Contact Lens

Clinical Pearls
POCKET GUIDE

FIRST in Education

[Link]
 VERTEX CONVERSION CHART
minus plus
-3.87 4.00 +4.25
-4.00 4.25 +4.50
-4.25 4.50 +4.75
-4.50 4.75 +5.00
-4.75 5.00 +5.25
-5.00 5.25 +5.62
-5.12 5.50 +5.87
-5.37 5.75 +6.12
-5.62 6.00 +6.50
-5.75 6.25 +6.75
-6.00 6.50 +7.00
-6.25 6.75 +7.37
-6.50 7.00 +7.62
-6.62 7.25 +8.00
-6.87 7.50 +8.25
-7.12 7.75 +8.50
-7.25 8.00 +8.87
-7.50 8.25 +9.12
-7.75 8.50 +9.50
-7.87 8.75 +9.75
-8.12 9.00 +10.12
-8.37 9.25 +10.37
-8.50 9.50 +10.75
-8.75 9.75 +11.00
-8.87 10.00 +11.37
-9.37 10.50 +12.00
-9.75 11.00 +12.75
-10.12 11.50 +13.37
-10.50 12.00 +14.00
-10.87 12.50 +14.75
-11.25 13.00 +15.50
-11.62 13.50 +16.12
-12.00 14.00 +16.75
-12.37 14.50 +17.50
-12.75 15.00 +18.25
-13.00 15.50 +19.00
-13.50 16.00 +19.75
-13.75 16.50 +20.50
-14.12 17.00 +21.50
-14.50 17.50 +22.25
-14.75 18.00 +23.00
-15.12 18.50 +23.75
-15.50 19.00 +24.75
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CONTENTS
Vertex Conversion Chart 2

Spherical GP Lenses 4

Soft Toric Lenses 6

GP Back Surface and Bitoric Lenses 8

Multifocal Lenses 10

Orthokeratology15

Keratoconus18

Scleral Lens Fitting and Handling 20

Diopter to Radius (mm) Conversion Chart 27

Special Thanks
To the GP Lens Advisory Board and especially
Mile Brujic OD, FAAO; Stephen Byrnes OD, FAAO; Karen Carrasquillo
OD, PhD, FAAO, FSLS; Greg DeNaeyer OD, FAAO, FSLS; Tim Edrington
OD, FAAO; Barry Eiden OD, FAAO, FSLS, Rob Ensley OD, FAAO, FSLS;
Daddi Fadel DOptom, FBCLA, FAAO, FSLS; Chris Gilmartin OD; Bob
Grohe OD, FAAO; Lynette Johns OD, FAAO; FSLS; Matt Kauffman OD,
FAAO, FSLS; Jamie Kuhn OD, FAAO, FSLS; John Laurent OD, PhD, FAAO;
Norman Leach OD, FAAO; Michael Lipson OD, FAAO, FSLS: Derek Louie
MSc, OD, FAAO; Brooke Messer OD, FAAO, FSLS; Langis Michaud OD,
MS, FAAO, FSLS; Madison Moss OD, FAAO; Marcus Noyes OD, FAAO,
FSLS; Roxanna Potter OD, FAAO, FSLS; Miles Press OD; Tom Quinn OD,
MS, FAAO; Buddy Russell FCLSA, COMT, FSLS; Jack Schaeffer OD;
Cristina Schnider OD, MBA, FAAO; Christine Sindt OD, FAAO, FSLS; Eef
van der Worp OD, PhD, FAAO, FIACLE, FBCLA, FSLS; Jeff Walline OD,
PhD, FAAO; Michael Ward FCLSA, FAAO; and Frank Weinstock MD.

[Link]

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SPHERICAL GP LENSES
Before the Fitting
• Present initial adaptation with terms such as “lens awareness”
and “lid sensation.”
• Consider using a topical anesthetic prior to initial lens application.

Empirical versus Diagnostic Fitting

• Diagnostic fitting has the benefit of more quickly obtaining an
optimum fit and power through the application of diagnostic
lenses at the initial fitting.
• Empirical fitting has the benefit of often having the first
experience with GP lenses be a very positive one visually.

Fitting Pearls
• Use a cobalt blue filter in combination with a yellow (Wratten)
filter for optimum evaluation of the fluorescein pattern.
• Strive for an alignment fit. This is often
achieved with a base curve radius (BCR)
equal to the flatter K reading (termed
“on K”) or slightly flatter than K due to the
asphericity of the cornea.
• Lid attachment is preferable to reduce
presence of peripheral desiccation (3-9
staining). Alignment Fit
• Increasing the optical zone diameter (OZD) increases sagittal
depth and effectively tightens the fit. Decreasing the OZD
decreases sagittal depth and effectively loosens the fit.

OZD
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 • Flattening the peripheral curve radius (PCR)
and/or the secondary curve(s) and/or
increasing the curve width(s) of these curves
will increase edge clearance.
• Steepening the PCR and/or the secondary PCR
curve(s) and/or reducing the curve width(s) will
decrease edge clearance.
• When you make a design change, make it a
significant one.
» Change the base curve by ≥0.50D; OAD/OZD ≥ 0.3mm;
center thickness ≥0.03mm; peripheral curve radius/
width ≥1.0/0.2mm.
• Order a plus lenticular bowl to reduce edge thickness on all high
minus (≥ ­5.00D) and a minus lenticular bowl on all plus and low
minus (≤ ­1.50D) lenses to increase edge thickness.
» The use of a lenticular bowl, when indicated, in
combination with an ultrathin center thickness, will
reduce the risk of inferior decentration.
• To predict the lens power, take the spherical refractive value
at the corneal plane. If selecting a BCR flatter than K, add the
corresponding amount of plus power. If fitting steeper, add minus
power (SAM/FAP or steep add minus, flat add plus). Ignore the
cylinder power and the steeper K value.
» Example:
Rx -4.50 -0.75 x 180; K’s 43.00 @ 180/ 43.75 @ 090
BCR 42.50D (0.50D flatter than K)
The predicted power is -4.25D (-4.25D at the corneal
plane) + 0.50D (FAP) = -3.75D
• To control possible lens flexure with fluctuating vision, consider
adding 0.03mm to lens thickness to provide better clarity.

Resources
Resources on fitting and problem-solving GP lenses are available at
[Link].
5
SOFT TORIC LENSES
Before the Fitting
• Patients with as low as 0.75D refractive cylinder are often good
candidates.
• If a patient has ≥ 0.75D cylinder and is wearing a spherical lens,
provide them with a toric lens to compare the quality of vision.

The Fitting Process

• Select diagnostic lenses as close to the refractive power at the
corneal plane as possible.
» Example:
A patient with a refraction of: -4.75 -1.50 x 180 should
be fit with a diagnostic lens of -4.50 -1.25 x 180 (the
powers at the corneal plane). If the exact cylinder
power is not available, select the lower cylinder power
lens. For instance, if the patient has -1.50 x 180 cylinder
power at the corneal plane and the soft toric lens
cylinder is available in either -1.25 or -1.75 x 180, select
the -1.25 x 180 lens.
• Prioritize axis > cylinder power > sphere power when selecting an
initial diagnostic lens.
• Allow the lens to settle for a minimum of 10 minutes prior to
evaluation.
• To determine the amount of lens rotation, use a degree scale on
the biomicroscope to line up an optic section with the axis mark
on the lens. With this method, an exact amount of rotation can be
read directly off the degree scale. If this scale is not available, the
clock approach can be used to estimate the amount of rotation.
With this method, each hour on a clock is equivalent to 30˚. In
addition, apps such as “axis assistant” can be downloaded to a
mobile device.

6
• To determine the axis of the final lens, use the “left add, right
subtract” (LARS) technique. If the patient has a refraction of
-2.00 -1.25 x 180, and a lens with these identical parameters is
applied to the patient’s right eye and rotates 10˚ to the observer/
practitioner’s right (nasally), a lens with an axis of 170˚ should be
fitted. If it rotates 10˚ to the observer’s left (temporally), a lens with
a 10˚ axis should be fitted.
• Subtract the amount of rotation from the glasses prescription, not
the diagnostic lens. Also, the final lens ordered should fit in the
same skewed position as the diagnostic lens.
• Tolerance for rotation is reduced as the cylinder power increases.
Always compensate the rotation when ordering the final lens.

Rx axis at 180° Rx axis at 180° Rx axis at 180°

and no rotation and 10° right rotation and 10° left rotation
Order Lens Axis at 180° Order Lens at Axis 170° Order Lens at Axis 010°

Poor Visual Response

• If reduced vision is present with a spherical over-refraction (OR),
a sphero-cylindrical OR should be performed. To determine the
recommended cylinder power and axis based upon the OR, use
one of many available online cross cylinder calculators. This is
effective only if the lens is rotationally stable.
• If the patient experiences a persistent problem with vision due to
lens rotation or other reasons, a GP lens should be considered.

7
GP BACK SURFACE AND BITORIC LENSES
Before the Fitting
• Good candidates are individuals with > 2.00D of corneal cylinder
who do not achieve good centration and/or have a poorly
aligned fit, or are dissatisfied with their vision from soft toric
lenses, or have critical vision needs.

Decision-Making Process
• A back surface toric lens induces a cylinder equal to almost half
of the back surface toricity with the same axis (the exact amount
depends upon the refractive index of material).
• When the cylinder is corrected on the front surface, it results in a
bitoric lens.
• A back toric design (spherical front surface) is recommended
when the residual astigmatism is approximately one half of the
back surface toricity and has an axis equal to the flat K reading.
This should also be considered when the patient’s refractive
cylinder is approximately 1½ times the corneal cylinder.

Empirical Versus Diagnostic Fitting

• Although some diagnostic fitting sets – often with 3D of toricity –
are still available, advances in manufacturing technology make
empirical fitting a very desirable and popular option. This has
the benefit of making the initial patient experience with GP toric
lenses a positive one visually.
• The GPLI has several calculators on their website ([Link])
to make toric lens design a very simple process. This includes the
GPLI Toric and Spherical Lens Calculator, the Mandell-Moore
Guide, and the Newman GP Toric Guide.

8
Fitting Pearls
• Bitoric lens power determination only differs from spherical lenses
in that two tear lens power calculations are needed, not one.
• The flatter base curve is typically selected equal to - 0.25D flatter
- than flat K. The steeper base curve radius is typically 0.75D
flatter than steep K. This creates 0.50 - 0.75D of toricity, which
would simulate the ideal cornea to fit a spherical lens. The result
should be an approximate alignment fitting relationship.
• If a diagnostic lens is selected, a spherical over-refraction should
be performed and the resulting power should be added to the
power in each meridian. If the diagnostic lens powers are plano
in the 180˚ meridian and 3 ­ .00D in the 90˚ meridian and the over-
refraction is -1.00D, the final powers are -1.00D and -4.00D. This
lens can rotate on the eye without affecting vision (spherical
power effect).
• If the patient has residual astigmatism, it is likely that a sphero-
cylindrical over-refraction will result in optimum acuity. If so,
the over-refraction in one meridian should be added to the
lens power in that meridian. In the above example, if the over-
refraction is -1.00 – 1.00 x 180, -1.00D would be added to plano,
and -2.00D (in the 90˚ meridian) would be added to -3.00D
resulting in powers of -1.00/-5.00D. (see optical cross below)

• Toric GP lenses are not often indicated with irregular cornea

patients as the refractive axis differs from the corneal axis and
bitoric designs have base curve radii and corresponding powers
90˚ apart.

9
MULTIFOCAL LENSES
Decision-Making Process
• You may explain all options to every presbyope or emerging
presbyope including single vision lenses/reading glasses,
monovision, and multifocal lenses, but always make a firm,
confident recommendation based on the following:
» The benefits of multifocals versus monovision
include improved quality of vision due to increased
binocularity and stereopsis (depth perception).
» Many comparison studies between soft and/or
GP multifocals versus monovision have resulted
in approximately 75% of the patients preferring
multifocals.
» Monovision is indicated when the patient either
has miotic pupils (insufficient power effect may be
obtained from the paracentral aspheric region), or
pupils larger than 6mm (which may cause visual
disturbance from the mid-periphery of the lens),
or when the patient is unhappy with the vision of a
multifocal lens.
• Determine what the patient’s goals are for these lenses.
» Have the patient rank the importance of distance,
intermediate, and near vision. By concentrating on the
two most important, the patient will likely be satisfied
with their vision in multifocal lenses. It is important to
explain that modality will require neural adaptation.
Neural adaptation can take several weeks.
• Patients need to be given realistic expectations.
» Most contact lens multifocal designs utilize the
simultaneous vision principle in which multiple
corrections are overlapping in front of the eye. Educate
the patient that their vision quality will look different
when compared to spectacles.
10
 » Neuroadaptation occurs for most patients. It may take
7-10 days to get the optimal outcome of a fit. Do not
make modifications too early in the process.
» In addition, it may take one or more lens exchanges to
achieve a successful fit and acceptable vision.
» Finally, patients should be told that they may
still require spectacles. Some multifocal wearers
appreciate a low minus over-correction when driving
while others may desire some additional plus for
reading fine print. Inform the patient that good light
will also help improve near vision.
» Patience and motivation are required for success. We
highly recommend you work with your local laboratory
representative, particularly when just beginning with a
new multifocal design.

The Fitting Process

• Important tests to perform include a detailed refraction, corneal
shape assessment, pupil size measurement, tear film evaluation,
and measuring lower lid position.
• When possible, it is important that the patient’s first experience in
multifocal lenses is with lenses in their prescription so order your
first pair of GP multifocals empirically, or if fitting a soft multifocal,
use lenses from a soft lens inventory.
• After lenses are applied, assess vision at distance and near under
binocular conditions. Consider using a topical anesthetic drop
at first dispense to maximize patient comfort and allow for best
assessment of vision, as reflex tearing can affect accuracy of
over-refraction and acuity measurements. If vision is reduced,
over-refract bi-ocularly with hand-held diagnostic lenses or a
flipper bar held over one eye at a time. As a general rule you will
add minus to the dominant eye to improve distance vision and
plus to the non-dominant eye to improve near vision. However, if
additional minus does not improve the level of acuity and vision
quality, consider decreasing the add zone size or encouraging
11
 further adaptation rather than changing lens power. Even small
(0.25D) changes can have a significant effect in overall vision.
Sometimes you will want to change add power to improve vision.
Follow the manufacturer’s fitting guide.
• When assessing vision at near, have the room lights up and make
sure the patient is reading commonly encountered text (magazine,
cell phone, etc.) that is similar in font to their everyday material
and consistent with what they desire to see at near.
• Once the lenses have been evaluated, have the patient walk
around the office and perform normal visual tasks. Encourage
binocular viewing. Discourage viewing monocularly (the “contact
lens salute”). Explain “these lenses are designed to work together.”
• If satisfactory vision and fitting relationship is achieved, schedule
an appointment, at minimum, one week later to allow the patient
to become adapted to the lenses.

Soft Multifocal Lenses

• Good candidates include individuals who do not have highly
critical vision demands, have ≤ 0.75D refractive cylinder (unless
using toric multifocals), and are satisfied spherical soft lens
wearers. If they decide to be fit with soft multifocals, they should
be informed about the GP multifocal option if vision becomes
problematic.
• For the initial diagnostic lens, follow the manufacturer’s fitting
guide. Often it is recommended to select the power equal to the
spherical equivalent of the manifest refraction vertexed to the
corneal plane. For example, if the refraction at the spectacle plane
is -4.50 -0.50 x 180, the initial diagnostic lens would be equal to
-4.50D. Some soft lens multifocal manufacturers recommend you
begin by increasing the distance power for each eye by +0.25 D.
• The final lens power should be the lens that emphasizes “least
minus, most plus” if there is a range of lenses that provide
acceptable distance vision.
• Allow the lenses to settle at least 10 minutes after application
before evaluation.
12
 • Be sure to consult the manufacturers’ fitting guides and problem-
solving recommendations for their unique lens design.
• It is a good practice to evaluate lens position (centration) with the
topographer if available.

GP Multifocal Lenses
• This option is great for patients nearly all patients, but particularly
those with astigmatism or with critical vision demands.

Aspheric lenses
• Aspheric lenses are a great option, particularly for those who
perform a wide variety of tasks each day. Be cautious about
prescribing aspheric lenses for individuals who have a large
(≥ 6mm) pupil diameter. For uninterrupted vision at distance
and near, segmented translating (bi) multifocal lenses are
recommended. Aspheric lenses should result in good centration,
and limited (1mm) movement with the blink.
• If the lens moves excessively, select a lens with a 0.50D steeper
base curve radius. If continued movement is noted, consider
repeating cornea measurements and/or increasing the lens
overall diameter.

Segmented lenses
• Segmented, translating bifocal lenses typically have the seg
line positioned at or slightly below the lower pupil margin. Many
designs have an aspheric or segmented intermediate zone, which
should be positioned right above the lower pupil margin.
• The lens should move minimally (1mm) with the blink.
• Great candidates for this design are any patient requiring crisp
vision. Poor candidates for this design include anyone with a
lower lid that rests below the lower corneal limbus.
• When viewing through the biomicroscope, have the patient look
down and the lens should shift upward, or translate, as the edge
comes in contact with the lower lid.

13
 • If the lens does not translate (or only does so intermittently),
adjust according to the lens manufacturer’s troubleshooting
recommendations.
• If the lens moves excessively, increase the prism ballast, steepen
the BC or peripheral curves to reduce interaction with the eyelids.

Resources
For assistance with problem-solving GP bifocal and multifocal
lens designs, the Contact Lens Manufacturers Association (CLMA)
laboratory consultants are an invaluable resource. In addition, the
GP Lens Institute has numerous resources, like the one pictured here,
available at [Link].

14
ORTHOKERATOLOGY
Before the Fitting
• Good candidates include < 5.00D myopia, ≤ 1.50D WTR corneal
cylinder or ≤ 0.50D ATR cylinder; < 6mm pupil diameter, and less
than 0.75 D lenticular cylinder who are compliant and motivated.
• Important screening tests include refraction, slit lamp evaluation,
pupil diameter evaluation, corneal topography and anterior
segment optical coherence tomography (AS-OCT).
• Topography will rule out patients with irregular corneas as well
as provide corneal eccentricity values and horizontal visible iris
diameter.

The Fitting Process

• The “Jessen formula” can often be used to determine the base
curve radius.
» It uses the FAP (flat add plus) tear lens factor to result
in a final power of +0.50 to +0.75D, which will allow for
regression during the day.
» If the patient has a refractive error of -3.00 -0.75 x 180
and keratometry values equal to 44.00 @ 180/ 44.75 @
090, the base curve should equal 3.75D (3.00D + 0.75D)
flatter than flat K, which is equal to 44.00D -3.75D or
40.25D.
» The initial diagnostic lens is selected in an effort
to achieve a bull’s eye fluorescein pattern (central
bearing, paracentral pooling, midperipheral bearing,
and slight peripheral clearance).
• Wait at least 10 to 15 minutes before evaluating the fit.
» Instill fluorescein, wait 1 minute more and evaluate
fluorescein pattern.
» Good centration with minimal (≤1mm) lag with the blink
is desired.
15
• The patient should be evaluated the morning after dispensing.
» Assess the lens-to-cornea fitting relationship.
» The lenses should be removed to assess corneal
integrity. If coalesced corneal staining is present, the
lens is too flat centrally. Improvement in unaided visual
acuity should be present.
» Corneal topography should be performed and a
bull’s eye pattern (central flattening, paracentral
steepening) should be present indicating that the
treatment is centered on the eye and symmetrical.
» Remember that the lens position under the slit lamp
may differ from the lens real behavior during sleep.
Performing pre- and post-fit topographic map
analysis is the best way to assess lens position on the
eye. AS-OCT can be performed to assess epithelial
thickness to monitor treatment position and provide
supplemental information to topography on fitting
characteristics.
» If the lens sits superior, resulting in a “smiley face”
topography pattern, the lens is too flat/shallow. If the
lens decenters laterally, inferiorly, or there is a “central
island” topography pattern, the lens is too steep/deep.
» If the lens is centered, check the over-refraction. If
the over-refraction is –0.50 D or more minus, then
flatten the base curve by 0.1 mm for every –0.50 D; if
over refraction is +0.50 D or more plus, then steepen
the base curve by 0.1 mm for every +0.50 D unless the
manufacturer recommends otherwise.
» If no obvious topography pattern is present, the
patient should wear the lenses for 2 more days and be
re-evaluated.
• On average, it takes approximately 10 days to reach the
treatment goal although it will likely be less for lower myopic and
higher for more moderate myopic powers.
16
• Provide the patient daily disposable lenses of approximately
half of the patient’s myopic refractive error [to keep it simple for
patient?] to wear during the treatment period and re-evaluate at
one week.
• Patients can self-monitor retainer wear. Whenever the distance
vision becomes blurred, they can wear the lenses overnight. This
may range from every night for someone originally manifesting
moderate myopia to as low as 1 – 2 times a week for the low
myope.
• Applying a highly viscous artificial tear prior to inserting the
lens has been found to optimize centration and lessen corneal
staining.
• Lens removal should occur a few minutes after awakening.
• Rewetting drops should be applied before removal and the lower
lid margin can be used to gently nudge the lower lens edge to
break suction if present.
• It is important to get certified – via the manufacturer of a specific
orthokeratology lens design – prior to fitting that specific lens.

17
KERATOCONUS
Before the Fitting
• Hallmark biomicroscopic signs of keratoconus are Fleischer’s ring,
Vogt’s striae, prominence of corneal nerves, and possibly stromal
scarring. Apical steepening/thinning can be difficult to assess
with slit lamp examination alone.
• With corneal topography in keratoconus, the steepest area
of the corneal topography is typically >48.00D. Also, if the
eccentricity value is greater than or equal to 0.8, it is suspicious
for keratoconus. Additionally, other indications for keratoconus
include asymmetry of superior vs. inferior curvature of over 1.25D
and non-orthogonal astigmatism with a skewed axis of >20
degrees. Scheimpflug-based corneal tomography has the ability
to measure shape of both the anterior and posterior cornea as
well as measurement of global corneal thickness. Abnormalities
of the posterior corneal shape (elevation) always exceed those of
the anterior corneal shape (elevation). Abnormalities of corneal
thickness distribution (rate of change of corneal thickness from
the thin point out to the periphery) is a key finding in keratoconus
whereas abnormalities of central corneal thickness are not
specific nor sensitive for the detection of keratoconus.
• In a moderate-to-advanced keratoconic patient, in the absence
of a corneal topographer, the use of a +1.25D diagnostic lens over
the patient’s side of the keratometer will extend the keratometer’s
range by about 8.00D. A +2.25D diagnostic lens will extend the
range by approximately 14.00D. This can help you “ballpark” the
patient’s K values.

The Fitting Process

• If the apex of the cone is relatively small and centrally located, a
traditional small diameter keratoconic lens may be used.
• If a large oval or globus cone is present or the apex is decentered
inferiorly: intralimbal, scleral, piggyback, or vaulting hybrid
designs have all been successful.
18
 • With most designs, minimal apical
clearance or mild touch is desired. This
“three-point touch” or bull’s eye fluorescein
pattern is most likely achieved on a
relatively well-centered apex.
» Gross apical bearing can result Three Point Touch
in corneal staining and possibly
accelerate scarring.
» Excessive apical clearance can result
in peripheral seal off.
» The presence of excessive inferior
edge clearance can be remediated
with designs that allow the inferior Excessive Apical
edge to tuck in (flat-steep, ACT, Bearing
quadrant specific).
• A piggyback design combination should
be considered if a GP lens alone results in
either poor centration, less than optimum
comfort, or if scarring is present.
» A very low power (+0.50D) silicone
hydrogel soft lens can be placed Excessive Apical
under the best fitted GP. Plus lenses Clearance
often are preferred to minus lenses
(see below). Due to the lens combination it is important
that a hyper Dk (>100) GP material be used.
» If the patient has a low corneal apex resulting in the
GP lens positioning low on the soft lens, the use of a
moderate plus power (+6.00D) soft lens may help the
GP lens center due to the thicker center of the soft lens.
This should result in little to no change in the GP power
as a soft lens contributes only about 20% of its power
when used in a piggyback system.

Resources
For assistance with keratoconic patients, communicate with your CLMA
laboratory consultant. For resources, contact the National Keratoconus
Foundation ([Link]), the International Keratoconus Academy
([Link]), and the GP Lens Institute ([Link]).

19
SCLERAL LENS FITTING AND HANDLING
Definition and Applications
• Scleral lenses are large diameter gas permeable lenses that
completely vault the cornea and limbus and align with the bulbar
conjunctiva overlying the sclera. They are no longer classified by
diameter size, but rather where they come to rest on the ocular
surface. Corneo-scleral lenses are lenses that rest partly on the
cornea (either on the apex or on the periphery of the cornea) and
partly on the conjunctiva overlying the sclera.
• Scleral lenses have a range of indications including irregular
corneas, severe dry eye or ocular surface disease, and
normal corneas. Corneo-scleral lenses have been typically
recommended for healthy cornea patients and scleral lenses
have been successful for patients with corneal irregularities
(e.g., keratoconus, pellucid marginal degeneration, corneal
transplants) and ocular surface disease and scarred, severely
pathological corneas.

Lens Handling and Patient Education

Lens Application (non-fenestrated)
• For initial fitting
evaluation, the lens
should be completely
filled with isotonic,
non-preserved saline or
approved preservative-
free filling solutions.
Fluorescein from a strip
should be added to the
filled bowl. If seated,
cover the patient’s lap
with paper towels before application as some of the solution and
fluorescein will overflow and may stain clothing. The lens can be
supported on a large DMV scleral suction cup/ DMV applicator or
equivalent. Alternatively, a tripod made up of the thumb, middle,
and index finger, can be used.
20
 • The face should be parallel to the ground and the lids must be
retracted and well-controlled. The patient should look straight
down toward the ground. The patient may assist in retracting either
a lower or upper lid and the lens is applied centrally covering the
cornea. The lids should be released prior to lowering the supporting
DMV applicator. If the suction cup is sealed, it should be squeezed
upon application to release the lens onto the eye; and then may be
pulled away. If it is not sealed, then the applicator may be gently
pulled away after the lens is applied to the eye.
• If a large bubble is observed after application, either the lens
was not applied in one continuous motion, it was tilted or the lens
well was not completely filled with solution. Remove the lens and
reapply.
• A handheld blue light can be used to easily determine if an insertion
bubble is present prior to evaluating the patient in the slit lamp.

Lens Removal
• As the lens will likely be semi-sealed to the eye, always loosen
the lens prior to removal. An appropriate rewetting drop should
be applied and the inferior periphery of the lens should be gently
pushed in a repeated motion for several seconds.
• With the superior lid well controlled, the inferior lid can be used to
lift the lower portion of the lens away from the eye.
• Alternatively, a medium DMV suction cup/plunger can be used.
If so, it should be applied to the lens periphery and then pulled in
a direction that is down and out with the removal force directed
perpendicular to the lens
surface, not along the visual
axis. The suction cup/plunger
should never be applied in
the center of the lens, as this
will provide increased suction
and discomfort upon lens
removal. The only exception
to removing the lens from the
center is if it is fenestrated.

21
 • If the suction force is not allowing for an easy release of the lens,
lightly pressing a finger against the inferior eyelid to indent the
sclera just below the lens edge can help release suction while
simultaneously using the DMV suction cup to remove the lens.

Fitting Principles
• It is important for the lens to completely vault the cornea while
aligning the lens to the bulbar conjunctiva.

Choose the Overall Diameter

• In general, larger lenses can hold more fluid in the corneal
chamber and tend to be more forgiving for the fitter, allowing for
more clearance over the cornea.
• Smaller lenses must more closely vault the cornea and demand a
more precise central fit.
• For highly irregular corneas, larger lens diameters may be
more appropriate in order to provide enough alignment on the
conjunctiva to support an increased sagittal depth of the vaulted
lens.
• For ocular surface disease, choose a larger diameter to provide
maximum ocular surface coverage and protection.
• Lens diameter may also be dictated by conjunctival
abnormalities, aperture size, and patient dexterity.
• In addition, some manufacturers provide guidelines for selecting
an overall diameter based on visible iris diameter.

Choose an Initial Diagnostic Lens

• Follow manufacturer’s fitting guide.
• In some cases, a simple approach is to stand beside the patient,
and observe the corneal profile. If very steep, choose a deeper
sagittal depth lens. If the profile is flat, select a shallower sagittal
depth lens.
• These lenses are fit on the basis of sagittal height, so this method
can be very effective when used properly.
22
 • Some manufacturers supply prolate and oblate lens profiles and
provide guidelines for selection. Typically, prolate designs are
indicated for keratoconus and oblate designs can be used with
post-penetrating keratoplasty or post-refractive surgical corneas.
Corneal topography or grossly observing the peripheral profile
by standing next to the patient may also assist in lens profile
determination
• Algorithms incorporated in corneoscleral profilometers help in
the identification of the diagnostic lens to be applied on the eye,
based on the patient’s scleral shape.

Examine the Corneal Fit

• With white light and an optic section at high illumination and
medium magnification, set the slit lamp housing off axis and
examine the central corneal clearance.
• You will see several layers in cross section. The outermost band
(dark black) is the lens. The dark area is straddled by two hairline
reflections that arise from the front and back surface of the lens.
Compare this black layer to the tear lens (green).

Good Fit - Optic Section Good Fit - Down Gaze

• For example, if the diagnostic lens is known to have a thickness of

300 microns and the tear lens appears to be half that thickness,
then the lens vaults the cornea by approximately 100 to 150
microns. Ideal clearance may vary by design and is often less
if the lens is fenestrated. Initial lens clearance should provide
enough room for settling over time. According to the evidenced-
based CLEAR report on scleral lenses, the recommended target
central vault ranges between 300-500 um immediately after
application and 100-300 um after lens settling.1
23
 • Apply diagnostic lenses until an acceptable central clearance has
been achieved that is recommended by the manufacturer and
allows for settling to occur.
• Note that after applying any type of scleral lens, it will settle into
the conjunctiva over a 30-to-40-minute period. As stated before,
settling will decrease the corneal vault and possibly lead to touch
in an area that was vaulted upon initial application of the lens.
• A diagnostic lens that shows gross, excessive vaulting of the
central cornea initially should be removed and replaced with a
shallower sagittal depth.
• However, if the corneal vault is only mildly excessive upon initial
application of the diagnostic lens, it is best to allow the lens to
settle since it may yield an ideal corneal vault after 30 to 40
minutes.

Corneal versus Peripheral Fitting Relationship

• Overall, the fit of a scleral lens can
be divided into two parts; the central
fit and the peripheral fit (over the
conjunctiva).
• Examine the entire corneal
clearance under diffuse cobalt blue,
a yellow Wratten filter, and high
illumination. Ensure there is good
clearance over the cornea and also
Good Fit
mild limbal clearance.
• When fitting an irregular cornea, it is
possible to observe touch or bearing
in the mid-peripheral or peripheral
cornea once acceptable central
clearance has been obtained.
• In these cases, additional clearance
must be created in the problem
area without grossly increasing the
Scleral Compression
central clearance.
24
 • An oblate or reverse geometry design can be employed to vault
over the areas of touch/bearing, but depending on the design,
increases in the central corneal clearance and compensatory
changes may be required. Discussion with manufacturer’s design
consultants can be very helpful.
• The peripheral portion of the lens should align with the bulbar
conjunctiva.
• Compression, or general indentation of the conjunctiva, whether
at the edge or mid-periphery of the lens, may result in seal
off, suction and indentation. Modification of the lens design is
warranted to loosen the areas resulting in seal-off and/or suction.
• When blanching occurs, flatten the peripheral curve associated
with the area of blanching.
• Excessive movement and/or bubble formation after lens
application may indicate the peripheral curve(s) are too loose;
therefore, tighten the peripheral curve(s).
• Impingement of the conjunctiva may occur, resulting in
conjunctival arcuate staining or in extreme cases conjunctival
hypertrophy. If impingement occurs, loosen the periphery by
flattening or raising the edge.
• The sclera may not be spherical. Careful observation of the
landing zone in each meridian may help determine if toric or
quadrant-specific peripheral curves of the landing zone may be
required.
• Conjunctival abnormalities or elevations may require
customization of the peripheral curve system. Options may
include vaulting, notching, or freeform and/or molded lenses.
Over-topography
• It is beneficial to perform computerized topography over the
contact lens in situ after it has settled for a few minutes. This
can reveal any lens flexure. Flexure can be addressed by careful
evaluation of the haptic alignment. If toric peripheral curves are
not indicated, increasing center thickness may reduce flexure.

25
Check for Tear Exchange
• Before a scleral lens is dispensed to ensure a lens does not seal off
or suction, proper tear exchange should be demonstrated. Apply
the lens without fluorescein in the filling media. After the lens has
been properly applied, instill a generous amount of fluorescein
dye over the top of the lens with a dye strip. Periodically examine
the tear lens and check for dye that has made its way behind the
lens into the tear chamber. After several minutes, there may be at
least a small amount of dye in the tear lens.
• Tear exchange does not need to be rapid, but it is useful for a
proper fit. If in the test for tear exchange there is no fluorescein
seen in the corneal chamber after waiting for several minutes,
flatten or loosen the peripheral fit or increasing the overall
diameter may help.

1. Barnett M, Courey C, Fadel D, et al. CLEAR – Scleral lenses. Cont Lens Anterior Eye 2021 Apr;
44(2):270-288.

26
 DIOPTER TO RADIUS (MM) CONVERSION CHART
Diopter Radius Diopter Radius
34.00D 9.92mm 44.00D 7.67mm
34.25D 9.85mm 44.25D 7.63mm
34.50D 9.78mm 44.50D 7.58mm
34.75D 9.71mm 44.75D 7.54mm
35.00D 9.64mm 45.00D 7.50mm
35.25D 9.57mm 45.25D 7.46mm
35.50D 9.50mm 45.50D 7.42mm
35.75D 9.44mm 45.75D 7.38mm
36.00D 9.37mm 46.00D 7.34mm
36.25D 9.31mm 46.25D 7.30mm
36.50D 9.24mm 46.50D 7.26mm
36.75D 9.18mm 46.75D 7.22mm
37.00D 9.12mm 47.00D 7.18mm
37.25D 9.06mm 47.25D 7.14mm
37.50D 9.00mm 47.50D 7.11mm
37.75D 8.94mm 47.75D 7.07mm
38.00D 8.88mm 48.00D 7.03mm
38.25D 8.82mm 48.25D 6.99mm
38.50D 8.76mm 48.50D 6.96mm
38.75D 8.70mm 48.75D 6.92mm
39.00D 8.65mm 49.00D 6.89mm
39.25D 8.60mm 49.25D 6.85mm
39.50D 8.54mm 49.50D 6.82mm
39.75D 8.49mm 49.75D 6.78mm
40.00D 8.44mm 50.00D 6.75mm
40.25D 8.39mm 50.25D 6.72mm
40.50D 8.33mm 50.50D 6.68mm
40.75D 8.28mm 50.75D 6.65mm
41.00D 8.23mm 51.00D 6.62mm
41.25D 8.18mm 51.25D 6.58mm
41.50D 8.13mm 51.50D 6.55mm
41.75D 8.08mm 51.75D 6.52mm
42.00D 8.04mm 52.00D 6.49mm
42.25D 7.99mm 52.25D 6.46mm
42.50D 7.94mm 52.50D 6.43mm
42.75D 7.89mm 52.75D 6.40mm
43.00D 7.85mm 53.00D 6.37mm
43.25D 7.80mm 53.25D 6.34mm
43.50D 7.76mm 53.50D 6.31mm
43.75D 7.71mm 53.75D 6.28mm

27