How to use this template
Copy the text below into your letterhead or EHR referral. Replace each bracketed field with your patient’s information, and delete any section that doesn’t apply. Don’t fill a field with a guess: “not measured” or “unknown” is more useful to the fitter than an estimate.
The reasoning behind each section is on the referral checklist page.
The template
[Date]
To: [Fitter name, credentials]
[Practice name]
[Address / fax / secure email]
From: [Your name, credentials]
[Practice name, phone, fax, secure email]
Re: [Patient name], DOB [date of birth]
Referral for scleral lens evaluation
REASON FOR REFERRAL
I am referring [patient name] for evaluation for scleral lenses for
[visual rehabilitation / ocular surface protection / both] in
[right eye / left eye / both eyes].
Patient's main goal: [e.g., driving, work tasks, reading, comfort].
DIAGNOSES
OD: [diagnosis, ICD-10 code]
OS: [diagnosis, ICD-10 code]
Other ocular conditions: [e.g., glaucoma suspect, amblyopia, none]
REFRACTION AND ACUITY (measured [date])
OD: [manifest refraction] BCVA [acuity]
OS: [manifest refraction] BCVA [acuity]
Current contact lens acuity, if any: OD [ ] OS [ ]
CORNEAL IMAGING
Most recent topography/tomography: [device, date] (attached)
Earlier scans: [dates] (attached / not available)
Progression: [documented / suspected / not observed / unknown]
Cross-linking: [done (date, eye) / planned / referred / declined / not evaluated]
CONTACT LENS HISTORY
[Lens type, approximate dates, reason stopped]
[Lens type, approximate dates, reason stopped]
SURGICAL HISTORY (reports attached where available)
Keratoplasty: [type, eye, date, surgeon; suture status; rejection
episodes and treatment; most recent specular microscopy and
pachymetry with dates, or "not available"]
Refractive surgery: [type, eye, date]
Glaucoma surgery: [type, eye, quadrant, date]
Other ocular surgery: [cataract, retinal, ring segments, other]
IOP AND OPTIC NERVE
IOP: OD [ ] OS [ ] ([tonometer], [date])
Glaucoma status: [none / suspect / diagnosed, treatment]
Baseline nerve testing: [OCT RNFL / fields / photos, dates, or "none"]
CURRENT MEDICATIONS
Ocular: [drug, preservative, dosing]
Systemic medications relevant to the eye: [e.g., immunosuppressants]
OTHER CONSIDERATIONS
Dexterity / neurologic: [e.g., tremor, arthritis, none known]
Immune status: [e.g., immunosuppression, diabetes, none known]
Help at home with lens handling: [yes, who / no / unknown]
Other: [atopy, eye rubbing, lid disease, occupational needs]
CO-MANAGEMENT
After fitting, I plan to continue managing: [e.g., glaucoma,
routine eye exams]. [Corneal surgeon name] manages the graft.
Please send reports to: [fax / secure email / EHR].
Please contact me directly if you find: [e.g., any rise in
pachymetry, IOP concerns, new infiltrates].
INSURANCE
[Plan name, member ID, any prior authorization started]
Thank you for seeing [patient name]. Please call me with any
questions at [phone].
[Signature]
[Name, credentials, NPI if required]
Attachments: [tomography, refraction, surgical reports, specular
microscopy, medication list]Notes on specific sections
Reason for referral. One sentence. If you want a second opinion on whether a scleral lens is the right option at all, say so.
Corneal imaging. Attach the maps rather than summarizing them. The fitter uses the history to separate progression from lens effects and to coordinate with cross-linking.
Surgical history. For graft patients, baseline and follow-up pachymetry and specular microscopy may be considered, so send whatever exists.[2]
Medications. List preservatives. The fitter will advise on drop timing; a review recommends waiting at least 10 minutes after drops before applying a lens.[2]
Other considerations. Handling is the leading reason patients stop wearing scleral lenses, accounting for 35% of discontinuations in one prospective study.[4] In a veteran cohort, comorbid neurologic disease was associated with discontinuation (OR 4.6).[3] These are not reasons to withhold referral, but the fitter can plan training and aids if they know in advance.
Setting expectations with the patient. In a multinational practitioner survey, fits took a mean of 3.8 visits and 2.4 lenses per eye.[1] Telling the patient this up front avoids surprise.
When the fitter replies, what the fitter sends back describes what a complete report should include.
Common questions
Can I send this as a fax or through the EHR instead of a letter?
Yes. The structure matters more than the format. If your EHR has a referral template, map these headings onto it and attach the imaging.
Should the patient carry a copy?
It helps, especially if the fitting practice is outside your network. Make sure the attachments (tomography, surgical reports) go directly to the fitter as well.
How much should I tell the patient before they go?
Tell them why you are referring, that fitting usually takes several visits, that learning to insert and remove the lens takes practice, and that you will stay involved in their care. Handling is the most common reason people stop, so naming it up front helps.
Is there a standard form for scleral lens referrals?
Not one that is universally used. If the practice you refer to has its own form, use it and attach this information.