Two young teenagers were recently referred to my office. Both had regular corneas and refractive error, with moderate-to-high levels of astigmatism that had failed in soft toric lenses. The referral reason was for scleral lenses, and the patients were prepared for such a lens fitting.

Scleral lenses have proven to be an amazing tool in our industry, solving problem after problem for many patients. However, there are a number of other problem solvers in our toolbox, and we shouldn’t default to scleral lenses every time that a patient fails in a standard soft contact lens. This is especially true for our young, normal, and healthy cornea population. Consider the following tips before taking the big leap into scleral lenses.

Measure for Troubleshooting

This age group typically does well in soft toric contact lenses. They are pleased to be out of glasses and are satisfied with their level of acuity as long as they can see the front of the classroom. When kids struggle with vision or comfort in soft toric lenses, consider gathering information such as corneal diameter, topography, and lid tonicity. It can also be helpful to place a lens on eye and evaluate its movement and positioning. Chances are that their cornea shape and size fall outside of the average bell curve; in such cases, standard soft lenses do not fit properly, leading to unstable vision and lens awareness.

Many times, these young patients have deeper-than-average anterior chamber depths from a large cornea size, and the traditional 14.5mm lens is simply not large enough to properly drape across the cornea. A custom soft contact lens with a larger diameter can be a simple fix to improve both comfort and vision. Most GP lens labs also make custom soft lenses, and a conversation with your favorite lab consultant can get your started.

Device-Induced Dryness

The significant use of electronic devices by today’s school-age population has become a concern for reasons including myopia progression, eye fatigue, blue light exposure, and an overall reduction in physical activity. Another side effect that we discuss less often is the change in blink patterns during device use.

If young patients complain of poor vision or comfort in their soft toric lenses, evaluate for incomplete blinks, lagophthalmos, and meibomian gland dysfunction. If soft toric lenses appear to be fitting well with minimal improvement on over-refraction, dryness from device use should be at the top of the list. Shift your focus to lens deposits, tear film stability, and meibum quality. The palpebral conjunctiva should also be considered, as lens deposits can promote papillary conjunctivitis and can negatively affect lens stability.

Good Ol’ Corneal GPs

There is still a lot to learn about how scleral lenses affect eyes. New research is released all the time about their long-term effects on the cornea, limbus, ocular surface, and optic nerve. Some medical diagnoses such as irregular corneas and severe ocular surface dryness warrant their use as a first-line tool. But in young healthy eyes, we can’t forget about corneal GPs, despite the stigma of initial discomfort. With the high Dk of today’s lens materials, consider fitting a spherical or bitoric intralimbal GP. This design will reduce lens movement to a more tolerable level for a new wearer, and the vision will certainly outperform any soft lens. A little handholding and positive coaching can go a long way in this situation.

Only When All Else Fails

Ultimately, some of these teens may end up in a scleral lens over time. But, other options should be tried first to keep patients’ long-term ocular health in mind. CLS