Dr. Moshe Schwartz O.D., F.A.A.O. is a Diplomate of Cornea & Contact Lenses who specializes in fitting various contact lenses, including scleral lenses, for treating irregular corneas and patients with keratoconus.
Do you find that scleral lenses have changed the eyecare industry?
I think that the reintroduction of scleral lenses into the eyecare field definitely has revolutionized our approach to ocular surface disease or disorder and corneal irregularities or anomalies and definitely post surgical corneas. Years ago, we realized that when we fit the corneal lenses especially with keratoconus patients, we need to be mindful of the clearance, the position of the lens, and the vaulting of the lens over the cone to avoid scarring and permanent vision loss. Through a scleral lens that is a large lens allows constant vault without fluctuation with a blink, which helps to improve the quality of vision and and of course it helps with acuity, which we quantify the vision. Scleral lenses help with the stability of the vision, since there’s no fluctuation between blinks.
So, even though the eye changes shape because of keratoconus, how do scleral lenses work?
The lens itself does not stop progression. What the lens does is that it vaults over the compromised area, the cornea, and the lens allows the patient to achieve good, comfortable, functional vision for 10, 12, or 16 hours a day. That changed everything for keratoconus patients and even gas permeable patients because – especially patients that have started to age or have had an issue with dry eyes – all of a sudden have no issues with their vision. They can wear the lenses successfully while maintaining good comfort for many hours.
Remember, the lens itself does not hinder progression by all means because there’s no touch or contact between the lens itself and the cornea, which is what we want. We don’t want the lens to have any contact with the cornea because, in particular, post refractive corneas or keratoconus corneas these are all compromised corneas, diseased corneas, so we want to make sure that there’s no contact and a sufficient amount of vault over it to protect that compromised area.
So, it’s like a protective shell that will never touch the eye so that the eye may change or make fluctuations, and you’ll still keep your vision steady.
What are the typical ages of your patients that wear scleral lenses in Maryland?
We can have a child of five year old and up to 85 year old. Age is not a for contact lenses – period. Because if we really think about it, nothing in the human eye as far as the physiology and anatomy are concerned really change to not allow the eye to have a good contact lens.
The rule of thumb is there isn’t an eye that can’t be fitted, but not every doctor can fit every eye.
How many how many fits do you think you’ve seen? Is keratoconus common?
Well, we’ve been doing scleral lenses for over 10 years. I’ve seen how the whole evolution in recent scleral lens technology. A kind of rebirth occurred from going to large lenses then back to small and now back to large to small diameter.
So, it’s becoming widespread?
Optometrists are trying to make it more common, but I think that the market is saturated to an extent. I think around 9% of the practitioners use GPs, and out of them, they, the scleral lens developers, try to convert most of that 9% of practitioners to start using scleral lenses. Still, you’re not going to have a guy who doesn’t fit gas permeable lenses do scleral lenses.
So, scleral lens use grew to some extent because nobody was really fitting them eight to ten years ago, yet now more people (who specialize in sclerals) are fitting them. Just not a lot of people do it to the scale that it should be done.
How do scleral lenses relate to corneal collagen cross-linking?
They complement each other. One does not come to replace the other. Cross-linking, basically, has the sole purpose to enhance the bond, the connection between the collagen to make it stiffer so that the cone will not continue to progress, but it’s not going to reverse it. Therefore, patients will still need to have a correction. Normally, cross-linking is aimed for patients who still have a progression in the cornea from keratoconus changes. So, in short, cross-linking can make the cone stiffer and harder, so that their keratoconus will not continue to progress,
So if somebody had a situation where they needed to get cross-linking performed, even though you would send them to an ophthalmologist, the ophthalmologist would send them right back to you for the fittings?
Correct.
I’ve seen cross-linking presented as a new treatment, but based on what you said, as a reality check, there’s no real cure for keratoconus with this, and a patient will still have issues, correct?
Yes, I’ve have had numerous patient who had a cross-linking, and they still need scleral lenses. When it comes to the human eye, there isn’t a magical fix, and if it’s magical (or presented that way), it’s probably not a fix. Definitely not a long-term fix.
We need to realize that we are discussing a living tissue that changes. Sometimes for the the worse, especially when the cornea is very thin. We have a pressure inside the eye that keeps pushing the cornea out, and that’s why you have those changes. So, yes, a cross-linking procedure will help to hopefully prevent progression, but we don’t really have a really long 10, 15, or 20 year study to show that. But, it looks very promising. I agree especially if you start to catch keratoconus like in teenage years when things starting to change, yes. But, when you already have keratoconus, you’re still going to need an eye doctor.
Any tips for people with keratoconus? Anything to alleviate symptoms?
People that currently have or have been diagnosed with keratoconus need to be really excited – not about their condition by all means – but about the numerous options that there are out there for them. That can achieve good, comfortable, and functional vision. It’s not the way it used to be years ago. Even the hybrid lenses now have changed tremendously. There are so many different designs of scleral lenses, and of course, there’s the EyePrintPro. A keratoconus patient who feels, “That’s it! I’m doomed. I’m never going to see.” Well, it’s far from being true as far as optically. We have so many different ways and tools to help achieve good, comfortable, functional vision that it’s really exciting and it’s really extremely promising.
Yes, it’s a devastating condition.
Yes, it’s a condition that they live with every day there all day 365 till the rest of their life.
But yes, there are a lot of solutions that can help them achieve whatever they want to achieve and not feel that their vision is an obstacle in their way to success.
That’s where a patient with this disease can get the help and direction they need from a contact lens specialist?
It’s very important in finding eye care provider in particular when you have keratoconus, a corneal transplant, or had a refractive surgery that didn’t go well to go to a practitioner who specializes in this particular area. Not everyone can address every cornea. In particular, practitioners that are Diplomates are specialists in the field of cornea and contact lenses and were recognized by the American Academy of Optometry as specialists. It’s not that they just decided to start fitting difficult corneas and be successful. It’s not unusual for us to face patients who come in after being burned so to speak by seeing different practices and everybody was giving them false promises. Since it never worked out, they’re very leery about the outcome and rightfully so. They spent a lot of money, a lot on lenses, and a lot of time. Not to mention all the time that they to take off from work, etc. So, it’s very important to go to a specialist in the field. And, if possible, someone that was actually recognized by American Academy.
Do you encourage second opinions?
A second opinion can’t go wrong as long as that second opinion comes from an authority in the field. You can’t receive a second opinion from a guy who doesn’t specialize in specialty contact lenses, who doesn’t understand the nature of your condition. I encourage second opinions when patients come here because I understand to suddenly hear that there’s a solution that’s great after being burned by other practitioners can sound a little bit odd. So, when they want a second opinion, I say go right ahead but make sure that the second opinion will be with a Diplomate in Cornea & contact lens.
Because if you get stuck with a gas permeable guy again you’re just gonna go right back to square one?
Right.
