Streamline Your Scleral Contact Lens Fits (2025)

While attending optometry school, I was fortunate to gain a wealth of experience with retinal and neurological disease, but I did not get much exposure to keratoconus or other corneal conditions, nor did I have the opportunity to fit a single scleral contact lens. When I opened my private practice in 2013, I quickly realized the need for specialty contact lenses in the greater Lafayette, LA area. I was always interested in learning more about specialty lenses—particularly sclerals—because I wear contact lenses myself and had heard that fitting sclerals can be a rewarding and a lucrative specialty. But I had to seek out the training myself. Coincidentally, a lens manufacturer was hosting a wet lab just a couple of hours down the road in New Orleans. I learned the basics, bought a fitting set and dove in.

Since then, I’ve grown my practice from a handful of specialty fits per year to over 70 in 2024. This exponential growth required me to revisit my systems and efficiencies; the processes I had implemented for myself and my associate for family practice were not adequate for what’s required of sclerals and other specialty lenses.

After attending many specialty lens conferences, workshops and networking events with peers and vendors, and lots of learning by failing, I feel confident that I have developed a great way to streamline scleral fits. Perhaps some elements of my story can help guide you.

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A pamphlet designed to help market Scott Eye Care’s specialty services to patients and referring doctors.Click image to enlarge.

The Referral

If you’re just getting started with scleral lenses, you can probably find keratoconus cases among your patient base easily, as it affects about one in every 400 people. But if you really want to specialize in this area, getting referrals is crucial, and having the right marketing materials can help bring in new patients.

One example that’s worked for me is detailed pamphlets that show patients holding scleral lenses as well as images of the tools that have been instrumental in my practice, such as a topographer and a profilometer. Most importantly, there is a small referral section on the pamphlet that the doctor can fill out and give to the patient. The form also has a QR code that the doctor can scan; it leads them to a Google form they can fill out and send to me securely (Note: Google Workspace is HIPAA compliant if their Business Associate Agreement is signed). I keep these handy for society meetings and conferences, and sometimes I will arrange a lunch with doctors to introduce myself and my clinic’s special services.

Not only is this important for the act of referring, but it’s also important for my brand. You want referring doctors to know you’re the real deal and that they think of you first when it comes to scleral contact lenses.

Getting Your Staff Involved

If a patient has a vision plan with medically necessary benefits, it is usually easy to bring them in and get fit on their initial appointment. However, some patients may not have the budget and others may not need scleral contact lenses—perhaps they’d be better off with a simple rigid gas permeable lens for mild keratoconus or a custom soft lens for high astigmatism. Each case is unique, as certain patients may need something much simpler (for their eyes or for their budget) and we don’t want to risk losing business over a price that did not adequately apply to them.

For specialty contact lens consultations, obviously a corneal topography is essential. Obtaining scans can easily be delegated to well-trained staff. They know the eye needs a stable tear film and have been taught to capture three quality and consistent topographies of each eye. If a patient is already in scleral contact lenses or if they have full medically necessary benefits, my staff also obtains a profilometry scan, which can save you and the patient multiple follow-ups.

By the time I walk into the exam room, I have the patient’s referral records, autorefraction and topography with K readings at my disposal. I examine my patient, provide education necessary and give my lens recommendations. This visit usually at least qualifies for CPT codes 99204 and a 92025; corneal pachymetry is sometimes ordered as well, which my staff are also trained to do. The patient is given pricing and scheduled to come back for their fit.

Over the years, I’ve narrowed down my go-to lenses to a few designs that I find fit will into my practice flow. I chose ones where the diagnostic sets have toric haptics, as greater than 90% of the scleral patients we see will require toric sclerals. There are lots of great scleral designs out there to consider, but I find that concentrating on a few helps me really develop my expertise in those products.

I also particularly like the fitting algorithm provided by the manufacturer I use, and I am usually finalizing these patients’ lenses within a few visits. The profilometer generates information for a best-fit lens, and my staff is trained to pick the closest diagnostic from their fit set. This makes it extremely easy for the staff to go as far as placing the lens on the patient’s eye without waiting for me to approve. Other doctors may prefer a more hands-on approach and opt to design the entire lens themselves for greater customization.

The profilometer also assures that the first diagnostic lens placed on the patient’s eye is more than adequate to obtain overrefraction and OCT if necessary. This cuts down on a lot of time potentially wasted on inserting and removing poorly fitting diagnostic sclerals, especially in a nervous, new patient. You will not be walking into an exam room with the diagnostic fit showing central touch, limbal clearance problems or too much vault.

Streamline OCT Capture

Depending on the design I choose, either I will design the first prescription lens based on the profilometry data or my staff will obtain anterior segment OCT images of the diagnostic lens on the eye to help the consultant make any necessary adjustments to get a great first prescription lens.

My staff obtains the following scans:

1. A central vertical and horizontal scan. This allows us to measure precisely how much the lens is vaulted over the central cornea. It also shows if there may be decentration—this shows up as an uneven vault from one side of the scan to the other.

2. Edge scans at the toric markers, the rotation dot and 180° away from the rotation dot. This assures you and the consultant can see how the edges align in the steep and flat meridians of the haptics. Alignment in these areas is essential to prevent fogging.

3. Edge scans at three o’clock and nine o’clock. Sometimes the toric markers align at these positions, so this scan is indicated if they are not. This will help you see if any potential pingueculae may interfere with the fit.

Doctor's Evaluation

By the time I walk in with the patient, I have a best-fit diagnostic lens on the eye, an over-autorefraction, an OCT if necessary and a profilometry file ready to be sent to my lab of choice.

The slit lamp evaluation is still very important, even with all of the technology I use. Remember that each OCT scan is one tiny slice of the scleral lens at one point in time, and profilometry is highly dependent on a cooperative patient and a stable tear film. Seeing the whole picture through your slit lamp is valuable.

If something seems off with the fluorescein pattern—e.g., if the patient shows tear exchange as is evident with a lissamine green exchange test or if there is obvious blanching—I have equipped all four of my exam lanes with a camera-enabled slit lamp, so I snap a photo to can send to my lab of choice.

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An OCT scan of the temporal edge of a scleral contact lens, illustrating good haptic alignment and adequate limbal clearance.Click image to enlarge.

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This scleral prolifometer scan will be used to select a best-fit diagnostic scleral lens and to design a prescription scleral lens. Click image to enlarge.


The Orders

The system I have developed for ordering and tracking saves me so much time, and I am excited to be training my staff on how to make these orders to free up even more of my time so I can do more fits.

I am not content with my current EHR’s scleral documentation abilities nor its ordering; I’ve demoed other EHRs and feel they are all severely lacking. Knowing that my subscription to Google Workspace is HIPAA compliant, I went about making my own system.

I’ve made a Google form where my staff or I can type in a patient’s name, DOB, the lab and lens of choice and the overrefraction and notes for each eye on a spreadsheet. For example:

John Doe, 01/01/2001, ABB Ampleye, OD -3.25 overrefraction, OD Ampleye diagnostic SAG 4200 BC 8.04 DIA 16.5 PWR -2.00 + attach OCT images.

I used ChatGPT to help me design the spreadsheet to highlight orders that have yet to be placed and to color code each lab. This makes it extremely easy to copy and paste information into my lab of choice portal or onto the Eaglet direct connect screen. My staff adds order numbers and marks when each order arrives.

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The spreadsheet created from the Google Form entries. (Note, patient last name, first name and DOB are blacked out). The spreadsheet highlights rows of orders that have not been placed yet, color codes the lab and what team member is responsible for placing the order.Click image to enlarge.

The Rewards

The best part of a scleral lens fit is the patient’s reaction when they can see what they had given up on seeing. It never gets old when a patient leaves the office crying tears of joy, being able to drive safely for the first time in years or see their family members’ faces in detail.

The revenue comes with great patient care. Show your expertise and charge for it. But keep this in the back of your mind: scleral contact lens fitting can be lucrative only when you are finalizing these lenses. The more technology you invest in, the more knowledge you obtain through continuing education. Most importantly, the more experience you gain from fitting many patients, the more follow-ups you can cut out of your schedule and replace with revenue-generating visits—possibly more scleral fits. This is why it is so important to streamline this process, because too many follow-ups can really take a bite out of your bottom line.

Happy fitting, docs!

Dr. Cazares is a graduate of the University of Houston College of Optometry. In 2013, he opened Scott Eye Care, a cold-start clinic, in his hometown of Scott, LA. A former president of his local Acadiana Optometric Society and former member of the Optometry Association of Louisiana Board, Dr. Cazares is currently in pursuit of his fellowship of scleral contact lenses.

Streamline Your Scleral Contact Lens Fits (2025)
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