I am often asked by colleagues how to build a scleral lens practice. Here, I share how I built my scleral lens practice. But for most ODs, I recommend a different approach. Below, I will explain why.
Before I get to that, let me say that if you have the interest and commitment, it is realistic for you to make scleral lenses a viable part of practice. It is incredibly rewarding to elevate someone’s life with scleral lenses when nothing else will do. Additionally, scleral lens practice can support a healthy business as eyeglass and disposable contact lens revenue erodes to online and big-box retailers.
San Diego keratoconus and scleral lens practice
I opened ReVision Optometry in October of 2018 in central San Diego. I purchased an existing practice for its location, completely gutted the space, and rebuilt it to my specifications. ReVision Optometry serves as a referral-based keratoconus and scleral lens clinic. I am in solo practice with four ancillary staff. Eyecare practitioners in the community are kind to refer their irregular cornea patients to us.
ReVision Optometry is my third and only practice now. My previous two practices were large, multi-doctor, single-location practices, also in San Diego. These previous practices sold to private-equity affiliates. With each successive practice, I have increasingly concentrated on keratoconus and scleral contact lens prescribing while diminishing general optometric practice.
After graduating from UC Berkeley School of Optometry in 1999, I did a year-long optometric fellowship at UCLA Jules Stein Institute where I cared for the first two-dozen keratoconus patients in the U.S. undergoing Intacs surgery. That was a launching pad into irregular cornea practice. For example, in the early 2000s, I gained access to semi-scleral lenses like Epicon (Specialty UltraVision) and Macrolens (C&H Contact Lens). I served as a clinical investigator for SynergEyes KC prior to FDA clearance in 2006. By caring for many keratoconus patients, I gained significant experience with scleral contact lenses before this category went mainstream. By being in the right place at the right time, I was invited to share my clinical experience through trade publications, professional meetings, and providing industry-sponsored training.
Along the way, I have developed close working relationships with eyecare practitioners throughout San Diego and beyond. Many are ODs with retail subleases. Several corneal specialists and optometrists in private practice also refer their scleral lens candidates as well.
My recommended approach to scleral lens practice
My specialty scleral practice culminated over two decades of clinical and business experience while working with eyecare practitioners in my community. I feel fortunate to have completed post-graduate training and gained experiences open to few. The path I took to specialized practice was long and arduous. I realize it is not practical for most ODs to retrace. For most of my colleagues, I recommend a different approach.
“I feel the best place to start with scleral lens prescribing is your existing patient base.”
Great candidates are among your current patients, including those wearing custom soft toric contact lenses, corneal gas permeable lenses, hybrid contact lenses, and those that have failed out of one or more of these modalities. In many cases, you can notably improve vision and wearing comfort over their previous contact lenses while increasing positive cash flow from the higher fees commanded by these services and lenses.
With vision plans with necessary contact lens provisions—for high ametropia, anisometropia, or keratoconus—patient out-of-pocket costs are limited to co-payments, which allays patient cost concerns. I feel that this is like learning to swim at the shallow end of the pool, as it will give you the confidence to move to deeper water.
If you are successful with scleral lens prescribing and build a solid foundation, then it can make sense to seek new patients from corneal specialists, refractive surgeons, other ODs, and perhaps rheumatologists. However, reaching that level of competency and confidence takes time and dedication.
I encourage practitioners who are serious about scleral lens prescribing to earn fellowship in the Scleral Lens Education Society.
Not only does it publicly demonstrate your command of the specialty, but it puts you in touch with other like-minded colleagues and education resources to continue refining your skills. It is more enjoyable too to share the journey with other colleagues.
Selecting the right scleral lens design for your practice
After committing to begin scleral lens prescribing, you need to acquire a diagnostic scleral lens set. With nearly 50 different commercially available lens designs, where do you start? It is a good idea to consult trustworthy colleagues. Here are factors that can influence your decision.
Choose based on design, not cost
You may believe that cost of the set is important, but that should be a relatively unimportant criterion. This is because the cost of most scleral lens sets is less than the revenue generated by a single scleral lens patient. It is more important to select a lens design and associated lab that helps you deliver desirable outcomes.
A poor lens design, even if a diagnostic set is given to you complimentarily by the lab, ends up having a high cost due to lost time and frustration by patients and yourself.
Instead, select a lens set that allows you (with reproducibility) to:
- Adjust sagittal vault independent of the base curve.
- Alter limbal clearance depth.
- Specify toric scleral landing zones.
- Add toric and multifocal optics.
- Introduce peripheral recesses to dodge conjunctival lesions.
The best scleral lens designs are paired with great clinical training and support, from on-demand webinars to online calculators, to clinical consultants, and in-office, hands-on training. Not all laboratories offer these resources, but these are particularly helpful to get you started and working with challenging cases. Some labs will offer to send a consultant to your office when you prescribe scleral lenses for your first few patients. This is a significant investment by the lab and invaluable to getting started.
Consider the lab standards
Also consider scleral lens and lab selection based on:
- Delivery time.
- Consistency of manufacture.
- Material availability.
- Ease of the lens ordering (whether by phone or online).
- Warranty policies (duration and ease of returns and exchanges).
- Cost of goods.
Admittedly, sometimes you cannot know the performance of these factors ahead of time. But if a particular design or lab does not meet your standards, then you simply switch.
The shortcut to finding a lens design and lab is to find a practitioner whom you trust that has used several scleral designs and labs. Get their opinion on where to start.
Once you are familiar with the scleral lens basics, it is time to get your staff trained. Ask your scleral lens lab rep to train your staff on application and removal and lens care, so that in turn, they can instruct your patients. Most reps are happy to help. Even better, prescribe scleral lenses for one of your staff so they have first-hand knowledge and unparalleled credibility as the designated “go-to” employee for patient training on scleral lens handling and care.
Scleral lens business
If you were to dream up the ideal contact lens to support optometric business, what features would it have? You might say it has a high success rate without a clinical substitute, require a reasonable but significant amount of chair time and expertise to prescribe, and enhances the patient-doctor relationship such that the patient organically understands that professional services are desirable and necessary.
“Bear in mind, consumption of chair time is desirable because it brings the patient closer to a desirable outcome and provides the basis for generating service-based revenue.”
Lo and behold, these features describe a scleral lens!
While disposable contact lens manufacturers sometimes promote their lenses as requiring minimal chair time and little skill to prescribe, scleral lens prescribing requires a higher level of clinical thought, making scleral lenses ill-suited to commoditizing and automating their distribution. With disposable contact lenses, patients commonly attribute their desired outcome to their lens brand, where any prescriber suffices. To no surprise, the disposable space is now experiencing increased online prescription renewal activity and self-verified purchases even without a valid prescription.
The two major vision plans support necessary contact lens reimbursements for eligible keratoconus patients of up to $2,500 for bilateral prescribing, which is less than usual and customary global fees for services and scleral lens materials in many geographies. Unlike a single-use disposable contact lens, where a prescription is often finalized at the initial visit, scleral lens prescribing is a process requiring multiple visits and iterative lens exchanges during the lens warranty period.
Therefore, if it takes six visits to complete scleral lens prescribing (initial exam, diagnostic lens evaluation, dispensing, progress visit, exchange visit, progress visit), the gross receipts may not stand as high as one would believe when considering the greater level of time and attention needed.
For costs, figure that the scleral lens materials, including shipping costs for exchanges, will run approximately 20% of gross collections attributable to the scleral patient.
This is less than the cost of goods for a traditional, retail-oriented optometric practice; however, this is counterbalanced by additional fixed costs related to instrumentation helpful for scleral lens prescribing including a corneal topographer (~$15,000) and an ocular coherence tomographer with anterior segment capability (~$30,000). Then, figure that there are costs related to staffing, occupancy, insurance, marketing, accounting, information technology, supplies, utilities, licensing, and so forth.
You should be left with slightly greater net revenue than if you did traditional retail-oriented optometry.
Third-party billing and coding documentation is critical
While there is never an appropriate time for careless billing and coding, the stakes are elevated when obtaining third-party reimbursement for scleral lens prescribing. Due to the relatively high reimbursements per patient through the two leading vision plans, practices with high necessary contact lens authorization volume are more likely to get audited.
What is disturbing is that even if you initially bill and code incorrectly and inadvertently, you may still receive full reimbursement —only to find out, during a subsequent targeted audit, that you must pay back an amount extrapolated over three years for all your necessary contact lens patients. Depending on your billing volume, it is not unheard of having to return over $100,000 to the vision plan for non-compliance with your provider agreement while also getting put onto probation. This can happen even if you provided appropriate clinical care.
Therefore, it is important to carefully follow the criteria in your provider network manual for necessary contact lens authorizations. Each vision plan is different in its criteria. For example, with Vision Service Plan, the severity of keratoconus does not influence eligibility for necessary contact lens reimbursement. But with EyeMed, the stepped-up reimbursement for keratoconus requires either corneal scarring, a steep keratometry of 53 D or higher, a corneal thickness of less 475 µm or less, or unmeasurable refraction.
Also, realize that necessary contact lens authorizations do not give you permission to inflate your usual and customary fees to the vision plan.
“Your billed fees should match what you charge a self-paying patient, else you risk violating your provider agreement.”
Some scleral lens practice owners may question if it is worth staying on a vision plan’s provider network. Vision Service Plan requires a minimum inventory of 200 eyeglass frames meeting specific criteria, whereas with EyeMed the minimum is 100 frames. For the dedicated scleral lens clinic without the desire to dispense eyewear, managing frame inventory and optician staffing can pose a distraction.
On balance, the large number of lives covered by these vision plans will also help you retain these scleral lens patients, since there is a significant financial incentive for them to stay in-network.
Technology-driven scleral prescribing
Several instruments measure a much larger area of the ocular surface than just the cornea. Take for example the sMap 3D (Visionary Optics), Pentacam with CSP software (Oculus), and Eye Surface Profiler (Eaglet Eye) which all also measure a large portion of the sclera. These instruments can drive the manufacture of freeform custom scleral lenses and exactly pattern the unique ocular shape. There is also the impression-based scleral lens, EyePrintPRO (EyePrint Prosthetics), where the lens is produced based on an impression or mold taken of the eye.
Does it make sense to acquire technology like this in your practice? For the dedicated scleral lens clinic, it can. It is helpful to have the ability to encompass the most irregular ocular surfaces, above and beyond what a conventional scleral lens can offer. Yet, it probably does not make sense for the beginning scleral lens prescriber to jump directly to one of these instruments without first developing and refining the fundamentals of scleral lens prescribing. Most patients gain exceptional outcomes with well-prescribed, non-freeform scleral lenses. For many practitioners, it can make sense to refer patients who need freeform scleral lenses to a colleague.
It is relevant to know that the future of scleral lens fitting will increasingly become technology-driven. Notice I mentioned that fitting will be technology-assisted, but not scleral lens prescribing. Prescribing will remain a privilege and authority given to a doctor’s judgment. Better to get the terminology straight now, as this assistive technology becomes commonplace in the future. If you call yourself a “fitter”, expect to be replaced by technology. The existential threat to your professional service does not apply if you are a “prescriber”.
Shift your practice emphasis slowly
While the sale of eyewear and disposable contacts continues to move out of the traditional optometric practice, new opportunities abound in specialty areas, where ODs can explore scleral lenses, vision therapy, low vision, myopia management, dry eye, and medical eyecare. With scleral lens practice, a constraining factor is that there are relatively few patients with irregular corneas, Sjögren’s syndrome, Graft vs. Host Disease, degenerative myopia, high astigmatism, and other conditions where scleral lenses can help. Sclerals can be a great addition to your practice offerings, but make sure to transition slowly in order to avoid putting all your eggs in one basket.
While many practitioners will dabble with scleral lenses, only about 20% of eyecare practitioners will account for 80% of the total scleral lens volume.
That said, if you discover a passion for prescribing these lenses, you may find that you are increasingly shifting your practice in this direction. Even if you don’t become a specialized practice (only providing scleral contact lens care with no optical and no third-party network participation), you can still make scleral lens prescribing an important part of your overall practice.
Keep these tips in mind as you explore new opportunities to expand into scleral lens prescribing. Not only is this a way to support a health business, but it is an immensely rewarding field that enables you to continuously elevate your patient care!
