you the first lens based on your measurements” and it’ll be a Plano lens.
Then you’ll get that lens, and we know it’ll fit, you may have some minor tweaks, maybe not.
And that is your diagnostic lens, and we’ll order it, and they’re going to do that at no charge.
Personally, I think that’s where it’s going to go.
I think we’re going to go straight to empirical fitting as the norm in a very short period of time because that way,
then we’re not fudging around with “is this quad? How much toricity? Where is the toricity?
Do I need to be quad? Do we need an oval optical zone?”
Whether you scan it on the instruments or whether you actually take an impression mould
like guys like Ken Pullam in the UK there, right down the road from you had been doing for years, and others.
You’re not worried about all of that, because that lens is going to fit because it’s going to
mirror all the lumps and bumps and irregularities that are present.
So, empirical fitting, that’s my opinion.
Martin: But that obviously can’t be done without the use of these new instruments – profilometers –
that you mentioned.
As I said, I spoke to Greg DeNaeyer last week, and he was describing one of them, the sMap, that he’s closely involved with.
Are you familiar with that one? What are you using in your practice?
Tom: I’m not using the sMap but friends of mine who are say its an excellent instrument,
and the studies that Greg and his team have published are quite impressive.
Martin: What are you using?
Tom: I use a Pentacam, I’m a fan of Oculus and Pentacam,
and their scleral mapping software is called corneal-scleral profiler (CSP).
I also have an Eaglet, from the Netherlands,
the Eaglet scleral profiler (ESP).
I use them both, they’re different, they have different attributes.
For the average practitioner, I don’t think you have to have both, I’m fortunate that I’m able to have both.
So, they’re different. It’s interesting to contrast and compare the two instruments.
But with either instrument, whichever one you use, they will point you to your first diagnostic lens,
if you still want to use a diagnostic lens, they will suggest the parameters of that.
Or as I said, many manufacturers are willing to use that software to design the first lens empirically
and send you that trial.
Martin: So, the software is linked directly to the manufacturer and so you still have a choice of lens
manufacturers to use. You’re not linked to just one particular manufacturer.
Tom: That is correct. The Eaglet and the Oculus, you can work with whoever you would like.
Martin: I think practitioners in Europe will be familiar with the name Oculus obviously
and the Eaglet Eye have been present in and around Europe for several years now.
So, I think they’ll be familiar with the technology that they’re using.
Do you think the labs find this favourable?
Do you think it cuts down their remakes, the fact that you have so much information up front?
Tom: I would hope so! We’re still at the start of this, and with COVID we haven’t had any activity.
However, I was starting to see them before COVID and yeah, I think they’re going to be quite excited.
I’ve done a couple of these empirical lenses off both instruments I mentioned:
the Oculus and the Eaglet, and they’re spot on. They are much better than diagnostic lenses.
The issue is, Christine Sind, who I know you know from Eye Print Pro,
she told me when I first started doing Eye Print Pro which is the impression mould process,
a few years ago they approached me and I said “well, I like sclerals but I don’t see that dramatic a case”.
And she says “Well, the more you do this, the more you will”. And that’s absolutely true.
So as you get more and more complicated cases, and if you’re trying to fit them diagnostically, to be quite honest,
you take your measurements and you put on a lens and it’s not right, you put on another lens, it’s not right,
and you say “well I better try another brand”. By the time you get on your third diagnostic lens,
two things happen: the patient gets very fatigued, and then you start looking like you really are struggling
– “does this person know what they’re doing?”. And so, with empirical fitting, that first lens
is going to be a heck of a lot closer than anything you’ve been struggling with in a trial set.
I think it’ll increase your efficiency, increase your success, and make your patients happier.
They’re not thrilled with putting lens after lens after lens on their eye.
Martin: Well of course that’s if you can do it in one visit. Very often,
if requires ordering lens from a laboratory, a wait, a revisit, which again, in these COVID times
we’ll be trying to minimise when we actually get back into practice.
Thank you for watching
We’ll take a break from the conversation at this point, and rejoin at a later date.
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Thank you once more, and I’ll see you next time.