I discovered Dry Eye Talk forums when I was researching scleral lenses as a result of conversations at the ANA Eye Issues Forum. It’s part of the very helpful site Dry Eye Zone, which also hosts news items pertaining to dry eye, an encyclopedia of dry eye topics, a computer blink reminder, and a Dry Eye Shop.

I never knew there were so many causes of dry eye, or that LASIK was one of them. As a extremely nearsighted, middle-aged woman with large pupils, I am fortunate to be a LASIK success story. However, thanks to post-surgical facial paresis, I became all too familiar with the pain and misery of dry eye. Early on I got a platinum eyelid implant. It aided nighttime closure but still left an incomplete blink.

One of the forum categories at Dry Eye Talk is Our Dry Eye Triumphs. After more than five years, I feel that I have finally arrived at that point. The remainder of this post is a before and after comparison of my dry eye care routine.

Before

I tried every type of eye drop, gel and ointment I could find. Eye drops and gels, no matter how thick, gave only a fleeting moment of relief. Standard eye ointments containing about 15% mineral oil and 85% white petrolatum offered 15-20 minutes of relief before I needed to reapply. Refresh PM, with a higher proportion of mineral oil (42.5%), gave me much longer relief. I always applied it before bedtime and first thing in the morning. During the summer that might be all I needed; during the winter I usually required a mid-afternoon application as well. Although some less expensive store brands, such as Walmart and Walgreens, contain the same proportion of ingredients, they did not work as well for me.

My eyes felt pretty good, but the vision on the left side was blurry, like looking through a lens smeared with vaseline. My brain learned to compensate, relying more on the clear vision in my right eye while utilizing the images from the left eye for depth perception. My overall vision was similar to this image, courtesy of Visionsimulations.com:

My method of applying ointment was a bit unconventional. Instead of squeezing it onto my eye from the tube, I put a small amount on my ring finger and applied it to the sclera below the iris, then closed my eye to distribute it over the cornea. I’m sure ointment manufacturers and eye care professionals alike would be appalled, but it worked for me. For nearly five years, 24/7 application of Refresh PM ointment comprised my eye care routine.

For a while, the absence of dry eye pain compensated for the loss of crystal clear vision. But over time I began to experience mental fatigue from the continuous effort of concentrating on my right-side vision. That, with the nearly constant nuisance of extra ointment under my eye – which also made wearing eye makeup an impossibility – led me to begin researching scleral lenses in earnest.

After

A scleral lens is much larger than a standard gas permeable contact and vaults the cornea, allowing a pool of saline to remain between the lens and the surface of the eye to combat dryness. Scleral lenses are more expensive because they require a precision fitting process. In my case, the first lens turned out to be too loose, but the second one is just right.

Here is the rest of my new eye care routine. Yes, it costs more and takes more time.

Solutions:

• Scleral lenses must be filled with preservative-free saline prior to insertion. Large bottles of saline contain preservatives, which leaves the more expensive option of individual vials. There are many brands with varying levels of lubricating agents added. Individual vials contain 2-3ml of fluid, which is just enough to fill a scleral lens. I found a much more cost-effective option to be sterile saline vials manufactured for nebulizer use. They are available in 3ml, 5ml and 15ml sizes. They contain no lubricating ingredients, and the lid can’t be snapped back on once opened. I prefer the 5ml size because it contains enough to both rinse and fill the lens. Beginners often need more than one attempt at insertion, so there is extra to allow for that. Any extra saline can either be discarded or used at the end of the day to rinse the lens after removal, but should not be kept for use the next day. I’m fairly sure 5ml would still be sufficient for two scleral lenses. Amazon.com has the lowest prices I’ve found for nebulizer saline. I usually buy 100 vials for around $15, but they are also available in quantities of 1000 for about $125.
• At the end of the day when I remove my lens. I use a daily cleaner called Lobob ESC to remove surface dirt and oils.
• I prefer UniquePH multipurpose solution for soaking and disinfecting. It is not available locally (at least here) and is sometimes hard to find online, in which case I use Lobob CDS but I don’t like it as well.

Tools:

• DMV Lens Insertion Tool – there is a great YouTube video that shows techniques for manual insertion and removal of scleral lenses, but I don’t like the thought of it, plus there is the possibility of getting skin oil or soap/lotion residue on the lens. I prefer to use an insertion tool, like the one pictured at left.
• DMV Removal Tool – the thought of breaking the suction between the lens and my eye using my fingers just gives me the creeps. I very very very very much prefer to use a removal plunger, pictured at right. There is also a plain suction cup without a hollow, but I prefer the way this one allows suction to be started and stopped by squeezing the bulb.
• Mirror – I place a hand mirror on the bathroom counter during lens insertion. The insertion tool is hollow all the way through, so I line up the reflection. When I can see the excess fluid spilling out, I know the lens is in the right place. I use the regular bathroom mirror during removal to find the right spot to apply the suction cup.

Tips:

• During insertion, tuck your chin toward your chest until your eye has to look slightly up toward the mirror. That keeps the lens level and the fluid in the cup through the insertion process.
• Blink hard a few times after insertion to help center the lens. You will notice your vision getting appreciably clearer with each blink.
• If you see ghosted images after insertion, too much fluid was displaced and there is an air bubble in the lens. Take it out right away to refill and reinsert, because in just a few seconds it will begin to smart like crazy.
• During removal, apply the suction cup to the outer edge of the lens. If the suction cup is in the middle of the lens, it will increase rather than break the suction. Placing a drop of saline on both the contact and the removal tool helps a lot. If the suction is still hard to break, try gently moving the edge of the lens slightly back and forth with the suction cup before trying again.
• If your vision starts to blur during the day, apply a drop of saline over the lens and blink a couple of times. If this doesn’t help, remove the lens, refill with fresh sterile and reinsert. Blink hard a few times to recenter the lens.

Nighttime care: At first, I continued using Refresh PM whenever I was not wearing the scleral lens. My optometrist recommended using lubricating eye drops with a silicon eye shield at night, but I needed the security of my old method for a few weeks. I was extremely happy once I made the switch. The lens stays cleaner and my eyes feel even better in the morning. Often I can wait two or three hours before having to put in my scleral.

• TheraTears Liquid Gel drops – I’ve tried a lot of different lubricating eye drops and this one is my favorite. It’s a thick solution and my eyes feel better in the morning than with any other drop I have tried. The top of these vials can be snapped shut, and although it is not recommended, I generally use a vial for two nights. Bonus: there is a $2 coupon good through 2013 available here and a $1 coupon good through 2014 available here.
• Quartz silicon eye shield – also available in a dark version called Onyix. It was originally developed to combat dry eye among  CPAP users, and is made by the same manufacturer as another nighttime dry eye product, TranquilEyes. I have found a couple of drawbacks with the Quartz shield. First, it tends to leave marks on my cheeks that take up to an hour to fade. Also, the adjustable fabric band tends to slip so I use hair clips or bobby pins to keep it in place. Fortunately, that way it does not have to be as tight so the morning marks aren’t quite so bad. TranquilEyes are supposedly less likely to leave marks, but they are not available in a clear version so I will probably stick with the Quartz shield.

The vision in my right eye has slightly diminished to -1.0 since my LASIK surgery thirteen years ago. I am not currently wearing a contact on that eye. I wear a pair of prescription glasses with clip-on sunglasses to drive and sometimes at the movie theater or to watch TV. Since I ended up with classic monovision, I rarely need to wear readers to read or work on the computer. I will decide by my next scleral appointment, currently scheduled for July 2014, whether I want another lens for the right side or if I am content to continue this way.

I keep a a few necessities in my purse in case of emergency – a spare set of insertion and removal tools, contact case, saline and Thera Tears Gel vials, alcohol wipes, a compact mirror and a tube of Refresh PM. My new eye routine definitely requires more money, time and stuff. But is it worth it? Well, the optometrist tells me that my eye is healthier. I am less fatigued at the end of the day. I no longer have to worry about wiping extra eye ointment off my cheek. I can wear eye makeup when I choose to. And best of all, I now see like this:

I am still waiting for the outcome of an appeal to my insurance company to cover the scleral lens as a prosthetic device for a nonfunctional eyelid. My argument is that it will decrease the possibility of corneal disease and accident. Whatever their decision, there is no question that the lens enhances my quality of life.

Read my next post on scleral lenses.

Five years ago, on June 2, 2008, I underwent brain surgery: microvascular decompression of the seventh cranial nerve in an attempt to cure hemifacial spasm. Unfortunately my facial nerve was damaged during surgery and I awoke with left side facial paralysis; I could neither smile nor blink, and my eye no longer produced tears. In addition to the trauma of losing my pretty smile, I experienced extreme pain from dry eye. Over time the nerve healed. I have recovered quite a bit of facial function. My smile is not what it used to be, but most people don’t notice that anything is wrong. I’ve learned how to make a smaller smile to minimize the difference between sides. I now produce tears when I cry or eat spicy food, but not under normal circumstances. I have tried every type of eye drop and gel I could find, but Refresh PM ointment is the only one that keeps dry eye pain at bay. My brain learned to compensate for the blurry vision on the left side, but over time it became mentally exhausting. This is the story of my nearly lifelong quest for sharp vision. It’s long and a bit on the clinical side now and then, but I feel it is important to be as thorough as possible in case it can help someone else out there.

I grew up nearsighted. In third grade I failed the school vision screening and made my first visit to an ophthalmologist. I remember leaving the optical shop after getting my first pair of glasses and marveling at seeing individual leaves on the trees. I was 8 years old. Thus began a progression of horrible nerdy glasses, the early ones complete with real glass lenses. Every year my vision got progressively worse and the lenses thicker. I disliked wearing eyeglasses, but couldn’t see without them.

Those despised spectacles did provide some dramatic moments. Once during a bombardment game in elementary school PE, I got hit in the face with a beanbag. My glasses flew across the gym and the glass lenses shattered. I was blind for a week waiting for a new pair. In high school I was invited on a horseback ride. During the home stretch across a hayfield, the horses began to gallop and my glasses – new of course – flew off my face. The next day my friend’s father, a career military man, organized a search line. Miraculously we found the glasses. Fortunately for me, lens technology had progressed to thinner and lighter plastic with scratch resistant coating.

My senior year in high school, a miracle occurred. I had my annual appointment with the ophthalmologist, anticipating yet another pair of geeky specs. To my amazement, my mom and dad had decided to surprise me with contact lenses. I was fitted with soft contacts and was at long last able to forgo the coke bottle glasses. I could see better and looked better. Win-win.

By the time my three children had been born, my prescription was -7.5 on the left and -9.0 on the right.

Weary of glasses, contacts, and solutions, I also hated not being able to see my kids at the swimming pool. I had been monitoring the development of laser surgery, and it had finally progressed to the point where I felt comfortable asking my ophthalmologist about it.

In February of 2000 I had LASIK performed in Kansas City. My refractive surgeon was reputed to be one of the top three in the country. He gave me ten units of correction on the right eye (at that time, the most that he would do) and eight on the left. I had been warned that my level of correction would probably require an enhancement surgery a few months later, but I was fortunate not to need it. My eyes healed perfectly. (I do see halos and starbursts around light sources, but I had that before surgery due to extreme nearsightedness and large pupils, so it causes me no distress.) After some mild post-surgical dry eye that resolved after a few months, I never looked back.

For eight years, I was able to take my vision for granted. Then came the microvascular decompression surgery and severe left side dry eye. I do not know how I was able to tolerate the plane ride home, but I made it somehow. After a few weeks of trial and error, I settled into a routine of applying Refresh PM ointment around the clock to keep my cornea moist. It gave me relief from dry eye pain, but also blurred my vision. In August I had a 1.8 gram platinum weight implanted into my eyelid to aid in closure. It helps to keep my eye shut at night, but unfortunately does not provide a complete blink.

In September 2008 I first asked my ophthalmic surgeon about the advances in scleral lenses being made by the Boston Foundation for Sight. Instead of resting on the cornea, the edges of these lenses extend to the sclera, or white of the eye, creating a moisture chamber on the surface of the eye, relieving dry eye pain while providing clear vision.

The surgeon dissuaded me, stating that the lens was only indicated for debilitating facial injuries such as Gulf War soldiers who had lost their eyelids altogether and had no protection for their eyes. I resigned myself to a lifetime of accepting less than optimal eyesight in exchange for keeping my cornea healthy and pain free. But it seemed to me that a scleral lens would be ideal for a situation such as mine, so a little more than a year ago, I brought the subject up again. I think the doctor realized I would not be giving up the idea, and reluctantly granted permission to find and consult with a specialist in contacts for dry eye. He warned me that my eye might be too sensitive to be fitted successfully.

Extenuating circumstances kept me from pursuing it right away, but a few months ago I began to see an increasing number of posts on the Acoustic Neuroma Eye Issues Forum concerning scleral lenses. I live in a small city, so I was not surprised to find that my local ophthalmologist does not fit scleral lenses. I contacted the manufacturer of one of the lenses mentioned on the forum and received a referral to an optometrist in a nearby city.

I emailed a brief history to the doctor and received a reply that he believed he could help me. At my initial appointment he recommended that I try Restasis twice a day for a couple of months to see if it would give me relief without needing a lens. He also recommended eyeglasses because the vision in my right eye had degraded slightly, to -1.0.

Unfortunately, I did not do well at all with Restasis. Both of my eyes burned whenever I applied it, and I could hardly stand to wait for the required fifteen minutes to pass before I could apply drops or ointment. I did some research and discovered that Restasis was not effective for dry eye due to nerve damage and contacted the doctor to ask to discontinue the Restasis and proceed with a scleral lens fitting.

The first lens turned out to fit too loosely even though it looked perfect from the fitting kit. I brought it home so that I could practice inserting and removing the lens. I could only wear it an hour at a time because the lubricating drops slowly leaked out of the bottom of the lens making the lens uncomfortable and blurring my vision. I am currently testing a second lens with a tighter fit. If my eye doctor was 10% satisfied with the last lens, he is 80% satisfied with this one. We will decide at my appointment next week whether to tighten the fit a bit more as it still settles just under center. I can wear it for increasing lengths of time, starting with 3 hour increments and increasing by an hour every day.

On the right side, we tried several regular soft lenses, but my cornea is so flat post-LASIK (remember the diagram above?) that the lens slides and does not hold its shape. I can’t afford a second scleral lens at this time, so my doctor has recommended a custom soft lens to take into account my flat cornea and large pupil size. I’ll be able to try that next appointment also.

Update (07/15/13): The name of the custom soft lens I tried is SpecialEyes. I have also seen one called RevitalEyes. There are likely others as well; if you are interested I suggest googling for “custom soft contact lenses” or “post-LASIK soft contact lenses.” I did not keep the lens. As it turns out, the -1 in my right eye with the corrected vision from the left scleral gives me more-or-less textbook monovision. The increase in distance vision from the right lens was not enough to compensate for the loss in near vision.

Although I did not reach my goal of crystal clear vision for my fifth post-MVD anniversary, I am close enough at this point to celebrate. I am happy to report that – severe myopic, post-LASIK and post-MVD – there is light at the end of my tunnel.

Here is a list of scleral lenses I have been able to identify. Let me know if I have missed any, and I will add them.

• Acculens Maxim
• Advanced Vision Technologies AVT Scleral – this is the one I am using
• Art Optical Scleral Lens Options (Rose K2 XL, Paragon NormalEyes 15.5, SoClear)
• Essilor Large Diameter Series (Jupiter, Perimeter)
• iSight Scleral
• Lens Dynamics Dyna Semi-Scleral
• SynergEyes Hybrid Lenses (Duette, UltraHealth. Post Surgical)
• TruForm Tru-Scleral and DigiForm
• Valley Contax Valley ICD 16.5
• Visionary Optics Jupiter Scleral
• X-Cel Atlantis Scleral Titan Large Diameter

Some unusual cases and harder-to-fit eyes may require custom scleral lenses. Instead of starting with ready-made fitting kits, these lenses are custom designed for each eye. The fitting process requires approximately a week of travel to their location.

• BostonSight PROSE – custom scleral lenses by the Boston Foundation for Sight. US providers are located in Needham, MA, Los Angeles and San Francisco, CA, San Antonio and Houston, TX, Chicago, IL, Ann Arbor, MI, Miami, FL, Baltimore, MD, and Great Neck and New York, NY. Overseas in India and Japan.
• Global Refractive Solutions Laserfit – custom designed lenses using high resolution digital imaging. The design process was developed and patented by Dr. Greg Gemoules of Coppell, TX (Dallas area). Lenses are manufactured to his specifications by TruForm.

Update (09/17/14): I ran across this option that is manufactured to order by the manufacturer of AVT Sclerals (the lens that I wear):

• EyePrintPro – Custom prosthetic scleral cover shells made using a direct impression of the surface of the eye. The developer of the scleral shell practices in Iowa City, IA. According to the website there are additional practitioners across the country, but I was unable to find a list on the website, though there is a contact form for questions or comments.

Read my next post on scleral lenses.