Insertion of Scleral Trial Shell or Prosthesis Over a Dysfunctional Globe
(Instructions for Caregiver)

Insertion Technique:  The best method for placing a scleral cover shell over a corneal sensitive eye is with the use of the fingertips, rather than a suction cup.  You will have better control of the unit.  Whereas, using a suction cup, a blink reflex or an uncontrollable squeezing of the eyelids during the insertion process could cause a loss of suction, and if the shell was partially over the globe, the edge of the shell may hit or rub against the cornea causing discomfort and irritation.

Step 1. All Important Hygiene Care

1. Scrub Hands and Fingertips:  A thorough hand scrub with emphasis on the fingertips is necessary to prevent introduction of bacteria to the eye.  We recommend using a 'no more tears' baby shampoo for this cleansing process, because it destroys bacteria.
2. Hygiene for Eyelids and Lashes:  Another source of bacteria and irritation to the eye is the crusting of secretions on the eyelids and eyelashes, so it is best to clean this area prior to insertion of the shell.  Apply a warm wet facecloth with the 'no more tears' shampoo on the eyelids.  Let it remain for a few moments to soften the crusted secretion, then wipe it clean.  There should be no concern about stinging or smarting of the eyes, since the shampoo has a neutral pH.
3. Cleansing of Scleral Shell:  Even though the scleral shell is cleaned immediately after removal, it is a good habit to clean it again prior to its insertion.  You may give it a gentle, but vigorous rubbing with the shampoo soaked facecloth. Rinse it well.

Step 2. Moisten Shell Prior to Insertion:

We would recommend a drop of hard or soft contact lens wetting solution be placed on the shell.  This will allow for a more comfortable insertion of the shell between the lids and the eye, although some patients (with less corneal sensitivity) do moisten with water.

Step 3. How to hold the Shell (The black marking is top):

Grasp hold of the inner and outer edge of the shell with the thumb and forefinger.  (The index finger will be utilized in Step #5)

Note shell markings:  The single black dot is the top of the left eye shell while the double dots indicate top of the right shell.

Step 4. Preparation for Insertion of the Scleral Shell/Prosthesis:

Have the patient look downward.  This will allow most of the cornea to be protected by the lower eyelid.  Then place your thumb of the free hand on the patient’s upper eyelid and lashes and draw the lid upward.

Step 5. Insertion

1. Partial Insertion:
   Bring the top edge of the scleral shell past the lower eyelid and beyond the upper edge of the cornea prior to setting it flush over the globe.  At this juncture, place the index fingertip on the front of the scleral shell to hold it in position.  Withdraw the thumb and forefinger hold.
    
2. Complete Insertion:
   Once the index finger has made contact with the shell, release hold of the upper eyelid and pull the lower eyelid downward past the lower edge of the shell.  The scleral unit should now be setting flush on the globe.

Step 6. Closing the eyelids:

1. Squeeze the Eyelids:  Close the eyelids tightly and gently press on the lids with your finger for several seconds to allow any trapped air between the shell and the eye to be released.
2. Relax the Closure of Eyelids:  Continue to keep the eyelids shut, but let it be with a more relaxed mood for at least 30 seconds to a minute.  For a more corneal sensitive eye, this may take three to five minutes to dispel any foreign body reaction.

Step 7. Follow your wearing schedule:

1. Phase I Scleral Trial Shell:  Follow the wearing schedule as planned for you.  Do not exceed the timetable.  If you have a corneal sensitive eye, we must gradually increase your wearing time (with wearing comfort) to at least 8 hours.
2. Phase II Scleral Ocular Prosthesis:  The object is to wear your scleral prosthesis with comfort for all of your waking hours.  If you do experience a burning sensation or irritation for at least ten minutes, remove the prosthesis and look under your eyelid for any loose eyelashes or a dirt speck.  Also check the scleral prosthesis.  Do not replace it if the eye is irritated.